Expressive Spoken Language Development in Deaf Children with Cochlear Implants who are Beginning Formal Education

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1 Deafness and Education International Deafness Educ. Int. 11(1): (2009) Published online 23 January 2009 in Wiley InterScience ( Expressive Spoken Language Development in Deaf Children with Cochlear Implants who are Beginning Formal Education 39 JAYNE RAMIREZ INSCOE, AMANDA ODELL, Speech and language therapy department, Nottingham Cochlear Implant Program, UK; SUSAN ARCHBOLD, Chief Executive, Ear Foundation, Nottingham, UK; THOMAS NIKOLOPOULOS, ENT Surgeon, Nottingham University Hospitals, UK ABSTRACT This paper assesses the expressive spoken grammar skills of young deaf children using cochlear implants who are beginning formal education, compares it with that achieved by normally hearing children and considers possible implications for educational management. Spoken language grammar was assessed, three years after implantation, in 45 children with profound deafness who were implanted between ten and 36 months of age (mean age = 27 months), using the South Tyneside Assessment of Syntactic Structures (Armstrong and Ainley, 1983) which is based on the Language Assessment and Remediation Screening Procedure (Crystal et al., 1976). Of the children in this study aged between four and six years, 58 per cent (26) were at or above the expressive spoken language grammatical level of normally hearing three year olds after three years of consistent cochlear implant use: however, 42 per cent (19) had skills below this level. Aetiology of deafness, age at implantation, educational placement, mode of communication and presence of additional disorders did not have a statistically signifi cant effect (accepted at p 0.05) on the development of expressive spoken grammar skills. While just over half of the group had acquired spoken language grammar skills equivalent to or above those of a normally hearing three year old, there

2 40 Inscoe et al. remains a sizeable group who, after three years of cochlear implant use, had not attained this level. Spoken language grammar therefore remains an area of delay for many of the children in this group. All the children were attending school with hearing children whose language skills are likely to be in the normal range for four to six year olds. We therefore need to ensure that the ongoing educational management of these deaf children with implants addresses their spoken grammar delay in order that they can benefi t more fully from formal education. Copyright 2009 John Wiley & Sons, Ltd. Key words: expressive grammar, cochlear implants, deaf children, outcomes, speech production, spoken language, educational placement INTRODUCTION Children begin school in the UK from the age of four years, and are in the early years of formal education between the ages of four and six years. For hearing children, a level of spoken grammatical competence in their fi rst language can be assumed at this stage (Crystal et al., 1976). The development of grammatical competence is important as it not only enables the child to understand and express complex ideas, but it is also a major factor in predicting literacy development (Bishop and Adams, 1990). For a child with hearing loss, it is diffi cult to learn the grammatical rules of spoken language; for example, a normally hearing child learns the plural form in spoken English by hearing s. Therefore for many profoundly deaf children, the development of spoken language grammar has been challenging due to lack of hearing input (Blamey et al., 2001; Mogford, 1993). The advent of multi-channel cochlear implants has enabled young deaf children to develop expressive spoken language to a higher degree than would have been possible had they been wearing conventional hearing aids (Svirsky et al., 2002; Tomblin et al., 1999). Researchers now suggest that young cochlear implant wearers can expect to acquire spoken language through audition (Archbold, 2006; Geers, 2004; Spencer and Marschark, 2003). Several early studies of children in the fi rst 12 to 15 months following implantation indicated that these children actually acquired language faster than their normally hearing peers (McConkey-Robbins et al., 1995, 1997; Miyamoto et al., 1997; Vermeulen et al., 1999). This early accelerated progress led researchers in the fi eld to predict that profoundly deaf children using cochlear implants might eventually close the gap in linguistic abilities with normally hearing peers of the same chronological age (Geers, 2004; Stacey et al., 2006). McConkey-Robbins et al. (1997) stated that it is crucial to extend the data from the early years to look at the long-term skills of implanted children to see whether or not faster progress is maintained. Language skills need several years

3 Expressive spoken language development 41 to develop (Fenson et al., 1994), and the more complex areas of grammar develop later (Crystal et al., 1976). Longer term analyses have been carried out for certain areas of linguistic development. For example, Geers et al. (2003) explored the development of verbal reasoning, narrative ability, utterance length and lexical diversity. Results indicated a wide range of performance in children with cochlear implants, but found that approximately half of the implanted children were able to achieve a level of skill commensurate with their normally hearing peers for these parameters in their preferred modality. Similarly, Moog (2002) found that more than 65 per cent of a group of fi ve to 11 year olds (N = 17) who had used a cochlear implant and had been given a highly focused oral education programme scored within the average range for hearing children on the Clinical Evaluation of Language Fundamentals 3 (Semel et al., 1995), but she did not specifi cally look at expressive grammar scores. In a study of receptive grammar skills, although implanted children showed considerable progress at the three year post implant interval, 87 per cent of children implanted under the age of four were found to perform more poorly than the average normally hearing child of the same age (Nikolopoulos et al., 2004). Age at implantation, aetiology of deafness, presence of additional disabilities, educational placement and mode of communication are all variables which have been suggested as possible factors affecting spoken language outcomes. Studies have found that when children are implanted early in life their spoken language outcomes are better than those found in children implanted later. For example, Nikolopoulos et al. (1999) found that a younger age at implantation was signifi cantly correlated with better outcomes in speech perception and speech intelligibility. Nicholas and Geers (2007) found that children implanted earlier (around 12 months) achieved a higher Language Factor score when tested at age three and a half years. Dettman et al. (2007) found that implantation before the age of 12 months led to language growth which matched growth rates achieved by normally hearing peers. The literature describing the impact of aetiology of deafness on spoken language outcomes following cochlear implantation is varied. Regarding speech perception skills, Nikolopoulos et al. (2006) found that aetiology, looking only at those deafened by meningitis and those congenitally deaf, was not a signifi - cant factor in predicting outcome from cochlear implantation; however, additional diffi culties may play an important role in the progress of children after implantation. For example, Pyman et al. (2000) found that diffi culties over and above the deafness which could arise from various aetiologies, particularly cognitive impairments, did have a negative impact on spoken language outcomes. Several children who would be described as having profound and multiple learning diffi culties were not included in this study, as there was no expectation that a cochlear implant would allow the children to acquire expressive spoken language competence.

4 42 Inscoe et al. Investigating the effect of mode of communication, the literature is once again variable, but there is a trend towards promoting a highly focused oral input and rehabilitation aimed at speech and auditory skill development. Archbold et al. (2000), Geers (2006) and Moog (2002) found that children using an oral approach to communication development performed signifi cantly better on measures of speech perception and speech intelligibility than those using a signing approach. They found that this was true whether the children had been using an oral approach throughout, or whether they changed modality after implantation. Watson et al. (2008) described communication changes after implantation; those implanted under three tended to change to oral communication, while those implanted older did not, or took longer to do so. Choice of communication approach may not be the measurable factor once thought, since it often changes over time. Even though many studies have shown the enhanced speech perception and production skills in children with cochlear implants (for example, Allen et al., 1998; Geers, 2006; Iler-Kirk, 2000; O Donoghue et al., 2000), the literature exploring expressive spoken grammar skills, important for those children beginning formal education, is limited. This paper explores the expressive spoken language grammar skills of a group of young children aged four to six years who were beginning formal education. It compares their linguistic attainment, using a picture-based spoken language elicitation test, with that of normally hearing children and investigates possible factors which might have accounted for the results obtained. The majority of the children in this study (89%) had also been tested using the Reynell Developmental Language Scales III (RDLS III; Edwards et al., 1997). This measure is standardised on hearing children aged 1 : 9 months to 6 : 11 months. Firstly, fi ve/45 children had reached the three year post implant interval prior to the RDLS III being used. Secondly, the format of the RDLS III requires a child to produce specifi c structures in order to obtain a score, and in practice the therapists on the Nottingham team have found that children who use a cochlear implant have diffi culty producing word endings such as plurals and third person singular verb tense structures after 3 years of implant experience. The South Tyneside Assessment of Syntactic Structures (STASS; Armstrong and Ainley, 1983) assessment was thought to be more useful for planning appropriate therapy and teaching goals, as it allows for an analysis of spontaneous speech based on the developmental profi le of a typically developing hearing child and determines the child s stage of grammatical development. We looked at STASS Stage IV as this is the stage attained by hearing children by the age of 2½ to 3 years, and thus we would expect all the children to have reached at least this stage after 3 years of cochlear implant use if their grammatical development was progressing as fast as other linguistic areas have been shown to progress in other studies.

5 Expressive spoken language development 43 METHOD Participants The present study prospectively assessed the spoken grammar skills of 45 children with pre-lingual profound deafness who were implanted under three years old; 29 were born deaf and 16 deafened before the age of two. The demographic details of the children are shown in Table 1. Information related to individual children is shown in Table 2, including age at implant, device and tuning strategy used, aetiology of deafness, mode of communication, educational placement at time of testing, age at testing and presence of any additional diffi culty likely to affect progress in spoken language development. Prior to implantation, all of the 19 male and 26 female subjects had a profound, bilateral sensori-neural hearing loss with unaided hearing levels greater than 95 db across the speech frequencies (500 Hz, 1 khz, 2 khz and 4 khz), and had demonstrated no benefi t from conventional hearing aids for the development of spoken language skills. At the time of implantation, all the children were rated as pre-verbal in spoken language on the Profi le of Actual Language Skills (Nikolopoulos et al., 2005) which is part of the Nottingham Early Assessment Package (Nikolopoulos et al., 2005). Just over half of the children were in oral educational settings at the time of testing, whilst the Table 1: The demographic details of children in this study. Number of children 19 males, 26 females Onset of profound bilateral sensori-neural deafness 29 congenital 16 deafened under 2 Mean unaided hearing thresholds prior to >95 db across 500 Hz, 1 khz, implantation 2 khz and 4 khz Spoken language status prior to implantation 45 pre-lingual Aetiology Unknown = 25; meningitis = 16; genetic = 1; CMV = 2; Usher = 1 Presence of known additional diffi culties at time of 9/45 (20%) testing Mean age at implantation 27 months (range = months) Age at testing months (mean = 65 months) Cochlear implant device Nucleus 22 = 15; Nucleus 24 = 23; Nucleus Contour = 7 Mode of communication (at time of test) 25 Oral 20 Total Communication Educational placement (at time of test) 30 Mainstream; 15 hearingimpaired units in mainstream school CMV = Cytomegalovirus.

6 44 Inscoe et al. Table 2: Subjects in study. Subjects Age at CI (mo) Age at testing (mo) Aetiology Educational placement Mode of communication Additional diffi culties Unknown Mainstream TC / Meningitis Mainstream OA / Meningitis Mainstream TC Cognitive/physical Meningitis Mainstream OA Vocal tract anomalies Meningitis Mainstream OA / Meningitis Mainstream TC / Unknown Mainstream OA / Unknown Unit TC / Meningitis Unit OA / Unknown Mainstream TC / Unknown Mainstream TC / Unknown Mainstream OA / Meningitis Mainstream OA Cognitive/ behavioural/visual Meningitis Unit TC / Genetic Mainstream OA / Unknown Mainstream OA / Meningitis Mainstream OA / Meningitis Unit TC Cognitive Unknown Mainstream OA / Unknown Mainstream OA / Unknown Mainstream TC / Unknown Mainstream TC Autistic Meningitis Unit TC / Unknown Mainstream OA / Meningitis Mainstream OA / Meningitis Mainstream OA / Unknown Unit TC / Meningitis Unit TC / CMV Unit TC Behavioural Unknown Unit TC Behavioural CMV Unit OA / Unknown Mainstream TC / Unknown Mainstream TC / Unknown Mainstream OA / Unknown Mainstream OA / Unknown Unit OA / Unknown Unit TC / Ushers Unit TC Visual Unknown Mainstream OA / Unknown Unit TC Vocal tract anomalies Unknown Mainstream OA / Meningitis Unit OA / Unknown Mainstream OA / Meningitis Mainstream OA / Unknown Mainstream TC / CI = Cochlear implant; TC = Total Communication; OA = oral; CMV = Cytomegalovirus.

7 Expressive spoken language development 45 remainder were in environments where sign supported English was used. At the time of testing, 30 children attended their mainstream school, whilst 15 were based in units attached to a mainstream school. Over the three year post implant period, all children had been encouraged to acquire spoken language, 25 of them through listening and lip-reading, and 20 through sign supported English, depending on the communication philosophy of the child s local education service. At the time of testing, 20 per cent of the children had at least one known additional diffi culty likely to affect progress in spoken language development, as identifi ed by the Nottingham Cochlear Implant Programme (NCIP) teachers of the deaf and speech and language therapists. These were autistic spectrum disorder (N = 1), behaviour difficulties (N = 3), cognitive problems (N = 3), visual impairment (N = 2) and vocal tract anomalies (N = 2). All were implanted using the Nucleus TM implant system, and were using the latest and most appropriate tuning strategy (Spectral Peak (SPEAK) or Advanced Combination Encoder (ACE)). Children implanted at the NCIP are brought back for regular review by the audiologists to ensure that they are using the most effective and up-to-date tuning strategy. Expressive grammar measure A cochlear implant team speech and language therapist assessed each child using the STASS, a test of expressive spoken language (Armstrong and Ainley, 1983). This is a picture-based spoken language elicitation task, standardised on 204 normally hearing children aged three, four and fi ve years in the UK. It is administered using live voice and uses questions or statements to prompt spoken responses. It allows a spoken language sample to be collected in a systematic way, video recorded, transcribed and analysed in terms of syntax and morphology at clause, phrase and word levels. It is based on the internationally known Language Assessment and Remediation Screening Procedure (LARSP; Crystal et al., 1976) which is a comprehensive analysis of spoken grammar that has been standardised on a large group of 350 normally hearing children. LARSP was used in a study of 263 hearing-impaired children to investigate which features were most signifi cant for refl ecting grammatical development (Bamford and Bench, 1979). It provides a profi le of developmental norms to show the emergence of various grammatical and morphological structures produced by normally hearing children during the period of typical spoken language development, and the age at which these structures emerge. It can be used on any spontaneous spoken language sample, and is designed to elicit Stage I to IV clause, phrase and word features, corresponding to age bands of between nine months and three years. The STASS allows therapists to collect this sample in a more systematic and time effi cient way. In this study, the children did not use any spoken words prior to cochlear implantation, and therefore did not score on this assessment. Three years after implantation, the children were assessed to determine whether they were producing grammatical

8 46 Inscoe et al. clause and morphological structures described on the LARSP profi le and on the highest level of the STASS screening assessment, Stage IV, equivalent to those acquired by normally hearing children between two and a half and three years of age. A record was also made of those children who were producing coordinated and subordinated clauses (Stage V) and those who had not reached this level of grammatical development (below Stage IV). An example of a typical Stage IV response might be: He s giving the girl some presents Subject Verb Indirect object Direct object = SVOO clause ( auxiliary (-ing) (determiner) (determiner) (plural) = morphological be ) structures For those children whose mode of communication was described as Total Communication at the time of testing, the therapist presented the prompts using sign supported English. This did not invalidate the test, as the purpose of the STASS is to elicit and analyse the spoken language produced by the child, not to assess their receptive language ability. Indeed, Iler-Kirk (2000) found no difference in spoken language outcome if the child s habitual mode of communication was used in the assessment of expressive language skills of implanted children. Data collection Data were collected using the Bawtry Computer Services Database (Robbins et al., 2008) which is used by several cochlear implant programmes in the UK for collecting information about children and adults who have received a cochlear implant from their service. Statistical analysis Standard percentages of subjects at or above Stage IV were calculated and compared to those below Stage IV on STASS. Chi squared test was used to determine whether age at implantation, presence of known additional diffi culties, educational placement, mode of communication or aetiology of deafness had any signifi cant effect on the outcome; statistical signifi cance was accepted at the p value of Yates s correction for small samples was also used. RESULTS After three years of cochlear implant use, 18 (40%) of the implanted children were achieving the highest level on the STASS assessment, Stage IV. A further eight (18%) of the implanted children scored above it and the remaining 19 (42%) below (Figure 1).

9 Expressive spoken language development 47 % Below STASS stage IV Equal to STASS stage IV Above STASS stage IV Figure 1: Spoken language levels of children with three years cochlear implant experience (N = 45). STASS = South Tyneside Assessment of Syntactic Structures. Achieved stage IV Not yet achieved stage IV Unknown Meningitis CMV Ushers Genetic Figure 2: Number of children who achieved South Tyneside Assessment of Syntactic Structures (STASS) Stage IV after three years of cochlear implant use, relative to aetiology of deafness. Figure 2 splits the group according to their aetiology of deafness. The numbers of children with deafness attributed to Cytomegalovirus (CMV), Ushers or genetic causes, were small (respectively 2, 1 and 1 children). However, all these children achieved spoken language grammar at STASS Stage IV or above. Among the children whose deafness was caused by meningitis, nine reached this level whereas seven did not. The remaining 25 children did not have a known cause for their hearing loss. Of these, 14 achieved STASS Stage IV, 11 did not. These differences were not statistically signifi cant (p = 0.9). Figure 3 looks at the difference in outcome related to educational placement. There were 30 children placed in mainstream classrooms. Of these, 17 achieved STASS at Stage IV, 13 did not. The remaining 15 children were placed in specialised classes within a mainstream school (units). Of these, ten

10 48 Inscoe et al mainstream school unit Achieved stage IV Not yet achieved stage IV Figure 3: Number of children who achieved South Tyneside Assessment of Syntactic Structures (STASS) Stage IV after three years of cochlear implant use, relative to educational placement Achieved stage IV 10 5 Not yet achieved stage IV 0 Oral Total Communication Figure 4: Number of children who achieved South Tyneside Assessment of Syntactic Structures (STASS) Stage IV after three years of cochlear implant use, relative to the mode of communication. achieved Stage IV, fi ve did not. These differences were not statistically signifi - cant (p = 0.4). Figure 4 looks at mode of communication. Of the 24 children using oral communication, 17 achieved STASS Stage IV, seven did not. There were 21 children using total communication, of whom ten achieved STASS Stage IV, 11 did not. These numbers were small and the differences did not achieve statistical signifi cance (p = 0.2). Figure 5 looks at additional diffi culties. Eight of the children in this study had a diagnosed diffi culty in addition to their deafness, with a potential impact on their spoken language development. Of the eight, three achieved STASS Stage IV in the fi rst three years after cochlear implantation, fi ve did not. Among the rest of the group, 24 achieved STASS Stage IV, 13 did not. These differences were not statistically signifi cant (p = 0.1). Figure 6 investigates age at implant. Fourteen of the children in this study were implanted under two years old. Of these, seven achieved STASS Stage IV in the fi rst three years after implantation, seven did not. The remaining 31 received their cochlear implant between 24 and 36 months of age. Twenty of these achieved STASS Stage IV, 11 did not. These numbers were small and the differences did not achieve statistical signifi cance (p = 0.9).

11 Expressive spoken language development Children with an Children with no additional recorded difficulty additional difficulty Achieved stage IV Not yet achieved stage IV Figure 5: Number of children who achieved South Tyneside Assessment of Syntactic Structures (STASS) Stage IV after three years of cochlear implant use, relative to the presence of additional diffi culties Implanted under 2 Implanted 2-3 Achieved stage IV Not yet achieved stage IV Figure 6: Number of children who achieved South Tyneside Assessment of Syntactic Structures (STASS) Stage IV after three years of cochlear implant use, relative to age at implant. Figure 7 looks at the relationship between age at implant and mode of communication. STASS Stage IV was achieved by 25 per cent of children using total communication implanted between two and three, and 35.7 per cent of children implanted at the same age but using oral communication. There was also a difference in the children implanted under two; STASS Stage IV was achieved by 17.6 per cent of the children using total communication, and 41.1 per cent of those implanted at the same age but using oral communication. These differences were not statistically signifi cant (p = 0.5 for those implanted under the age of two years and p = 0.4 for those implanted between two and three years). DISCUSSION The results of this analysis indicate that children with cochlear implants continue to have diffi culty acquiring certain aspects of spoken language. After implantation, children of this age in the UK are increasingly likely to attend mainstream schools (Archbold et al., 2002). This is in line with UK

12 50 Inscoe et al. % Total comm. Oral comm. 0 CI 2-3 CI < 2 Figure 7: Percentage of children three years post implant achieving at or above South Tyneside Assessment of Syntactic Structures (STASS) Stage IV in relation to communication mode and age at implant. CI 2 3 = Children implanted between two and three years N = 28; CI < 2 = children implanted under two years N = 17. government policy for all children with special educational needs. All of the children in this study attended mainstream school, with the majority of children (67%) attending their local mainstream school, and the remainder in units based in mainstream schools. After three years of implant use, these children were being educated alongside their normally hearing peers of the same chronological age, four to six years, although they were not likely to have the same expressive spoken language competence. Although 58 per cent of the participants had acquired three or more years of spoken grammar development after three years of cochlear implant use, it seems that the development of expressive spoken grammar may be more diffi - cult for children using a single cochlear implant than anticipated, even after comparatively early implantation and use of the most effective tuning strategy. It may be that the improved levels of intelligible speech typically attained after cochlear implantation (Allen et al., 1998; Niparko, 2004) compared to those previously attained using conventional hearing aids and the exceptionally improved speech perception abilities following cochlear implantation (Geers, 2006; Iler-Kirk, 2000) mask the true levels of spoken language grammar. Normally hearing children acquire spoken language through over-hearing conversations as well as in direct one-to-one daily interactions with their carer from their earliest days. These interactions, vital to linguistic development, take place in the noisy surroundings of the typical family home or nursery setting. The usual acquisition of grammar in hearing children takes place over

13 Expressive spoken language development 51 the fi rst few years of life within this context. Children who have received cochlear implants before the age of three years have been shown in numerous studies to have the potential to acquire spoken language via audition, so long as they have suffi cient opportunities to understand and use spoken language in an adapted and enhanced way from those interacting with them (Archbold et al., 2000; Geers, 2006; Hogan et al., 2008; Moog, 2002). However, the children of the present study had on average 27 months before being able to perceive spoken language, and therefore a signifi cant delay before beginning to learn language through hearing. Neural pathways responsible for processing auditory information in working memory are typically built up in the fi rst and second year of life (Pisoni and Cleary, 2003). Pisoni and Cleary (2003) suggested that implanted deaf children may undergo atypical working memory development as a result of their early auditory deprivation, and their neural pathways may be disrupted. Children using cochlear implants were indeed found to have shorter working memory spans in a variety of tasks involving digit span, verbal and visual material (Cleary et al., 2001). Given this limited memory, such children might preserve semantic information and neglect other information. With regard to this delay, Dettman et al. (2007) hypothesised that implantation under the age of 12 months would lead to increased rates of language acquisition as this was still within the sensitive period for child language acquisition, with others supporting this (de Villiers et al., 1994; Nicholas and Geers, 2007). Age at implantation is falling in the UK, and one would expect the current population to have improved spoken grammar outcomes. However, there are currently large numbers of children in full-time education who received a cochlear implant after a comparatively long period with no useful hearing for the development of spoken language. Therefore teachers and therapists need to be particularly aware of their possible language diffi culties and educational needs. Many important grammatical markers in English rely upon the detection of high frequency, unstressed speech sounds, which are particularly diffi cult to perceive in noise, and therefore more diffi cult for these children to acquire. In addition, there are still limitations in the ability of cochlear implants to allow users to perceive less salient auditory information (Teoh et al., 2003). These children continue to have a hearing loss, with typical aided thresholds through the implant system of 30 db across the speech frequencies and a profound loss in the other ear, if unilaterally implanted. Such children are likely to have diffi culty in the typical noisy language learning situation (Bess et al., 1986; Most, 2004), which may partly account for the diffi culty that children using a cochlear implant have in understanding and using unstressed grammatical and morphological features found in spoken English. In noisy situations, the use of a cochlear implant system is severely compromised and likely to affect spoken language acquisition through hearing. Attention to the listening conditions in school, to the everyday functioning of the implant system and to teaching styles is vital to ensure that they can access the spoken language of the classroom,

14 52 Inscoe et al. and continue spoken language development. Additionally, other factors, such as increased provision of early bilateral implantation and improved speech processing strategies should improve a child s listening in background noise, which one would hope would lead to grammatical and morphological skills being acquired more naturally and easily. Traditional assessments of speech perception in quiet or in clinically produced noise may not replicate the normal language learning environment, which is more demanding. Hazan and Markham s (2004) work demonstrates that perception can be improved by increasing the salience of acoustic patterns. Other studies suggest that it is possible to enhance children s spoken language skills using techniques which aim to promote increased attention to auditory oral information (Nye et al., 1987) and that this can be useful for young implanted children (Geers, 2006; Hogan et al., 2008; Moog, 2002). The children in this study are likely to benefi t from structured and differentiated programmes to develop their spoken grammar skills to a level of competence that will allow them to develop their literacy skills using the same techniques as their hearing peers. CONCLUSION This study provides evidence from a group of 45 children that early experience with a cochlear implant may not yet result in age appropriate expressive spoken grammar skills for all. Accommodating the needs of this group of children, who are likely to have expressive spoken language abilities behind those of their normally hearing peers and therefore considerable diffi culties expressing complex ideas, in a mainstream class, is challenging. These children are likely to benefi t from collaboration between teachers of the deaf, classroom teachers, speech and language therapists and the cochlear implant teams to ensure that listening conditions are optimised and that progress in spoken language development is closely monitored and assessed. In this way, individual educational or language programmes can be tailored to their identifi ed needs which may include targeting those aspects of spoken grammar that are less acoustically prominent. The current emphasis on early implantation and on bilateral implantation may result in improved early acquisition of spoken language grammar. However, the children will continue to need specialist monitoring and support, as some will lack the basic syntactic abilities which support spoken and written language growth as the child gets older. Therefore there is a need for long-term monitoring of these children s spoken language development, in order to identify the specifi c needs of individual children and meet them within the educational context.

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