expressive vocabulary, morphology, syntax and narrative skills in profoundly deaf children after...

Research in Developmental Disabilities 34 (2013) 2008–2022

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Research in Developmental Disabilities

Expressive vocabulary, morphology, syntax and narrative
skills in profoundly deaf children after early cochlearimplantation
Tinne Boons a,b,*, Leo De Raeve c,d, Margreet Langereis e, Louis Peeraer b,Jan Wouters a, Astrid van Wieringen a

a ExpORL, Department Neurosciences, KU Leuven, Leuven, Belgiumb Institute of Allied Health Sciences, Fontys University of Applied Sciences, Eindhoven, The Netherlandsc Independent Information Center on Cochlear Implants (ONICI), Zonhoven, Belgiumd Department of Deaf Children in KIDS, Hasselt, Belgiume ENT Department, Radboud University, Nijmegen, The Netherlands

A R T I C L E I N F O

Article history:

Received 17 January 2013

Received in revised form 1 March 2013

Accepted 4 March 2013

Available online 11 April 2013

Keywords:

Children

Deafness

Cochlear implants

Language development

A B S T R A C T

Practical experience and research reveal generic spoken language benefits after cochlear

implantation. However, systematic research on specific language domains and error

analyses are required to probe sub-skills. Moreover, the effect of predictive factors on

distinct language domains is unknown. In this study, outcomes of 70 school-aged children

with cochlear implants were compared with hearing peers. Approximately half of the

children with cochlear implants achieved age-adequate language levels. Results did not

reveal systematic strong or weak language domains. Error analyses showed difficulties

with morphological and syntactic rules and inefficient narrative skills. Children without

additional disabilities who received early intervention were raised with one spoken

language, and used a second cochlear implant or contralateral hearing aid were more likely

to present good language skills.

� 2013 Elsevier Ltd. All rights reserved.

1. Introduction

There are about 200.000 cochlear implant users worldwide, including approximately 80.000 infants and children (Kral &O’Donoghue, 2010; NIH, 2011). A cochlear implant (CI) transmits sounds directly to the auditory nerve through electricalstimulation of the cochlea. Especially when cochlear implantation takes place at an early age, age-appropriate spokenlanguage levels are feasible (Nicholas & Geers, 2007).

1.1. Language domains

Language development can be described by separable domains, such as vocabulary, morphology, syntax and pragmatics.In most of the studies on language outcomes of children with CIs, language development is evaluated by means of vocabularytests, like the Peabody Picture Vocabulary Test (PPVT) (Da Silva, Comerlatto Junior, Bevilacqua, & Lopes-Herrera, 2011).However, vocabulary tests may not tell the whole story. Research rarely focuses on non-vocabulary linguistic skills

* Corresponding author at: ExpORL, Department Neurosciences, Herestraat 49 Bus 721, B-3000 Leuven, Belgium. Tel.: +32 16330495; fax: +32 16330486.

E-mail address: [email protected] (T. Boons).

0891-4222/$ – see front matter � 2013 Elsevier Ltd. All rights reserved.

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T. Boons et al. / Research in Developmental Disabilities 34 (2013) 2008–2022 2009

(e.g. morphology, syntax, narrative skills), while these skills are important to structure speech and language and contributeto the effectiveness of children’s language (Da Silva et al., 2011). Moreover, analysis of different language domains enablesefficient rehabilitation (Geers, Moog, Biedenstein, Brenner, & Hayes, 2009).

Few studies evaluated several language domains. Young and Killen (2002), Spencer (2004) and Duchesne, Sutton, andBergeron (2009) measured vocabulary, syntactic and morphological skills. Young and Killen (2002), and Spencer (2004)observed strong vocabulary skills and good understanding of word order in sentences, but problems with syntactic andmorphological skills, such as pronouns, possessive markers, and verb tense. Examination of individual patterns byDuchesne et al. (2009) revealed four different language profiles. One profile consisted of language components withinnormal limits. The second profile demonstrated a general language delay on all tasks. The third profile showed normallexical abilities with receptive grammar delay and the fourth one consisted of discrepancies across language domains.However, these studies were based on a relatively small sample size (n < 30) which hinders generalization of the findings tolarger populations. A comprehensive study (n = 153) conducted by Geers et al. (2009) reported that fewer children with CIsachieved age-appropriate scores on measures of verbal intelligence, connected language and syntactic knowledge whencompared to performance on vocabulary measures. In their study, a small number of children was using bilateral CIs (n = 4)which is in contrast with the increasing trend toward pediatric bilateral cochlear implantation (Peters, Wyss, & Manrique,2010). Moreover, none of these studies included complex linguistic tasks involving pragmatic abilities such as narrativeskills.

1.2. Error analyses

Most studies use standardized language tests with norm scores (Da Silva et al., 2011) and do not report error analyses.Although the comparison with a norm group is useful, the comparison with a normal hearing control group provides thepossibility to compare both groups on skills and sub-skills that cannot be derived from general norm scores. In themorphological domain, the correct use of auxiliary verbs (Ruder, 2004), adverbs (Le Normand, Ouellet, & Cohen, 2003),prepositions (Le Normand et al., 2003) and articles (Coene, Daemers, & Govaerts, 2010; Szagun, 2004) can be problematic inchildren with CIs. Additionally, these children often have difficulties using plurals (Ruder, 2004; Svirsky, Stallings, Lento,Ying, & Leonard, 2002) and the past tense (Hammer, 2010; Svirsky et al., 2002). Morphological error analyses not onlycontribute to developing better-targeted interventions, but also provide evidence for theories on underlying mechanismssuch as the auditory prominence hypothesis or the Morpheme-In-Noise perception Deficit (MIND). The auditory prominencehypothesis postulates that the grammatical acquisition sequence is related to the perceptual prominence of thecorresponding acoustic markers (Ruder, 2004; Svirsky et al., 2002; Szagun, 2004). The MIND-hypothesis adds that asuboptimal perception of low salient grammatical morphemes delays the acquisition of these morphemes (Hammer, 2010).Qualitative error analyses on other language domains are rare.

1.3. Predictive factors

The limited number of participants in studies including different language domains prevents an analysis of factorsassociated with language sub-skills. Young and Killen (2002) (n = 7), Spencer (2004) (n = 13) and Duchesne et al. (2009)(n = 27) did not report on associations between the results in specific language domains and predictive factors such as age atimplantation, gender, type of implant or school environment. Although a number of studies investigated the relationshipbetween generic language outcomes and possible predictors (Boons et al., 2012a; Geers, Strube, Tobey, Pisoni, & Moog, 2011;Niparko et al., 2010), as yet, it is unknown whether the effect of a predictive variable differs between language domains.Additionally, most studies report on language results in children who receive early intervention compared to children whoreceive later intervention (Frush Holt, Svirsky, Neuburger, & Miyamoto, 2004; McDonald Connor, Craig, Raudenbush,Heavner, & Zwolan, 2006; Miyamoto, Hay-McCutcheon, Iler Kirk, Houston, & Bergeson-Dana, 2008). Early interventiongroups generally presented homogeneous outcomes, but now that more and more children receive CIs at an early age it ispossible to probe sub-skills of language development and possible predictors. Due to changing policies, the currentpopulation consists of an increasing number of children receiving early and bilateral CIs, intense oral rehabilitation andmainstream education. For that reason, a detailed evaluation of a broad range of language skills in combination withpredictive factors in this unique group is crucial with regard to retaining optimal care and follow-up procedures.

1.4. Present study

The present study had two goals. First of all, it aimed at providing a quantitative and qualitative comparison of theoutcomes on four expressive language domains (vocabulary, morphology, syntax and narratives) of a contemporary group ofschool-aged children with CIs with a matched group of normal hearing and typically developing peers. Expressive languagetests were used to maximally differentiate between participants since good language production requires passive as well asactive linguistic knowledge. In addition to vocabulary skills, morphology and syntax development were evaluated sincethese language domains, which are crucial to structure language, are reported to be problematic in children with CIs.Narrative skills were included in order to evaluate pragmatic aspects and because they are strong predictors of later readingcomprehension (Crosson & Geers, 2001) and pre-requisites for academic success (Gillam, Pena, & Miller, 1999). Additionally,

T. Boons et al. / Research in Developmental Disabilities 34 (2013) 2008–20222010

in depth analyses of error patterns and types were performed within each language domain to characterize the languageoutcomes on a detailed level. Secondly, 12 child related, auditory and environmental factors were inventoried in order toexamine their association with language outcomes. Understanding the effect of these factors on language properties willhelp parents and therapists to optimize the circumstances for children with CIs to acquire age adequate spoken languageskills.

2. Methods

Two cochlear implant centers and one school for the deaf and hard of hearing participated in this cross-sectionalprospective multicentre study; two were located in Flanders (part of Belgium) and one in the Netherlands. Apart from someminor deviations, the Dutch language in both areas is identical.

2.1. Participants

Seventy children with a CI, aged 5–13 yr 3 mo, participated in this study. All were prelingually deaf and received their firstCI before the age of five (median = 1 yr 8 mo, IQR = 1 yr 9 mo). The majority of the children (80%) participated in the generalnewborn hearing screening program, established in Flanders since 1999 and in the Netherlands since 2006. Auditoryintervention with hearing aids or a cochlear implant started at an early age (median = 9 mo, IQR = 12 mo). At the time oftesting, 39% of the children used two CIs, 28% used a CI and a hearing aid contralaterally and 33% of the children solely used aCI. In the bilaterally implanted group, three children received the two CIs simultaneously. The time between the first andsecond CI in sequentially bilaterally implanted children ranged from 6 mo to 5 yr 3 mo. Every participant had normalintellectual abilities. No children with indications of mental problems (e.g. severe general development delay) or non-verbalIQ-scores lower than 80 were included. IQ-tests were administered during clinical follow-up between December 12th, 2000,and May 7th, 2010. Due to high variability in test instruments and test moments, exact test IQ-scores were not incorporatedas predictive factor in the study. Despite their normal intelligence, 27% of the participants were diagnosed with additionalbehavior (e.g. ADHD, ASD), learning (e.g. dyslexia), motor or balance disorders. Sixty-three percent of the children went tomainstream schools and 37% went to special schools. Seventy percent of the parents used oral communication with theirchild in the course of this study and 27% used oral communication supported with signs. Parents who were severely hearingimpaired themselves (3%, 2 participants) used sign language to communicate with their child. Table 1 lists the demographicinformation of the participants.

Each child with a CI was matched with a typically developing, normal hearing control child based on three criteria.First of all, the control child had the same gender since in studies with normal hearing children (Le Normand, Parisse, &Cohen, 2008) as well as in studies with children using CIs (Geers & Brenner, 2003) girls presented a small advantage overboys in language development. Secondly, the control child had the same chronological age with a maximum deviation of3 mo. Finally, because geographically related language differences (dialect variations) could affect detailed analyses, thecontrol child lived in the same area (Flanders: n = 37, the Netherlands: n = 33) as the child using CIs. All control childrenwere reported to have normal hearing by their parents; this was subsequently confirmed by audiological assessment. Airconduction thresholds at 500 Hz, 1 kHz, 2 kHz and 4 kHz were not higher than 20 dB HL. Pure tone audiometry wasadministered in a quiet room by means of a laptop with Apex 3 software (Francart, Van Wieringen, & Wouters, 2008), a24-bit external sound card type RME Fireface UC and Sennheiser HDA200 headphones. None of the control children werepart of multilingual families, were adopted or in foster care. Socio-economic status of the family was quantified by meansof the maternal education level, which was categorized as High School or College/University degree. The mothers of 47children with CIs (67%) provided information on their education level. Although the normal hearing controls were notmatched to the CI group based on socio-economic status, a post hoc comparison of the pair wise proportions of maternaleducation level (by means of the Mc Nemar test) did not reveal a significant difference (p = .219) between children withCIs (High School: n = 23, College/University: n = 24) and normal hearing controls (High School: n = 19, College/University:n = 28).

This study was approved by the KU Leuven Medical Ethical Committee and was conducted in accordance with theDeclaration of Helsinki (1975). Parents of all participants (hearing and hearing impaired) gave informed consent for theirchildren to participate in this study.

2.2. Test materials

Data were obtained from four spoken language (sub)tests: (1) the Expressive One Word Picture Vocabulary Test(EOWPVT), (2) the CELF Word Structure (CELF-WS), (3) the CELF Formulating Sentences (CELF-FS) and (4) the Bus Storysubtest of the Renfrew Language Scales.

The EOWPVT (Martin & Brownell, 2011) is a standardized expressive vocabulary test which evaluates the ability toname objects, actions, and concepts presented with color illustrations. The CELF-4-NL (Kort, Schittekatte, & Compaan,2010) is a standardized general language test. It consists of several receptive and expressive subtests. In the currentstudy, the subtest Word Structure was used to evaluate the expressive morphological abilities. The children were asked tocomplete a sentence that pertains to an illustration using the targeted word structures. The subtest Formulating

Table 1

Demographics of participants with CIs.

Child related factors

Gender Boy n = 31 [44%]

Girl n = 39 [56%]

Additional disabilities No n = 51 [73%]

Behavior n = 7 [10%]

Motor n = 5 [7%]

Learning n = 2 [3%]

Multiple n = 5 [7%]

Chronological age at testing Median 8 yr 2 mo Min 5 yr 0 mo

IQR 3 yr 10 mo Max 13 yr 3 mo

Etiology Unknown n = 21 [30%]

Genetic with connexin mutation n = 6 [8%]

Genetic without connexin mutation n = 11 [16%]

Infection n = 20 [29%]

Congenital malformation of cochleae n = 9 [13%]

Premature birth n = 3 [4%]

Auditory factors

Age at first fitting Median 1 yr 8 mo Min 6 mo


Duration of CI use Median 6 yr 4 mo Min 1 yr 6 mo


Contralateral stimulation CI -/ n = 23 [33%]

CI – HA n = 20 [28%]

CI – CI n = 27 [39%]

Environmental factors

Communication mode Oral n = 49 [70%]

Total n = 19 [27%]

Bilingual n = 2 [3%]

Oral multilingualism No n = 61 [87%]

Yes n = 9 [13%]

School type Mainstream n = 44 [63%]

Special n = 26 [37%]

Parental involvement Median 3.67 Min 1.83

IQR 1.23 Max 5.00

Socio-economic status Unknown n = 23

High School degree n = 23

College/University degree n = 24


Sentences, was used to focus on the expressive syntactic skills. The test leader read a word or expression and asked thechild to use it in a spoken sentence in reference to a picture cue. The Bus Story subtest of the Renfrew Language Scales(Renfrew, 1998) was used to evaluate narrative skills. In this narrative task, children were asked to retell the bus storywith picture support.

The EOWPVT, CELF Word Structure and CELF Formulating Sentences provide norm-referenced test scores as well as ageequivalent scores, which are based on typical language levels for normally developing children with normal hearing. In orderto correct for the increasing variability in language age as children get older, the age equivalent score can be divided by thechild’s chronological age to calculate a language quotient (LQ). This quotient indicates the ratio between the expected level ofperformance based on the chronological age and the actual performance of the child. This scale is frequently used in researchon language development in hard of hearing and deaf children (Angeli, Suarez, Lopez, Balkany, & Liu, 2011; Eisenberg, IlerKirk, Schaefer Martinez, Ying, & Miyamoto, 2004; Rance, Barker, Sarant, & Ching, 2007). A language quotient close to 1.00indicates an age appropriate language level and a quotient of 0.50 corresponds to a delay of half the chronological age. Aquotient of 0.82 corresponds to a delay of one standard deviation below the norm.

Since Dutch norm scores of the Bus Story test are not available yet, age equivalent scores and language quotients werecalculated in a different way. Based on the results of the 70 children in the control group a development curve wasestablished by fitting a regression line. The quadratic regression function age equivalent = 45.6 + 3.9 � raw score � 0.04 � raw

score2 (p < .001) best fitted the data (R2 = 0.41). This equation was used to determine the age equivalent scores based on theraw scores. Finally, language quotients were calculated similarly as in the other tests: language quotient = age equivalent/chronological age.

All tests were administered orally by qualified speech-language pathologists; signs used by the child were not included inthe scoring. Every child was tested individually in a quiet room at school or at home. The test sequence was varied randomlyand video recordings were made to allow precise and detailed scoring. Since testing took place in a clinical setting, it was notpossible to administer all tests in every child due to time restrictions. Results on all four language domains were available in62 children.


2.3. Error analysis

Besides the traditional general scoring of each language test, an error analysis was carried out. Firstly, within eachlanguage domain, language sub-skills were analyzed in detail. For every test, sub-skills were classified into categories.Table 2 provides an overview.

Secondly, when a child had problems with a certain sub-skill, the error types were analyzed. Errors were categorized indifferent groups. An overview and description of the error types is provided in Table 3.

All statistical analyses were performed using SPSS 19.0. Significance criteria were set at p < .05 and Bonferroni correctionsfor multiple comparisons were applied.

3. Results

3.1. Comparison of children with CIs versus normal hearing children

The language quotients of the CI group and normal hearing controls are plotted in Fig. 1. As expected, the control groupreached language quotients close to one (median: see triangles on horizontal axes in Fig. 1 and see Table 4). The inter quartilerange (IQR) was equal for the vocabulary and the morphology test (0.24), but somewhat larger for the syntax (0.29) and thenarrative (0.28) test. The median language quotients of the CI group were close to 0.82, which corresponds to the norm minusone standard deviation (see triangles on vertical axes in Fig. 1 and see Table 4). The inter quartile range was 0.20 for thevocabulary, 0.22 for the narrative, 0.32 for the syntax and 0.36 for the morphology test. Since the data were not normallydistributed (Shapiro–Wilk, p < .05), Wilcoxon Signed Rank tests were used to compare results of the CI group with results ofthe matched comparison group. As a group, the children with CIs performed significantly weaker on every language test(p < .001) (see Table 4). Although, approximately half of the CI group was able to achieve age-adequate language quotientshigher than one standard deviation beneath the norm (vocabulary = 57%, morphology = 52%, syntax = 45%, narratives = 47%),approximately one fourth of the group demonstrated a severe delay (more than 2SDs beneath the norm) (vocabulary = 19%,morphology = 26%, syntax = 30%, narratives = 26%) (see Fig. 1).

3.2. Comparison of language domains

A general analysis based on the results of 62 children on four language tests did not reveal strong or weak domains.Mann–Whitney U-tests were applied to analyze differences between language tests within the CI group and Spearman’s

Table 2

Sub-skills classification.

Test Sub-skills classification Example

Vocabulary [EOWPVT]

Noun trompet -trumpet-

Verb vliegen -flying-

Category eten -food-

Morphology [CELF-Word Structure]

Plural–regular form boeken -books-

Plural–irregular form eieren -eggs-

Diminutive boompje -small tree-

Separable verb afwassen -washing the dishes-

Past participle–regular form heeft gebouwd -has built-

Past participle–irregular form is gesprongen -has jumped-

Pronoun hem -him-

Demonstrative pronoun die/dat -that-

Comparative and superlative adjectives groter -bigger-

Present simple–third person singular schildert -paints-

Preposition voor de boom -in front of the tree-

Article het huis/de kip -the house/the chicken-

Adjective rode bloem -red flower-

Syntax [CELF-Formulating Sentences]

Noun auto -car-

Verb vergat -forgot-

Adjective lachend -smiling-

Adverb altijd -always-

Conjunction en -and-

Prepositional expressions in plaats van -instead of-

Narratives [Bus Story]

Essential De bus ging ervandoor -The bus ran off-

Subsidiary De koe zei: ‘‘Boe’’ -The cow said: ‘‘Moo’’

Table 3

Error classification.

Test Error classification Description

Vocabulary [EOWPVT]

No Answer The child is not able to name the picture and does not respond with an existing or

non-existing word.

Neologism The child responds with a non-existing word.

Not Related The child responds with an existing word which is not related (by meaning or

sound) to the target word.

Circumlocution The child responds with a description of the target word.

Related–Meaning–General The child responds with a more general term from the correct semantic field (e.g.

target word = cabbage, response = vegetable).

Related–Meaning–Neighbor The child responds with a term from the correct semantic field at a similar

specificity level (e.g. target word = cabbage, response = carrot).

Related–Meaning–Specific The child responds with a more specific term from the correct semantic field (e.g.

target word = cabbage, response = cauliflower).

Related–Sound The child responds with an existing word which sounds like the target word, but is

not related in meaning.


No Answer The child is not able to respond with an existing or non-existing word.

Neologism The child responds with a non-existing word.

Not Related The child responds with an existing word which is not related to the target word.

Related–lexeme The child responds with the lexeme of the target word (e.g. target word = ran,

response = run).

Related–neighbor The child responds with the correct lexeme, but an incorrect word form (e.g. target

word = ran, response = had been running).

Related–overgeneralization The child responds with the correct lexeme, but uses a general, not appropriate rule

to create the word form. (e.g. target word = ran, response = runned)

Related–other The child responds with the correct lexeme, but an incorrect word form which

cannot be categorized as a neighbor or overgeneralization.


Mild error The child responds with:

(a) a complete sentence with correct structure and only 1 or 2 deviations in

grammar or semantics

(b) a complete sentence that holds few information

(c) a complete sentence that is not related to the context of the picture

Severe error The child responds with:

(a) an incomplete sentence

(b) a complete sentence with more than 2 deviations in grammar or semantics

(c) a complete sentence that does not make sense

(d) a complete sentence that does not contain the target word or phrase

(e) a complete sentence that is not related to the context of the picture


Rank correlations were applied to analyze the coherence between different language tests. The language quotients of thetotal group on the vocabulary, morphology, syntax or narrative test were similar (p > .05). However, weak to modestcorrelations between the four language domains (min rs = .41, max rs = 0.69, p < .01) indicated good divergent validity. Thisconfirms that distinct language skills were assessed.

For every participant in the CI and the control group, the difference between the strongest language domain and theweakest language domain was calculated. These differences between highest and lowest language quotients were not largerin the CI group than in the control group (p > .05). Inter quartile ranges were similar in the CI and the control group for thevocabulary, the syntax and the narrative test scores (see Table 4). The variation in morphology test scores in the CI group(IQR = 0.36) was somewhat larger than the variation in the control group (IQR = 0.24).

Table 4

Difference between CI group and control group.

CI group Control group Total group

Median IQR Median IQR Z p n

EOWPVT 0.84 0.20 1.05 0.24 �5.707 <.001 68

CELF-WS 0.84 0.36 0.98 0.24 �4.376 <.001 69

CELF-FS 0.82 0.32 1.00 0.29 �4.957 <.001 66

Bus Story 0.82 0.22 1.02 0.28 �5.443 <.001 66

Note: IQR = Inter Quartile Range, Groups were compared with Wilcoxon Signed Rank Tests.

Fig. 1. Language quotients of the CI group and matched control group.

Note: * = matched pair with score of control child on horizontal axis and score of child with CI on vertical axis, ~ = group median.


3.3. Error analysis

In a first step, error analyses were carried out using all scores of children with CIs in order to track systematic errorsrelated to hearing impairment. In a second phase, error analyses were carried out on two subgroups. The first subgroupconsisted of children with CIs achieving language quotients higher than 2SDs beneath the norm (= good performingsubgroup). These analyses provide information on the sub-skills that develop problematically despite the overall goodoutcomes. The second subgroup consisted of children with CIs demonstrating a severe delay with language quotients lowerthan 2SDs beneath the norm (= poor performing subgroup). These analyses provide information on the systematic strengthsand weaknesses in sub-skills within the group of poor performers.

3.3.1. Vocabulary

The percentage distribution of sub-skills on which mistakes were made was similar for the children with CIs as for thenormal hearing control group (p > .05). This also applies for the good and poor performing subgroup since no significantdifferences could be found between these groups and the normal hearing control groups (p > .05). Statistical analyses of sub-skills are reported in Table 5.

Table 6 contains information on statistical analyses of error types. When children with CIs made a mistake, they moreoften did not give any response (Z = �3.14, p = .002) and less frequently responded with a neighboring word from the samesemantic field (related-meaning-neighbor) (Z = �2.67, p = .039) than normal hearing children. Within the poor subgroupchildren with CIs responded less often with a neighboring word (Z = �2.97, p = .021) than the controls. Within the good

Table 5

Sub-skills analysis: comparison of CI group versus control group.

Total group Poor performing subgroup Good performing subgroup

Vocabulary [EOWPVT]

Noun NS NS NS

Verb NS NS NS

Category NS NS NS


Plural–regular form p = .006 p = .012 NS

Plural–irregular form NS p = .007 NS

Diminutive p < .001 p = .005 NS

Separable verb NS NS NS

Past participle–regular form NS p = .010 NS

Past participle–irregular form p < .001 p = .003 NS

Pronoun p = .013 p = .005 NS

Demonstrative pronoun p < .001 p = .003 p = .001

Comparative and superlative adjectives p < .001 p = .002 p = .049

Present simple–third person singular NS NS NS

Preposition NS p = .010 NS

Article p < .001 p = .003 NS

Adjective p < .001 p = .010 p < .001


Noun p < .001 p = .002 p = .037

Verb p < .001 p = .001 p = .004

Adjective p = .027 p = .010 NS

Adverb p < .001 p = .001 p = .010

Conjunction p < .001 p = .001 NS

Prepositional expressions p < .001 p = .001 p = .019

Narratives [Bus Story]

Essential p < .001 p = .001 p = .002

Subsidiary p = .001 p = .001 NS

Note: Wilcoxon Signed Rank Test, NS = not significant, p < .05 = Control group demonstrates less errors on this sub-skill than CI group.


performing subgroup, children with CIs more often did not give any response (Z = �2.89, p = .027) than the normal hearingchildren.

3.3.2. Morphology

In general, children with CIs produced a higher percentage of errors on the sub-skills regular plurals, diminutives,irregular past participles, pronouns, comparative and superlative adjectives, demonstrative pronouns, articles and adjectives(see Table 5). The children within the poor performing subgroup scored significantly lower on all sub-skills of the CELF-WSexcept on the separable verbs and present simple. Children who generally achieved good morphological language levels didnot demonstrate difficulties with particular morphological structures, except comparative and superlative adjectives(Z = �2.89, p = .049), demonstrative pronouns (Z = �3.99, p = .001) and adjectives (Z = �4.25, p < .001).

The error analysis (see Table 6) revealed that children from the CI group less often produced overgeneralizations(Z = �3.00, p = .017) and more often used lexemes (Z = �3.23, p = .008), neologisms (Z = �2.83, p = .028) or did not respond atall (Z = �3.98, p < .001) than children from the control group. Children in the poor performing subgroup more often producedlexemes (Z = �3.44, p = .003) or did not respond at all (Z = �2.59, p = .010). Children in the good performing subgroup morefrequently chose not to respond (Z = �2.94, p = .003), and they produced a larger amount of neighboring answers comparedto the normal hearing controls (Z = �3.08, p = .012).

3.3.3. Syntax

The total group of children with CIs had significantly more difficulties with all sub-skills of the CELF-FS (p < .05) than thenormal hearing control group (see Table 5). Similarly, the subgroup of children with poor syntactic scores produced asignificantly higher percentage of errors on all sub-skills than the control children (p < .01). However, the good performingsubgroup reached similar scores as the control group on the adjectives (Z = �0.77, p > .05) and conjunctions (Z = �1.35,p > .05). Yet, they did demonstrate more errors on the nouns (Z = �2.74, p = .037), the verbs (Z = �3.41, p = .004), the adverbs(Z = �3.14, p = .010) and the prepositional expressions (Z = �2.95, p = .019).

Analyses of error types (see Table 6) revealed that the total CI group, as well as the poor and good performing subgroups,made significantly more severe errors and significantly less mild errors than the normal hearing controls (p < .010).

3.3.4. Narratives

While reproducing the Bus Story, children with CIs mentioned a significantly lower percentage of essential (Z = �4.95,p < .001) as well as subsidiary elements (Z = �3.46, p = .001) than the control children. The poor performing subgroup also

Table 6

Error analysis: comparison of CI group versus control group.

Total group Poor performing subgroup Good performing subgroup

Vocabulary [EOWPVT]

No Answer Co < CI (p = .002) NS Co < CI (p = .027)

Neologism NS NS NS

Not Related NS NS NS

Circumlocution NS NS NS

Related–Meaning–General NS NS NS

Related–Meaning–Neighbor Co > CI (p = .039) Co > CI (p = .021) NS

Related–Meaning–Specific NS NS NS

Related–Sound NS NS NS


No Answer Co < CI (p < .001) Co < CI (p = .010) Co < CI (p = .003)

Neologism Co < CI (p = .028) NS NS

Not Related NS NS NS

Related–lexeme Co < CI (p = .008) Co < CI (p = .003) NS

Related–neighbor NS NS Co < CI (p = .012)

Related–overgeneralization Co > CI (p = .017) NS NS

Related–other NS NS NS


Mild error Co > CI (p < .001) Co > CI (p = .001) Co > CI (p = .007)

Severe error Co < CI (p < .001) Co < CI (p = .001) Co < CI (p = .007)

Note: Wilcoxon Signed Rank Test, NS = not significant, Co > CI = Control group demonstrated error more frequently than CI group, Co < CI = Control group

demonstrated error less frequently than CI group.


demonstrated this problematic reproduction of essential (Z = �3.63, p = .001) and subsidiary (Z = �3.63, p = .001) elements,but the good performing subgroup did not differ from the control group on the percentage of subsidiary elements (Z = �0.94,p > .05) (see Table 5).

3.4. Factors related to language outcomes

Additional analyses were applied in order to explore which factors were related to good and poor outcomes on the fourlanguage domains. Twelve factors were taken into account; four child related, three auditory and five environmental factors(see Table 1). (1) The gender of the child, (2) the presence of additional disabilities, (3) chronological age at the time of testingand (4) etiology of the deafness were categorized as child related factors. These characteristics are inherent to the child andconsequently cannot be changed or influenced by others. (5) Age at first fitting, (6) duration of CI use and (7) contralateralstimulation were labeled as auditory factors, which are characteristics of the pediatric auditory rehabilitation process. (8)The communication mode (oral/total/bilingual) used by the parents at the time of testing, (9) one or more spoken languagesused (e.g. French, Turkish) by the family, (10) school type (mainstream or special), (11) parental involvement in therehabilitation process and (12) socio-economic status of the family (quantified by the education level of the mother) wereconsidered environmental factors. These are external characteristics determined by the child’s environment at the time oftesting. Parental involvement in the rehabilitation process was measured by asking audiologists or speech-languagetherapists to complete a questionnaire (see Appendix) that rates parents on 7 indicators of involvement (e.g. requests helpfor child, attends appointments, etc.) using a 5-point scale (0 = not involved, to 5 = highly involved). The maximum score forthis measure is 35. This parental involvement inventory was constructed for use in this study but is similar to otherinventories measuring this construct (e.g. Calderon, 2000).

Logistic regression models with stepwise backward elimination based on likelihood-ratios were constructed to analyzeindependent factors related to language skills when adjusting for potential confounders. Because duration of CI usecorrelated with chronological age (r = .87, p < .001) and socio-economic status was strongly related to parental involvement(U = 107.5, p < .001), both variables were excluded from the model owing to multicollinearity problems. In addition,educational setting and communication mode were not included, because they were often chosen on the basis of languageoutcomes and therefore could not be incorporated as an independent variable. In order to draw conclusions on the basis of alogistic analysis, some assumptions should be valid: (1) the model should have little or no multicollinearity, (2) thepredictors should have non-zero variance and (3) the values of the outcome variable have to be independent. Since thefactors duration of CI use and socio-economic status were excluded from the model, none of the predictors had zero variance,and each value of the outcome variable came from a separate child, data met these assumptions.

Three factors were significant predictors of good or poor vocabulary outcomes (see Table 7). The presence of additionaldisabilities (p = .017) and more than one spoken language (p = .015) in the family enlarged the odds of poor vocabulary skills.Children with multiple additional disabilities (80%) demonstrated most often poor language quotients. Additionally, 55% ofthe children who were raised with more than one spoken language achieved poor vocabulary scores. Finally, as children gotolder they had a significantly larger chance to be in the good performers group (p = .029).

Table 7

Logistic regression.

Vocabulary Morphology Syntax Narratives

Auditory factors

Age at first fitting NS NS NS NS

Contralateral stimulation NS NS NS p = .030

Child related factors

Gender NS NS NS NS

Chronological age p = .029 p < .001 NS p = .067

Etiology NS p = .005 NS NS

Additional disabilities p = .017 NS NS p = .049

Environmental factors

Multilingualism p = .015 p = .039 p < .001 p = .024

Parental involvement NS NS NS NS

Cox and Snell R2 .313 .459 .192 .306

Nagelkerke R2 .495 .675 .271 .452

Note: NS = not significant.


The performance on the morphology test was also related to three factors (see Table 7). Similar as in the case ofvocabulary scores, chronological age (p < .001) and more than one spoken language used by the family (p = .039) had asignificant effect on the odds to demonstrate good morphological scores. Additionally, etiology was a significant predictor ofthis outcome variable (p = .005). Post hoc inspection of the data showed that two of the three children who became deaf afterpremature birth achieved poor morphological skills. These two children also suffered multiple additional disabilities.

One factor was significantly related to the outcome on the syntax test; more than one spoken language used in the family(p < .001) (see Table 7). Seventy-five percent of the multilingually raised children achieved poor syntactic languagequotients.

The narrative outcomes were related to the same predictors as the vocabulary outcomes: chronological age (p = .067),more than one spoken language (p = .024) and additional disabilities (p = .049) (see Table 7). Additionally, contralateralstimulation was significantly related to narrative outcomes (p = .030). Eighty-eight percent of the children with bilateral CIsand 93% of the children using a hearing aid at the contralateral ear achieved good narrative quotients, but only 64% of theunilateral CI users demonstrated a good score.

Although educational setting and communication mode were not included in the regression model, the relationshipbetween these variables and the language outcomes was analyzed post hoc. Children achieving good vocabulary(x2(1) = 15.8, p < .001), morphology (x2(1) = 12.4, p < .001), syntax (x2(1) = 25.0, p < .001) or narrative quotients (x2(1) = 7.8,p = .005) were more likely to participate in mainstream education. Fifty-six percent of the children in the subgroup achievingpoor vocabulary scores attended mainstream education compared to 95% in the subgroup with good vocabulary scores. Inthe group with poor morphology skills, half of the children (50%) attended mainstream schools, while 88% in the goodperforming group participated in mainstream education. Thirty-five percent of the children with poor syntax outcomesparticipated in mainstream schools, whereas 92% of the children with good syntax outcome attended mainstream education.With regard to the narrative test, 54% of the children with poor outcomes and 86% of the children with good outcomes wentto mainstream schools. Children with good results on the CELF-sentence formulation subtests had the best chance to beincluded in mainstream education.

For the four language tests, more parents of children with poor skills used oral communication supported with signs orsign language to communicate with their child (vocabulary: 28%, morphology: 50%, syntax: 44%, narratives: 31%) comparedto parents of children with good language skills (vocabulary: 17%, morphology: 16%, syntax: 24%, narratives: 25%). Thisassociation between language quotients and communication mode used by the parents was only significant for themorphology test (x2(2) = 8.4, p = .015).

4. Discussion

4.1. General language levels and variability

The median scores of the control group were close to 1 which confirmed that the selected comparison children were arepresentative sample of the normally developing population. The median scores of the CI group were close to 0.82 whichcorresponds to the norm minus one standard deviation. This was remarkably higher than the average language quotientsmentioned in a preceding retrospective study (Boons et al., 2012a). In that study, the mean language quotient on the ReynellDevelopmental Language Scales and Schlichting Expressive Language Test of a large group (n = 288) of children with CIs was0.66 three years after cochlear implantation. While the mean age at implantation (2 yr 2 mo, SD = 1 yr 1 mo), percentage ofparticipants with additional disabilities (23%) and rehabilitation procedures (standard procedures in Flanders and the


Netherlands) were similar to the present study, participants did differ strongly on two characteristics. In the retrospectivestudy, participants were younger (2–8 yr, present study 5–13 yr) and fewer had bilateral CIs (19%, present study 39%).Presumably, children catch up as they get older (Hayes, Geers, Treiman, & Moog, 2009) so that the present, older groupreached higher language quotients. Additionally, the large percentage of participants with bilateral CIs (39%) in this studypossibly had an impact on the general language level of the group. It has been demonstrated that the improved ability toperceive speech in noise may possibly relate to better language development (Tait et al., 2010). The mean language quotientsof bilaterally implanted children (mean = 0.82) (Boons et al., 2012b) were equal to the median language scores of the currentparticipants.

Several studies reported the large amount of variability in language outcomes (Frush Holt & Svirsky, 2008; Geers et al.,2009) with some children achieving age-adequate language levels and others lagging behind (Niparko et al., 2010; Peterson,Pisoni, & Miyamoto, 2010). In the current study, variation within the CI and the control group, expressed as inter quartileranges, was similar for the vocabulary (controls: IQR = 0.24, CI: IQR = 0.20), the syntax (controls: IQR = 0.29, CI: IQR = 0.32)and the narrative test scores (controls: IQR = 0.28, CI: IQR = 0.22). The variation in morphology test scores in the CI group(IQR = 0.36) was somewhat larger than the variation in the control group (IQR = 0.24). Although in general, variability inoutcomes was not higher in the CI group, this variation was interpreted differently. Since the median of the control groupwas age-adequate, variation ranged from a mild advantage to a mild delay. The median of the CI group was at the level of amild delay, so the variation ranged from age-adequate to a severe delay, which might give the impression of a largervariability.

4.2. Characteristics of language domains

The results of the children with CIs did not yield systematic strong or weak expressive language domains. Schorr, Roth,and Fox (2008) also reported an even pattern of strengths and weaknesses in structural language when they evaluatedreceptive and expressive vocabulary, syntax and morphology, and metalinguistics in a sample of 39 congenitally deafchildren, ages 5–14 yr. The study of Duchesne et al. (2009) in which vocabulary, grammatical morphemes, and syntacticconstructions were evaluated in a group of 27 French-speaking children aged 3–8 yr who received a CI, revealed fourdifferent language profiles: one within normal limits, one with general language delay on all tasks, one with normallexical abilities but receptive grammar delay, and one with discrepancies across language domains. However, theseprofiles were based on examinations of individual results and did not reflect a group pattern of systematic strengths andweaknesses.

Analysis of sub-skills in the vocabulary test EOWPVT did not reveal differences in the knowledge of nouns, verbs orcategory words between the CI group and the controls. This was to be expected since a qualitative analysis of early lexicon(50- and 100-word lexicons) showed similar distributions of word categories in early CI users and in hearing controls (Nott,Cowan, Brown, & Wigglesworth, 2009). Additionally, in the field of abstract vocabulary, the study of Kunisue et al. (2007) didnot report qualitative differences between children with normal hearing or hearing loss. Analyzing the error types did showsome specific characteristics of the CI group. The subgroup with poor vocabulary skills less frequently used a neighboringword from the same semantic field and the subgroup with good vocabulary skills more frequently failed to reply than thecontrol group. Since their vocabulary was smaller, children with CIs have less opportunity to find a neighboring word in thesame semantic field. Additionally, the fact that they experienced years of impaired language development, might have led toa kind of fear of failure causing them to avoid errors and preferring not to respond instead of using the general term ormaking a mistake. The fact that there was no difference in not-related responses or sound-related responses can be anindication that the semantic fields of children with CIs were organized correctly and they related the picture to theappropriate content.

On the morphological subtest CELF Word Structure, the total CI group and all subgroups did not differ from thenormal hearing controls on separable verbs and the present simple. The separable verbs were difficult for children withCIs (49% correct) as well as for normal hearing controls (54% correct), which explained why there was no differencebetween both groups. Children with CIs and normal hearing controls achieved high percentages correct on the presentsimple (CI group 83% correct, control group 89% correct). This type of conjunction was well known by most children,which was to be expected since it is one of the first forms they learn after the infinitive (Schaerlaekens & Gillis, 1987).The subgroup with good morphological language quotients did not differ significantly from the control group on thesub-skills, except on comparative and superlative adjectives, demonstrative pronouns and adjectives. An explanation forthese persistent problems can be found in the auditory prominence or morpheme-in-noise hypothesis. The acousticdifference between the two pronouns (‘die’ and ‘dat’), the suffixes in comparative and superlative adjectives (‘-er’, ‘-ste’)or the suffix-schwa in attributive adjectives is very small and might not be picked up by pediatric cochlear implantusers. Another reason for the difficulties with demonstrative pronouns and adjectives can be the fact that they areflexions without a semantic basis. The gender of Dutch nouns (masculine, feminine, or neuter) determines thedemonstrative pronouns referring to it and the flexion of the attributive adjectives combined with it. The gender of theword has no semantic correlate, which makes it an abstract feature that is difficult to train. Analyzing the error typesrevealed significantly less overgeneralizations and more lexemes, neologisms and non-responses in the CI group than inthe normal hearing controls which indicated that they generally lack knowledge of morphological rules and regulations.The children who demonstrated poor morphological language quotients, more frequently responded with a lexeme than


the normal hearing controls. They seem to lack knowledge on when to apply flexions. The good performing subgroupmore often responded with an incorrect word form (lexeme-neighbor). Although they were more aware of when toapply flexions, they still confused the flexion types.

On the syntactical subtest CELF Formulating Sentences, the CI group had a higher percentage of errors on all sub-skillsthan the control group. Additionally, their errors were more often severe than the error types of the control children.Similarly, the children with poor syntactic outcomes had a higher percentage of severe errors than the controls, and mademore errors on all syntactic structures. However, the good performing subgroup did not differ from the normal hearingcontrols on adjectives and conjunctions. This contrasts with the fact that the good performing subgroup made more errors onadjectives in the morphological task. The task to create correct sentences including given adjectives seems less difficult thanthe task to complete a given sentence by filling in correct adjectives.

The narrative error analysis of the Bus Story revealed a higher amount of difficulties reproducing essential as well assubsidiary elements in the CI group with poor narrative language quotients than in the matched control groups. The CI groupwith good narrative language quotients did not perform differently on the subsidiary elements, but did show higherpercentages of errors on essential story elements. It has been reported that children with hearing problems, despite earlydiagnosis and intervention, demonstrate problems with story content (Worsfold, Mahon, Yuen, & Kennedy, 2010).Apparently, it is very challenging for children with CIs to focus on the core content of the story, even if they have goodlanguage skills and can reproduce the subsidiary elements well.

4.3. Factors related to language outcomes

The major final aim of pediatric cochlear implantation is to enable deaf children to achieve good spoken language levelsin order to provide optimal opportunities for social and academic development. Seventy to eighty percent of the childrenwith CIs demonstrated good language outcomes (<�2SD). Some factors were related to the development of good languageskills.

The use of one spoken language by the parents was consistently related to better language outcomes. However, 7out of 9 multilingual families were Turkish, Moroccan, Iranian immigrant families. In addition, in 4 families theparents had limited knowledge of the Dutch language. Conclusions about the negative influence of a second orallanguage on the development of Dutch in children with CIs should be nuanced by the complex situation of immigrantfamilies.

Testing language outcomes at various ages, may introduce variance reflective of different developmental stages.Chronological age was a significant predictor for performance in all language domains, with the exception of syntax. Thisindicates that the likelihood of good language outcomes increases as children with CIs get older, which seems to point outthat they are catching up. This is in contrast with findings from a previous study (Boons et al., 2012a) in which no differencewas found between language scores 1 yr, 2 yr and 3 yr after implantation. However, the current group of participants wasolder (5–13 yr 3 mo instead of 2–8 yr) and had more experience with the CI (median: 6 yr 4 mo, IQR: 3 yr 8 mo). Thisextended period of experience with the CI in combination with cognitive maturation has enlarged the probability of goodlanguage outcomes.

The negative effect of behavioral disabilities and multiple disabilities on language outcomes was significantfor the vocabulary and narrative test results. Both language domains are less structured and regulated than morphologyand syntax and are strongly related to language semantics. Apparently, the effect of additional disabilities wasstronger on content related language domains than on form related domains. Probably, additional disabilitiesaffect general cognitive development and knowledge of the world, which can, in turn, lead to diminished semanticknowledge.

For the morphological language quotients, the factor etiology was a significant predictor. Post hoc inspection of the datarevealed that mainly children who became deaf after premature birth demonstrated poor morphological skills. Since themajority of these children were diagnosed with multiple disabilities, the negative effect of prematurity on languagedevelopment was probably enforced by the additional disabilities.

Contralateral stimulation was a significant predictor for narrative language outcomes; children with a hearing aid orsecond CI at the other ear were more likely to demonstrate good narrative language quotients than children withoutauditory stimulation at the other ear. The effect of this variable was only significant for the narrative task, which mightindicate that the positive effect of bilateral and bimodal stimulation mainly appears in complex tasks in which auditoryperception, working memory and language production must be adequately combined in order to perform the taskcorrectly. This is in accordance with the finding that advantages for children who had some bimodal experience wererestricted to language abilities that are generative in nature (Nittrouer & Chapman, 2009). Only recently, studies onbilateral CIs have reported on the impact of improved lateralization (Basura, Eapen, & Buchman, 2009; Steffens et al., 2008),localization (Grieco-Calub & Litovsky, 2010; Van Deun et al., 2010) and speech recognition skills (Litovsky, Johnstone, &Godar, 2006; Van Deun, Van Wieringen, & Wouters, 2010; Zeitler et al., 2008) on language development (Boons et al.,2012b; Tait et al., 2010). The current findings support the idea that the improved auditory skills facilitate the ability to pickup language in daily life.

Age at first fitting was not a significant predictor for any of the language test scores. This is in contrast with previousresearch on the positive effect of early cochlear implantation on language development (Dettman, Pinder, Briggs,


Dowell, & Leigh, 2007; Geers, Tobey, Moog, & Brenner, 2008; Johnson & Goswami, 2010; Tait, Nikolopoulos, &Lutman, 2007). Since cochlear implantation was applied quite early in the current group of participants (median age:1 yr 8 mo), and every child received auditory intervention (with CI or hearing aid) before the age of 2 yr, the effect of ageat first fitting on language outcomes at the age of 5–13 yr 3 mo was not significant. This does not imply that age atcochlear implantation does not have an important effect on later language development. It indicates that the effect wasnot measurable within this group of children who were quite homogeneous on the area of early detection andintervention.

The current study also showed that communication mode and school type are associated with language outcomes. Thevast majority of parents of children with good language quotients communicated orally. However, this does not imply thatoral communication leads to good language skills or that good language development will lead to a preference for oralcommunication. Nevertheless, the present study demonstrated the interrelationship between both. Additionally, asignificantly higher percentage of children with good language quotients attended mainstream education. Probably, theirgood language levels enabled them to participate in hearing classes often supported by remedial teaching. It is noteworthythat the vast majority of the children with good language quotients went to mainstream schools, but they still demonstratedsignificant difficulties with specific morphological structures (e.g. demonstrative pronouns, adjectives), syntactic tasks (e.g.nouns, verbs) and the narrative reproduction of essential story elements. It is important to realize that although childrenachieve relatively good general language skills and attend mainstream schools, they still require a specialized rehabilitationprogram focusing on specific language aspects.

Although the present study extended the knowledge on several factors contributing to language acquisitionin children with CIs, the influence of other skills and developmental areas such as auditory processing (Duchesneet al., 2009), working memory (Engel-Yeger, Durr, & Josman, 2011), non-verbal IQ (Geers, Nicholas, & Moog, 2007;Geers et al., 2008), cognitive processing of language (Nittrouer, Caldwell, & Holloman, 2012), and phonologicalawareness (Johnson & Goswami, 2010) on language outcomes still needs further exploration. Additionally, althoughthe total sample size was sufficiently large, the number of children at each individual value of the predictors wasrelatively small. Bearing these limitations in mind, the current findings allow clinicians to optimize rehabilitationprocedures.

5. Conclusion

As a group, children with CIs performed significantly weaker than normal hearing peers on four expressive languagedomains. However, approximately half of the group was able to achieve age-adequate language levels and the variability wasnot larger within the CI group compared to the control group. Analyses of error types revealed no systematic problem areaswith regard to vocabulary skills, but a general lack of knowledge on morphological and syntactic rules and regulations andinefficient narrative skills. These findings characterize the language outcomes of a new target group that consists of childrenwho received early diagnosis and intervention, and the majority of whom used contralateral auditory stimulation by meansof a hearing aid or second cochlear implant.

Children without additional disabilities who were raised with one spoken language were more likely to present goodlanguage skills. As they got older, more children achieved good language outcomes which indicated a tendency to catch upwith hearing peers. Additionally, in the most complex expressive task, story retelling, the positive effect of contralateralstimulation was significantly present. The majority of the children with good language quotients was able to use oralcommunication with their parents and attended mainstream classrooms, but still demonstrated systematic weaknesses onmorphological, syntactic and narrative sub-skills. Therapeutic intervention focusing on specific weaknesses remainsnecessary to optimize these children’s language development.

Acknowledgements

The authors wish to thank Sarah De Broe, Kim Goossens, Karen Op de Beeck and Hanne Schoofs for their contribution tothe data collection. Moreover, the authors wish to acknowledge all the children, their parents, CI-teams, schools, andteachers for their commitment to the study.

Appendix A. Questionnaire on parental involvement.

With this questionnaire, you can report on the involvement of the parents of ________________________________These are the response options:0 = not at all2 = a little3 = average4 = more/better than average5 = exceptionally well


Not applicable
I don’t know 0 2 3 4 5
– The parent knows what the child is capable of.(E.g. Knows in which situation the child experiences

difficulties understanding speech)

Clarification:

– The parent understands how the CI worksand can handle the device correctly.

(E.g. Checks whether the batteries are charged)

Clarification:

– The parent strictly attends appointments.(E.g. Is always on time)

Clarification:

– The parent contacts us/searches for help in case ofdoubts about the development of the child.

Clarification:

– The parent contacts us/searches for help in case ofdoubts about the functioning of the CI.

Clarification:

– The parent takes the initiative to additionallystimulate the child’s development.

(E.g. Summer camp for children with CIs)

Clarification:

– Something else.Clarification:

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