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Case Study of a 5-Year-Old Boy with Unilateral Hearing Loss

Jan 15, 2015 | Pediatric Care | 0 |

Case Study | Pediatrics | January 2015  Hearing Review 

A reminder of what our tests really say about the auditory system..

By Michael Zagarella, AuD

How many times have I heard— and said myself—that the OAE is not a hearing test? How many times have I thought to myself that, just because a child passes their newborn hearing screening test, it does not mean they have normal hearing? This case brought those two statements front and center.

A 5-year-old boy was referred to me for a hearing test because he did not pass a kindergarten screening test in his right ear. His parents reported that he said “Huh?” frequently, and more recently they noticed him turning his head when spoken to. He had passed his newborn hearing screening, and he had experienced a few ear infections that responded well to antibiotics. The parents mentioned a maternal aunt who is “nearly totally deaf” and wears binaural hearing aids.

Initial Test Results

Otoscopic examination showed a clear ear canal and a normal-appearing tympanic membrane on the right side. The left ear canal contained non-occluding wax.

Tympanograms were within normal limits bilaterally. Unfortunately, otoacoustic emissions (OAE) testing could not be completed because of an equipment malfunction.

Behavioral testing with SRTs was taken, and I typically start with the right ear. The child seemed bright and cooperative enough for routine testing. I obtained no response until 80 dB.

I switched to the left ear and he responded appropriately. This prompted me to walk into the test booth and check the equipment and wires; everything was plugged in and looked normal. I tried SRTs again with the same results, even reversing the earphones. Same results. When the behavioral tests were completed, the results indicated normal hearing in his left ear and a profound hearing loss in his right ear.

The child’s parents were informed of these results, and we scheduled him to return for a retest in order to confirm these findings.

Follow-up Test

One week later, the boy returned for a follow-up test. The otoscopic exam was the same: RE = normal; LE = non-occluding wax.

Tympanograms were within normal limits. I added acoustic reflexes, which were normal in his left ear (80-90 dB), and questionable in his right ear (105-115 dB).

DPOAEs were present in both ears. The right ear was reduced in amplitude compared with the left, but not what I would expect to see with a profound hearing loss (Figure 1).

I repeated the behavioral tests with the same results that I obtained the first time (Figure 2). Bone conduction scores were not obtained at this time because I felt I was reaching the limits of a 5-year-old, and the tympanograms were normal on two occasions.

Recommendation to Parents

After completing the tests, I explained auditory dyssynchrony to the parents, and told them that this is what their son appeared to have. Since they were people with resources, I advised them to make an appointment at Johns Hopkins to have this diagnosis confirmed by ABR.

Johns Hopkins Results

The initial appointment at Johns Hopkins was at the ENT clinic. According to the report from the parents, the physician reviewed my test results and said it was unlikely that they were valid. She suggested they repeat the entire test battery before proceeding with an ABR. All peripheral tests were repeated with exactly the same results that I had obtained. The ABR was scheduled and performed, yielding:

“Findings are consistent with normal hearing sensitivity in the left ear and a neural hearing loss in the right ear consistent with auditory dyssynchrony (auditory neuropathy). The normal hearing in the left ear is adequate for speech and language development at this time.”

Additional Follow-up

The boy’s mother was not completely satisfied with the diagnosis or explanation. After she arrived home and mulled things over, she called Johns Hopkins and asked if they could do an MRI. The ENT assured her that it probably would not show anything, but if it would allay her concerns (and since they had good insurance coverage), they would schedule the MRI.

Further reading: Vestibular Assessment in Infant Cochlear Implant Candidates

Figure 1. DPOAEs of 5-year-old boy.

Findings of MRI. Evaluation of the right inner ear structures demonstrated absence of the right cochlear nerve. The vestibular nerve is present but is small in caliber. The internal auditory canal is somewhat small in diameter. There is atresia versus severe stenosis of the cochlear nerve canal. The right modiolus is thickened. The cochlea has the normal amount of turns, and the vestibule semicircular canals appear normal.

The left inner ear structures, cranial nerves VII and VIII complex, and internal auditory canal are normal. Additional normal findings were also presented regarding sinuses, etc.

Key finding: The results were consistent with atresia versus severe stenosis of the right cochlear nerve canal and cochlear nerve and deficiency described above.

The Value of Relearning in Everyday Clinical Practice

Figure 2. Follow-up behavioral test of 5-year-old boy.

According to the MRI, the cochlea on the right side is normal—which would explain the present DPOAE results. The cochlear branch of the VIIIth Cranial Nerve is completely absent, which would explain the absent ABR result and the profound hearing loss by behavioral testing.

This case has certainly caused me to re-evaluate what I think and say about my test findings. How many times have I heard—and said myself!—that the OAE is not a hearing test? How many times have I thought to myself that, just because a child passes their newborn hear- ing screening test, it does not mean that they have normal hearing?

This case has surely brought those two statements front and center. In addition, what about auditory neuropathy? In about 40 years of testing, I had never seen a case that I was convinced was AN. Naturally, I was somewhat skeptical about this disorder: Is it real, or does it reside in the realm of the Yeti. (Personal note to Dr Chuck Berlin: I truly don’t doubt you, but I do like to see things for myself!)

Finally, this case only reinforces my trust in “mother’s intuition” and the value of deferring to the sensible requests of parents. If she had not felt uneasy about what she had been told at one of the most prestigious clinics in the country, the actual source of this problem would not have been discovered.

So what? Does any of this really make a difference? The bottom line is we have a 5-year-old boy with a unilateral profound hearing loss. How important is it that we know why he has that loss? From a purely clinical standpoint, I think that it is poignant because it brings home the importance of understanding what our tests really say about the hearing mechanism and auditory system (ie, is working or not working?).

And although it may not make a large difference in the boy’s current treatment plan, I do know that the boy’s mother is grateful for understanding the reason for her son’s hearing loss and that it’s at least possible the boy may benefit from this knowledge in the future.

Michael Zagarella, AuD, is an audiologist at RESA 8 Audiology Clinic in Martinsburg, WVa.

Correspondence can be addressed to HR or or Dr Zagarella at:  [email protected]

Citation for this article: Zagarella M. Case study of a 5-year-old boy with unilateral hearing loss. Hearing Review . 2015;22(1):30-33.

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Mobile learning for hearing-impaired children: Review and analysis

• Survey Paper
• Published: 24 September 2021
• Volume 22 , pages 635–653, ( 2023 )

Cite this article

• Susana I. Herrera   ORCID: orcid.org/0000-0003-1462-6517 1 ,
• Cristina Manresa-Yee   ORCID: orcid.org/0000-0002-8482-7552 2 &
• Cecilia V. Sanz   ORCID: orcid.org/0000-0002-9471-0008 3  

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2 Citations

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Currently, a common objective for most countries is including people with disabilities in the various aspects of everyday life. As part of this objective, access to computer technologies that can help improve the learning of these people should be considered. In the case of hearing impairment, cochlear implants allow children with severe or profound hearing loss to develop natural language, which increases their chances of insertion in mainstream schools. However, the success of this depends on the auditory training process that involves various professionals and family members surrounding the implanted child. In this context, the use of mobile technologies has advantages due to their low cost and ubiquity; using mobile phones, children could learn new concepts as they train their hearing skills. Considering the above, in this paper, we present a review of mobile applications that hearing-impaired people can use for their learning and auditory training. The review is organized in two parts: (a) a systematic literature review, which included 297 articles on mobile technologies applied to hearing loss, and (b) a review of mobile applications aimed at teaching and training hearing-impaired children, which included 43 applications. The review was carried out taking into account technological, pedagogical and auditory aspects. The results obtained show the scarcity of learning applications that contribute to language development in hearing-impaired children. Additionally, some aspects that could be considered in the design of new mobile applications have also been identified, such as lack of visual interfaces based on augmented reality. This study opens up a new area where researchers and developers could work together in context-based mobile learning for hearing-impaired children.

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Diagnosing a learning disability in a hearing-impaired child. A case study

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• DOI: 10.1353/aad.2012.0525

In the past, the learning problems of hearing-impaired children have been attributed solely to the child's hearing loss. A hearing impairment and its associated language deficit make it difficult to determine whether an underlying learning disability contributes to the hearing-impaired child's learning problems. This report describes a case study that used an interdisciplinary diagnostic approach to determine whether a hearing-impaired child had a learning disability and to determine the type of disability. The approach included teacher observation, standardized assessment procedures, interpretation, and subsequent recommendations. Applying this approach to various educational settings is also discussed.

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A hearing-impaired child in the mainstream: a case study.

Norma J. Chapman

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Master of Science in Education in Literacy

Reading, Foundations, and Technology

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James Layton

The intent of this case study was to demonstrate that the mainstreaming of a hearing impaired child could be successfully achieved by determination of the current academic and social status of the child through a case study approach followed by research into current practices in teaching hearing impaired children and concluding with intensive teaching and training to modify the current academic skills of reading and letter-sound association along with social performance. A pre-test, post-test approach was used in the teaching sessions and a record was kept of each session as to the tests, results, and teaching approaches implemented. The student gave evidence of gain in both the affective and academic domains. It was concluded by the researcher that this type of approach--case study, research into teaching methods used effectively with a specific handicap, and use of varied approaches to teaching reading skills to find the one most effective for a particular student, can be of major benefit to a handicapped student in the mainstream.

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Outcome of language therapy in bimodal-fit children versus unilateral cochlear implant children in bilateral sensorineural hearing impairment: a case-control study

• Megahed M. Hassan   ORCID: orcid.org/0000-0001-8225-2436 1 ,
• Ahmed Mamdouh Emam 1 ,
• Amal Fouad Sayed 1 &
• Ahlam Abdel-Salam Nabieh El-Adawy 1  

The Egyptian Journal of Otolaryngology volume  38 , Article number:  76 ( 2022 ) Cite this article

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Treating hearing-impaired children aims not only to improve their hearing but also to enhance language acquisition capability. In our community, the CI usually performed on one side because of financial issues at least for a period of time. Consequently, the brain may neglect the unfitted ear. Contralateral hearing aid is an alternative solution when bilateral CI is unavailable. Our purpose is to evaluate the language outcome in bimodal-fit children who using cochlear implant (CI) and contralateral hearing aid (HA) compared to children using unilateral cochlear implant only.

In this case-control study, 15 children who are using binaural-bimodal stimulation by unilateral CI and contralateral HA and 15 children using monaural cochlear implant received auditory training and language therapy. All participants have been assigned randomly from the Phoniatrics and Audiology clinics. Filtering of patients was made to get the two groups matched regarding age, sex, family motivation, age of implantation, and age of hearing impairment. Evaluation and language therapy were performed in the Phoniatrics clinic. Language progress in each group was compared over different time-points. Also, it was compared between the two groups in each time-point. Both groups revealed significant language improvement over time with intensive auditory training and language therapy. In addition, the bimodal-fit children showed better language and speech outcomes than the unilateral CI children in receptive semantics, expressive semantics, word class, mean length of utterance, and speech intelligibility. The differences were significant with P -values 0.047, 0.034, 0.03, 0.016, and 0.028, respectively, after 9 months of rehabilitation.

Bimodal-fit children showed better improvement in language than the unilateral CI group. The contralateral hearing aid may be complementary to the unilateral cochlear implant by covering wider speech frequency range. Also, it prevents auditory deprivation and enables binaural hearing with positive impact on language outcome.

Bilateral cochlear implantation is considered the most recent method for binaural stimulation in bilateral severe-to-profound sensorineural hearing loss in many countries. However, in others, bilateral cochlear implantation may not be available due to the limited financial support and low socioeconomic statuses of citizens. The bimodal fitting (monaural cochlear implant and hearing aid fitting in the contralateral ear) is an alternative way for binaural stimulation in children with residual hearing in the non-implanted ear [ 1 , 2 ]. Recent studies of deafness in children showed evidence of an “aural preference syndrome” in which single-sided deafness in early childhood reorganizes the developing auditory pathways toward the hearing ear, with weaker central representation of the deaf ear. Delayed therapy consequently compromises benefit for the deaf ear, with slow rates of improvement over time. Therefore, asymmetric hearing needs early identification and intervention. Early effective stimulation in both ears through appropriate fitting of auditory devices within the sensitive period of development has a cardinal role for securing the function of the impaired ear and for restoring binaural/spatial hearing [ 3 , 4 ]. A child with hearing loss is facing certain problems arising from deficits in spoken language abilities. Deficient language commonly leads to reading problems and limits academic performance. Children with severe-to-profound hearing loss treated by cochlear implant can understand and produce spoken language better than those treated by hearing aids [ 5 ]. Children with untreated unilateral hearing loss experience deficits in speech perception and language learning [ 6 , 7 , 8 ]. So, it is likely that binaural hearing is essential for speech perception and language learning. The evidence demonstrated that binaural benefits for sound localization and speech perception can be obtained by many individuals using either bimodal stimulation or bilateral implantation [ 9 ]. The bimodal stimulation can improve sound localization and speech recognition in both quiet and noisy environments as reported in extensive researches [ 10 , 11 , 12 , 13 ]. Many studies had investigated the benefits of binaural stimulation as regard auditory processing. However, there is lacking in researches investigating the language development and outcomes following bimodal stimulation in children.

The binaural hearing promotes nearly normal auditory cortical organization. This facilitates auditory skills development in early childhood and avoids the risk of auditory deprivation with positive impact on language perception and acquisition [ 3 , 4 ]. Learning language involves more than just recognizing words, whether in noise or in quiet and whether in isolation or in sentences. A child can learn the native language without any previous knowledge or expectations about the syntactic structure or grammar of that language. Children must discover how the language they have to learn is structured at all levels. For example, a child must understand and produce simple and complex sentences, verb tense, plurals, pronouns, question, etc., which is important in his/her native language. Learning about these linguistic features generally happens within the first 3 years of life. The aim of the current research is to evaluate the efficacy of auditory training and language rehabilitation in bimodal fitting compared with unilateral cochlear implant children regarding language perception and production in an effective communication. Receptive and expressive language abilities, syntactic structure of sentences, and speech intelligibility will be addressed. This is in order to determine the impact of binaural-bimodal stimulation and unilateral CI on the language acquisition and development.

Participants

This study was conducted in the Sohag University Hospital after approval of the Institutional Ethical Committee. Written informed consents were obtained from all parents for having their children participate in this research work. This study included 30 participants with bilateral severe-to-profound sensorineural hearing impairment (HI) who did not use any form of sign language. The majority of subjects had symmetrical hearing impairment (severe to profound or profound). Few subjects in the bimodal group ( n = 4) had asymmetrical hearing impairment (severe to profound and profound HI). The participants have been recruited from the Phoniatrics outpatient clinic. In this case-control study, all participants were matched regarding age, sex, IQ category, family motivation, age of implantation, and time of hearing impairment in relation to first language learning.

The inclusion criteria included the following:

Severe-to-profound peripheral sensorineural hearing loss

Aided-hearing threshold should not be more than 65 dB for HA use in group A.

Nonverbal IQ above 80

Age at CI is not more than 6 years.

Parents with typical hearing who reported speaking only Arabic to their children

Motivated families to work with their children at home

Children with any major health condition other than hearing impairment that could delay language, cognitive, or motor development were excluded from the study.

All participants were treated by cochlear implantation (CI) in one ear. Parents of all participants were instructed to use HA in the contralateral ear after explaining its potential benefit. Fifteen children followed the instructions and received hearing aid in the contralateral ear. However, there are other 15 families did not follow the instructions and refused to use HA anymore; hence, their children remained with unilateral CI only. In the current research, there are 2 groups, each composed of 15 subjects: the subject group or group A (binaural-bimodal stimulation) and the control group or group B (monaural CI). There was no bias at all in assigning participants to either group. The only factor which determines groups is the willingness of parents whether to use contralateral HA for their children or not.

The participant’s information was listed in Table 1 . All participants were implanted with the MED-EL Sonata in the Otolaryngology Department, Sohag University Hospital. The IQ was measured for all children by nonverbal section of the Stanford-Binet 5 Arabic version (SB5-AR) [ 14 ]. Family motivation was based on 3 items according to history taking: (a) regular attendance to the language therapy sessions before implantation, (b) real family expectancy that CI operation itself will not get their child to speak without language therapy, and (c) willingness of the family to have their child speak. Family counseling given aimed mainly at improving language stimulation environment at home and stress on attending language therapy sessions for at least 2 years after implantation. The language-stimulating environment can be measured by the average number of hours the parents interact verbally with their child at home. Assessment for speech reading ability was performed by asking the child to identify or repeat 10 common words and 10 common sentences spoken by the examiner. These words and sentences including their pictures were taken from unpublished Arabic speech reading test done in the Ain Shams University Hospital. All children received intensive course of auditory training and language therapy as part of their rehabilitation program in the Phoniatrics Unit, Sohag University Hospital. Every child received 4 therapy sessions per week; each is 60 min. The content of session varies according to the language level of the child. Generally, therapy sessions included auditory training, self-talk, and parallel-talk commenting on actions made by the child or by therapist in front of the child. These actions were made using flash cards, toys, and structured speech situations with stress on semantic, syntax, and phonology as well as conversational or play therapy (auditory-verbal therapy). Families were given counseling to work with their children at home by commenting on everyday listening/speech situations and structured listening/speech situations. Family expectancy and motivation were assessed in the interview, and any misconception was fixed during family counseling. The stated goal set from therapy was enabling the children to learn spoken Arabic language. Language assessment was conducted pre-therapy and post-therapy at 3 time-points (3, 6, and 9 months). The language parameters assessed were receptive semantics, expressive semantics, mean length of utterance, word class, and speech intelligibility. The language outcomes were compared over time within each group and in each time-point between the two groups.

Language assessment

Receptive semantics (RS) : recognition of pictures is a measure of how well children comprehend spoken language. Every child has to point to a specific picture from multiple options (6 pictures) in response to verbal stimuli. The pictures included 10 semantic groups (6 pictures for each). These groups included body parts, family members, surrounding furniture, cloths, foods, fruits, vegetables, animals, transportations, and colors. The pictures within each semantic group were structured to be 2 familiar pictures, 2 less familiar pictures, and 2 rare picture items. The RS score was measured as the correct responses to the total picture items (60).

Expressive semantics (ES) : it is the total number of vocabs uttered by the child and estimated by summation of vocabs collected by the two methods:

Behavioral testing of ES: it is the ability of children to name given pictures in question. The examiner shows the child a picture and asks him/her directly about its name. The same semantic groups in RS were used. The ES score was measured as the correct responses to the total pictures (60). We usually started by ES; if the child names the item correctly, then he definitely knows it and no need for testing RS of that item. Items which were not named by the child were tested for RS.

Spoken words list: it is a list of words which the child usually utters in everyday life as listed by parents and not included in the ES.

Word class score : it represents the word class level which the child acquires in his/her vocabulary. The word class score (1–7) was proposed for this study as hierarchy of grammatical words acquired by children (Table 2 ). It was taken from the expressive syntax items of the Preschool Language Scale 4th edition Arabic version (PLS4-AR) [ 15 ]. The score is based on the same order of normal grammatical development in our community as in the standardized PLS4-AR.

Mean length of utterance (MLU) : this was evaluated by observing spontaneous speech of the child in the interview or a pre-recorded video at home, behavioral testing, and parent telling. Observing the child during play with his/her mother and by eliciting open-ended conversation with the child or watching a pre-recorded video provide rough measurement about the current linguistic ability. Then, behavioral testing was made by asking the child to describe 2 pictures; each contains multiple events which need formulating long and complex utterances. These pictures were taken from SB5-AR test [ 14 ]. Evaluating the MLU by picture description was made by 3 Phoniatricians and matched with spontaneous speech observation. About 20–30 utterances were used for each child for calculating the MLU according to the child’s response. The MLU is equal to the number of morphemes (words) in the whole utterances divided by the number of utterances.

Speech intelligibility : The examiner elicited child’s speech during playing with toys. A sample of child’s speech was recorded during interview. Also, a pre-recorded audio or video made by parents at home was used. The speech samples were perceptually judged for intelligibility by 3 Phoniatricians. The percentage of incomprehensible speech in the sample is inversely related to the degree and score of speech intelligibility as shown in Table 3 .

All children were implanted before 2 years of life except 3 subjects (one in group A and 2 in group B) were implanted after 3 years. All verbal children have fair to good speech reading abilities with minimal insignificant differences among them. The mean IQ in group A and group B was 92.8 ± 7.6 and 93.2 ± 6.4, respectively, with insignificant difference. The children were deprived from language stimulation environment at home before treatment. However, with family counseling, the number of hours of parent-child interaction by structured speech situation was increased from 1.5 ± 0.6 to 4.5 ± 1.8 in total participants with insignificant difference between the two groups. In the first 6 months, all sessions were individual. Type of therapy sessions was mainly individual. Group therapy started for those children who uttered 3-word sentence or more only in the last 3 months of the course. There were few drops out of sessions which were compensated in the same week. All the children included in the research completed the therapy course with good compliance of their families.

Comparison of language outcomes over time across different time-points was conducted using repeated measures one-way ANOVA in each group. In addition, the posttest (Tukey’s multiple comparison) was used to show the biggest mean difference. These comparisons were made for receptive and expressive vocabulary and MLU.

Receptive semantic (RS): An analysis of variance showed that the receptive semantic was increasing over the 3 time-points of evaluation in group A with significant differences ( P < 0.001). Tukey’s multiple comparison test showed significant differences in the all 6 comparisons among different time-points (pre- vs 3 months, pre- vs 6 months, pre- vs 9 months, 3 months vs 6 months, 3 months vs 9 months, and 6 months vs 9 months). The highest mean difference was 27.8 in pre-therapy versus 9 months comparison followed by 21.67 in pre-therapy versus 6 months comparison. Similarly, analysis of variance showed that the receptive semantic was increasing over the 3 time-points of evaluation in group B with significant differences ( P < 0.001). The Tukey’s multiple comparison test showed significant differences in all comparisons among different evaluation time-points with highest mean difference was 19.6 in (pre- versus 9 months) comparison followed by mean difference 11.47 in (pre- versus 6 months) comparison (Table 4 ).

Expressive semantic (ES): An analysis of variance showed that the expressive semantic in group A was increasing over the 3 time-points of evaluation with significant differences ( P = 0.0056). Tukey’s multiple comparison test showed significant differences in the all 6 comparisons among different time-points with highest mean difference 68.4 between (pre- versus 9 months) comparison followed by 55.07 in the (3 months versus 9 months) comparison. Also, analysis of variance showed that expressive semantic was increasing over the 3 time-points of evaluation in group B with significant differences ( P = 0.003). Tukey’s multiple comparison test showed significant differences in all comparisons except (pre- versus 3 months). The highest mean difference was 20.53 in (pre- versus 9 months) followed by 18.2 in (3 months versus 9 months) comparisons (Table 4 ).

Mean length of utterance (MLU): An analysis of variance showed that MLU in group A was increasing over the 3 time-point evaluations with significant difference ( P < 0.001). Tukey’s multiple comparison test showed significant differences in all comparisons with biggest mean difference 2.4 in (pre-therapy versus 9 month) followed by 1.67 in (3 months versus 9 months) comparisons. Similarly, analysis of variance showed that MLU in group B was increasing over the 3 time-point evaluations with significant difference ( P < 0.001). Tukey’s multiple comparison test showed significant differences in all except (3 months versus 6 months) comparisons with biggest mean difference 1.86 in (pre-therapy versus 9 month) followed by 1.46 in (3 months versus 9 months) comparisons (Table 4 ).

Although the data of word class and speech intelligibility were numeric, they were discrete (noncontinuous). So, the nonparametric repeated measures one-way ANOVA (Friedman test) was used for word class and speech intelligibility scores. In addition, the posttest (Dunn’s multiple comparison) was used to show the highest rank sum difference.

Word class: it ranges from (0–1) in both groups pre-therapy. The word class ranged from (0–3) in 3-month and 6-month time-points and from (1–6) in the 9-month time-point in group A. In contrast, the word class in group B ranged from (0–1), (0–2), and (1–3) in the 3-month, 6-month, and 9-month time-points, respectively. Statistically, there were significant increases of word class score over time in both groups ( P < 0.001 for each). The Dunn’s multiple comparison test for group A revealed significant differences in 3 comparisons: (pre- versus 6 months), (pre- versus 9 months), and (3 months versus 9 months). The highest rank sum difference was 36.5 for (pre- versus 9 months) in group A. In contrast, the Dunn’s multiple comparison test for group B revealed significant differences in only one comparison (pre-therapy versus 9 months) with highest rank sum difference (28) (Table 4 ).

Speech intelligibility: There were significant increases of speech intelligibility score over time in both groups ( P < 0.001 for each). The Dunn’s multiple comparison test for group A revealed significant differences in 3 comparisons: (pre- versus 6 months), (pre- versus 9 months), and (3 months versus 9 months). The highest rank sum difference was 34 for (pre- versus 9 months) followed by 24.5 for pre- versus 6 months. In group B, the Dunn’s multiple comparison test revealed significant differences in only 2 comparisons: (pre- versus 9 months) and (3 months versus 9 months) with the highest rank sum differences were 29 and 23, respectively (Table 4 ).

The unpaired t -test was used to compare between the two groups in each time-point (two-tailed p -value and confidence interval 95%). The measure of G power revealed that effect size is 1.364 and DF = 28. The means, standard deviations, and p -values of the comparison between the 2 groups were shown in Table 5 . The improvement of language outcome was significantly better in group A as evidenced by the t -test results. Although the receptive and expressive semantics showed no significant difference between the two groups pre-therapy, they revealed significant differences in the time-points 3, 6, and 9 months (Figs. 1 and 2 ). The receptive semantic in group A was more than that of group B after 3 months ( P = 0.027). Similarly, group A revealed more receptive semantic than group B after 6 and 9 months with significant differences: P = 0.011 and 0.047, respectively (Fig. 1 ). Similarly, the expressive semantic in group A was more that of group B in the 3-, 6-, and 9-month time-points: P = 0.013, 0.016, and 0.034, respectively (Fig. 2 ). The word class score revealed no significant difference between the two groups before therapy ( P = 0.14). Over time, word class revealed significant differences between the two groups in 3-, 6-, and 9-month evaluations in favor of group A: P = 0.025, 0.042, and 0.03, respectively (Fig. 3 ). The mean length of sentences (MLU) showed significant differences between the two groups before therapy and in 3-, 6-, and 9-month time-points: P = 0.02, 0.009, 0.036, and 0.016, respectively (Fig. 4 ). Speech intelligibility showed no difference between both groups before therapy ( P = 0.07). The speech intelligibility score increased in both groups; however, this increase was more evident in group A than group B with significant differences in the 3-, 6-, and 9-month time-points: P = 0.003, 0.006, and 0.028, respectively (Fig. 5 ).

Comparison of the receptive semantics between group A and group B. Results of unpaired t -test (two tailed) revealed better receptive semantic in the group A (bimodal) over time. CI, cochlear implantation; ns, nonsignificant, *significant ( P < 0.05)

Comparison of the expressive semantics between group A and group B. Results of unpaired t -test (two tailed) revealed better performance in group A (bimodal) over time. CI, cochlear implantation; ns, nonsignificant, *significant ( P < 0.05)

Shows more diversity of word classes in the vocabulary of group A (bimodal) compared to group B (monaural CI). Results of Mann Whitney test revealed significant differences over time in favor of group A. CI cochlear implantation, ns non-significant, *significant ( P <0.05)

Shows comparison of the mean length of utterance (MLU) between group A and B. Results of Mann Whitney test revealed longer MLU in group A over time with significant differences. CI  cochlear implantation, ns non-significant, *significant ( P <0.05), **significant ( P <0.01)

Showing better speech intelligibility score in group A (bimodal) compared to group B (monaural CI). Results of Mann-Whitney test show better performance over time in group A. CI, cochlear implantation; ns, nonsignificant, *significant ( P < 0.05), **significant ( P < 0.01)

In the current research, 4 subjects from group A did not use a HA soon after CI operation but used it after an average of 3 months. After that period, they showed no response (NR) in the ABR for aided hearing in the contralateral ear, although they had auditory response preoperatively when they were using bilateral HA. Then, they reused the HA in the contralateral ear regularly for sufficient period (3–5 months). After that, the auditory response for aided hearing recovered again nearly as it was before (55–65 dBs).

In the current research, there was no significant difference between the 2 groups pre-therapy. However, group A performed better than group B with significant differences after 3-month, 6-month, and 9-month evaluations as regard receptive and expressive semantics. The binaural hearing has strong impact on language acquisition in children. Martínez-Cruz et al. [ 16 ] found that children with unilateral hearing loss demonstrated lower scores on both receptive and expressive language tests when compared with their peers with binaural typical hearing. Also, bilateral CI users predict faster rates of receptive and expressive language development than unilateral CI when controlling other factors [ 17 ]. Binaural hearing has positive impact on language development particularly when achieved early in the life. Robbins [ 18 ] stated that the average child who receives a CI in the first 2 years of life learns approximately 1 year of language in 1-year time, while children implanted at 3 or 4 years show slower rate of language growth due to the significant delays that already exist in children’s language at the time they receive their implants. Similar result was found in the current research. Our children with bimodal fitting moved from many single words (> 10) to 3-word sentences in 9 months of extensive language therapy, while children with only CI moved from few single words (< 10) to 2-word sentences in the same period. Following language therapy and in spite there was an improvement, our subjects still had a gap compared to their typically developed peers. The cause may be the relatively delayed implantation in our subjects (ages of CI ranged from 18 to 60 months) and short rehabilitation period of study. It has been found that children with any experience with bimodal stimulation had better generative language abilities than children without bimodal experience at all. The explanation made was that the low-frequency signal heard by these children through hearing aids facilitated their acquisition of language [ 19 ]. Also, it has been found that acoustic signal of the contralateral HA provided the largest benefits to speech understanding in bimodal-fit patients [ 20 ]. Moreover, a recent study revealed that bimodal participants did report a benefit of bimodal hearing ability in various daily life listening situations [ 21 ]. These research [ 20 , 21 ] were conducted in adult bimodal listeners. However, similar effect may be expected to occur in bimodal-fit children.

There was no significant difference between the 2 groups in the ES before therapy. However, group A performed better than group B after 3 months, 6 months, and 9 months with significant differences. Sarant et al. [ 17 ] conducted a study showed that children with bilateral CIs achieved significantly better vocabulary outcomes than did comparable children with unilateral CIs. Also, there was no significant difference in language outcomes between 44 children with bimodal fitting and 49 children with bilateral cochlear implants after controlling for a range of demographic variables [ 22 ]. Moreover, it was found that earlier age at cochlear implant activation is associated with better outcomes [ 22 ]. Hearing aids may not achieve adequate gain for children with severe-to-profound sensorineural hearing loss. Nonetheless, it provides benefit of the binaural hearing in the bimodal stimulation. This is because HA usually achieve good gain in the low-frequency sounds which may be complementary for the CI in cases of short electrode or incomplete insertion. This is because the hair cells specific for low-frequency sound are located near the apex of the cochlea. This can fill the gap and covers all speech sound frequency range with positive impact on the language outcomes.

Word class can be considered as a measure for early grammatical competency. Word class showed significant differences between the two groups in 3-month and 6-month evaluations in favor of group A. Furthermore, group A performed much better than group B in 9 months. Group A-acquired varied grammar words over time like pronouns “I and you”; locative words “above, below, behind, in front”; possessives “mine, yours”; questions “what, who, where”; adjectives with their antonyms; and prepositions “in, by, on, from, with” were acquired later in 9-month evaluation. The regular plurals and negation in Arabic are quite different than in English. Regular plurals composed of the nouns plus two sounds merged at its end /at/ instead of /s/ in English. Also, negation in the informal spoken Arabic language composed of the negation word /ma/ followed by verb merged with sound /ʃ/ at its end. In group B, there was less varieties of grammar words (nouns, verbs, and prepositions). The average length of spoken sentence in group A was 3–4 words compared to 2–3 word sentences in group B. Neither of the two groups produced complex sentences. However, children in group A were able to produce larger variety of grammatical words in their simple sentences. Similar finding was reported by Nittrouer and Chapman [ 19 ] who compared the numbers of pronouns produced by bimodal-fit and CI only children. They found that the mean (SD) of the numbers of pronouns for bimodal-fit children was 20.79 (13.55), and CI only children was 17.43 (11.28). The numbers of grammatical words acquired by bimodal fit were more than those acquired by CI only children with significant differences [ 19 ].

The MLU was increased much more in group A than group B especially in the 9-month evaluation. Only one subject had many single words; the rest of group A had their MLU ranged from 2 to 5 word sentences by the end of study (mean 3.07). In contrast, group B had MLU ranged from 1 to 3 word sentences by the end of study (mean 2.07). Although these improvements, both groups still had delayed language development compared to their peers with matched age. Our participants still need more language therapy for at least 2-year duration. The normal children aged from 4.5 to 5 years can tell long and complex sentences with nearly mature syntactic rules.

Generally speaking, group A performed better than group B at 3 months, 6 months, and 9 months after therapy. Previous researches conducted a study comparing speech intelligibility between 51 children with unilateral cochlear implants and 47 children with typical hearing. They found that typical hearing children achieved ceiling speech intelligibility around the age of 4 years, but a similar peak was not observed for the children with cochlear implants, who were significantly less intelligible than typical hearing children, when controlling both chronological age and length of auditory experience. They attributed that to the auditory deprivation prior to implantation that appears to be associated with at least some delay even after implantation [ 23 , 24 ]. This is in consistent with our current research. Moreover, the lower intelligibility score in group B than in group A can be explained by the abnormal cortical auditory configuration in monaural hearing which adversely affect speech comprehension, phonological and word learning, and therefore speech production. Unlike group A, the speech output of group B contains multiple phonological omissions and substitutions. One major factor which affected speech intelligibility in our subjects is speech prosody. Children spoke with deviated intonation and stresses; this was more evident in group B than group A. So, late and unilateral treatment of sensory-neural hearing impairment may be the main predisposing factors for deviated prosodic patterns of speech in the hearing-impaired children. Other variables have been mentioned to affect speech intelligibility in the prelingual CI children including duration of wearing HA, duration of therapy before CI, age of CI, and duration of therapy after CI [ 25 ]. Our current research is consistent with the age of CI as those implanted after 3 years are among the poor speech intelligibility children.

In the current study, large variability in the vocabulary size, length of spoken sentences, and general language outcomes were found even within the same group. This can be explained by multiple factors which showed some variability among our subjects. These are the age of CI operation, speech reading ability, and language-stimulating environment at home and outdoors. This included how the parents and caregivers talked to their children and to what extent they followed the family counseling given by the Phoniatrician and practiced the structured speech situations. Generally speaking, faster rates of vocabulary growth and language development were found in children with bimodal fitting in the current research. This finding suggested that the perceptual benefits of bilateral hearing through CI and hearing aid conferred a significant advantage, in terms of language acquisition in those children. Binaural hearing improves speech perception in both quiet and noisy listening conditions and sound localization ability [ 26 ]. Also, the binaural hearing reduces listening effort and therefore reduced tiredness and provided a greater ability to concentrate [ 27 ]. These perceptual benefits reported for children with binaural stimulation may facilitate a greater ability to access the spoken language of others and to learn from these increased opportunities [ 28 , 29 ]. There were 4 children in group A showed response of their aided hearing about 55–65 dBs after they had NR. This may be explained by recovering of aided hearing from the brain neglect following re-aiding of the deprived ear. Further researches with more subjects are needed to confirm this finding. The HA may be complementary to the CI not only for achieving binaural hearing but also for covering speech frequency range. Intraoperatively, the electrode may not reach the apex of the cochlea which contains hair cells specific for low-frequency sounds. On the other hand, the HA usually achieves good gain for low-frequency sound which fills the gap. The Arabic language contains more consonants and fewer vowels than English. However, Arabic and English have closely similar intonation patterns in contour and meaning [ 30 ]. We recommend preserving the ear with residual hearing in unilateral CI for aiding unless there is a strong surgical cause. This is to keep that ear for possible HA fitting later on. Also, the regular use of both HA before CI operation and the use of contralateral HA after operation in case of unilateral CI are advisable.

Many children with bilateral sensorineural hearing impairment received unilateral cochlear implant at least for an extended period of time. These children may not continue wearing a hearing aid in the contralateral/non-implanted ear. This results in auditory deprivation which adversely affects the hearing and oral language acquisition. We recommend using a HA in the non-implanted ear (with residual hearing) in unilateral CI children until the second CI become available. Also, such children may continue using bimodal fitting whenever bilateral cochlear implant is not available. Like any research, ours has their own limitations which are small sample size and short period of study. The current research provided preliminary results. Further longitudinal studies with more subjects may be required to generalize our results. Also, we recommend studying the prosodic patterns in bimodal fitting compared to unilateral CI over longer periods.

Bimodal-fit children showed significantly better language outcomes with longer sentence production and more developed syntactic rules than monaural-CI children. The methods of stimulating the auditory nerve are different between the two modes. However, with intensive auditory training and language therapy, the brain can incorporate and benefit the impulses received from both ears simultaneously in the bimodal-fit children. This achieves auditory skills development in early childhood which improves oral language perception and development in different speaking situations.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Megahed M. Hassan, Ahmed Mamdouh Emam, Amal Fouad Sayed & Ahlam Abdel-Salam Nabieh El-Adawy

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MMH made concept and design and data acquisition, drafted the manuscript, and analyzed and interpreted the patient data regarding the patient information and language evaluations. AAN and AME formulated the concept, interpret results, develop the intellectual content, and critically revise the manuscript. AFS participated in the design of the work, acquisition, and analysis of data and drafted part of the manuscript and develop intellectual content of the manuscript. All authors have agreed to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The authors read and approved the final manuscript.

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Hassan, M.M., Emam, A.M., Sayed, A.F. et al. Outcome of language therapy in bimodal-fit children versus unilateral cochlear implant children in bilateral sensorineural hearing impairment: a case-control study. Egypt J Otolaryngol 38 , 76 (2022). https://doi.org/10.1186/s43163-022-00266-2

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Important Factors in the Cognitive Development of Children with Hearing Impairment: Case Studies of Candidates for Cochlear Implants

Heloisa romeiro nasralla.

1 Department of Audiology, Universidade de São Paulo, São Paulo, SP, Brazil

Maria Valéria Schimidt Goffi Gomez

2 Department of Otorhynolaryngology, Hospital das Clínicas da FMUSP, São Paulo, SP, Brazil

Ana Tereza Magalhaes

Ricardo ferreira bento.

3 Department of Otolaryngology, Universidade de São Paulo, São Paulo, SP, Brazil

Introduction  The factors that affect the development of children with and without hearing disabilities are similar, provided their innate communication abilities are taken into account. Parents need to mourn the loss of the expected normally hearing child, and it is important that parents create bonds of affection with their child.

Objective  To conduct a postevaluation of the development and cognition of 20 candidates for cochlear implants between 1 and 13 years of age and to observe important factors in their development.

Methods  The following instruments were used in accordance with their individual merits: interviews with parents; the Vineland Social Maturity Scale; the Columbia Maturity Scale; free drawings; Bender and Pre-Bender testing; and pedagogical tests.

Results  The results are described.

Conclusion  Parental acceptance of a child's deafness proved to be the starting point for the child's verbal or gestural communication development, as well as for cognitive, motor, and emotional development. If the association between deafness and fine motor skills (with or without multiple disabilities) undermines the development of a child's speech, it does not greatly affect communication when the child interacts with his or her peers and receives maternal stimulation. Overprotection and poor sociability make children less independent, impairs their development, and causes low self-esteem. Further observational studies are warranted to determine how cochlear implants contribute to patient recovery.

Introduction

The cognitive development of children with hearing impairment is similar to that of normally hearing children, provided their innate communication capabilities are acknowledged and capitalized upon. In the case of congenital deafness, when parents are given a prenatal diagnosis, or during the first few months after birth, the parents' anguish and feelings of guilt should be addressed. Parents should be offered alternatives and support, as it is important that they accept the child as they are developing and can mourn the loss of the expected normally hearing child. Furthermore, it is vital that their relationship with the child remains spontaneous, in particular that between the mother and child, because, as Preisler et al pointed out, 1 these early bonds form the foundation of language, emotional, social, and cognitive development.

The child should be made to perceive the existence of sound, and visual contact should be encouraged, as it aids the development of orofacial reading. For this, parents should ensure rich expression of affection and abundant physical and gestural contact should be maintained. From the perspective of behavioral psychology, language is a behavior, and like any other behavior, its learning thus occurs through environmental stimuli. 2 The famous psycholinguist Noam Chomsky 3 proposed (1965, 1972) that humans have a language acquisition device that facilitates its learning. That is, we humans seem to be biologically predisposed to acquire language. This view is shared by Pinker. 4

However, the most predominant perspective on language development today is a combination of two opposing views. Thus, although it is believed that children have an innate capability to learn language, 5 it is also strongly suggested that their experiences play an important role in that acquisition. These social-interactive approaches, based on the theories by Piaget 6 and Vygotsky, 7 espouse that children's verbal development depends on the quality of their social interactions.

In fact, children and their parents decide how to develop their language, whether it is verbal or gestural. Every option involves various family, social, emotional, cognitive, neurological, and motor coordination issues.

According to Tonietto et al, 8 subcortical development occurs during the first 3 months of life, which allows infants to suckle and sleep. Even in this early stage, it is the mother's responsibility to identify the child's desires and anxieties by, as Virole indicates, 9 symbolizing and giving meaning, providing answers and nurturing. Such symbolizations will allow the child to recognize the objects in the world. Furthermore, Tonietto et al, 8 Carpenter et al, 10 and Tomasello 11 point out that by the age of 9 or 10 months, cortical activity increases, allowing the child to have shared attention, which is important for behavior regulation. The child displays mirror behavior, as he or she is able to imitate gestures and show interest in the surrounding objects and environment. The child is capable of pointing to objects that call for his or her attention and following adults' pointing gestures. Baron-Cohen 12 put forth that the absence of these characteristics indicates a developmental delay, a specific language delay, or a more serious condition such as autism, in which the absence of symbolic games is observed. In addition to the desire of communicating, understanding other people's intentions is a prerequisite for language development.

In the case of children with hearing impairment, autism may occur as a comorbidity. In addition to the importance of early diagnosis and intervention, as emphasized by Roper et al, 13 we see that autism may develop because of the isolation caused by the lack of the development of any form of communication. In this context, Deggouj and Eliot suggested that the autistic features might manifest later in the life of children with hearing impairment. 14 Therefore, they recommended the use of progressively programmed hearing aids to help the child gradually get used to the world of sound. They reported that hearing aids are not easily accepted by these children and are often viewed as physical aggression, given their difficulty in comprehending the world. Further, Deggouj and Eliot added that indications for using a cochlear implant (CI) are limited by the child's behavioral problems, but depending on the case, CIs can also be beneficial. 14 Children's difficulties in adapting to CIs are related to programming, because in addition to having to develop a different form of hearing, words are meaningless for them. Therefore, the authors stressed the importance of a slow process for programming to help the children accept the implants. Furthermore, Azema and Virole recommended great caution, 15 because perceptual reality is full of emotion and is profoundly distressing. Thus, it is possible to place the implants in these children provided they are offered the opportunity to express themselves, which involves the use of sign language by both the family and the professionals.

According to Gayda and Saleh, 16 hearing impairments can have an effect on the development of psychomotor, communication, and language-acquisition skills. Similarly, they can affect psychoaffective balance, time-space structuring, and, in some cases, the organization of the central nervous system and motor skills. However, the opposite may also be true. Disabilities, delays, or immaturity of the distinct functions can be recovered with overall improvement in hearing function. In fact, the pleasure of hearing, which is absent in psychic and/or hysterical deafness, and the level of anguish in autistic individuals, to a point that they do not accept being challenged by a human voice, hampers structuring, memorization, discernment, and understanding, which can be improved by the recovery of hearing in these patients.

It is very important to observe the relationship of the child within the family, noting how the family mobilizes and restructures itself around the child's deafness.

With reference to the age-related developmental pattern discussed earlier, Tonietto et al revealed that “at 4 years of age there is a peak of cortical metabolic activity” (pp. 250) 8 which contributes greatly to both the child's language and cognitive development. At 4 years of age the child also understands the difference between his beliefs and those of others, which strongly shows that she has the ability to conceive mental states. 17 This ability, described as Theory of Mind, allows the child to consider others' beliefs and predict their behavior, which is key to adaptation and social interaction. This topic was discussed by Baron-Cohen et al in the area of autism. 17 He attributed this specific difficulty to autistic patients, independent of their mental level, which distinguishes them from people with other medical conditions or other types of cognitive impairments. A child with autism exhibits an inability to consider other peoples' beliefs and predict their behavior, which explains their problems in social interactions. Thus, relationships are unpredictable and incomprehensible to them. It also explains their inability to indulge in “make-believe” play, because they do not understand what other people know, want, feel, or believe in (i.e., metarepresentation).

The primary objective of the present study was to conduct a postevaluation of 20 CI candidates age 1 to 13 years to examine the factors that were important for their development.

For this purpose, we conducted interviews with the parents or just the mother and used the Vineland Social Maturity Scale (VSMS) to assess the development of motor skills, socialization, communication, and daily life activities. 18 19 The VSMS provides the age level of the child with reference to these skills. It can be applied to individuals up to 19 years old. In addition to the VSMS, the cognitive capacity of children age 5 years and above was assessed using the Columbia Mental Maturity Scale (CMMS). 20 In addition to providing the child's mental age and IQ, this scale determines the child's attention to detail and his or her ability to conceptualize. A free drawing activity was used to examine the child's level of writing, motor control of the hands, coordination in the fingers, and self-representation, including self-identification and self-esteem. In addition, the Bender Visual Motor Gestalt Test and the Pre-Bender Visual Motor Gestalt Test 21 were used to assess the child's visual and motor organization of space, to explore the presence of development delay interferences, and to indicate organic neurologic impairments or increased levels of anxiety, which are indicative of emotional impairment. Finally, the pedagogical tests were used to assess school performance and alphabetization levels of these children. 22 The instruments were used according to their individual merits.

The 20 cases were assessed using the psychological tools appropriate to their age group. In all cases, parents were interviewed and the patients were observed in the clinic. The VSMS was used to assess the 13 patients aged between 1 year and 11 months and 4 years and 10 months, 18 19 which included free drawing or activity with pencil and paper. Visual and motor organization of space was evaluated using the Pre-Bender test when possible. 21 Six patients age 5 to 13 years were eligible to be evaluated using the CMMS 20 ; however, it could be implemented on one patient only, due to the other patients' disabilities or because they did not return for the consultation. The patient who did not return for the consultation exhibited good learning abilities and was eligible to undergo the cognitive evaluation with the CMMS, but the family did not have the financial means to bring the child to the clinic repeatedly. The Bender test, 21 free drawing, and the pedagogical tests 22 were used with patients who were age 6 years or more.

We had 13 cases (65%) of the sample with development expected for their age, with issues rating the physical and family dynamics. We had one absolutely normal patient, both in his development and in relation to his family, representing 5% of the sample. We had another patient with borderline development (5%), and five patients (25%) declined further study because of personal issues. Nine patients (45%) between 2 years and 6 years and 2 months had fine motor problems, and 70% of them had multiple disabilities (hemiplegia, neuropsychomotor development delay, prematurity, cytomegalovirus, rubella in the mother's pregnancy, visual problems, or Usher syndrome). Of these nine patients, three had good communication, sounds, or gestures, four spoke a few words, and two had communication difficulties due to other organic matters. In addition to good sociability, shared proper attention and good communication development was observed in 8 of the 20 children. Other children who were not scored on these issues had mothers who provided little stimulation with nonacceptance of deafness and impaired communication, apart from a case that, despite belonging to this group, maintained proper relationships with their peers and good communication.

Nine patients (45%), all between the ages of 2 years and 6 years and 2 months, exhibited impairments in fine motor skills. Seven of these nine cases (78%) had multiple disabilities (hemiplegia, neuropsychomotor development delay, prematurity, cytomegalovirus, rubella, or visual impairment), which could have been the cause of an impairment in the fine motor skills rather than their hearing ailment. However, Gayda and Saleh 16 emphasized that hearing impairments have an impact on motor skills. Furthermore, of these nine patients, three exhibited good communication skills, either through sounds and/or gestures (indicative gestures and through sign language along with sounds). Four of them spoke a few words, and one showed good communication skills through sign language. All were classified as normal in terms of overall development. Three of them had excellent orofacial reading (ages 3 years and 8 months, 3 years and 11 months, and 5 years, respectively). Two more cases exhibited accentuated communication difficulties and interference of specific problems, including a 2-year-old child who sometimes made the sound pa (interpreted as dad ) but had orofacial motor problems. The other patient was 6 years and 2 months old and made sounds and spelled isolated words without sounds, did not make complete sentences, and exhibited a delay in visual and motor space organization, with indicative signs of a brain lesion. We also wish to highlight another patient who made gestures, sounds, and used sign language. The patient was very lively, but after the CI procedure, he became quiet, refused to talk, and only communicated through gestures, sounds, and rich drawing activity. His mother was very anxious and she did everything for her son. She received guidance with regard to this problem but she did not put it into practice. Thus, out of the nine patients, seven had good communication skills, which leads us to believe that the problems with fine motor skills were associated with their hearing disability, as described by Horn et al. 23 This did not hinder communication, but affected speech. The authors predicted that this may have occurred because both speech and motor skills share the same sources of cortical processing. We aim to conduct further studies to relate these data to the development of speech in these children following CI intervention. According to Siegel et al, 24 early motor development has proven to be a good predictor of future language development. There is a correlation between visual, motor, and cognitive development, because they are connected in the same brain-body system. 25 Thus, there was a change in the perception of language and motor development, which are now viewed as interdependent (see Fig. 1) .

Twenty cases ranged from 1 years and 11 months to 13 years. Interviews, free drawings, Vineland, Columbia, Bender, Pre-Bender, pedagogical tests were applied. Tests showed 65% developing middle range ( n  = 13) with some compromises; 5% normal ( n  = 1); 5% borderline ( n  = 1); 25% the CI was not indicated due to family members or personal difficulties ( n  = 5); 45% problems with fine motor skills, closely associated with deafness, and speech development is harmed ( n  = 9). 3 vocalize, 4 of them speak, and 2 have other disabilities.

However, the emotional, cognitive, and language differentiation depended on other factors, because 70% of the sample had multiple disabilities, which was above the 30 to 40% cited range of comorbidities in children with hearing impairment. 26 The rate of occurrence of comorbidities has increased with the advancement in medicine, specifically in the area of neonatology. Therefore, premature children and children with other medical conditions are found to exhibit profound hearing disabilities associated with overall developmental impairments. 15 In our cases with multiple disabilities, deafness was found to occur along with hemiplegia, Usher syndrome, meningitis, cytomegalovirus and rubella infections, neuropsychomotor development delay, prematurity and visual impairment (decreased vision), serious developmental delays, and autism. As explained before, these patients also exhibited delays or problems in motor skills. For example, the patient with Usher syndrome had walking, balance, and attention impairments and problems related to the development of shared attention. However, seven of these patients had good communication skills through sounds, speech, and sign language and understood the spoken language well. All of them exhibited good sociability and/or creative maternal relationships. Moreover, they all seemed emotionally healthy. Four of these patients exhibited good sociability, whereas the other three had stimulating mothers as well. The remaining seven cases were not well developed and had communication or behavioral impairments, were overprotected, or their family dynamics were compromised. Sometimes in these cases, appropriate measures were not adopted because the children's deafness was not accepted by the parents. There were also cases in which delayed development or autism was associated with poor family structure, and the lack of assistance contributed to the maintenance of the condition.

We observed irregular development with impaired communication and speech when a child, despite having good potential, encountered environmental barriers such as poor language stimulation and/or little interaction with peers, often caused by maternal overprotection. Sociability and interaction with peers compensated for organic ailments such as delayed fine motor skills and impairments caused by comorbidities. Thus, sociability provides an escape from the limiting environment. Moreover, it offers the child an opportunity to train and stimulate the mind's creativity, imagination, and skills of theory of mind, allowing the child to understand other people's intentions and create self-conscience. Behavioral problems were also responsible for children's poor social interaction and led to low self-esteem because of the feeling of inadequacy and exclusion. Sahli and Belgin reported an improvement in self-esteem after CI intervention. 27

In one case, financial difficulties superseded family dynamics and hindered the patient's progress. However, we also found that when the child has social opportunities, these limitations can be overcome partly, even in overprotective environments. This was especially the case with another patient, in whom good socialization was found to compensate for overprotection and delay in motor skills. This was found to happen even when the mother did not adequately stimulate the child, did not acknowledge or let the child manifest her communication potential and sign language skills, and did not value her gestures. We found that the child could still compensate for these lags through environmental stimulation and by receiving the benefits of socialization. However, social inclusion and good relationships with peers did not eliminate all problems. One child needed additional motor skills training due to delayed neuropsychomotor development. We also found that overprotection imprisons the child in a protective web and limits his or her progress.

The majority of our patients received an implant. This will allow us to verify the improvement in selective attention after the CI procedure and the improvement in self-esteem in future studies. 28 Nonacceptance of deafness by the mother, with explicit rejection of the child's situation, was found to be the worst factor for the child, with regard to speech, cognitive, motor, and emotional development. These observations led us to conclude that children who understand other people's intentions, feelings, and beliefs and, therefore, exhibit shared attention were those who were well stimulated by their mothers and/or had good sociability and exhibited better communication through words, gestures, and/or sounds, as Tonietto et al 8 and Piaget 6 proposed. It should be noted that a case exhibited regression in terms of contact and shared attention and did not show improvements in language.

We observed that patients without shared attention and poor communication skills were overprotected and had mothers who did not stimulate them adequately and did not accept their deafness. All these patients had poor sociability. This was also observed by Baron-Cohen et al in patients with serious development impairments and/or signs of autism. 12 One case exhibited good sociability, which compensated for his problems, and showed good communication skills despite belong to this group.

Acceptance of the deafness of the child is the starting point for the development of communication (either verbal or gestural) and cognitive, motor, and emotional skills. Similar to Horn et al, 23 we observed the association between deafness and impairments in fine motor skills. Although this hindered speech development, it did not hamper communication when there was interaction with peers and maternal stimulation. Problems in family dynamics, including overprotection, accompanied by poor sociability lead to lack of independence, low self-esteem, and poor overall development in children with hearing impairment. In contrast, sociability and peer interaction compensate for organic impairments caused by comorbidities such as delayed fine motor skills and neuropsychomotor development delay. Similarly, a good child–mother relationship is a positive factor for development and for overcoming the consequences of these impairments.

We observed that impairment in fine motor skills, multiple disabilities, and an adverse family environment, such as maternal overprotection, can cause developmental delays. These are compensated for by social opportunities, in particular if the child has a stimulating mother. We will conduct further studies to observe how CIs contributes to the recovery of these same patients, as well as to the improvement of selective attention and self-esteem. We will focus on the importance of enhanced social inclusion.

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CASE STUDY OF REDEEM GARDEN: A SCHOOL FOR THE HEARING IMPAIRED CHILDREN IN AIZAWL CITY

This study aims to find out the status and problems of Redeem Garden, a school for the hearing impaired (HI) children in Aizawl, Mizoram. The researchers used a case study method for conducting research. All the teachers of Redeem Garden were taken as cases. The researchers developed an interview schedule as a tool for data collection and along with general observation, the necessary data were collected. The percentage and frequency were used as a statistical treatment and the data were analyzed and interpreted accordingly. It was found that there were good facilities provided by the school for educating the children with special needs (CWSNs) such as play materials which would attract and develop willingness among the children to come to school; most importantly hearing aids and teaching-learning materials which will help the children to learn properly and transport facilities for to and fro for the children from home to school. It was also found the school has been providing free medical checkup every three month interval to the children. However, there were some problems facing by the schools like inadequate classroom, lack of adequate trained teachers, etc. The researchers also made suggestions for improving the status and solving the problems facing by the school therein.

Related Papers

International Journal of Nursing Research

Aparna Kale

Aim: The aim of the study was to study the effectiveness of planned teaching program regarding the care of children with hearing impairment among the caretakers in selected schools of Sangli district in India. Background: Hearing impairment means that you cannot hear well out of one or both ears, or you cannot hear at all. Hearing loss can range from mild to severe. There can be mild, moderate, severe, or severe impairment. Hearing loss as a child is a huge burden and handicap. It hurts the child’s quality of life because the disability affects all parts of his or her development, either directly or indirectly. The results include not being able to understand speech sounds, which often means not being able to communicate verbally, a delay in learning a language, a delay in cognitive development, a disadvantage in economics and education, social isolation, and a stigma. Methodology: The research approach for this study is quantitative approach and purposive research design was used. ...

Public Policy and Administration Research

Shahida Sajjad

Priyanka Srivastava

A study was undertaken in Mumbai city, aimed at, to compare the awareness of teachers in special schools and parents of the children with hearing impairment about schemes, facilities and concessions for Persons with Hearing Impairment. In the light of this objective, total 112 samples were taken out of which 56 were teachers, having minimum two years of experience of teaching in special schools of children with hearing impairment and 56 subjects were parents of those children with hearing impairment whose age range was from 12 to 18 years and studying in special schools. The obtained data was analyzed in terms of percentage and the results were compared by using chi-square test and't'-test between teachers and parents. The obtained results have indicated that there is a significant difference between teachers and parents in the awareness of schemes, facilities and concessions for persons with hearing impairment. The results also show low percentage of knowledge about these schemes, facilities and concessions to both teachers and parents. And less percentage of teachers (25%) and parents (10.7%) who are aware, when 50% taken as the cut off score of having the criteria for awareness. The study results, in turns indicating having a strong influence towards all round development in education of Children with Hearing Impairment.

Eternal Research: Multidisciplinary Edited Research Book

Rebeck Lalrinpuii

The present study is an attempt to highlight and have an in-depth analysis on Special Blind School which is located in Aizawl, Mizoram with reference to different criteria using case study method. Special Blind School is a residential school for students with visual impairment or blind. The school was founded in 1 st May 2011 by an association called Samaritan Association for the Blind (SAB) and is funded by the Social Justice Empowerment Department, Central Government. The school follows the school curriculum under Mizoram Board of School Education (MBSE) and the medium of transaction is English and Mizo. The school has been organizing and undergoing different programs inside and outside the school and various assistive devices are used in the process of teaching and learning. As the school is under the management of SAB, it has also received many funds from different organizations. It has also attained many achievements in education and has been playing an important role in producing individuals with visual impairment to be capable and qualified for the post of different government jobs around Mizoram.

Dr. Rubina Masum

The longitudinal case study investigates the impact of hearing impairment on the learning experience of students in inclusive education. The participants of the study were students with hearing impairment (N=2) who were studying in an English-medium school located in Karachi. The data was gathered through observations and unstructured interviews. The study employs grounded theory for interpreting and analyzing the data related to the experiences of students with hearing impairment. The results of the study present students' perception of their own learning, attitude of the teachers towards them and the absence of infrastructural provisions to cater for their special needs in the mainstream schools. The study recommends teachers' training programs for creating a more enriching learning experience for the students with hearing impairment and the involvement of the administrative staff in providing optimal learning environment and infrastructural provisions. Moreover, recommendations are made for investigating the adverse effects of other disabilities on student' learning in the mainstream educational institutions.

Maria Mustafa

This research paper has been carried out to explore the role of teachers and parents in the social development of the hearing impaired children and transforming them as a potential being of society with technological and pharmaceutical support. Purposive or judgmental sampling method was used comprising 125 respondents. Respondents were the parents of the hearing impaired children. For data collection, a structured questionnaire was developed and data was tabulated by the chi-square method. This research highlighted that many special educators, trainers, teachers, psychologists, and philanthropists promotes social and academic success and teach social skills in order to make the hearing impaired children, the useful citizens of the society. For the social development of the hearing impaired children in the metropolitan city, it is supposed that modern technology and innovative teaching techniques are to be applied for the training and development of the hearing impaired children. It is suggested that special schools should organize annual trainings, workshops and courses for the teachers of the special schools so that they are to be updated by the passage of time. It is also suggested that awareness seminars and counseling of the parents of the special children should be compulsory. The parents, teachers and the general public should understand the problems faced by the hearing impaired children in the society.

TIJ's Research Journal of Social Science & Management - RJSSM

Kagnew Tarekegn

The purpose of this study was to examine the current status of quality teaching provision for students with hearing impairments in Gondar City primary schools. To achieve this purpose, descriptive design was employed including 181 participants of primary schools principals, teachers, students with hearing impairments and their parents. Special needs education teachers, students with hearing impairments and principals were selected purposively, whereas parents and regular class teachers were selected using simple random sampling technique. The data were collected through questionnaire, observation checklist and interview and then analyzed using descriptive statistics. The findings revealed that inputs of quality teaching including teachers’ skill in sign language, their teaching experiences in integrated classes, their experiences in using pre-assessments and students’ questions to guide the lesson and the instruction, and availability of teaching materials and aids are too poor to p...

The main purpose of this study was to find out the contributions and challenges of Sebeta Special School for the students with visual impairments. The research design used was qualitative case study method as this would enable the researcher to make in-depth study of the case from different perspectives. For responding to this main purpose of the study, purposive sampling was used and the subjects of the study were selected by purposive sampling technique as they were taught to have the necessary information for the problem under study. Accordingly, twelve teachers, (six males and six females), ten members of the support staff (five males and five females) and twelve students of grades five to eight (six males and six females) were selected for focus group discussions. Besides, interview was conducted with the director and vice-director of the school and two teachers (a male and a female) and two students of grades five to eight (a male and a female).Relevant documents and observation checklists were also used as data sources. Finally, the data collected were organized, thematically analyzed and presented. Regarding the contributions made, the findings revealed that the school has been serving the students as school to learn in and succeed, home to live in and family to leave with. There were also services being delivered for the students and different resources were also available in the special school. Findings displayed that challenges to the special school as manpower assignment was not need based and there were lack of skills necessary to run activities in the special school as reading and writing braille, inadequate budget and resources like student textbooks transcribed in to braille and wastages in usage of the available resources. Besides, there were conditions that violate the safety of students. The recommendations made included such things as alleviating the challenges the school encountered such as appropriate use of resource, availing the necessary resources as braille textbooks, budget and others.

International Journal of Academic Research in Progressive Education and Development

saeid hassanzadeh

Adjustment leads to a continuous interaction between the individuals needs and the environmental constraints in the setting in which the needs are to be fulfilled. It is a continuous process by which an individual varies his behaviour to produce a more harmonious relationship between himself and his environment. The significance of adjustment in the overall development of an individual is in general and its even greater significance in case of Special Need Children (SNC). The present study is based on descriptive-survey method. The investigator has taken purposively 203 Hearing-Impaired students studying in six different special schools selected from Purvanchal region of Uttar Pradesh. For collection of data, the investigator has used self-developed 'Adjustment Inventory of Hearing-impaired students'; t-test and F-test were used for analysis and interpretation of data. The main findings of the study are: (a) There exists significant difference in Adjustment between/among different subgroups of Hearing-Impaired students formed on basis of : (i) Gender, (ii) Class, (iv) Perception about Facilitation for Hearing-impairment; while (b) There exists no significant difference in Adjustment between/among different subgroups of Hearing-Impaired students formed on basis of :(iii) Type of Disability.

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