Warning: mkdir(): Permission denied in /home/virtual/lib/view_data.php on line 81 Warning: fopen(/home/virtual/audiology/journal/upload/ip_log/ip_log_2023-06.txt): failed to open stream: No such file or directory in /home/virtual/lib/view_data.php on line 83 Warning: fwrite() expects parameter 1 to be resource, boolean given in /home/virtual/lib/view_data.php on line 84 Language Intervention Instead of Speech Intervention for Children With Cochlear Implants

Language Intervention Instead of Speech Intervention for Children With Cochlear Implants

Article information

J Audiol Otol. 2023;27(2):55-62
Publication date (electronic) : 2023 April 10
doi : https://doi.org/10.7874/jao.2022.00584
1Department of Speech and Language Pathology, Faculty of Education and Rehabilitation Sciences, University of Zagreb, Zagreb, Croatia
2Department of Hearing Impairments, Faculty of Education and Rehabilitation Sciences, University of Zagreb, Zagreb, Croatia
Address for correspondence Luka Bonetti, PhD Department of Hearing Impairments, Faculty of Education and Rehabilitation Sciences, University of Zagreb, Borongajska cesta 83f, 10000 Zagreb, Croatia Tel +385-(0)1-245-7500 Fax +385-(0)1-245-7559 E-mail luka.bonetti@erf.unizg.hr
Received 2022 December 16; Revised 2023 February 18; Accepted 2023 February 24.


Cochlear implants are a standard rehabilitation option for children with severe hearing loss or deafness, allowing access to speech sounds necessary for the development of spoken language. However, the speech-language outcomes of pediatric cochlear implant users vary widely and are not directly or exclusively linked to technology but to combinations of individual audiological, personal, technical, and habilitational factors. These combinations may not favor spoken language development, which may further be linked to the issue of prior insistence on spoken language learning and associated with a high risk of language deprivation. Here, we discuss the outcomes of cochlear implantation from a habilitative perspective and lay down the efforts and resources necessary for the development of communication competence after cochlear implantation rather than the achievement of specific hearing, language, or speech skills that have limited socioemotional and educational contributions and do not guarantee an independent or productive life.


Owing to the constant increase in the already large population of deaf and hard-of-hearing people (DHH) [1], cochlear implant (CI) technology is constantly improving. Hence, modern devices of this type enable the audibility of the entire speech spectrum which implies great potential for spoken language development or conservation [2]. Continuous efforts to improve CI performances resulted in the rise of this technology to the status of the most successful implantable device in modern medicine [3]: as of December 2019, approximately 736,900 registered devices have been implanted worldwide [4].

In some cases, CIs enable spoken language, literacy, and educational development consistent with hearing peers [2,5,6]. In adults [7-9] and elderly adults [10,11] with postlingual hearing loss, the potential of CIs is reflected in the improvements in quality of life. For the wide use and further development of this technology, an important illustration of its success is 9,000 to even 40,000 US dollars worth of annual gains in quality of life per patient [12], mostly due to improvements in employment and job retention.

Candidates for cochlear implantation are people with severe-to-profound or higher degrees of sensorineural hearing loss, who do not benefit from classical hearing aids, have good general health and psychosocial status, and have no structural obstructive findings in the auditory pathway. The rapid development of this technology and the positive outcomes of implantation constantly contribute to lowering the preoperative criteria; therefore, recently, people with lower pure tone thresholds, more favorable aided speech perception, and unilateral deafness have been implanted [13].

Emphasis on the positive side of CI technology can lead to the conclusion of its universal (re)habilitation success, but this conclusion is biased, considering the abundance of evidence of significant variability in its outcomes. Postlingually implanted persons obtain hearing functionality that positively affects their quality of life, and there is no doubt that this technology is a valuable solution for most individuals with postlingual sensorineural hearing loss who do not benefit from classical hearing aids. However, this technology still cannot uniformly compensate for the consequences of congenital or early acquired hearing loss on the development of listening, communication, language, speech, cognition, and, ultimately, academic achievement.

Given the documented coexistence of excellent pre-implantation characteristics and subsequent poor language and speech outcomes [14], the variable success of CIs in a population with prelingual hearing loss should be viewed through the prism of the complex inter-relationships of several important factors [15]. A fact that is often (opportunely) overlooked is that the brain stimulation provided by a CI is by no means the same—or even very similar—to that provided to the brain by the hearing ear: in comparison, it is incomplete, degraded and for some users clearly insufficient for speech development [16,17]. However, some pediatric CI users manage to utilize this receptive, “raw material” to achieve spoken language outcomes in line with their peers. The question of why such variability occurs despite equal entry characteristics and early interventions remains open. The aim of this study is to highlight the factors so far identified as important for spoken language outcomes in pediatric CI users. In the paper, the CI technology is viewed ecologically and multidimensionally, considering overall impact of this technology on communication and subsequent quality of life, and not only on listening, language, and speech development, as it is often the case [18]. This aim was set in accordance with empirical evidence of the romanticization [19] of CI technology as a universal and optimal solution [20], which prevents the realization of: 1) its real current reach in the delivery of a quality signal to the auditory centers in the brain, and 2) the importance of non-technical aspects of the intervention, which is reduced by the nonobjective presentation of this technology [21].

Predictors of Cochlear Implantation Outcome in the Pediatric Population Identified So Far

The greatest potential near-peer receptive and expressive language development is generally associated with very early cochlear implantation [22-31]—at the age of up to 4 years of life, in the period of the greatest plasticity of the central nervous system [32]. Only early, continuous, and rich stimulation of the auditory pathway promotes the development of auditory centers in the brain, and without it, it is impossible to expect the brain to develop all the resources necessary for speech communication [33,34]. The earliest possible stimulation of auditory centers creates a direct neurophysiological possibility for the development of perceptual abilities that precede learning to listen to speech, which is the basis of learning spoken language, reading, writing, and learning in general [2]. The exploitation of neural plasticity by stimulating the auditory centers with CIs implies their use during all waking hours [35,36]. The number of hours of daily use of CIs and the duration of their use from the point of implantation are also important factors in language and speech outcomes in the pediatric population.

Increasingly advanced speech processing strategies that deliver signals to the auditory nerve through a greater number of active electrodes with a better dynamic range favor more successful hearing, language, and speech development [37-39]. Therefore, the success of CI technology is logically connected with expert performance management of these devices, that is, the programming of their processors according to the specific needs of individual users.

The literature suggests that optimal habilitation after cochlear implantation is oriented towards abundant spoken language stimulation [23,40], facilitated through continuous guidance and training of family members by a team of experts [41]. Specific personal and environmental factors—gender, nonverbal IQ, affinity for listening and oral language development, and family educational and socioeconomic characteristics— may also play an important role in the final outcomes of cochlear implantation [17,42,43].

Neurocognitive Studies of Cochlear Implantation Outcomes in the Pediatric Population

The aforementioned factors have limited predictability [44], so recent research has focused on the search for additional factors that could explain the variability in the language outcomes of pediatric CI users [45]: the neurobiological and neurocognitive aspects of spoken language learning. According to the “neurocognitive theory,” some pediatric CI users cannot compensate for the absence of the earliest stimulation of the auditory centers in the brain, and even after early cochlear implantation show weaknesses in the development of sensory coding and corresponding language processing skills of speech sounds provided by the device. This theory highlights specifics in the neurocognitive development of children with a CI (more precisely, in verbal working memory), caused by the absence of listening in the months before implantation and consequential failure in learning the time-sequential features of speech sounds [45-47]. Neurocognitive theory points out that auditory deprivation that precedes early cochlear implantation hinders some pediatric CI users in the development of cognitive functions necessary for language processing, such as learning to recognize a series of sounds in which words are made up (i.e., in the development of phonological awareness).

However, “sensory theory” emphasizes the still insufficiently reliable quality of the sounds delivered to the auditory centers in the brain by the implanted device. This theory also focuses on verbal working memory [48], but from the perspective of difficulties in learning the correct phonological codes and consequent weaknesses in the development of phonological awareness due to the degraded signal that arrives for processing [16]. This enables the coexistence of minor lexical and major phonological difficulties in the language of children who use CIs. Therefore, due to the inability of speech signal processors in CIs to faithfully transmit all the acoustic features of speech, mental representations of speech sounds are not formed correctly, which negatively affects the further language development [49].

Further research focused more closely on the working memory model [48] to gather evidence for a stronger argumentation of one or the other mentioned theory. In this regard, some authors state that non-verbal (visuo-spatial) working memory in pediatric CI users also appears to be inferior compared to their hearing peers [44,46,50,51], which is considered a potential predictor of the variance in their language outcomes. However, other studies suggest that the effects of early auditory deprivation and poor signal resolution provided by CIs are reflected differently in verbal and non-verbal working memory. Some authors report that weak working memory skills, even with good audibility, first refer to the verbal aspect (coding, storage, and manipulation of verbal information), while in the visuo-spatial aspect (storage and manipulation of non-verbal information), pediatric CI users demonstrate skills consistent with their peers [52,53]. Therefore, it is possible that the different organization of working memory in children with CIs is not actually an exclusive consequence of early hearing deprivation, but that in its verbal component, it results from difficulties with the coding of speech sounds, and in the non-verbal component from the verbal mediation of visual information whose processing is being observed (e.g., verbal encoding of numbers or colors in working memory tasks). When this mediation is avoided, the performance of children with CIs on non-verbal tasks improves [52]. In simpler terms, research on the non-verbal working memory of children with CI has shown that they have the same cognitive potential as their hearing peers if there is no verbal mediation in the working memory tasks, which undermines the cognitive theory of a specific brain architecture due to early auditory deprivation and contributes to the sensory theory about the still insufficient resolution of speech sound provided by the CIs. It seems that early hearing deprivation does not generally affect the cognitive potential of children with CIs, but in relation to their hearing peers, they achieve poor results only on cognitive tasks that are verbally saturated or indirectly rely on verbal skills, which is a consequence of technology that does not provide sufficient resolution for spoken language learning; if the verbal aspect is excluded from cognitive tasks, the performance of children with CIs becomes comparable to that of their hearing peers [52,54,55].

Working memory is a constitutive part of so-called executive function—higher cognitive processes necessary for directing, organizing and self-controlling behavior [56]—which was also marked as inferior in children with CI to one of their hearing peers, and language skills seem to be a mediating factor for cognitive functionality, but not vice versa (poor results of executive function tests did not lead to poorer language skills) [57]. This indicates that prelingual hearing impairments do not affect cognitive architecture per se, but higher cognitive mechanisms are formed in accordance with the received stimulation during development [58]. In other words, brain plasticity has an experiential basis [59], so the organizational and functional specifics of its development depend on the stimulation it is exposed to. Therefore, along with parental bonding, attention-getting strategies, socio-cognitive development, and other stimuli [60], a crucial element for brain development is exposure to quality linguistic stimulation [61].

Practical Considerations of Neurocognitive Research on Outcomes of Cochlear Implantation in a Pediatric Population

What do the presented facts mean in the everyday life of pediatric CI users and their families who rely on spoken language for communication? There is abundant evidence that these children, regardless of the excellent pre- and post-operative conditions and the modern sophisticated technical solutions they use, achieve significantly poorer results on standardized language measures compared to their hearing peers [62]. Therefore, in this population, one can talk about general low-quality language stimulation (even language deprivation [20]), which is reflected in more developmental areas, such as perception, language, and speech, and consequently cognition, intelligence, and emotional, social, and academic success [63-65]. The consequences of “low-calorie” language stimulation in this population include poorly developed vocabulary [66,67], receptive and expressive morpho-syntactic skills [68-70], phonological awareness [71-73], and reading and writing skills [74,75]. As the expected increase in the complexity of language fails to emerge with increasing age, and as academic requirements start to become more demanding and difficult to fulfill, language delays become more obvious [76-78].

The aforementioned underdeveloped receptive and expressive language and speech skills of DHH children can be further connected to cognitive and socio-emotional domains, such as increased risk of emotional and behavioral difficulties and undesirable and destructive behaviors [79-81], generally weak social functioning [82,83], and increased risk of stigma, discrimination, and the appearance of mental problems such as depression [84,85]. People with hearing loss who have not developed the expected language competence (despite the advanced technological solution they use) in general have poor access to social services [86] and are at increased risk of emotional and physical neglect and abuse, sexual trauma, depression, and anxiety [87].

It should be noted that the increased developmental risks of inappropriate language stimulation presented in this way refer to children with hearing loss as a population [20]. CIs provide the best audibility compared to the preoperative pure tone thresholds at speech frequencies [88], and can enable competent spoken language use [20]. Therefore, the increased developmental risks should not be directly and exclusively linked to the technology of CIs but rather broadly viewed through all the factors considered responsible for the variable language outcomes in this population [60,61]. It is known that the development of the spoken language of children with CIs often does not correspond to expectations [23,89-91], but it should also be taken into account that under certain conditions (for example, with very early implantation and the best post-operative hearing results), the situation can be reversed [92,93]. Part of the variance in spoken language outcomes is related to habilitation variables, so successes in spoken language can be partially attributed to the appropriate adaptations of habilitation, based on constant monitoring of language progress and the factors that led to it [23]. The adaptation of the habilitation should be based on neurocognitive and other knowledge about the predictors of the success of language development after cochlear implantation, which certainly includes [52]:

1) Its earliest onset—before the end of the first year of life [94].

2) A further technological leap in the fidelity of the signal sent from the processor of the device to the brain, advances in programming strategies, and the promotion of language learning strategies based on recent research into working memory, cognitive development, and the preferred way of learning of DHH children [95,96].

3) Stronger involvement of families in habilitation, especially mothers, and their better empowerment to encourage early language development through continuous guidance and coaching, which is closely related to the overall success of the intervention [93].

Communication Competence and Synergy of Sign Language and Cochlear Implantation Interventions

While waiting for technological advances in CIs, taking stronger measures in the earliest stages of habilitation to enrich the linguistic stimulation to which their pediatric users are exposed is of the greatest importance. Rich language stimulation includes [20]:

1) Educated and engaged family as the most important encourager of habilitation success, prepared to use daily situations for the development of communication, language, and speech by adding meaning to sounds (and not only speech sounds, but all sounds), to generalize them in everyday life, and to provide a socio-emotional context for communication and language experiences.

2) An expert team that will propose combinations of instructional and random learning strategies, detect the child’s current abilities, determine the optimal learning content (compatible with the curriculum) and the difficulty of the tasks in the listening lessons, and determine the factors that promote or inhibit progress through continuous formal assessment.

3) Focus on communication competence or independent, sovereign, and purposeful communication, corresponding to age and cognitive abilities.

Therefore, rich language stimulation includes all communication resources, from auditory to visual communication solutions, meaning that in habilitation it is important to be aware of every sensory channel and their combinations that can shape the child’s communication competence in the best possible way. Nevertheless, there are functional and qualitative differences between the use of various sensory channels to acquire more complete information (i.e., multimodal learning) and the use of the most elaborate communication systems for the same purpose (i.e., bimodal bilingual learning) [97-99]. Unfortunately, although contemporary literature highlights this scientifically based fact, surprisingly, few families have been encouraged to explore it [100]. However, evidence clearly indicates that ignoring the achievement of communication competence in DHH children, including children with CIs, and insisting on the development of spoken language carries a high risk of failing to acquire any language (language deprivation), which negatively affects cognitive development, academic success, socio-emotional health, and overall quality of life (for details see [20,101,102]). Today, we know that a precondition for neurocognitive development, and everything else that follows it developmentally, is language, but not necessarily spoken. It should be clearly stated that all developmental risks brought about by an incomplete approach to speech sounds and thus to spoken language can be avoided by encouraging the learning of sign language as an elaborate language system, in all its features parallel to spoken language. This should be done from the earliest age to take advantage of the critical language learning period, regardless of the use of CIs. DHH children who were exposed to sign language in a natural way (within the family) from the beginning are not at risk of developmental delays associated with children who were implanted but who did not acquire sign language [102-104]. The emphasis must be on early learning, since later learning of sign language, when it is clear that poorly developed spoken language skills do not allow effective communication (when sign language becomes “plan B”), does not allow the achievement of the highest levels of fluency [105]. Children with CIs who learned sign language from an early age achieve significantly better language and speech results than children who relied only on listening to speech in language learning [106,107], and have higher chances of achieving other developmental milestones [20,101,102], such as the development of self-esteem and good social skills [108]. Data on the quality of life of children with CIs and spoken language alone showed a positive impact of implantation on their communication, social relationships, self-reliance, confidence, and family well-being. Nevertheless, this positive impact is constrained, as the success of future education, further use of spoken language, and further support for a child remain parental concerns [109-111], indicating that the exclusive use of spoken language after cochlear implantation may still not be enough to meet developmental potential and parental expectations. Moreover, the general quality of life of children with CIs and their parents seems to be significantly lower than that of hearing children and their parents, as well as the care burden on parents of children with CIs, indicating that cochlear implantation does not necessarily eliminate psychosocial problems faced by these families [112]. One can argue that this is because language skill development after cochlear implantation only generally follows the trajectory of language development of typically developing children, with great individual variability relating to specific skills [113].


Families of DHH children should be informed about the realistic reach of CI technology and about documented facts that bilingualism (the earliest exposure to natural sign language as a first language and parallel exposure to spoken language) prevents language and all other developmental delays, especially low literacy, which represents a permanent barrier to achieving a high quality of life [64]. The United Nations Convention on the Rights of Persons with Disabilities [114] ensures families of DHH children the right to bilingualism and highlights the benefits of achieving communication competence, that is, enabling upbringing and education in a language that children can access unhindered and in an environment that allows for the maximum development of all their potential (physical, cognitive, socio-emotional, and educational). Moreover, the Convention calls on policymakers to promote sign language, as it is an integral part of the right to free expression, seeking and receiving information, and organizing appropriate early intervention designed to prevent the development of further difficulties and disorders. Therefore, the implementers of early intervention must, immediately after identifying a DHH child, inform the family objectively and impartially about all habilitation options, which especially excludes the spread of linguistic prejudices and misinformation that sign language will hinder the development of speech [20]. Scientific evidence that early learning of natural sign language improves the outcomes of educational activities that precede or follow cochlear implantation is abundant. Therefore, it can be safely said that bilingual habilitation provides optimal conditions for the development of DHH children. The advantages of bilingualism are numerous [101]: it increases executive function (the brain is faster and has a stronger focus), enhances cognitive function and flexibility, improves language processing, and enables proper language and cognitive functioning. It is likely that parents, to whom the real achievements of CIs are explained, will finally be able to shift the focus of care from the imperative of speech development to the overall quality of life of their children, that is, towards building a healthy, respectful mutual relationship through which their children can develop into happy and self-confident individuals with full educational potential, capable of productive independent living.




Conflicts of Interest

The authors have no financial conflicts of interest.

Author Contributions

Conceptualization: Luka Bonetti, Ivana Šimić Šantić. Investigation: Ivana Šimić Šantić. Supervision: Luka Bonetti. Visualization: Luka Bonetti, Ivana Šimić Šantić. Writing—Ivana Šimić Šantić, Luka Bonetti. Writing—review & editing: Luka Bonetti, Ivana Šimić Šantić. Approval of final manuscript: Luka Bonetti, Ivana Šimić Šantić. Approval of final manuscript: Ivana Šimić Šantić, Luka Bonetti.


1. World Health Organization. Deafness and hearing loss. [cited 2022 Sep 6]. Available from: https://www.who.int/news-room/factsheets/detail/deafness-and-hearing-loss.
2. Cole EB, Flexer C. Children with hearing loss: developing listening and talking, birth to six 2nd edth ed. San Diego, CA: Plural Publishing, Inc; 2010. p. 1–365.
3. Wilson BS, Dorman MF. Cochlear implants: current designs and future possibilities. J Rehabil Res Dev 2008;45:695–730.
4. National Institute of Deafness and Other Communication Disorders. Cochlear implants. [cited 2022 Sep 12]. Available from: https://www.nidcd.nih.gov/health/cochlear-implants.
5. Crowson MG, Semenov YR, Tucci DL, Niparko JK. Quality of life and cost-effectiveness of cochlear implants: a narrative review. Audiol Neurootol 2017;22:236–58.
6. van Wieringen A, Wouters J. What can we expect of normally-developing children implanted at a young age with respect to their auditory, linguistic and cognitive skills? Hear Res 2015;322:171–9.
7. Muigg F, Bliem HR, Kühn H, Seebacher J, Holzner B, Weichbold VW. Cochlear implantation in adults with single-sided deafness: generic and disease-specific long-term quality of life. Eur Arch Otorhinolaryngol 2020;277:695–704.
8. Sousa AF, Couto MIV, Martinho-Carvalho AC. Quality of life and cochlear implant: results in adults with postlingual hearing loss. Braz J Otorhinolaryngol 2018;84:494–9.
9. Moberly AC, Harris MS, Boyce L, Vasil K, Wucinich T, Pisoni DB, et al. Relating quality of life to outcomes and predictors in adult cochlear implant users: are we measuring the right things? Laryngoscope 2018;128:959–66.
10. Ramos A, Guerra-Jiménez G, Rodriguez C, Borkoski S, Falcón JC, Perez D. Cochlear implants in adults over 60: a study of communicative benefits and the impact on quality of life. Cochlear Implants Int 2013;14:241–5.
11. Amin N, Wong G, Nunn T, Jiang D, Pai I. The outcomes of cochlear implantation in elderly patients: a single United Kingdom center experience. Ear Nose Throat J 2021;100(5_suppl):842S–7.
12. Francis HW, Chee N, Yeagle J, Cheng A, Niparko JK. Impact of cochlear implants on the functional health status of older adults. Laryngoscope 2002;112(8 Pt 1):1482–8.
13. Arnoldner C, Lin VY. Expanded selection criteria in adult cochlear implantation. Cochlear Implants Int 2013;14 Suppl 4:S10–3.
14. Peterson NR, Pisoni DB, Miyamoto RT. Cochlear implants and spoken language processing abilities: review and assessment of the literature. Restor Neurol Neurosci 2010;28:237–50.
15. Lin FR, Niparko JK. Measuring health-related quality of life after pediatric cochlear implantation: a systematic review. Int J Pediatr Otorhinolaryngol 2006;70:1695–706.
16. Nittrouer S, Sansom E, Low K, Rice C, Caldwell-Tarr A. Language structures used by kindergartners with cochlear implants: relationship to phonological awareness, lexical knowledge and hearing loss. Ear Hear 2014;35:506–18.
17. Geers AE, Sedey AL. Language and verbal reasoning skills in adolescents with 10 or more years of cochlear implant experience. Ear Hear 2011;32(1 Suppl):39S–48.
18. Gautam A, Naples JG, Eliades SJ. Control of speech and voice in cochlear implant patients. Laryngoscope 2019;129:2158–63.
19. Cooper A. Hear me out: hearing each other for the first time: the implications of cochlear implant activation. Mo Med 2019;116:469–71.
20. Hall ML, Hall WC, Caselli NK. Deaf children need language, not (just) speech. First Lang 2019;39:367–95.
21. McConkey Robbins A. 12 guiding premises of pediatric cochlear implant habilitation. World J Otorhinolaryngol Head Neck Surg 2018;3:235–9.
22. Almomani F, Al-Momani MO, Garadat S, Alqudah S, Kassab M, Hamadneh S, et al. Cognitive functioning in deaf children using cochlear implants. BMC Pediatr 2021;21:71.
23. Boons T, Brokx JP, Dhooge I, Frijns JH, Peeraer L, Vermeulen A, et al. Predictors of spoken language development following pediatric cochlear implantation. Ear Hear 2012;33:617–39.
24. Nott P, Cowan R, Brown PM, Wigglesworth G. Early language development in children with profound hearing loss fitted with a device at a young age: part I--the time period taken to acquire first words and first word combinations. Ear Hear 2009;30:526–40.
25. Holt RF, Svirsky MA. An exploratory look at pediatric cochlear implantation: is earliest always best? Ear Hear 2008;29:492–511.
26. Dettman SJ, Pinder D, Briggs RJ, Dowell RC, Leigh JR. Communication development in children who receive the cochlear implant younger than 12 months: risks versus benefits. Ear Hear 2007;28(2 Suppl):11S–8.
27. Tait ME, Nikolopoulos TP, Lutman ME. Age at implantation and development of vocal and auditory preverbal skills in implanted deaf children. Int J Pediatr Otorhinolaryngol 2007;71:603–10.
28. Tait M, De Raeve L, Nikolopoulos TP. Deaf children with cochlear implants before the age of 1 year: comparison of preverbal communication with normally hearing children. Int J Pediatr Otorhinolaryngol 2007;71:1605–11.
29. Connor CM, Craig HK, Raudenbush SW, Heavner K, Zwolan TA. The age at which young deaf children receive cochlear implants and their vocabulary and speech-production growth: is there an added value for early implantation? Ear Hear 2006;27:628–44.
30. Nikolopoulos TP, Dyar D, Archbold S, O’Donoghue GM. Development of spoken language grammar following cochlear implantation in prelingually deaf children. Arch Otolaryngol Head Neck Surg 2004;130:629–33.
31. Svirsky MA, Teoh SW, Neuburger H. Development of language and speech perception in congenitally, profoundly deaf children as a function of age at cochlear implantation. Audiol Neurootol 2004;9:224–33.
32. Kral A, Sharma A. Developmental neuroplasticity after cochlear implantation. Trends Neurosci 2012;35:111–22.
33. Kral A, Kronenberger WG, Pisoni DB, O’Donoghue GM. Neurocognitive factors in sensory restoration of early deafness: a connectome model. Lancet Neurol 2016;15:610–21.
34. Sharma A, Dorman MF, Kral A. The influence of a sensitive period on central auditory development in children with unilateral and bilateral cochlear implants. Hear Res 2005;203:134–43.
35. Easwar V, Sanfilippo J, Papsin B, Gordon K. Impact of consistency in daily device use on speech perception abilities in children with cochlear implants: datalogging evidence. J Am Acad Audiol 2018;29:835–46.
36. Yuksel M, Cesur S, Ciprut A. Time of cochlear implant use obtained from data logging and word discrimination performance of children. J Otolaryngol ENT Res 2017;9:617.
37. Velandia S, Martinez D, Goncalves S, Pena S, Bas E, Ein L, et al. Effect of age, electrode array, and time on cochlear implant impedances. Cochlear Implants Int 2020;21:344–52.
38. Wouters J, McDermott HJ, Francart T. Sound coding in cochlear implants: from electric pulses to hearing. IEEE Signal Process Mag 2015;32:67–80.
39. Patrick JF, Busby PA, Gibson PJ. The development of the nucleus freedom cochlear implant system. Trends Amplif 2006;10:175–200.
40. Geers AE, Tobey EA, Moog JS. Editorial: long-term outcomes of cochlear implantation in early childhood. Ear Hear 2011;32(1 Suppl):1S.
41. Ganek H, McConkey Robbins A, Niparko JK. Language outcomes after cochlear implantation. Otolaryngol Clin North Am 2012;45:173–85.
42. Tobey EA, Geers AE, Brenner C, Altuna D, Gabbert G. Factors associated with development of speech production skills in children implanted by age five. Ear Hear 2003;24(1 Suppl):36S–45.
43. Moog JS, Geers AE. Early educational placement and later language outcomes for children with cochlear implants. Otol Neurotol 2010;31:1315–9.
44. Harris MS, Kronenberger WG, Gao S, Hoen HM, Miyamoto RT, Pisoni DB. Verbal short-term memory development and spoken language outcomes in deaf children with cochlear implants. Ear Hear 2013;34:179–92.
45. Pisoni DB, Kronenberger WG, Harris MS, Moberly AC. Three challenges for future research on cochlear implants. World J Otorhinolaryngol Head Neck Surg 2018;3:240–54.
46. Kronenberger WG, Colson BG, Henning SC, Pisoni DB. Executive functioning and speech-language skills following long-term use of cochlear implants. J Deaf Stud Deaf Educ 2014;19:456–70.
47. Conway CM, Pisoni DB, Kronenberger WG. The importance of sound for cognitive sequencing abilities: the auditory scaffolding hypothesis. Curr Dir Psychol Sci 2009;18:275–9.
48. Baddeley A. Working memory. Curr Biol 2010;20:R136–40.
49. Nittrouer S, Caldwell-Tarr A, Low KE, Lowenstein JH. Verbal working memory in children with cochlear implants. J Speech Lang Hear Res 2017;60:3342–64.
50. AuBuchon AM, Pisoni DB, Kronenberger WG. Verbal processing speed and executive functioning in long-term cochlear implant users. J Speech Lang Hear Res 2015;58:151–62.
51. Pisoni DB, Kronenberger WG, Roman AS, Geers AE. Measures of digit span and verbal rehearsal speed in deaf children after more than 10 years of cochlear implantation. Ear Hear 2011;32(1 Suppl):60S–74.
52. Davidson LS, Geers AE, Hale S, Sommers MM, Brenner C, Spehar B. Effects of early auditory deprivation on working memory and reasoning abilities in verbal and visuo-spatial domains for pediatric CI recipients. Ear Hear 2019;40:517–28.
53. Conway CM, Karpicke J, Anaya EM, Henning SC, Kronenberger WG, Pisoni DB. Nonverbal cognition in deaf children following cochlear implantation: motor sequencing disturbances mediate language delays. Dev Neuropsychol 2011;36:237–54.
54. Torkildsen JVK, Arciuli J, Haukedal CL, Wie OB. Does a lack of auditory experience affect sequential learning? Cognition 2018;170:123–9.
55. Castellanos I, Kronenberger WG, Beer J, Colson BG, Henning SC, Ditmars A, et al. Concept formation skills in long-term cochlear implant users. J Deaf Stud Deaf Educ 2015;20:27–40.
56. Šimleša S, Cepanec M. The development of executive functions and their neurological correlates. Suvrem Psihol 2008;11:55–72.
57. Botting N, Jones A, Marshall C, Denmark T, Atkinson J, Morgan G. Nonverbal executive function is mediated by language: a study of deaf and hearing children. Child Dev 2017;88:1689–700.
58. Rudner M, Andin J, Rönnberg J. Working memory, deafness and sign language. Scand J Psychol 2009;50:495–505.
59. Twomey T, Price CJ, Waters D, MacSweeney M. The impact of early language exposure on the neural system supporting language in deaf and hearing adults. Neuroimage 2020;209:116411.
60. Marschark M, Hauser PC. How deaf children learn. 1st edth ed. Oxford: Oxford University Press; 2011. p. 1–168.
61. Marshall C, Jones A, Denmark T, Mason K, Atkinson J, Botting N, et al. Deaf children’s non-verbal working memory is impacted by their language experience. Front Psychol 2015;6:527.
62. Erbasi E, Hickson L, Scarinci N. Communication outcomes of children with hearing loss enrolled in programs implementing different educational approaches: a systematic review. Speech Lang Hear 2017;20:102–21.
63. Absalan A, Pirasteh I, Dashti Khavidaki GA, Asemi Rad A, Nasr Esfahani AA, Nilforoush MH. A prevalence study of hearing loss among primary school children in the south east of Iran. Int J Otolaryngol 2013;2013:138935.
64. Lederberg AR, Schick B, Spencer PE. Language and literacy development of deaf and hard-of-hearing children: successes and challenges. Dev Psychol 2013;49:15–30.
65. Wauters LN, Van Bon WH, Tellings AE. Reading comprehension of Dutch deaf children. Read Writ 2006;19:49–76.
66. Vohr B, Jodoin-Krauzyk J, Tucker R, Topol D, Johnson MJ, Ahlgren M, et al. Expressive vocabulary of children with hearing loss in the first 2 years of life: impact of early intervention. J Perinatol 2011;31:274–80.
67. Thal D, Desjardin JL, Eisenberg LS. Validity of the MacArthur-Bates Communicative Development Inventories for measuring language abilities in children with cochlear implants. Am J Speech Lang Pathol 2007;16:54–64.
68. Koehlinger KM, Van Horne AJ, Moeller MP. Grammatical outcomes of 3- and 6-year-old children who are hard of hearing. J Speech Lang Hear Res 2013;56:1701–14.
69. Moeller MP, Tomblin JB, Yoshinaga-Itano C, Connor CM, Jerger S. Current state of knowledge: language and literacy of children with hearing impairment. Ear Hear 2007;28:740–53.
70. Friedmann N, Szterman R. Syntactic movement in orally trained children with hearing impairment. J Deaf Stud Deaf Educ 2006;11:56–75.
71. Ambrose SE, Fey ME, Eisenberg LS. Phonological awareness and print knowledge of preschool children with cochlear implants. J Speech Lang Hear Res 2012;55:811–23.
72. McQuarrie L, Parrila R. Phonological representations in deaf children: rethinking the “functional equivalence” hypothesis. J Deaf Stud Deaf Educ 2009;14:137–54.
73. Easterbrooks SR, Lederberg AR, Miller EM, Bergeron JP, Connor CM. Emergent literacy skills during early childhood in children with hearing loss: strengths and weaknesses. Volta Rev 2008;108:91–114.
74. Kyle FE, Cain K. A comparison of deaf and hearing children’s reading comprehension profiles. Top Lang Disord 2015;35:144–56.
75. Luckner JL, Cooke C. A summary of the vocabulary research with students who are deaf or hard of hearing. Am Ann Deaf 2010;155:38–67.
76. Paatsch LE, Toe DM. A comparison of pragmatic abilities of children who are deaf or hard of hearing and their hearing peers. J Deaf Stud Deaf Educ 2014;19:1–19.
77. Harris M, Terlektsi E. Reading and spelling abilities of deaf adolescents with cochlear implants and hearing AIDS. J Deaf Stud Deaf Educ 2011;16:24–34.
78. Most T, Shina-August E, Meilijson S. Pragmatic abilities of children with hearing loss using cochlear implants or hearing AIDS compared to hearing children. J Deaf Stud Deaf Educ 2010;15:422–37.
79. Theunissen SC, Rieffe C, Kouwenberg M, De Raeve LJ, Soede W, Briaire JJ, et al. Behavioral problems in school-aged hearing-impaired children: the influence of sociodemographic, linguistic, and medical factors. Eur Child Adolesc Psychiatry 2014;23:187–96.
80. Hogan A, Shipley M, Strazdins L, Purcell A, Baker E. Communication and behavioural disorders among children with hearing loss increases risk of mental health disorders. Aust N Z J Public Health 2011;35:377–83.
81. Austen S. Challenging behaviour in deaf children. Educ Child Psychol 2010;27:33–40.
82. Rieffe C, Terwogt MM. Anger communication in deaf children. Cogn Emot 2006;20:1261–73.
83. Terwogt MM, Rieffe C. Behavioural problems in deaf children: theory of mind delay or communication failure? Eur J Dev Psychol 2004;1:231–40.
84. Theunissen SC, Rieffe C, Kouwenberg M, Soede W, Briaire JJ, Frijns JH. Depression in hearing-impaired children. Int J Pediatr Otorhinolaryngol 2011;75:1313–7.
85. Fellinger J, Holzinger D, Sattel H, Laucht M, Goldberg D. Correlates of mental health disorders among children with hearing impairments. Dev Med Child Neurol 2009;51:635–41.
86. Murray JJ, Hall WC, Snoddon K. Education and health of children with hearing loss: the necessity of signed languages. Bull World Health Organ 2019;97:711–6.
87. Humphries T, Kushalnagar P, Mathur G, Napoli DJ, Padden C, Rathmann C, et al. Bilingualism: a pearl to overcome certain perils of cochlear implants. J Med Speech Lang Pathol 2014;21:107–25.
88. Alonso-Luján LR, Gutiérrez-Farfán I, Luna-Reyes FA, Chamlati-Aguirre LE, Durand Rivera A. Audiometric evaluation short and medium term in cochlear implants. Rev Invest Clin 2014;66:415–21.
89. Geers AE, Nicholas JG. Enduring advantages of early cochlear implantation for spoken language development. J Speech Lang Hear Res 2013;56:643–55.
90. Percy-Smith L, Busch G, Sandahl M, Nissen L, Josvassen JL, Lange T, et al. Language understanding and vocabulary of early cochlear implanted children. Int J Pediatr Otorhinolaryngol 2013;77:184–8.
91. Niparko JK, Tobey EA, Thal DJ, Eisenberg LS, Wang NY, Quittner AL, et al. Spoken language development in children following cochlear implantation. JAMA 2010;303:1498–506.
92. Dettman SJ, Dowell RC, Choo D, Arnott W, Abrahams Y, Davis A, et al. Long-term communication outcomes for children receiving cochlear implants younger than 12 months: a multicenter study. Otol Neurotol 2016;37:e82–95.
93. Hay-McCutcheon MJ, Kirk KI, Henning SC, Gao S, Qi R. Using early language outcomes to predict later language ability in children with cochlear implants. Audiol Neurootol 2008;13:370–8.
94. Naik AN, Varadarajan VV, Malhotra PS. Early pediatric cochlear implantation: an update. Laryngoscope Investig Otolaryngol 2021;6:512–21.
95. Nittrouer S, Caldwell-Tarr A, Lowenstein JH. Working memory in children with cochlear implants: problems are in storage, not processing. Int J Pediatr Otorhinolaryngol 2013;77:1886–98.
96. Lyxell B, Sahlén B, Wass M, Ibertsson T, Larsby B, Hällgren M, et al. Cognitive development in children with cochlear implants: relations to reading and communication. Int J Audiol 2008;47 Suppl 2:S47–52.
97. Swanwick R. Deaf children’s bimodal bilingualism and education. Lang Teach 2016;49:1–34.
98. Yanbay E, Hickson L, Scarinci N, Constantinescu G, Dettman SJ. Language outcomes for children with cochlear implants enrolled in different communication programs. Cochlear Implants Int 2014;15:121–35.
99. LaSasso C, Lollis J. Survey of residential and day schools for deaf students in the United States that identify themselves as bilingualbicultural programs. J Deaf Stud Deaf Educ 2003;8:79–91.
100. Haualand H, Allen C. Deaf people and human rights Helsinki: World Federation of the Deaf; 2009. p. 1–71.
101. Humphries T, Kushalnagar P, Mathur G, Napoli DJ, Padden C, Rathmann C, et al. Language choices for deaf infants: advice for parents regarding sign languages. Clin Pediatr (Phila) 2016;55:513–7.
102. Humphries T, Kushalnagar P, Mathur G, Napoli DJ, Padden C, Rathmann C. Ensuring language acquisition for deaf children: what linguists can do. Language 2014;90:e31–52.
103. Hall ML, Eigsti IM, Bortfeld H, Lillo-Martin D. Auditory deprivation does not impair executive function, but language deprivation might: evidence from a parent-report measure in deaf native signing children. J Deaf Stud Deaf Educ 2017;22:9–21.
104. Henner J, Caldwell-Harris CL, Novogrodsky R, Hoffmeister R. American sign language syntax and analogical reasoning skills are influenced by early acquisition and age of entry to signing schools for the deaf. Front Psychol 2016;7:1982.
105. Cheng Q, Halgren E, Mayberry R. Effects of early language deprivation: mapping between brain and behavioral outcomes. Proceedings of the 42nd Annual Boston University Conference on Language Development; 2017 Nov 3-5; Boston, MA, USA: Cascadilla Press;2018. p.140-52.
106. Davidson K, Lillo-Martin D, Chen Pichler D. Spoken english language development among native signing children with cochlear implants. J Deaf Stud Deaf Educ 2014;19:238–50.
107. Hassanzadeh S. Outcomes of cochlear implantation in deaf children of deaf parents: comparative study. J Laryngol Otol 2012;126:989–94.
108. Kushalnagar P, Topolski TD, Schick B, Edwards TC, Skalicky AM, Patrick DL. Mode of communication, perceived level of understanding, and perceived quality of life in youth who are deaf or hard of hearing. J Deaf Stud Deaf Educ 2011;16:512–23.
109. Warner-Czyz AD, Nelson JA, Kumar R, Crow S. Parent-reported quality of life in children with cochlear implants differs across countries. Front Psychol 2022;13:966401.
110. Molla M, Asha NJ, Kamrujjaman M. Parents perceived quality of life for children with cochlear implants. Int J Otorhinolaryngol Head Neck Surg 2019;8:13–24.
111. Archbold S, Sach T, O’neill C, Lutman M, Gregory S. Outcomes from cochlear implantation for child and family: parental perspectives. Deaf Educ Int 2008;10:120–42.
112. Vermi Sli Peker S, Demi R Korkmaz F, Cukurova I. Quality of life and parental care burden in cochlear implanted children: a casecontrol study. Int J Pediatr Otorhinolaryngol 2020;136:110164.
113. Hand LS, Liu CK, Hardman G, Mahon M. Language skill development in children with cochlear implants and the impact of age at switch-on. Deaf Educ Int 2023;25:59–78.
114. United Nations. Convention on the rights of persons with disabilities New York: United Nations; 2006. p. 3.

Article information Continued