Study critical revieew

2. ● Hearing loss is the fourth highest cause of
disability globally.
● Disabling hearing loss accounts for 5.3% of the
world’s population of which 9% are children
(WHO 2012)
Hearing
impairment can
affect a child’s
ability to develop
speech, language,
and social skills.

3. Cochlear Implant

4. WHY COCHLEAR IMPLANTS?
❖ The primary benefit of CI in children are:
Acquisition of hearing, which promotes
development of spoken language.
❖ Cochlear implants promote development of
hearing in children and the best outcomes are
achieved by providing early access to sound
(Sharma & Cushing et al 2020).
Greater variability in
language outcomes are
reported in children
using CI ( Caelli et al
2012; Majorano et al
Attributes of these variabilities
are:
★ Environmental factors
★ Patient related factors
★ Device related factors
★ Surgical related factors

5. Let’s talk about environmental factors
Maternal Language Characteristics & Surrounding Acoustic Environment
Maternal language
characteristics: Quality &
Quantity- Facilitate
language production and
acquisition
Children able to perceive caregiver
inputs only if the environment provides
good acoustic conditions.
Consistent maternal language
facilitation strategies - Better
language level of the child
(Cruz et al 2013)

6. Ci technology to access surrounding acoustic
characteristics of the user
=
Data Logging
Acoustic scene
analysis

7. ACOUSTIC SCENE ANALYSIS Speech
in
noise
Noise
Case et al., 2011
Step 3
The acoustic
environment
is also
divided into
six categories
of loudness
Step 1
Algorithm
classifies,
once per
second, the
microphone
input into
six
different
acoustic
scenes
Step 2
The
algorithm
determines
the amount
of time (daily
hours) spent
in each
scene, using
six time
counters (one
per scene).
> 40 dB SPL)
40–49 dB SPL
50–59 dB SPL
60–69 dB SPL
70–79 dB SPL
</= 80 dB SPL

8. DATA LOGGING
How many hours per
day they're using the
cochlear implant.
The volume levels they
use throughout the day
The different sound
environments they
experience in a day
03
01 02
Automatically tracks usage and records the information which can then be
accessed by the audiologist through programming software.

9. Do Acoustic Environment
Characteristics Affect the Lexical
Development of Children with Cochlear
Implants?
A Longitudinal Study Before and After
Cochlear Implant Activation
Marinella Majorano,a Margherita Brondino,a Letizia Guerzoni,b Alessandra Murri,b Rachele
Ferrari,a Manuela Lavelli,a Domenico Cuda,b Christine Yoshinaga-itano,c Marika Morelli,a And
Valentina Persicia
Year Of Publication :2021
American Journal of Audiology (AJA)

10. NEED OF THE STUDY
● There are no reported studies which longitudinally
investigate the influence of daily acoustic speech
exposure on the lexical development of children
implanted within 3 years of age
● Current study also attempted to consider the
individual differences in early vocabulary while
exploring the influence of daily acoustic speech
exposure on lexical development

11. AIM
● To investigate the effect of daily
acoustic environment on lexical
development of children who
underwent cochlear implantation
within 3 years of age.
● To establish the relationship between
exposure to speech in noise and in
quiet and the children’s lexical
production over the first year after CI
activation.

12. To determine the
Environmental Acoustic
Exposure 3, 6, and 12 Months
after CI Activation
To understand the Effect of
Exposure to Acoustic Speech
Scenes and Individual
Differences in Receptive
Vocabulary Growth on the
Children’s Lexical Indices
01
02

13. Lexical development of the child would be affected both by early
growth in receptive vocabulary size and by exposure to speech in
quiet with specific characteristics of loudness.
To observe a higher frequency of loudness ranging between 40
and 69 dB
Effect of exposure to speech in noise on language measures
would be minimal as children has not been using CI for a long
time.
To observe higher frequency of speech in noise than speech in
quiet
04
03
02
01
HYPOTHESIS

14. METHOD

15. INCLUSION CRITERIA
TITLE
Some text goes
here. Some text
goes here. Some
text goes here
1
2
3
4
5
6
Normal-hearing parents
Diagnosed - profound bilateral sensorineural
hearing loss
CI surgery before 36 months of age
Children with no sensorimotor or developmental
disorders
Children with no cognitive disability
Enrollment in an oral communication program before
or after implantation

16. 11
7
Causes
Genetics 8
Cytomegalovirus 2
Unknown 8
● Nucleus 5 (Cochlear LTD) CP
920- 5 children;
● Nucleus 7 CP 1000 in 12
children
Sound processor
All participants -
Unilateral CI
implantation
( except one)
Italian monolingual speakers
(Mothers and children)
PARTICIPANTS (N) = 18

17. Hearing loss was
verified using the
click-evoked and tone-
bursts-evoked
auditory brainstem
response.
Diagnosed
between 2 and 28
months
Implanted between 10
and 35 months of age
Age at first session before implantation (months) 17.52 (mean)
Age at diagnosis (months) 7.94 (mean)
Age at implantation (months) 17.44 (mean)
Mean PTA (dB/HL) 101.39 (mean)

18. Procedure &
Instruments

19. 1 2

20. Children’s
vocabulary
size
RLA & ELA
Number of
types and
tokens
Lexical
development
(T2)
6 months
post
implantation
(T1)3 months
post
implantation
(T3) 12
months
post
implantation
(T0) before
implantation
1. LEXICAL DEVELOPMENT

21. Age
range
8 and 24
months
Parents were
instructed to mark the
words from the list
that the child could
verbally comprehend
and spontaneously
produce
nouns, verbs, adjectives, adverbs,
and closed-class words
CHILDREN’S VOCABULARY SIZE
“Word and Gesture” MB-CDI (Fenson et al., 2000) short form -
Italian version (Caselli et al., 2015)
Questionnaire -
vocabulary checklist
- 100 words

22. The children’s
spontaneous language
production
20 min of video
observations of mother–
child interaction
Mothers instructed to
play with their children
as they usually do at
home.
Semi structured play conducted
using the Assessing Linguistic
Behaviour protocol (Olswang et
al., 1987)
TOKEN AND TYPES
Video Observations

23. Data
logging
Daily hours of
CI use
The children’s
acoustic
environment
Acoustic input
analysed - automatic
scene classifier
system
SCAN
2. Acoustic Environment Characteristics

24. Vocabulary size
Receptive vocabulary size -
The total number of words
reported by the children’s
mothers as words that their
child comprehended.
Expressive vocabulary size-
The total number of words that
the children reportedly
produced.
Coding of children’s vocabulary size
and video observations
Video observations
Transcription & Coding
- CHAT
Token and types automatically
calculated - Computerized
Language ANalysis (CLAN)

25. (T2)
6 months
post
implantation
(T1)3 months
post
implantation
(T3) 12
months post
implantation
The average number of
hours per day spent in
each
● Acoustic scene
● Loudness interval
Coding Of Data Logging

26. A series of Repeated Measures Analysis of variance
(ANOVAs)
DATA ANALYSIS
★ Acoustic scenes ★ Loudness ranges
There were six categories of
loudness ranges in decibels
considered by DL
(vocabulary size and the
number of types and tokens
produced)
★ Children’s
lexical
development
There were 6 scenes the
children were exposed to.
This information is collected
from DL after CI activation.
1. Speech in Quiet
2. Speech in Noise
3. Quiet
4. Noise
5. Music
6. Others
>40 dB SPL, 40-49 dB
SPL , 50-59 dB SPL, 60-69
dB SPL, 70-79 dB SPL,
>/= 80 dB SPL

27. Path models [Mplus 8 given by Muthén & Muthén,
1998–2017]
To explore how predictive are
● The type of acoustic exposure to speech i.e,
speech in quiet or in noise between 40 and 69 dB
levels and the children’s early individual growth in
receptive vocabulary size (T1 & T2) were of lexical
production performance (T3)

28. RESULTS

29. Objective 1: Environmental Acoustic Exposure 3, 6, and 12
Months after CI Activation

30. 2
Statistically significant
difference in type
exposure - “Quiet” &
“Music” only as the
exposure across timeline
❖ T1 and T3 for quiet
❖ T1 and T2 and T1
and T3 for music
( Statistically significant
as on Post HOC test)
3
No significant difference
was found for exposure to
“Noise”and for exposure
to “Others”
1
Remarkable differences in
exposure to
● Speech in noise
● Speech in quiet
between time points, with
progressive increases over
time for both variables
( changes were not
statistically significant as
indicated by Post Hoc test)

31. ANOVA
Data analysis showed
significant exposure differences
at the all the time points
T1 ( p < .001)
T2 ( p < .001)
T3 ( p < .001)
Post Hoc
Post hoc comparisons
revealed:
1. Significant difference
between each scene and
“noise”.
2. Between each scene
and “other”at each time
point.
Repeated-measures ANOVAs to analyze whether children were more exposed to
some acoustic scenes than to others.

32. Most exposed loudness
Repeated-measures ANOVAs to analyze the loudness range children were more
exposed

33. Most exposed loudness
ANOVA & Post HOC
Data analysis showed significant increase in
exposure to each of the loudness ranges over
time ,except for levels above 80 dB
Repeated-measures ANOVAs to analyze the loudness range children were more
exposed

34. ANOVA
Data analysis showed
significant exposure
differences at the all
the time points
T1( p < .001)
T2 ( p < .001)
T3 ( p < .001)
Post HOC
Post hoc comparisons
showed:
Significant differences
between any two
loudness ranges except
between
● 40 -49 dB & >80 dB
● 50–59 & 60–69 dB.
Repeated-measures ANOVAs to analyze whether children were more exposed to
some loudness ranges than to others.

35. Most frequent acoustic
scenes at each time
point
❖ speech in noise
❖ music
❖ speech in quiet
Most frequent loudness
ranges in the children’s
acoustic environment at
each time point
❖ 50–59 dB
❖ 60–69 dB

36. Objective 2:
Effect of Exposure to Acoustic Speech Scenes and Individual
Differences in Receptive Vocabulary Growth on the Children’s
Lexical Indices

37. Analysis showed significant differences between time points in
receptive and expressive vocabulary size, as well as in the number
of tokens,and types produced between time points (before CI
activation and 3, 6, and 12 months after implantation
Expressive vocabulary scores were close to zero at T0 (range: 0–
3 words) and did not improve as much as comprehension scores
over the next 3 months (between T0 and T1)

38. Time points starting
from T1 for tokens
and types
Between T0 and T1 for
receptive vocabulary
scores
Between Time points starting from
T2 for expressive vocabulary scores
Statistically
significant
increase
Post hoc

39. Significant correlations between maternal
education and the tokens and types produced
on average by the children throughout the year
of observation.
Age at which children were diagnosed was
negatively correlated with their tokens and
types measures at the latest time points
Lexical measures did not correlate
with hours of device use
Spearman correlations

40. Three independent t tests - children’s lexical outcomes at T3
were not affected by whether they had been implanted before or
after the first year of life

41. Path analyses
Model
predicting the
children’s
02
03
01
Influence of speech acoustic scenes and of the children’s lexical production
● Variations in exposure to
speech scenes (in noise and
in quiet between 40 and 69
dB) between T1 and T2
● Early increase in individual
growth rate in receptive
vocabulary size between T0
and T1.
Controlling

42. children’s tokens
production -
55% of variance
children’s
expressive
vocabulary
scores-
34% of variance
children’s types
production-
51% of variance
Exposure to speech in noise did not show a statistically significant effect

43. DISCUSSION

44. LEXICAL DEVELOPMENT
Significant improvement in
their lexical skills over time-
(comprehension, production
token and types)
-Irrespective of age of
implantation
Comprehension and production
scores (token & types) showed
significant improvement over
time.
- High degree of variability
across participants observed.
Children’s vocabulary scores
for comprehension increased
more rapidly than expression.
- Production abilities needs
auditory motor representation +
development of phono-
articulatory skills.
Quittner et al 2004, Tomblin et al 2008, Uhler et al, 2011
 Lexical skill progress during first 12 months of implantation

45. IMPLANT USAGE
Significant increases in
device use across
observations
Avearge use :
Decrease in the hours that
the children spent
sleeping (Iglowstein et al,
2003)
Parents’ greater ability
to help with CI use
(Walker et al., 2013).
Busch et al.,
2017; Cristofari
et al., 2018
The hours of usage of device - not correlated with their
spoken lexical outcomes 1 year after implantation
Consistent with Gagnon et al, 2020- One year of CI
usage is not “’enough time” to have effect on
expressive language

46. ACOUSTIC ENVIRONMENT CHARACTERISTICS
>Children
spend most
of their time
in the context
of speech in
noise
> Most of
their
interactions
take place in
the presence
of noisy
backgrounds
(adult
conversation,
games,
television)
Acoustic environment characteristics showed a
general increase in exposure to various acoustic
scenes and to various ranges of loudness
Most frequent scene detected by DL:
Speech in noise > Music > Speech in quiet
(Not significant difference between acoustic
environment characteristics)
Most frequent loudness:50- to 59- and 60- to 69-dB
Least frequent ranges: Below 40 and above 80 dB.
In line
Cristofari et al.,
2018).
In line with
Busch et al,
2017, Rauch
et al, 2019

47. EARLY GROWTH IN RECEPTIVE LANGUAGE SKILLS
Early receptive languge growth -
Significant effects on children’s
1. Expressive vocabulary scores
2. Number of tokens produced
Supports “Learning mechanisms” have a
substantial degree of stability over time
(Plunkett & Elman, 1998)
 Children’s lexical growth rate
depends on the quantity of
input directed to them.
 This could have affected their
developmental trajectories
(Szagun & Schramm, 2016).
Early receptive ability
could have a stronger
effect on later language
outcomes.

48. Exposure to Speech acoustic scenes as a Predictor of
Expressive Vocabulary
• Degree of exposure to speech in quiet was a
significant predictor of the number of tokens and
types produced by the children.
In the present study
• Less exposure to speech in quiet have more negative
effects on vocabulary acquisition for children.
Revit 2010, Geers et al 2013
• The amount of exposure to speech in quiet, with
loudness levels below 70 dB, predicts vocabulary
competences in children with CIs
Guerzoni and Cuda (2017)
No significant
effect on lexical
outcomes was
found for
exposure to
speech in noise.

49. In optimal listening conditions -
speech perception performance is
better as auditory stimulus is
matched with stored phonological
representation
In poor listening conditions -
children need higher levels of
cognitive resources for speech
perception
ELU model
(Ronnberg et al., 2010)
Why Exposure to speech in Quiet ?
Language comprehension is through the interaction between
acoustic characteristics of the input and child’s ability to
process stimuli.
The children’s ability to deal with less-than-ideal acoustic environments is limited

50. Negative relationship between age at diagnosis and lexical outcomes 1 year after
implantation
Earlier diagnosis also affected the children’s lexical development possibly via earlier
intervention.
Early identified children usually receive earlier intervention services; the participation
in these programs facilitate vocabulary acquisition and language development.
Yoshinaga-Itano
et al., 1998
Effect of Co-Variants (Age at Diagnosis) on Lexical development as on
Correlation tests

51. In current study , Maternal education correlates with the children’s lexical
outcomes.
Suggests that child lexical development is influenced by the
quantity and quality of parental input received
(Quittner et al., 2013 & Ching & Dillon, 2013)
Effect of Co-Variants (Maternal Education) on Lexical development as on
Correlation tests

52. CONCLUSION

53. ● Both ,the characteristics of the acoustic environment, with specific reference
to speech in quiet, and individual differences in the children’s early skills, play
a role in children’s lexical development.
● Understanding the risk and protective factors that can influence the lexical
development of children with severe-to-profound deafness and CIs is
crucial to our making progress in how we support children and families in
the language acquisition and development processes.
● Understanding the relationship between different factors that can
affect the lexical development can support the planning of
personalized rehabilitation programs that include instructions and
advice for parents

54. Pros
Longitudinal study
Proposed a model for
predicting expression
skills ,types and tokens
based on reception
and exposure to
speech in quite
Details of exposure to
different scene is also
provided even though
that was not included in
the aim
Strong data analysis-
more data points -
precise information

55. CONS
The effect of higher
device use may only
become visible with
longer CI use time,
Limited sample size -
did not allow the
addition of other
predictors or covariates
in the model testing the
effect of speech-in-quiet
exposure and early
comprehension skills on
lexical outcomes 1 year
after implantation.
Processor used were
different

56. CRITICAL ANALYSIS OF THE STUDY
• Mean age of the children was given rather than the age range
• Hearing loss details is mentioned as PTA - which is difficult to obtain for this population
• Inclusion criteria included, no cognitive impairment- but the details of how it was assessed is not
provided
• Exposure to speech in noise and speech in quiet is given as not statistically significant but the table
value shows viceversa
• The complimentary analysis result says significant difference between any scenes and noise, but it was
not shown for quiet and noise in the table
• Control group not included
• Only mother - Child interactions were included for all the participants in the study. However criteria
for considering only mothers was not mentioned.
• Also only maternal education were taken into consideration.

57. Future Directions
03
04
01 02
To address whether
results are modified by
bilateral implantation or
specific intervention
program.
The role of individual and environmental variables in affecting lexical
development warrants further investigation, possibly with
➔ A control group of hearing children
➔ Data from various languages and communicative contexts
To include age
at diagnosis as
additional
variable in path
analysis
To study about
parental input
which also affects
child lexical
development

58. KEY POINTS
01 Parents could be advised to pay more attention to the
quantity of speech they direct to the child (such as in face-to-
face shared book reading) in a low-noise environment
02 Importance of timely diagnosis and implantation
03 The positive effect of children’s exposure to speech in quiet
04 Importance of CI daily usage hour
05 Importance of mother interaction and motivation
06 Encouraging use of personal assistive listening devices

59. REFERENCES

60. THANK YOU