YES. Davidson et al. (2013) Hassanzadeh et al. (2012) Rinaldi & Caselli (2014) Boons et al. (2012) Dettman et al. (2016) Dunn et al.

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1 (p = 0.06) SUPP Maximizing early cochlear implant benefits using spoken language Andrea Warner-Czyz Ann Geers University of Texas at Dallas Laurie Eisenberg University of Southern California Christine Mitchell Nae-Yuh Wang Johns Hopkins University YES NO Childhood Development after Cochlear Implantation (CDaCI) YES, all children with CI should learn sign language. Earlier access to language via visual modality Cerebral specialization for language not exclusive for spoken input Normal bilingual acquisition of spoken and signed languages in hearing children Study Davidson et al. (2013) Hassanzadeh et al. (2012) Rinaldi & Caselli (2014) Cochlear implant (CI) group 5 CI Deaf, ASL CA: 4;0-6;4 CI exp: 1;4-2;11 7 CI Deaf CA: 4;4-12;9 CI age: 2;1-4;11 1 CI TH, LIS ; CA: 2;6-5;1 CI age: 2;5 Comparison group 20 TH Deaf, ASL CA: 4;9-8;2 7 CI TH CA: 4;3-12;3 CI age: 1;10-4;2 Speech Perception Speech Language Literacy CI Deaf TH Deaf CI Deaf TH Deaf CI Deaf TH Deaf CI Deaf > CI TH CI Deaf > CI TH CI Deaf > CI TH CI TH Normative sample Davidson et al., 2013; Hassanzadeh, 2012; Humphries et al., 2012; Kushalnagar et al., 2010; Mitchiner, 2015; Petitto et al., 2000, 2001; Rinaldi et al., % of deaf children have hearing parents Better perception, production, and language skills Greater academic success Study Boons et al. (2012) Dettman et al. (2015) Dettman et al. (2016) Dunn et al. (2014) Cochlear implant (CI) group 102 CI ORAL Mean CI age: 2;2 145 CI ORAL CA: y; CI age: y 8 CI AVT CA: 5.4 y, CI age: 1.7 y 49 CI ORAL CA 3;11-15;11, CI age: 0;11-3;11 NO, not all children with CI should learn sign language. Comparison group 166 CI SIGN SUPP, 20 CI BI CA: y; CI age: y 101 CI SIGN SUPP CA: y; CI age: y Speech Perception Speech Language Literacy, CI BI 23 CI AUD ORAL 8 CI BI-BI CI AVT > CI AUD ORAL > CI BI-BI CI AVT > CI AUD ORAL > CI BI-BI 34 CI SIGN SUPP CA 3;11-15;11, CI age: 0;11-3;11 CI ORAL CI SIGN SUPP Geers et al. (2003) 98 CI ORAL CA 8;0-9;11, CI age: 1;6-5;4 83 CI SIGN SUPP CA 8;0-9;11, CI age: 1;6-5;4 Geers et al. (2011) 30 CI ORAL CA 15;0-18;6, CI age:1;6-5;4 82 CI SIGN SUPP CA 15;0-18;6, CI age:1;6-5;4 Nittrouer et al. (2016) 34 CI ORAL CA: M = 8;7, CI age: M = 1;10 17 CI SIGN SUPP CA: M = 8;7, CI age: M = 1;10 Phonology: CI ORAL CI SIGN SUPP Morphosyntax: CI ORAL > CI SIGN Percy-Smith et al. (2010) 40 CI ORAL CI age: M=3;0 85 CI SIGN SUPP; 30 CI SIGN LANG CI age: M=3;0 CI ORAL > CI SIGN LANG CI ORAL > CI SIGN LANG Percy-Smith et al. (2013) 70 CI ORAL CA: 1;5-6;2, CI age: 0;5-4;7 12 CI SIGN SUPP CA: 1;5-6;2, CI age: 0;5-4;7 Percy-Smith et al. (2017) 94 CI STANDARD Median CA: 3;11, Median CI age: 1;1 36 CI AVT Median CA: 4;1, Median CI age: 1;0 CI AVT > CI AUD ORAL AND SIGN SUPP Tobey et al. (2011) 80 CI ORAL CA 15;0-18;6, CI age: 1;6-5;4 30 CI SIGN SUPPORT CA 15;0-18;6, CI age: 1;6-5;4 Colletti et al., 2011; Dettman et al., 2012; Easterbrookes & Mordica, 2000; Geers et al., 2003; Kanda et al., 2012; Nittrouer et al., 2016; Percy-Smith et al., 2010; Percy-Smith et al., 2013; Tobey et al., 2011; Venail et al., 2010; Wieet al., Wie et al. (2007) Yanbay et al. (2014) 6 CI ORAL CA: 2;3-17;4, CI age: 1;5-15;1 14 CI AVT CI age: 0;6-2;1 64 CI ORALSIGN SUPP, 7 CI SIGN LANG CA: 2;3-17;4, CI age: 1;5-15;1 14 CI AUD ORAL, 9 CI SIGN SUPP CI age: 0;6-3;3 CI AVT and CI AUD ORAL CI SIGN SUPP CI ORAL CI SIGN SUPP for SS 1

2 Should all deaf children who are cochlear implant candidates learn sign language? Comprehensive literature review, Speech production Receptive and expressive language Speech perception Fitzpatrick et al., Favor oral communication + sign support No significant difference Favor oral communication The benefits of learning sign language clearly outweigh the risks. For parents who are willing and able, this approach seems clearly preferable to an approach that focuses solely on oral communication. Napoli et al., Childhood Development after Cochlear Implantation Study (CDaCI) External Advisors Karen Iler Kirk Mabel L. Rice Zwolan Arnedt Della Santina Marsiglia JHU DCC Wang Mitchell Vilche Geers et al., Eisenberg Johnson Fisher USC Geers Warner-Czyz Britt PCC Quittner Cejas UNC Cejas Martinez Oullette Mellon Teagle Woodard Participants (n = 97) Participants (n = 97) Childhood Development after Cochlear Implantation (CDaCI) Tested early and late elementary (n = 97) Reported early sign exposure (n = 129) CI 38 months (n = 137) Not tested early and late elementary (n = 32) Enrolled (n = 188) Did not report early sign exposure (n = 8) CI > 38 months (n = 51) Cochlear implant (CI) 38 months Parents with typical hearing No sign (n = 35) No sign used pre implant or the first 3 years post implant Short term sign (n = 26) Sign used pre implant and/or 1 year post implant, but discontinued Long term sign (n = 36) Sign used pre implant and at least 2 years post implant 2

3 Baseline characteristics of CI recipients Baseline characteristics of CI recipients Characteristic No sign (n = 35) Short term sign (n = 26) Long term sign (n = 36) Percent female 49% 35% 58% Household income < $50k 32% 44% 42% Mother graduated college 69% 50% 50% Aided PTA better ear a 75 db HL 73 db HL 78 db HL Age at onset of deafness 0.3 mos 1.2 mos 1.3 mos Amplification age 9 mos 11 mos 12 mos CI activation age 19 mos 22 mos 23 mos a Average of available thresholds between Hz, where at least 1 frequency was tested Characteristic No sign (n = 35) Short term sign (n = 26) Long term sign (n = 36) Maternal sensitivity a Baseline IQ b Vocabulary c Auditory perception d a Sensitivity scale from the NICHD Early Childcare Study codes; b Bayley Scales of Infant Development (BSID II) (Bayley, 1993); c Words understood and said on the MacArthur Bates Communicative Development Inventory (MBCDI: Words and Gestures Form; Fenson et. al. 1993); d Infant Toddler Meaningful Auditory Integration Scale (IT MAIS) (Robbins AM, 1991). Post Implant Outcome Measures Speech perception Speech Recognition Index in Quiet (SRI Q) Speech perception Speech Recognition Index in Quiet (SRI Q) 1, 2, and 3 years post CI Spoken language Comprehensive Assessment of Spoken Language (CASL) 5 7 and 9 11 years of age Speech intelligibility McGarr sentences 6, 7, or 8 years of age Reading comprehension Woodcock Johnson (WJ) Tests of Achievement 5 7 and 9 11 years of age 600 Hearing in Noise Test for Children (quiet) 500 Open set Phonetically Balanced Kindergarten words 400 Lexical Neighborhood Test 300 Pediatric Speech Intelligibility Test Closed set 200 Early Speech Perception Test 100 Parent report Meaningful Auditory Integration Scale Speech perception in quiet (Baseline 3 years post implant) Speech intelligibility McGarr sentences Speech recognition index in quiet (SRI Q) Closedset Openset Parent report Baseline (Pre CI) 1 Year Post CI 2 Years Post CI 3 Years Post CI p =.004 McGarr (1981) High Context 3 Syllable: Read the book. 5 Syllable: The cat chased the mouse. 7 Syllable: The flag is red, white and blue. Low Context 3 Syllable: Get the cake. 5 Syllable: Who wants this ice cream? 7 Syllable: Is the fat baby crying? 3

4 Speech production intelligibility (6 8 years of age) Comprehensive Assessment of Spoken Language (CASL) Percent intelligible speech p <.001 p <.01 No sign Short term sign Long term sign Antonyms Syntax construction Paragraph comprehension, Nonliteral language Pragmatic judgment Grammatical morphemes Sentence comprehension Woodcock Johnson Tests of Achievement Spoken language & reading comprehension (5 7 and 9 11 years of age) Passage Comprehension Understanding of printed words, phrases, and paragraphs Spoken Language (CASL) Reading Comprehension (WJ) CASL = Comprehensive Assessment of Spoken Language WJ = Woodcock-Johnson Test of Achievement Regression model Early elementary Late elementary Overall Characteristic Sign Language Exposure None(1), short term(2), long term(3) Activation Age Auditory Perception 1 year increase 1 point increase on IT MAIS Parent Infant Program Yes versus No Maternal Education College Grad versus Not Family Income Low versus Not Spoken language Reading comp. Spoken language Reading comp. Speech intelligibility * ** *** ** ** ** * * *<.05; **<.01; ***<.001 Summary Pediatric CI users with no sign exposure outperformed those with long term sign exposure on speech intelligibility and spoken language measures. These group differences persisted even after conservative correction for pre implant demographic characteristics. 4

5 Communication approach affects communication outcomes worldwide. Responsible interpretation of these data Children with CI in auditory verbal (AV) or auditoryoral programs outperform those in bilingual bicultural programs. 80% of children with CI in AV programs achieve ageappropriate language by 5 years Children with CI in AV programs have significantly higher language scores vs. those in standard habilitation. Dettman et al., 2013; Hogan, 2016; Percy-Smith et al., Participant characteristics CI by 38 months Parents with typical hearing Boons et al., % 5% 7% 55% Parents, Deaf, fluent sign Parents, typical hearing, fluent sign Parents, typical hearing, sign support Parents, typical hearing, no sign Responsible interpretation of these data Responsible interpretation of these data Participant characteristics CI by 38 months Parents with typical hearing Sign exposure Individual differences Dettman et al., 2013; Niparko et al., 2010; Yanbay et al., Communication approach may interact with other variables. Family characteristics Parental involvement Socioeconomic status High level parental involvement in speech and language therapy Higher socioeconomic status More advanced maternal education Type of insurance Ching et al., 2010; Dettman et al., 2015; Edgerton et al.; Geers et al., 2003; Harrison et al., 2016; Moeller, 2000; Percy- Smith et al., 2017; Walker et al., 2017; Yanbay et al., Communication approach may interact with other variables. Family characteristics Parental involvement Socioeconomic status Service delivery Dose and frequency Home or center based Ching et al., 2010; Dettman et al., 2015; Geers et al., 2003; Harrison et al., 2016; Moeller, 2000; Percy-Smith et al., 2017; Walker et al., 2017; Yanbay et al., Hours in EI over time Pre-CI (years) Post-CI (years) 5

6 Conclusion If development of spoken language is the primary objective for a child with a CI, intensive focus on early spoken input increases the odds of achieving that goal. Conclusion Families need access to research based evidence to guide decision making and inform treatment plans. White & Cooper, White & Cooper,