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Effect of Age at Cochlear Implantation on Auditory Skill Development in Infants

and Toddlers

Article in Archives of Otolaryngology - Head and Neck Surgery · June 2004

DOI: 10.1001/archotol.130.5.570 · Source: PubMed

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 ORIGINAL ARTICLE

Effect of Age at Cochlear Implantation on Auditory

Skill Development in Infants and Toddlers
Amy McConkey Robbins, MS; Dawn Burton Koch, PhD; Mary Joe Osberger, PhD;
Susan Zimmerman-Phillips, MS; Liat Kishon-Rabin, PhD

Objectives: To investigate the effect of age at cochlear im- Results: Infants and toddlers who receive implants
plantation on the auditory development of children younger show rapid improvement in auditory skills during the
than 3 years and to compare these children’s auditory de- first year of device use regardless of age at implantation,
velopment with that of peers with normal hearing. although younger children achieve higher scores. Chil-
dren who undergo implantation at a younger age
Design: Using a repeated-measures paradigm, auditory skill acquire auditory skills nearer to those of their peers
development was evaluated before and 3, 6, and 12 months with normal hearing at a younger age. The mean rate of
after implantation. Data were compared with previously acquisition of auditory skills is similar to that of infants
published data from cohorts with normal hearing. and toddlers with normal hearing regardless of age at
implantation.
Participants: One hundred seven hearing-impaired chil-
dren (age range, 12-36 months) who received a coch- Conclusion: Performing implantation in children with
lear implant during clinical trials in North America. profound hearing loss at the youngest age possible al-
lows the best opportunity for them to acquire commu-
Main Outcome Measure: Auditory skill develop- nication skills that approximate those of their peers with
ment was assessed using the Infant-Toddler Meaningful normal hearing.
Auditory Integration Scale, a tool that provides a quan-
titative measure in children as young as newborns. Arch Otolaryngol Head Neck Surg. 2004;130:570-574

R
ECENT RESEARCH INDI- There is little information, however,
cates that early identifica- concerning the effect of age at implanta-
tion and intervention have tion on meaningful listening skills in chil-
a significant positive effect dren as young as 12 months who un-
on communication devel- dergo implantation. Evaluating device
opment in very young hearing-impaired benefit in these young children poses sig-
children. For example, Yoshinaga-Itano et nificant challenges. First, they have short
al1 found that infants whose hearing losses attention spans and variable levels of com-
From the Communication were identified and who were fit with hear- pliance. Second, they present with lim-
Consulting Services, ing aids before 6 months of age demon- ited skills in understanding and using lan-
Indianapolis, Ind strated significantly better language scores guage. Third, few clinically useful
(Ms McConkey Robbins);
Advanced Bionics Corporation,
than children identified after 6 months of measures exist to evaluate auditory devel-
Valencia, Calif (Drs Koch and age. In another study, Moeller2 evaluated opment in infants and toddlers, regard-
Osberger and vocabulary and verbal reasoning skills in less of whether they have impaired or nor-
Ms Zimmerman-Phillips); and a group of 112 children with hearing loss mal hearing.
Department of Communication who were enrolled at various ages in a The objectives of this study were (1)
Disorders, Tel Aviv University, comprehensive intervention program. At to investigate the effect of age at implan-
Tel Aviv, Israel 5 years of age, children who had been en- tation on the auditory development of chil-
(Dr Kishon-Rabin). rolled before 11 months of age demon- dren who undergo implantation before age
Ms McConkey Robbins has strated significantly better vocabulary and 3 years and (2) to compare the auditory
served as a consultant to and
verbal reasoning skills than children en- development of these young children with
Drs Koch and Osberger and
Ms Zimmerman-Phillips are rolled after 11 months of age. Similarly, a that of peers with normal hearing (NH).
employees of Advanced Bionics positive relationship has been shown be- The auditory capabilities of the children
Corporation. The authors have tween early age at implantation and en- who received implants and those with NH
no relevant financial interest in hanced cochlear implant (CI) perfor- were assessed and compared using the In-
this article. mance in children.3-5 fant-Toddler Meaningful Auditory Inte-

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gration Scale (IT-MAIS),6 a structured parent interview
tool developed to yield quantitative results in children Demographic Characteristics of 107 Children With Implants
as young as newborns. The IT-MAIS scores for NH in-
fants and toddlers have been published.7 Group

1 2 3
Characteristic (n = 45) (n = 32) (n = 30)
METHODS
Age at implant, mo 12-17 19-23 24-36
Mean preimplant pure-tone
PARTICIPANTS average, dB HL
Implant ear 116 107 110
One hundred seven hearing-impaired children who had re- Non–implant ear 115 109 113
ceived the CLARION Multi-Strategy (Advanced Bionics Corpo-
ration, Sylmar, Calif) CI during clinical trials in North America
participated in this study. Clinical centers participating in the
trials conducted testing with the approval of their individual in- 80
stitutional review boards. The Table lists the demographic char-
acteristics of the children who use implants. 70

60
TEST MATERIALS

IT-MAIS Score, %
50
Auditory skills were assessed using the IT-MAIS.6 The IT-MAIS
was developed and standardized as an assessment tool of audi- 40
tory skill development in children. The test is a structured in- Age at
30 Implantation, mo
terview schedule that queries parents about their child’s spon-
taneous listening behaviors in everyday situations.8 The IT- 20
12-18
MAIS is not a questionnaire in which parents are asked direct 19-23
questions regarding their child’s auditory behavior. Rather, the 10
24-36
test uses interview elicitation techniques similar to those used
0
with the Vineland Adaptive Behavior Scales.9 Assessment mea- Before Implant 3 mo 6 mo
sures like the Vineland are widely used in developmental psy- Time After Implantation, mo
chology and are accepted as reliable tools. One of the advan-
tages of structured interview tools is that clinicians may obtain Figure 1. Mean Infant-Toddler Meaningful Auditory Integration Scale
information about behavior without requiring a young child’s (IT-MAIS) scores over time by age at implantation.
compliance or attention. Another advantage is that information
about behavior is independent of the language used. In the case
of the IT-MAIS, the auditory behaviors evaluated are universal Group 3 (n=30) consisted of children who underwent implan-
and represent developmental milestones. tation between 24 and 36 months of age (Table). The IT-MAIS
In the IT-MAIS, 10 questions are posed to parents that scores from each group were compared with scores that were
sample 3 different areas of auditory skill development. These obtained from the parents of 109 children with NH aged 5 to
include changes in vocalization associated with device use (ques- 36 months (mean age, 12.5 months). The distribution of NH
tions 1 and 2), alerting to sounds in everyday environments children by age was as follows: 52% were younger than 12
(questions 3, 4, 5, and 6), and deriving meaning from sound months, 23% were 12 to 18 months old, 10% were 19 to 23
(questions 7, 8, 9, and 10). Using information provided by the months old, and 15% were 24 to 36 months old. Parents of these
parent, the examiner scores each question based on the fre- NH subjects were administered a translated version of the IT-
quency of occurrence of a target behavior. Scores for each ques- MAIS in Hebrew (n=68) or Arabic (n=41).7
tion range from 0 (“never demonstrates the behavior”) to 4 (“al-
ways demonstrates the behavior”). The highest possible score RESULTS
on the IT-MAIS is 40 (10 questions⫻ maximum score of 4).
The primary aim of the study was to compare the effect
PROCEDURES of age at implantation on auditory skill development and
Parents of children who use implants were administered the
performance. Figure 1 shows the mean performance on
IT-MAIS 4 times: before implantation (based on their child’s the IT-MAIS for the 3 groups of children before and 3
use of hearing aids) and 3, 6, and 12 months after implanta- and 6 months after implantation (12-month data were
tion. Clinical staff at each child’s cochlear implantation center omitted from this first analysis because of the small sample
conducted the test. To ensure consistency of test administra- size). The mean IT-MAIS scores for all 3 groups of sub-
tion and standardization of parent responses, the IT-MAIS jects were near zero before implantation but improved
protocol contains numerous written probes to which clini- rapidly over time with increased use of the device. There
cians must adhere. In addition, all clinicians had received prior were no differences in mean scores over time between
training in the administration of the test, further reducing the 2 earliest groups who received implants (groups 1
interexaminer variability. Each child’s IT-MAIS score at each and 2), whereas the mean scores for group 3 are lower
test interval was converted to a percentage correct score (total
score/40 ⫻ 100).
than scores for groups 1 and 2.
For data analysis, subjects with implants were divided into The second aim of the study was to compare audi-
3 groups based on age at implantation. Group 1 (n=45) con- tory skill development in children who use implants with
sisted of children who underwent implantation between 12 and that of NH children of the same chronological age. To
18 months of age. Group 2 (n = 32) consisted of children who make these comparisons, individual IT-MAIS scores for
underwent implantation between 19 and 23 months of age. each of the 3 CI groups were plotted with IT-MAIS data

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 Normal Hearing
100

90
+
80 +

70
IT-MAIS Score, %

60
+
50

40

30 Time After
Implantation, mo
20 Before Implant Figure 2. Individual Infant-Toddler Meaningful
3 Auditory Integration Scale (IT-MAIS) scores by age
6
10 + 12
for children in group 1 (12-18 months of age at
implantation). Blue line indicates best-fit exponential
function for those data over time:
0 4 8 12 16 20 24 28 32 36 40
y = 86/(1 + e[−{age-20}/2]); black solid and dotted lines,
Chronological Age, mo mean ± 2 SE data for normal hearing; diamonds, mean
scores.

Normal Hearing
100

90
+
80

70
+
IT-MAIS Score, %

60
+
50

40

30 Time After
Implantation, mo
20 Before Implant Figure 3. Individual Infant-Toddler Meaningful
3
6
Auditory Integration Scale (IT-MAIS) scores by age
10 for children in group 2 (19-23 months of age at
+ 12
implantation). Red line indicates best-fit exponential
0
function for those data over time: y = 78⫻ e(−e[age-22]/2.5);
4 8 12 16 20 24 28 32 36 40
black solid and dotted lines, mean ± 2 SE data for
Chronological Age, mo
normal hearing; diamonds, mean scores. The blue 12-
to 18-month best-fit curve is reproduced from Figure 2.

obtained from the 109 NH children (Figures 2, 3, and after 6 and 12 months of implant experience. A few of
4). For simplicity, only the mean ± 2 SE values are plot- them reached the normal range after only 3 months of
ted for the NH children. For the 3 CI groups, individual listening with the implant.
data are shown before and 3, 6, and 12 months after im- Results for the group 2 children, who underwent im-
plantation. Because children entered this study in a stag- plantation between 19 and 23 months of age, are plot-
gered manner, limited data are available for subjects at ted in Figure 3. These data also could be fit by an expo-
the 12-month interval after implantation. Therefore, data nential curve (r =0.80, P⬍.01), and 65% of the variance
at this interval should be interpreted cautiously. Each CI was attributable to CI use. About one third of the chil-
group’s data were fit with exponential functions, as shown dren fell within the normal distribution of IT-MAIS scores
in Figures 2, 3, and 4 for groups 1, 2, and 3, respec- after 6 and 12 months of implant experience. In con-
tively. trast to groups 1 and 2, the IT-MAIS scores from group
Rapid improvement in IT-MAIS scores over time is 3 children, who underwent implantation between 24 and
evident for all 3 age groups following implantation. For 36 months, showed such great variability that the data
the youngest children (group 1), the data could be fit by could not be predicted by duration of CI use in any sys-
an exponential curve (r = 0.82, P⬍.01), as seen in Fig- tematic way (Figure 4). Moreover, almost all group 3
ure 2. Notably, 70% of the variance in group 1 data was scores continued to fall below the NH range after 6 and
attributable to implant use (as indicated by months af- 12 months of CI use.
ter implantation), and more than two thirds of the chil- Figure 5 shows the mean data from the 3 groups
dren fell within the normal distribution of IT-MAIS scores of children plotted as a function of hearing age. Hearing

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 Time After
Implantation, mo Normal Hearing
100 Before Implant
3
90 6
12
80
+
70
IT-MAIS Score, %

60 +
50

40 Implant at +
<19 mo
30
Figure 4. Individual Infant-Toddler Meaningful
20
Auditory Integration Scale (IT-MAIS) scores by age
Implant at
for children in group 3 (24-36 months of age at
Implant at implantation). Black solid and dotted lines indicate
10 19-24 mo
24-36 mo
+ mean ± 2 SE data for normal hearing; diamonds, mean
scores. An exponential function could not be fit to
0 4 8 12 16 20 24 28 32 36 40 44 these data. The blue 12- to 18-month best-fit curve is
Chronological Age, mo reproduced from Figure 2. The red 19- to 23-month
best-fit curve is reproduced from Figure 3.

100

90
+ Normal Hearing

+ +
80
+
70
+
IT-MAIS Score, %

60 +
+
50

+
40

Age at
30
Implantation, mo

20 12-18 Figure 5. Mean Infant-Toddler Meaningful Auditory

19-23 Integration Scale (IT-MAIS) scores for children who
10 used implants and for those with normal hearing as a
+ 24-36
function of hearing age (months of implant use for
children who received implants and chronological age
0 4 8 12 16 20 24
for children with normal hearing). Solid and dotted
Hearing Age, mo
lines indicate mean ± 2 SE data for normal hearing;
diamonds, mean scores.

age reflects months of implant use and chronological age to achieve auditory milestones. Third, the mean rate of
for the NH children. The mean scores indicate that the acquisition of auditory skills is similar to that of NH in-
children who use implants acquired auditory skills at a fants and toddlers regardless of age at implantation.
rate similar to that of NH children, independent of age Specifically, mean IT-MAIS scores show that the 2
at implantation. However, as is evident in Figures 2, 3, groups of children who received implants before age 2
and 4, there is large intersubject variability. years had significantly faster rates of progress and higher
scores than the children who received implants be-
COMMENT tween 2 and 3 years of age. However, there were no sig-
nificant differences in mean IT-MAIS scores between the
Three main findings emerge from this study. First, mean 2 youngest groups. At first glance, a comparison of the
IT-MAIS scores from infants and toddlers who use im- mean data suggests that there is no advantage to per-
plants indicate rapid improvement in auditory skills dur- forming implantation in a child at 12 to 18 months of
ing the first year of device use regardless of age at im- age, as opposed to performing implantation at 19 to 24
plantation, although younger children achieve higher months of age. The rate of auditory skill acquisition is
scores. Second, children who undergo implantation at a the same. However, when IT-MAIS scores from group 1
younger age attain auditory skills nearer to those of their and group 2 children are compared with those of NH in-
NH peers at a younger age, as measured on the IT- fants and toddlers, a distinction emerges between the 2
MAIS. When children receive CIs at an older age, fac- youngest groups. Specifically, the youngest group 1 chil-
tors other than implant use begin to affect their ability dren achieved IT-MAIS scores within the normal range

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 at earlier intervals after implantation (and thus younger In summary, children younger than age 3 years un-
ages) than children in group 2. Similarly, children in group dergoing implantation demonstrated impressive audi-
2 achieved auditory milestones at earlier ages than chil- tory skill development during the first year of device use.
dren in group 3. These data suggest that performing implantation in chil-
What advantage might there be to the attainment dren with profound hearing loss at the youngest age pos-
of auditory milestones at ages closest to those achieved sible allows the best opportunity for them to acquire com-
by NH children? There are 3 primary advantages. First, munication skills that approximate those of their NH peers.
the goal of any intervention is for the child to master skills
as close as possible to the time that he or she is biologi- Submitted for publication September 22, 2003; final revi-
cally intended to do so, taking advantage of developmen- sion received December 9, 2003; accepted January 6, 2004.
tal “windows” of opportunity. This results in develop- This study was presented at the Ninth Symposium on
mental synchrony. Second, our primary interest in the Cochlear Implants in Children; April 25, 2003; Washing-
development of auditory skills is the fact that such skills ton, DC.
form the foundation for spoken language competence. Corresponding author: Amy McConkey Robbins, MS,
Therefore, delayed auditory development leads to de- Communication Consulting Services, 8512 Spring Mill Rd,
layed language skills. Although we did not assess lan- Indianapolis, IN 46260 (e-mail: [email protected]).
guage in this study directly, recent evidence suggests simi-
lar age-at-implantation effects on language that were found REFERENCES
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