Abstracts Week 1 - 9/8/2009

Abstract written by Rachel Foster

Reference
Duchesne, Louise; Sutton, Ann; Bergeron, Francois. “Language Achievement in Children Who Received Cochlear Implants Between 1 and 2 Years of Age: Group Trends and Individual Patterns”. Journal of Deaf Studies and Deaf Education, 14:4, Fall 2009, p 465-485. Accessed on line September 4, 2009, http://jdsde.oxfordjournals.org/.

Purpose of Study
The purpose of this study was to examine vocabulary (receptive/expressive) and grammar achievement in a group of children who received a cochlear implant (CI) between the age of 8 and 28 months, after using the device for a minimum of two years. This study examined both the group performance and the individual patterns of performance within the group. Specific questions targeted within the study include: 1a) Can children with congenital hearing loss who receive a CI between 8 and 28 months achieve age-appropriate vocabulary and grammar level after a minimum of 2 years of device use? 1b) Is the performance within the group, in term of language levels, representative of individual performance? 2a) What factors are more strongly associated with the language level reached: timing variable, variables related to functional use of the device, or social skills? 2b) Do individual patterns follow group trends that are associated with overall success? 2c) Are the associations different for younger and older children?

Subjects
Participants included 27 French-speaking children, 14 boys and 13 girls, with profound bilateral hearing loss. All children were between the ages of 42 to 99 months who had received a CI between the age of 8 and 28 months. Deafness was congenital in 25 children and the other 2 children had acquired a hearing loss as a result of meningitis (at 5 to 12 months of age). All participants’ primary language was French, and had no other diagnosis of disabilities or any language or cognitive condition that would be expected to interfere with language development. Out of 27 children, 23 had a Clarion device implant and 4 had a Nucleus device implant. All children were born to hearing parents except for one child whose mother had a profound bilateral hearing loss and received a CI a few months after her child. All participants were enrolled in an intensive early rehabilitation program for a period of 3 months after the activation of the device (5-6 hours a week) and continued to receive similar (type and approximate frequency) speech language intervention after the intensive rehabilitation period.

Method
Four measurements of language achievement were administered to each child. All standardized test used contained norms for Canadian French-speaking children.
· General measure of receptive and expressive language - the RDLS was administered to assess the child’s ability to comprehend and express a hierarchy of language structures.
· Receptive vocabulary – the EVIP (The Echelle de vocabulaire en images de Peabody) assessed the children’s receptive vocabulary knowledge.
· Receptive language: comprehension of concepts, grammatical morphemes, syntactic constructions – the Epreuve de comprehension de Carrow-Woolfolk (Test of Auditory Comprehension R; TACL-R) was administered to measure the children’s understanding of language with a focus on grammar. This test consists of threes subtest: Word Classes and Relations, Grammatical Morphemes, and Elaborated Sentences.
· Expressive Vocabulary – the Test de denomination Expressive One-Word Picture Vocabulary Test-R was administered.
All task were administered in a pseudorandomized order and completed within a months time.

Results
Children were separated into groups A (3-4 years) and B (5-8years). Group A was only tested on receptive vocabulary and social skills. Means fell within normal range (between 15 and 85) for all measures. The mean percentiles were not significantly different for receptive vocabulary for the two subgroups. For group B expressive vocabulary and comprehension of grammar were also within normal limits. In both groups A and B (as well as for all 27 participants) standard scores for social skills were below the mean range. Below is a summary of the data.

Language/Social Skills 3-4 years 5-8 years Total %of Children WNL
M SD M SD M SD
Receptive vocabulary 27 27.7 33.5 32.4 30.6 30 55.5
Expressive vocab. - - 52.9 36.2 - - 85.7
Comp. of concept - - 62.5 30.8 - - 85.7
Comp. of morphemes - - 27.1 34.1 - - 42.8
Comp. of syntax - - 19.8 27.8 - - 35.7
Social skills 78.75 7.6 84.13 7.0 81.7 7.6 44

When considering the individual performances there was no correlation between those who scored the highest with having had their CI fitted earlier. However, those that did receive the highest scores in receptive vocabulary also had above average scores for meaningful use of speech and auditory integration and on the socialization measures. In group B there were two extreme profiles found (language within normal limits and general language delay) and were not associated with age at activation or duration of CI use.

Discussion
It was expected that early CI fitting would be associated with language performance; however, the individual patterns of language achievement add a bit of different out look to this expectation. Profiles seen were 1) all language components were within normal limits, 2) general language delays in all language tasks, 3) normal lexical abilities with receptive grammar delay (children who were within normal limits at the word level but not at sentence level), 4) discrepancies across language domains (those that score within normal range in expressive vocabulary and comprehension of concepts but scored very low on all other measures). The language profiles do not appear to be related to gender, type of implant, or school environment. With this information in mind, it would be wise to counsel with families concerning the possible outcomes of cochlear implant. It is important to let the family know that receiving CI does not necessarily mean that your child will reach age/level norms. Another key factor that can be taken from this data (as far as counseling and clinical intervention goes) is the most important indicator of a child’s outcome is the child. All individuals are different and respond differently to CI, intervention, and their environment.

Opinion
I think this study is a well designed and looks at the primary indicator of overall outcome of a CI, the individual. I believe that it makes sense that the earlier the child is fitted with a CI the more likely they are to have an advantage over those who don’t. However like in all aspects of life everyone is different. Based on the individual they will need specific and individualized treatment (quantity and duration), environments, and family support to enhance their overall success.

Link to article
https://pod51000.outlook.com/owa/WebReadyView.aspx?t=att&id=RgAAAAD0rmmNh%2bcPSpnaVQvN9j2lBwDTwaHdlBKQR5jRmiMNtZvJAAAWjo02AACpEOq%2bGqgxRIDd3R%2fpJkptAAAAAKQkAAAJ&attid0=BAABAAAA&attid1=BAAAAAAA&attcnt=2


Abstract written by Kayla Thumann

Reference:
· Charlesworth, A., Charlesworth, R., Raban, B., & Rickards, F. “Reading Recovery for Children with Hearing Loss”. The Volta Review, 106(1), March, 2006, 29-51. Accessed September 3, 2009 from http://www.agbell.org/DesktopDefault.aspx?p=The_Volta_Review.

Purpose of Study:
· The purpose of the study was to determine if the Reading Recovery program would work for at risk children who are hard of hearing or deaf. The study also compared children who were deaf or hard of hearing against children who could hear who were experiencing similar reading difficulties.

Subjects:
· The subjects of the study included 12 children with typical hearing and 12 children who were deaf or hard of hearing. All of the children were in first grade and had been identified “at risk” by their teacher for difficulties with reading. Of the Deaf/ hard of hearing children 8 attended a full time school for the profoundly deaf. The others were in general education classrooms with aids and interpreters for support as well as spending time weekly in a “Deafness Unit” at their schools. The typical hearing children attended full time general education classrooms and were pulled to receive one on one instruction from a Reading Recovery teacher. The teachers who participated in the study were all trained in the Reading Recovery program as well as received ongoing professional development. All teachers used sign, speech or encouraged lip reading depending on the needs of the child. The children who participated in the Reading Recovery fall into the lowest 10 percent in reading ability and literacy activities for their grade.

Method:
· The study was conducted over a period of one school year. The children received instruction using the Reading Recovery program. The children’s progress was measured by administration of the Observation Survey of Early Literacy Achievement. This is not a standardized test but rather a measurement of achievement using a criterion- referenced assessment. The children were given the Observation Survey 4 times during the year. Once at the beginning, twice during the course of the year, and again at the end of the school year. The one given at the end of the school year was given by another teacher or Reading Recovery teacher to confirm her observations. Over the year the typical hearing children followed the Reading Recovery program. The deaf or hard of hearing children followed the Reading recovery program as well with some modifications biased on their amount of hearing loss.

Results:
· The results of the study confirmed that both typical hearing children as well as deaf or hard of hearing children benefited from the Reading Recovery program. Between the groups there was only a significant difference between the groups on the “book level” portion of the Observational Survey. The typical hearing children were above the national target for book level after Reading Recovery, and the deaf or hard of hearing children were slightly below the national target. Overall after the study the typical hearing children were reading within the average area’s of their grade. The deaf or hard of hearing children were also in the average range for their grade after completing Reading Recovery.

Discussion:
· This article presents information that is useful in treatment of children who may be deaf or hard of hearing. Literacy is more difficult for these children, knowing techniques and modifications of the Reading Recovery can help these children an SLP can direct families in the right direction. Or in a clinical setting work with the family and the child to get the modifications that the child needs.

Opinion:
· This article presents a large amount of information supporting Reading Recovery for children who may be deaf or hard of hearing. It was concerning considering the small sample size, however, the authors of the article address this issue and state that their results are consistent with that of the population. I think that this article is beneficial in proving that there are programs and techniques that can help children who are deaf or hard of hearing develop typical literacy skills. I think the researchers could recreate the study in another part of the world to make their results stronger. Overall, I found this article to be informative and beneficial in understanding techniques for teaching literacy skills to children who are deaf or hard of hearing.

Link to article:
https://pod51000.outlook.com/owa/WebReadyView.aspx?t=att&id=RgAAAAD0rmmNh%2bcPSpnaVQvN9j2lBwDTwaHdlBKQR5jRmiMNtZvJAAAWjo02AACpEOq%2bGqgxRIDd3R%2fpJkptAAAAAKQaAAAJ&attid0=BAAAAAAA&attcnt=1


Abstract written by Jason Chapman

Reference
Dunmade, AD, Segun-Busari, S, Olajide, TG, Ologe, FE. “Profound Bilateral Sensorineural Hearing Loss in Nigerian Children: Any Shift in Etiology?” Journal of Deaf Studies and Deaf Education, Vol.12, Number 1, 2007, 112-118. Accessed on Monday, 7, 2009 http://jdsde.oxfordjournals.org/cgi/content/full/12/1/112

Purpose of Study
The purpose of the study is to identify the present causes of profound sensorineural hearing loss in Nigeria, which in that context has devastating effects on an individual’s ability to live their life.

Subjects
The subjects consisted of 115 children 15 and below, presenting with severe to profound sensorineural hearing loss (M= 6.7 years, SD= 3.2). 55. 7% of the children with male. This provide a male:female ratio of 5:4. Age group 1–3 years had the highest proportion of hearing loss, 33 (28.7%), and there was a progressive decline in frequency as age of the subjects increased.

Method
This was a retroperspective survey of children 15 years of age and below who presented with severe to profound sensorineural hearing loss. Individual case records were identified and retrieved from the Central Medical Records. The subjects were given an examination of their ears using head mirror with light source, and or dry cell-operated otoscope , hearing acuity was assessed with a a Barany noise box, then assessed with tympanometer. Patients less than 5 years old were assessed using a free field and observation of their response to sounds. Older children were assessed using pure tone audiometry using an audiometer and headphones. Testing was administered in a double walled sound proof room.

Results
The results showed that about two thirds of the causes of deafness in the study were acquired. Of the acquired cases, percentages of the acquired cases broke down as follows: febrile illness (18.3%), measles (13.9%), meningitis (8.7%), mumps (6.9%), and severe birth asphyxia (4.3%).

Discussion
The study showed that about two thirds of causes of deafness in the present day were acquired. When the researchers compared the results of the study to studies done about two decades ago, they concluded that the causes of hearing loss are not drastically different from the causes in those studies. The researchers think that the steady nature of the causes of hearing loss means that the immunization programs that were implemented in may not have been effective as was desired. The researchers also thought that the hearing loss caused by hereditary and congenital factors have not been studied thoroughly because of the stigma families feel regarding the issue. The proportion of patients with profound sensorineural hearing loss secondary to mumps was twice the proportion reported in the studies from two decades ago. The researchers thought that may be due to that fact that senorineural hearing loss secondary to mumps is underreported. The researchers think that there is no significant shift in etiology of profound sensorineural hearing loss, within that environment, in the last two decades. They attribute that to the larger problem of consuming products from the western world and not concentrating enough attention on problems that exist at home. They also believe that intervention and preventative measures need to be cheaper.

Opinion
I think that the study did a good job of comparing the current research with research of the past concerning the etiology of binaural sensorineural hearing loss. The discussion section asserted that the results were due to the failure of the immunization programs. I would have liked them to compare their results with the results of a study concerning the causes of binaural sensorineural hearing loss in an industrialized country like the United States.

Link to article:
https://pod51000.outlook.com/owa/WebReadyView.aspx?t=att&id=RgAAAAD0rmmNh%2bcPSpnaVQvN9j2lBwDTwaHdlBKQR5jRmiMNtZvJAAAWjo02AACpEOq%2bGqgxRIDd3R%2fpJkptAAAAAKQhAAAJ&attid0=BAABAAAA&attcnt=1


Abstract written by Anna Loza

Reference
Easterbrooks, Susan., Lederberg, Amy., Miller, Elizabeth., et al. “Emergent Literacy Skills During Early Childhood in Children With Hearing Loss: Strengths and Weaknesses”. The Volta Review, 2, 2008, 91-94. Accessed on Sunday, 6, 2009
https://libproxy.library.unt.edu:2576/login?url=http://libproxy.library.unt.edu:2587/pqdweb?did=1629951921&Fmt=7&clientId=87&RQT=309&VName=PQD

Purpose of Study
The purpose of the study was to examine the early development of literacy skills in young children with hearing loss. Documenting changes in the participants over the course of a typical school year, the study was particularly interested in phonological awareness, alphabetics, and vocabulary. Not only are these foundational skills for children with typical hearing, but they may also have impications for children who are deaf and hard of hearing (DHH) who have access to spoken language and their acquisition of the foundation to read words and passages meaningfully.

Subjects
A participant pool of 44 children included those attending self-contained preschool, kindergarten, or first grade in large metropolitan areas who met the following criteria: (1) a Pure Tone Average (PTA) of more than 50 dB, (2) 3 to 6 years of age, (3) not severely handicapped by multiple disabilities (i.e., intellectual disability, autistic, severe medical involvement), and (4) demonstrated access to sound by showing at least the ability to detect patterns for spoken words (i.e., a score of 2, 3, or 4 on the Early Speech Perception Test; Moog & Geers, 1990). Twenty-eight of the participants had at least one cochlear implant; several used both a cochlear implant and a hearing aid.

Method
Examiners assessed participants in the fall and spring of the 2006-2007 school year. Examiners included three teachers with 5 to more than 20 years of experience teaching children with hearing loss, and a professor of deaf education. The Early Speech Perception (ESP) test was first used to screen the available pool. Children who met the participant criteria were then assessed using the IGDI (Individual Growth and Development Indicators)Rhyming, IGDI Alliteration, syllable segmentation, letter-sound knowledge, WJ-III (Woodcock Johnson Achievement Test) Picture Vocabulary, WJ-III Letter-Word Identification, and WJ-III Passage Comprehension.

Results
Three quarters of the participants had at least some spoken word identification and perception skills, and supports the notion that DHH children may have functional listening skills that can be utilized and nurtured for emergent literacy purposes. Additionally, this suggests that self-contained classrooms in early childhood aid DHH children in their development of auditory-based phonological and phonics skills. However, standard scores on literacy tasks showed a negative correlation with age, demonstrating a gap in literacy skills between children with and without hearing loss. Though delayed, progress was observed over the course of the year in blending, elision, alliteration, and learning letter-sound correspondences. Vocabulary was the only area in which progress was not demonstrated, and was thought to be attributed to the idea that children who are DHH must increase their vocabulary through explicit instruction and do not acquire it incidentally.

Discussion
Because the study depicts children who are DHH as having delays in preliteracy skills, but having the ability to make steady progress, I am interested in how we as clinicians can prevent the delay to being with – before they are school aged and already behind. With the early hearing loss detection that is now possible, I feel as though we can intervene and give the caretakers supports and daily activities such as shared story book reading and possibly visual phonics that can bolster these essential skills and create a language rich home environment that is also visually supportive.

Opinion
As the study examined so many facets of phonological awareness development, I felt it was a reputable study. Most clinicians are aware that children with HL typically lag in terms of literacy, but individual components were observed more closely. Additionally, I felt that it was beneficial to follow the children’s progress over the course of a year, so true trends could be observed. However, I would be interested in doing the same study in a more rural setting, as opposed to a large metropolitan area, and identifying the discrepencies between typically hearing children and DHH children when they are not exposed to an abundance of resources. Also, I would like to look at deficits in preliteracy skills of DHH kids who are in inclusive environments and not receiving special services

Link to article:
https://pod51000.outlook.com/owa/WebReadyView.aspx?t=att&id=RgAAAAD0rmmNh%2bcPSpnaVQvN9j2lBwDTwaHdlBKQR5jRmiMNtZvJAAAWjo02AACpEOq%2bGqgxRIDd3R%2fpJkptAAAAAKQiAAAJ&attid0=BAABAAAA&attcnt=1


Abstract written by Laena Schuman

Reference
Musselman, Carol, and Kircaali-Iftar, Gonul. “The Development of Spoken Language in Deaf Children: Explaining the Unexplained Variance”. Journal of Deaf Studies and Deaf Education, Volume 1, Spring 2006, 108-121. Accessed on Tuesday, 08, 2009 http://jdsde.oxfordjournals.org/cgi/reprint/1/2/108?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=auditory+verbal+therapy&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

Purpose of study
The purpose of this study was to identify factors of unusually high performance levels of spoken language of children with severe to profound hearing loss based on their hearing loss, age, and intelligence. The areas studied were personal characteristics, family background, and educational history.

Subjects
Twenty children ranging from 5-7 years old were selected for this study. Ten of these children had spoken language that was unexpectedly good, and 10 children had spoken language that was unexpectedly poor.

Methods
Two tasks were administered to assess spoken language. The first task consisted of a set of 36 standard words that were considered to be commonly known among young deaf children. The children were asked to label pictures representing each object. In the second task, a spontaneous language sample was elicited using picture story cards. Six measures were developed using Ling’s (1978) phonological level analysis: number of intelligible words, number of intelligible utterances, articulation, average number of syllable’s per utterance, number of non-segmental features present and highest level of linguistic structure present.
Hearing threshold levels (HTL’s) were obtained at the frequencies 250, 500, 1000, 2000, and 4000Hz.
An IQ test was administered.
Parent interviews were conducted, usually with the mother. Structured and open-ended questions were used to acquire information related to family background, children’s educational history, parent’s educational and social contacts relating to deafness, home-based educational activities, behavior management, parents’ experiences and feelings at the time of diagnosis, and the parents’ attitudes toward deafness and their child’s educational programs.

Results
Spoken language measures: the high speech (HS) (unexpectedly high spoken language) and low speech (LS) (unexpectedly low spoken language) groups differed significantly on each of the 6 measures.
HTL’s: The two groups were roughly equal (97 for the HS group and 98 for the LS group). The aided HTL’s also didn’t differ significantly. There were no differences in the audiogram shapes. Nearly half of the subjects in each group had flat audiograms, half were left sloping, and one LS child had a rising slope.
Hearing Aid History: The two groups did not differ significantly in the average age at which they were first fitted with an aid. However, they did differ in the type of aid used. At the start of the study, all of the LS children wore body aids. Five HS children wore body aids. Significantly, more HS children wore binaural, ear-level fittings, and more LS children wore other types of fittings. According to their mothers, all of the HS children and 7 of the LS children wore their hearing aids at least 90% of their waking hours.
IQ Score: Both groups had an average score of 114.
Mother’s Educational Background: Six HS mothers and 1 LS mother were college/university graduates, a significant difference.
There were no significant differences in the socioeconomic status’ of the families, maternal employment, and average age of first intervention.
Communication Modes: The methods of communication used at home were: 9 HS group parents used speech alone, and 1 used signs in addition to speech. Five LS group parents used speech alone, and the other 5 used speech plus gesture/sign/both.
Instructional grouping: Seven HS children and 1 LS child were receiving individualized instruction, a significant difference.
Classroom placement: Seven HS and 2 LS children had been integrated, a significant difference.
All parents of the children participated in parent training programs at some point in their child’s education.
In sum, the analysis proved that high levels of spoken language are associated with 4 educational variables: A/O Communication, individual instruction, integrated placement, and direct instruction by parents. Six families in the HS group and none of the LS group were enrolled in a program that combined these elements.

Discussion
The information gathered from this study can be used in a clinical setting generally during counseling and the application of the diagnosis to the therapy setting. It is important to know the variety of differences in a family’s history, their dynamics, and the educational aspects (classroom placement, instructional grouping, parent guidance, hearing aid history, etc.) of the hearing-impaired child in order to know what type of recommendations to make for the child and family. This knowledge would aide all speech therapists in providing the best possible therapy approaches and guidance to the family.
Musselman and Kircaali-Iftar state that the 10 children in the HS group represent the highest level of spoken language in a much larger sample, therefore, this group can only demonstrate what is possible, rather than what is likely, and this study can only demonstrate association and not causation.

Opinion
In my opinion, this study provided good quality information regarding the many different variables of the development of spoken language.
This knowledge would aide all speech therapists in providing the best possible therapy approaches and guidance to the family.
It was helpful to learn that these variables are not predictors of how spoken language will be developed in a hearing-impaired child, but they are associated with the development of spoken language.


Abstract written by Clary Rondan

Reference
Most, Tova. “Assessment of School Functioning Among Israeli Arab Children with Hearing Loss in the Primary Grades”. American Annals of the Deaf, 151, Summer 2006, 327-335. Accessed on Tuesday, September 8, 2009 http://muse.jhu.edu/journals/american_annals_of_the_deaf/v151/151.3most.pdf

Purpose of Study
Tova Most conducted this study to examine the school functionality of Israeli Arab children with hearing impairment who were included in regular education classrooms and compare them to their classmates with normal hearing. In Israel, recent efforts have been made to allow children to use assistive listening devices and sensory aids and in turn receive auditory rehabilitation. This study is meant to provide more evidence that children who can optimize their residual hearing have school functionality that is more comparable to their peers with normal hearing.

Subjects
93 Israeli Arab children in grades 1 through 6 participated in this study. They attended five regular elementary schools in northern Israel. 33 children had hearing loss, and 60 children had normal hearing. The children with hearing loss were included in a regular classroom, but they received remedial lessons from teachers after school. All of the children’s parents were hearing, and all of them used spoken Arabic to communicate.

Method
The children were evaluated by their teachers using the Arabic version of the Screening Instrument for Targeting Educational Risks (SIFTER). The SIFTER is a written questionnaire used to screen children’s functioning in the classroom and to identify those students educationally at risk. Graduate students from the School of Education and the Department of Communication Disorders at Tel Aviv University in Israel distributed the SIFTER questionnaire to teachers that were found through Shema, a nonprofit association in northern Israel that serves school-age children with hearing loss. The children’s achievement levels in Arabic and mathematics were also reported by the teachers. Next, the teachers were also asked to complete the SIFTER questionnaire and provide the Arabic and math achievement levels for two children with normal hearing from the same class as the child with hearing loss. These children were randomly selected by using the name listed above and below the child with hearing loss provided they did not have any additional learning difficulties.

Results
The findings of this study demonstrated that the children with hearing impairment had lower functioning than that of children with normal hearing. Children with unilateral and minimal hearing losses had higher functioning than those with more severe hearing loss. Also, as the grade level of the children increased, their functioning compared to peers decreased.

Discussion
Hearing impairment may have a negative effect on children’s classroom performance, so it is important to know which areas and what levels of difficulty a child with hearing loss may have. The SIFTER can identify these difficulties in different areas of classroom functioning so that educators can facilitate the appropriate tools and environment to help children with hearing loss learn optimally. The findings of the study suggest that using the SIFTER as a screening tool is cost-effective and with appropriate follow-up on its results, can better enable each child to perform at his or her best within the educational system.

Opinion
The intent of this study is to prove that children with hearing impairment do not perform as well in the classroom as children with normal hearing so that movements for more aural rehabilitation for students can progress. I agree with the results of this study as it is commonly known that students with hearing loss may have more difficulties in school functioning than students with normal hearing; however, I do not believe that this particular study is sufficiently reliable to prove her point. To assess the children’s school functionality, the researcher had the teachers use one assessment, the SIFTER. Also, they used their own subjective judgment to assess the mathematics and Arabic skills of the children. The researcher must utilize more objective measures in her study to obtain results that are more reliable.

Link to article:
http://muse.jhu.edu/journals/american_annals_of_the_deaf/v151/151.3most.pdf


Abstract written by Hayley Simpson

Reference
· Spencer, L., Barker, B., & Tomblin, J. “Exploring the Language and Literacy Outcomes of Pediatric Cochlear Implant Users”. Ear & Hearing, Vol. 24, No. 3, January, 2003, pgs 236-247. Accessed on Thursday, September 3, 2009, http://www.uiowa.edu/~clrc/pdfs/literacy.pdf.

Purpose of study
· The researchers wanted to compare the receptive, expressive and written language skills of pre-lingually deaf pediatric cochlear implant users to that of age-matched, normal hearing peers. The researchers hypothesized that the language and literacy skills of pediatric cochlear implant users would resemble that of the normal hearing group.

Subjects
· 32 participants were separated into two groups:
· Cochlear Implant: Sixteen children, 6 girls and 10 boys (average age of all 118 mos) were recruited, all of whom were pre-lingually deaf; i.e. deaf before the age of 2. They had all received cochlear implants between 30 and 76 months of age and had used them for an average length of 71 months. All participants in this group were mainstreamed into general education classrooms within their public school system; each child uses a sign language interpreter while at school.
· Normal Hearing: 7 girls and 9 boys (average age 118 mos) with normal hearing were originally part of a group of children who had been selected during kindergarten for a study of specific language impairment and later a longitudinal study of language and academic performance. All of these children selected have average language and reading skills. All participants within this group attend public school.

Method
· The participants in both groups were tested individually in a quiet room and an experimenter was present during the testing. Test measures were divided into three main areas: language, reading and writing. To test receptive and expressive language, the researchers used the “Formulated Sentences” and “Concepts and Directions” subtests of the Clinical Evaluation of Language Fundamentals (CELF-3). Testing was administered in both speech and Signed English for the cochlear implant group. Reading comprehension was assessed through use of the “Passage Comprehension Test” of the Woodcock Reading Mastery Tests Revised Form (WRMT). After hearing two to three sentences, the child was asked to complete a sentence with the correct word. The cochlear implant group was allowed to answer in sign only, voice only, or voice and sign together. Writing samples were taken by providing sets of picture sequences that depicted a setting, problem and resolution. Participants first read an example narrative written about one of the picture sequences they did not choose. The children were then asked to write a narrative; no time limit was given. Writing productivity, complexity and grammaticality were the measures used to evaluate the children’s writing and measured through the Systematic Analysis of Language Transcripts (SALT), T-units according to Hedberg and Westby and identifying usage of word classes: noun, pronoun, verbs, determiners, adjectives, adverbs, conjunctions and prepositions.

Results
· The results of the language performance measures were significantly different between the cochlear implant group and the normal hearing group for both “Formulated Sentences” and Concepts and Directions”; the cochlear implant group mean scored 1.6 SD below the means standard score of their normal hearing peers. Regardless of modality, expressive language performance it then seems is more difficult for cochlear implant users than receptive. On the “Passage Comprehension Test”, the cochlear implant group’s mean score fell below that of the normal hearing group but both fell within the expected or “normal” limits. While a significant difference between the mean standard score for the groups was identified, range of standard scores for both groups was similar. The cochlear implant group’s writing skills were immature when compared to their age-matched normal hearing peers. The two groups showed significant differences for two of the productivity variables: total words per sample and words per T-unit. It should be noted that the decrease in the total word count of the cochlear implant group can be attributed to their use of shorter and less complex T-units. Of the eight grammatical categories used, six were measured as being used significantly less times by the cochlear implant group; they are: pronouns, verbs, determiners, adverbs, conjunctions, and prepositions. Overall, analysis showed that the children in the cochlear implant group had language achievement below the level of their age-matched peers but it should be noted that performance within the cochlear implant group was variable. A strong positive correlation was found between language and reading for the cochlear implant group. Only the cochlear implant group showed a strong and significant correlation between language and writing productivity. The normal hearing group had a negative correlation; this can be attributed to the fact that children’s written language initially mirrors their spoken language but as their writing style matures their oral language and written language become detached.

Discussion
· While I do not know how heavy of a role being pre-lingually implanted had to do with these outcomes of language and literacy skills, I feel that this information would be important to share with parents considering implantation. This article shows that their literacy skills can advance beyond that typically reported for deaf children and become age appropriate, which is linked to the improvement in English language competency. Also, because these subjects were implanted pre-lingually, it indicates that there is possibly a time table to the level of language and literacy success with implantation and making the choice to implant can greatly affect the child’s academic success in regards to literacy if the child can be implanted before age 2.

Opinion
· I enjoyed reading this article not only for the study itself but the extensive background provided of previous research in the areas of Chall’s Stages of Reading Proficiency, the development of writing proficiency and the impact of literacy deficits. This study was one of the first to look at written language achievement in children with implants and I feel that more are warranted after reading this study.

Link to article:
https://pod51000.outlook.com/owa/WebReadyView.aspx?t=att&id=RgAAAAD0rmmNh%2bcPSpnaVQvN9j2lBwDTwaHdlBKQR5jRmiMNtZvJAAAWjo02AACpEOq%2bGqgxRIDd3R%2fpJkptAAAAAKQgAAAJ&attid0=BAABAAAA&attcnt=1


Abstract written by Lauren Pfieffer

Reference

Neuss, Deirdre. “The Ecological Transition to Auditory-Verbal Therapy: Experiences of Parents Whose Children Use Cochlear Implants”. The Volta Review, 106, Fall, 2006, 195-222. Accessed on Monday, September 07, 2009 http://dq4wu5nl3d.search.serialssolutions.com/?sid=CSA:cdd-set-c&pid=%3CAN%3Ellba%2D200808810%3C%2FAN%3E%26%3CPY%3E2006%3C%2FPY%3E%26%3CAU%3ENeuss%2C%20Deirdre%3C%2FAU%3E&issn=0042%2D8639&volume=106&issue=2&spage=195&epage=222&date=2006%2D10&genre=article&aulast=Neuss&aufirst=Deirdre&title=The%20Volta%20Review&atitle=The%20Ecological%20Transition%20to%20Auditory%2DVerbal%20Therapy%3A%20Experiences%20of%20Parents%20Whose%20Children%20Use%20Cochlear%20Implants.

Purpose of Study

The primary research objective was to determine what parents’ experiences are when they adopt Auditory-Verbal therapy with their children who use cochlear implants. The secondary objectives addressed changes in the parents’ roles, activities, and interpersonal relations, and the challenges and assistance presented by personal and family characteristics, elements of the AVT model and workplace and the policies and belief system regarding hearing loss.

Subjects

Five families were selected that met the following criteria:
Parenting a child who had been diagnosed with severe-to-profound HL and used a cochlear implant
Enrollment in a AVT program for at least one year
The presence of at least one older sibling with normal hearing and development


Method

The framework that guided the study was based on the levels described by Brofenbrenner as well as on the family systems theory. Brofenbrenner describes his model as four concentric circles, the microsystem, the mesosystem, the exosystem, and the macrosystem. Data was collected through several different methods, which included a family information questionnaire, observations, individual interviews, and a discussion group.

Results

Here are the results as organized by Brofenbrenner’s levels:
Microsystem- the immediate setting in which the individual participates. Parents reported the immediate changes in their roles as parents when they discovered the HL and when they implemented the AVT. In an interview parents reported feelings of loss and guilt. Some felt as if they had experienced their own personal growth. All of the parents described their children as happy and outgoing, which helped to facilitate the therapy. Communication with their children was key to these parents.

Mesosystem- characterized by roles, activities, and interrelationships between two or more microsystems. One example is that the parent provides a link between the child and the therapist as well as between the child and other members of the audiology team. The parents reported that it was the influence of the professionals that led them to choose AVT. The parents employed the AVT techniques taught in therapy at home. Parents also reported how support from therapists, teachers, and other parents was crucial.

Exosystem- consists of one or more settings that do not involve the person in transition directly, but nevertheless, impact that person. An example of this would be the legislation that regulates services provided to these children. Some families reported that they had moved to different cities in order to obtain more consistent services.

Macrosystem- comprises the belief system and ideology that characterize a culture. The parents reported how grateful they were for the cochlear implant and were encouraged when they met other children who spoke and had a cochlear implant. All of the parents were aware of Deaf culture, but were intent on giving their children the opportunity to speak.

Discussion

As AVT emphasizes the parental role to such a great extent, a design that places the parents’ perspective at the center of a broad societal context helps us understand this intervention method more effectively. This study reveals the role changes that the parents go through when their children are diagnosed with HL and how their role changes once again when implementing AVT.

Opinion

This study does a wonderful job of highlighting the experiences of parents who have children with cochlear implants receiving AVT. I think that therapists and parents would gain a lot of perspective from reading this article. It might help them decide on AVT therapy or just let them know that what they are going through is to be expected.

Link to article:
https://pod51000.outlook.com/owa/WebReadyView.aspx?t=att&id=RgAAAAD0rmmNh%2bcPSpnaVQvN9j2lBwDTwaHdlBKQR5jRmiMNtZvJAAAWjo02AACpEOq%2bGqgxRIDd3R%2fpJkptAAAAAKQbAAAJ&attid0=BAABAAAA&attcnt=1


Abstract written by Mallory Boteler

Reference
Burger, T., Spahn, C., Richter, B., Eissele, S., Lohle, E., & Bengel, J. “Parental Distress: The Initial Phase of Hearing Aid and Cochlear Implant Fitting.” American Annals of the Deaf, Vol. 150, number 1, 2005, pg. 5-10. Accessed on Sunday, September 7, 2009 from http://libproxy.library.unt.edu:2735/journals/american_annals_of_the_deaf/v150/150.1burger.pdf

Purpose of Study
The purpose of the study was to explore and measure psychic stress and impairment of quality of life, relative to the norm, of parents of deaf and hard of hearing children. It also questioned whether these psychosocial parameters change within the course of the child’s treatment.

Subjects
The subjects involved in the study were, within an 18 month period, brought to the Freiburg University Clinic for cochlear implant preexamination, or whose child was diagnosed as having a hearing impairment and was initially fitted with a hearing aid. The only criterion for exclusion was insufficient knowledge of the German language on the part of the parents. The parents of 66 children (116 fathers and mothers), at a median age of 29.1 months, participated in the study during test 1. Subjects included 50 parents of 32 children with hearing aids and 66 parents of 34 children with cochlear implants. Among the children with hearing aids involved in the study, 2 had slight hearing impairments, 5 had moderate hearing impairments, 12 had severe hearing impairments, and 13 only had remnants of hearing (8 received cochlear implants preexamination).

Method
The parents of the children fitted with a hearing aid or a cochlear implant were examined at two different times during the initial phase of fitting with a focus on psychic attributes. Test time 1 took place of the preexamination and test time 2 took place at the first fitting. Two measures were used to assess psychic stress and quality of life: German version of the SCL-90-R and Global Severity index.

Results
Results show, from the comparison of the two study groups, a significantly impaired quality of life for the cochlear implant parents at test time 1. At test time 2, the ratings show no statistically significant deviations from the norm. At test time 1 for hearing aid parents, there was significantly heightened psychic stress and impaired quality of life. Results were the same for test time 2. All in all, the measurement across time showed that quality of life improved significantly from the first to second measurement.

Discussion
This article peaked my interest because assessment and intervention of pediatric hearing loss does not only affect the child but affects the whole family. It can cause them to feel emotional distress and a changed quality of life. This information should help the SLP and audiologist understand how the family may be feeling throughout the time they serve the child (assessment, diagnosis, counseling, intervention, etc.).

Opinion
In my opinion, the article highlights something that a clinician should already know. If you try to put yourself in the shoes of the clients and their families, you need to feel empathy and demonstrate that to them.


Abstract written by Ashley Cummings

Reference

Most, T., Aram, D., & Andorn, T. Early Literacy in Children with Hearing Loss: A Comparison Between Two Educational Systems. Volta Review, 2006, Spring2006, 106(1), 5-28. Accessed on Sunday, 6th , 2009, https://libproxy.library.unt.edu:9443/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=21005920&site=ehost-live&scope=site

Purpose of Study
The study aims to evaluate and compare the early literacy skills of children with hearing loss in two different educational settings and in comparison with the skills of hearing children. They hypothesized that children with hearing loss who were individually integrated into a standard kindergarten classroom would exhibit stronger early literacy skills than would their counterparts who were mainstreamed in a standard kindergarten classroom along with a small special group of other children with hearing loss. In addition, they predicted that the children with normal hearing would outperform the hearing impaired children in both educational settings.

Subjects
The subjects were comprised of 42 kindergartners aged 62 to 84 months divided into three groups. The first group of participants consisted of 15 children, 7 children aged 5-6 years and 8 children aged 6-7 years with hearing loss who were in the individual inclusion track each child with a hearing loss was individually integrated into a standard kindergarten classroom with children who have typical hearing in his or her neighborhood. The second group of participants consisted of 16 children, 7 children aged 5-6 years and 8 children aged 6-7 years with hearing loss who were in the small group inclusion track, integrated within small groups into a standard kindergarten classroom. The control group consisted of 11 children, all aged 5-6 years, who had typical hearing and were enrolled in two standard kindergarten classroom settings. All 31 children with hearing loss were recruited from the Tel Aviv branch of MICHA. They all had prelingual hearing loss. All 31 children with hearing loss used sensory aids. In the second group, 12 children wore hearing aids, and three children had cochlear implants. In the first group, eight wore hearing aids and eight had cochlear implants. All children in the second group used spoken language except one who used Total Communication. In the first group, nine children used spoken language and seven children used Total Communication. The two groups differed significantly regarding age at onset of rehabilitation. All 42 children had hearing parents and they came from Hebrew speaking homes. They were scheduled to start first grade in the following school year and showed no cognitive, emotional or behavioral problems.

Method

Parents completed a demographic questionnaire including data on child's degree of hearing loss, type of sensory aid, mode of communication, age of onset of rehabilitation, other difficulties and parents' hearing status and profession. The children completed seven tests of early literacy: word writing, word recognition, phonological awareness, letter identification, orthographic awareness, receptive vocabulary and general knowledge. For the Word writing and Word recognition test, the children were asked to write four word pairs presented orally. To avoid any misunderstanding caused by the child's hearing loss, the examiner presented the child with four cards, each of which displayed identifying drawings of two nouns. The Phonological awareness test presented all the words as illustrations before and included 20 stimulus words, each accompanied by three alternatives: two distracter words and one target word that matched the stimulus on initial or final phoneme or syllable. The Letter identification test, the subjects were asked to name 12 printed letters, each presented on a separate card in large print. The Orthographic awareness test included 18 pairs of graphic items comprising one printed word and one non-word that included a mixture of Latin and Hebrew letters, numerals or illegal repetition of letters. The subjects were asked to select the printed word and explain his/her reasons. For the Receptive vocabulary, the Peabody Picture Vocabulary Test (PPVT) was selected to examine children's receptive vocabulary. General knowledge was tested using the subscale of the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) adapted to Hebrew administered either orally or simultaneously. Their data collection began around February during the kindergarten year and lasted for about 11/2 months for the whole group. The children were assessed individually during two sessions that took place in a quiet room in the classroom. We divided the test into two fixed sequence sets: (1) word writing of two word pairs, phonological awareness (the final phoneme/syllable), receptive vocabulary (PPVT), half of the orthographic awareness test and word recognition of two pairs; and (2) word writing of two word pairs, letter identification, phonological awareness (the initial phoneme/syllable), half of the orthographic awareness test, general knowledge (WPPSI) and word recognition of two pairs. Half of the sample started with set one and then completed set two, and the other half started with set two and then completed set one. In addition, parents completed the demographic questionnaire at home and returned it to the kindergarten teacher.

Results

The main findings indicated that children with hearing loss in the individual inclusive program yielded better achievements compared to those enrolled in the group inclusive program regarding phonological awareness, letter identification, general knowledge and vocabulary. Achievements of children with typical hearing in these parameters surpassed those of children with hearing loss in either of the inclusive programs. No statistically significant differences emerged between individual and group inclusive programs regarding reading, writing or orthographic awareness. Achievements of the hearing children in these parameters surpassed those enrolled in group inclusion but did not differ statistically from those enrolled in individual inclusion. Their findings showed a negative correlation between general knowledge and degree of hearing loss. Also, general knowledge, reading and writing correlated with age at onset of rehabilitation; no correlation emerged between socioeconomic status and children's early literacy skills. The results suggest that gaps in the academic achievements associated with literacy between children with and without hearing loss, as well as between children with hearing loss enrolled in different inclusive programs, already appear in kindergarten. Focusing on training and improvement of pre-literacy capabilities in kindergarten may decrease those gaps.

Discussion

I’m really interested in pre-literacy and how hearing loss can have an effect on language development, both spoken and written language. The clients that I want to be the focus on my future practice are children under the age of 8 and this age is the time when the fundaments for language development are learned and expanded. This information can be used when I’m developing intervention goals for children with hearing loss and as a diagnostic tool to help focus my assessment areas to where some children with hearing loss may have difficulty with.

Opinion

I think that the study was very well documented but I do wish that the groups used were more generalized based on ethnicity and social characteristics of the general United States population. This study may be hard to generalize to the population that I will be treating because of the homogeneity of the studies population. All of the study’s groups were from Hebrew speaking homes. For the study to be better, the groups should be expanded to include other peer groups so that this study can be used as evidence when developing evidence-based intervention.


Abstract written by Salima Barrister

Reference:
- Name: Manfred Hintermair
- Name of Article: “Prevalence of Socioemotional Problems in Deaf and Hard of Hearing Children in Germany
- Journal Title: American Annals of the Deaf, No. 3, 2007, 320-330, accessed on line – Accessed on Tuesday, September 08, 2009, http://muse.jhu.edu/journals/american_annals_of_the_deaf/v152/152.3hintermair.pdf


Purpose of Study:
The aim of the present study was to examine a German sample of deaf and hard of hearing children and discover to what extent the parents’ version of the SDQ might also be used as a screening procedure for these children. A further purpose of the study was to attempt a cautious and preliminary estimate of how prevalent socio-emotional problems are among deaf and hard of hearing children in Germany.


Subjects/Methods:
Questionnaires were sent to all the schools for deaf and hard of hearing children in the German state of Bavaria. It was requested to be handed out to parents with children between 4-12 years of age as these are the age scales given in the questionnaire. Identical questionnaires were sent out for both mothers and fathers with the request that they be filled out independently. Response rate = 35.5% and 213 parirs of questionnaires were turned in. This sample is not considered representative because parents of children in mainstream schools were not included and parents from other cultural backgrounds are probably not represented appropriately because with difficulties with reading German.
Parents had to score 25 statements pertaining to the child (many worries, often seems, worried, constantly differing or squirming, considerate of other people’s feelings) as not true (0), somewhat true (1), or certainly true (2). All analyses were performed with SPSS version 11.0.


Results:
There was a high correlation between mother and fathers with regard to how they rated their child. Internal consistency of the SDQ: homogeneity of the SDQ scale is seen when compared to the results of the German representative study done in 2002. Hyperactivity was shown to be greater in boys who were perceived to be more “abnormal” by both the mothers and fathers. Also, the total problem score is higher for children with additional difficulties (significantly higher in mothers sample and tending toward high in the fathers sample). Peer problems seem to be the most significant scale here. A significant correlation was shown children’s communicative competence and all the SDQ scores. The educational status of the parents on the other hand, could only be correlated to any significant degree with mothers’ scores given for peer problems in the SDQ.


Discussion:
This study helps me understand the importance for good parental communication with a deaf child. That parental sensitivity and responsiveness are essential prerequisite for this developmental process, as in the appropriate, functional and child-centered used of a system of language communication, no matter the actual form of language involved. I have learned that it is critical for deaf children to be able to have a sense of their own identity, particularly as they grow and mature. This information is important in that it will help me provide become more aware of the additional areas to assess and work on in therapy. I will assess to see how the child is reacting to his hearing difficulties and how his self image and identity are affected by it. In the case that it is suffering, I will write the goals to also informally address self confidence and self image issue.


Opinion:
I think this study was useful in assessing how a mother and father identify their deaf child’s difficulties and the intricate nature of deaf-therapy, one which includes internal perspective and self value(on the part of the child). My therapy will be more counseling and driven and will incorporate emotional supports and scaffolding teaching.


Abstract written by Laure Eysermans

Abstract written by Blaire Staggs

Reference:
Fellinger, J., Holzinger, D., Sattel, H., Laucht, M., & Goldberg, D. Developmental Medicine and Child Neurology, August, 2009, 635-41. Accessed on Sunday, September 6, 2009. http://www.ncbi.nlm.nih.gov/pubmed/19627335?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Purpose of Study:
The purpose of this study was to reveal factors to the high correspondence of mental health disorders in people with hearing loss.

Subjects:
95 children (47 females and 48 males) who ranged in age from 6;5 to 16 with hearing loss of at least 40 dB and normal IQ levels.

Methods:
The children were assessed audilogically as well as administered a clinical interview regarding diagnosis. The Strengths and Difficulties Questionnaire was also administered and detailed history was collected from the parents.

Results:
It was found that prevalence rates of psychiatric disorders and depression were higher in children with hearing loss than in children within the general population. The level of the psychiatric disorder or depression did not correlate with the severity of the hearing loss. Children who had been teased or mistreated by peers were six times more likely to present with a mental health disorder.

Discussion:
I thought it was a very good study that provides a great deal of information regarding the likelihood of a child with a hearing loss to develop and mental health disorder, including depression. I found it very surprising that the likelihood of developing one of these disorders was six times higher in children who had been teased. This information would be very helpful when educating parents or individuals with hearing loss regarding their mental health states. Being knowledgeable about these findings can also aid an SLP in recognizing potential distress in a patient and making appropriate referrals.

Opinion:
This study provided very helpful information that would prove to be very valuable in referring a patient to the correct medical personnel. It would be beneficial for an SLP to be familiar with these findings, however, it would be best not to present the information to every patient with a hearing loss that the risk is high for a mental health disorder, however, it is good information to have on hand, should the need to use it arise.


Abstract written by Reshma Rao


Dammeyer, Jesper. “Congenitally Deafblind Children and Cochlear Implants: Effects on Communication”. Journal of Deaf Studies and Deaf Education Spring 2009 14(2):278-288.
Accessed on Monday, September 07, 2009 http://libproxy.library.unt.edu:5259/cgi/content/full/14/2/278

Purpose of Study
The purpose of the study was to examine the extent of the effects of cochlear implants (CI) on social interaction and overall communication in congenitally deafblind children.

Subjects
Five congenitally deafblind children between 5 and 8 years old from different parts of Scandinavia were included. The children were recruited by consultants who worked with these children. Range of age at implant surgery was 2.2 to 4.2 years. At the time of testing, all children had used cochlear implants for at least a year. Four children were deaf and one was hard of hearing. All children were blind, but one child had low vision. Two of the children had at least low-average intelligence and three presented with mild mental retardation. All children received “usual” intervention before and after CI, but the frequency and type of the intervention was unknown.

Method

The children were observed by video in free play with a familiar adult in a familiar setting. The videotaping was done by the consultant. Due to the heterogeneity of the group, an appropriate control group could not be formed. Therefore, the children were videotaped for 30 minutes with the CI on and for 30 minutes with the CI off. A 2-minute clip was selected from each 30 minute episode for rating and analysis.

Rating procedure
Each episode was rated using six variables for every turn. A turn was defined as any verbal or behavioral action or reaction as part of the social interaction or communication between the child and the adult. The variables were rated by three professionals with relevant experience:
· Modality of communication (linguistic signs, linguistic speech and nonlinguistic communication).
· Dialogue (initiative, answer or no answer).
· Quality of communication: Rated using a scale of 1-5 (1=communicational act makes the communication interaction much worse, 3= communicational act makes the communication interaction neither worse or better, 5= communicational act makes the communication interaction much better).
· Manipulation of objects: Rated using a scale of 1-5 ( 1= manipulation of objects is not at all relevant and does not at all make the communicational interaction better, 3=neither better nor worse and 5= manipulation of objects is very much relevant and makes the communicational interaction much better).

· Attention: Rated using a scale of 1-5 (1=child does not pay any attention to social interaction and 5=child paid full attention to social interaction and 3- neither paid nor did not pay attention).
· Emotional response: Rated using a scale of 1-5 (1= emotional response not at all relevant to social interaction, 5= very much relevant and 3=neither relevant not irrelevant). It was not a score of positive or negative emotions.

Supplemental methods
Additional screenings, such as Categories of Auditory Performance (CAP) and Speech Intelligibility Rating(SIR) were completed by parents. Two single-item scales were designed to evaluate sign language production and understanding were designed and administered. Additionally, parents were interviewed and their input on the outcome of CI was obtained.

Results
As expected, the outcome of this study was not related to increase in speech output; rather it was increasing the communication and social interaction skills of the children. The interaction between the child and the partner measured by the parameters Quality of Communication, Attention, Manipulation of Objects and Emotional Response was better when CI was used. The parameter Dialogue was better only for one out of the five children in episodes with CI, therefore, no effect can be reported. Results of CAP yielded that two out of five children recognize speech sounds, while three were not. Only one child was able to speak at the time. CAP measures before CI were not available, but parents of two children reported significant progress in speech and auditory skills. Results indicated that intelligence levels were an important factor in determining CI outcome, even in children with just hearing loss. All parents reported that they would recommend CI to other parents/children. Parents of all the children gave an order of priority to 10 behaviors affected by CI. Attention and communicative outcome were rated as most important and education as least important.

Discussion
One of the interesting aspects of this article is that even though CI was not able to improve speech output of a deafblind child, it can improve his/her quality of life by improving interpersonal skills and social communication. The child can have more meaningful social interactions, which improves his/her overall communicative abilities. The results from this study can be used to highlight the positive effects of CI during a counseling session. Even if the child in question is deaf but not blind, the results can be used to focus on the effectiveness of CI in children with multiple disabilities. Clinically, the results can be used to focus therapy time not only on speech/sign language production, but also on developing social communication, as the results show that CI can help with it.

Opinion
This is a good study; however, there are some limitations. For example, the sample size is too small. Also, there is not much variability in terms of ethnic and cultural background. This may affect external validity. Also, the rating of the parameters is, to an extent, subjective. This may also affect the results. It will be interesting to find out the effects of CI on social interaction with unfamiliar people and settings.