Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2014) 15, 29–35

Egyptian Society of Ear, Nose, Throat and Allied Sciences

Egyptian Journal of Ear, Nose, Throat and Allied

Sciences
www.ejentas.com

ORIGINAL ARTICLE

Psycholinguistic abilities in cochlear implant

and hearing impaired children
Hatem Ezzeldin Hassan a,b,*, Sally Taher Kheir Eldin c,
Rasha Mohamed Al Kasaby d,e

a
Otorhinolaryngology Department, Sohag University, Egypt
b
King Fahd Hospital, Jeddah, Saudi Arabia
c
Otorhinolaryngology Department, Ain Shams University, Egypt
d
Otorhinolaryngology Department, Mansoura University, Egypt
e
Military Hospital, Riyadh, Saudi Arabia

Received 20 September 2013; accepted 14 December 2013

Available online 17 January 2014

KEYWORDS
Psycholinguistic;
Cochlear implant;
Language disorders;
Hearing
Abstract Background: Many congenitally sensorineural hearing loss (SNHL) children and
cochlear implant (CI) recipients develop near-normal language skills. However, there is a wide var-
iation in individual outcomes following cochlear implantation, or using hearing aids. Some CI
recipients or Hearing aids users never develop useable speech and oral language skills. The causes
of this enormous variation in outcomes are only partly understood at the present time. So, the aim
of this study was to assess the psycholinguistic skills in Arabic speaking children with either SNHL
or CI in comparison to normal controls in order to estimate the nature and extent of any specific
deficit in these children that could explain the different prognostic results of language intervention.
Subjects and methods: Three groups were selected, according to Language test, Pure tone audi-
ometry (PTA) & Auditory brain stem response (ABR). Group I included fourteen children with
severe and/or severe to profound SNHL aided with proper hearing aids. Group II consisted of four-
teen children with CI (MED-EL and Nucleus) and group III included fourteen children with normal
hearing. Receptive, Expressive and total language quotients were calculated using the Arabic
Language test. Assessment of psycholinguistic abilities was done using the Arabic version of the
Illinois Test of Psycholinguistic abilities.

* Corresponding author at: King Fahd Hospital, Jeddah, Saudi

Arabia. Mobile: +966 594183458.
E-mail address: hezzm268@yahoo.com (Hatem Ezzeldin Hassan).
Peer review under responsibility of Egyptian Society of Ear, Nose,
Throat and Allied Sciences.

Production and hosting by Elsevier

2090-0740 ª 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and Allied Sciences.
http://dx.doi.org/10.1016/j.ejenta.2013.12.006
30
Conclusion: HI individuals have poor auditory short-term memory (A-STM) in comparison to
normal hearing individuals. Also, HI individuals have visual short-term memory (V-STM) better
than normal hearing individuals. So, multisensory training is needed both in therapy sessions
and classrooms with more focus on visual stimuli.
ª 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and
1. Introduction
Many congenitally sensorineural hearing loss (SNHL) children
and cochlear implant (CI) recipients develop near-normal lan-
guage skills. However, there is wide variation in individual out-
comes following cochlear implantation, or using hearing aids.1
Some CI recipients or Hearing aids users never develop useable
speech and oral language skills. The causes of this enormous
variation in outcomes are only partly understood at the pres-
ent time.2 Unfortunately, deaf students often have been found
to have lower vocabulary skills than hearing age-matched
peers. The size of their vocabulary tends to be smaller, the rate
in which they acquire new vocabulary is slower, and they less
easily develop new word meaning acquisition processes (Pisoni
et al., 2000).
Several researchers have pointed out that early identifica-
tion of hearing loss (HL) has a positive effect on vocabulary
development. The result of early intervention services pro-
vides support for both language and cognitive development.
Aside from studies of early vocabulary development as part
of language acquisition, studies of vocabulary in deaf learn-
ers have focused on the relation between vocabulary and
reading.3
Psycholinguistic abilities, both auditory short-term memo-
ries (Auditory sequential memory, Sound blending, Auditory
closure, Auditory association and Verbal expression) and Vi-
sual short term memories (Visual sequential memory, Visual
reception, Visual closure and Manual expression) are impor-
tant predictors for language development in normal children
and children with disabilities.
Surowieck et al.4 claimed that many children using cochlear
implants are able to hear fine differences between speech
sounds but are not progressing as wel1 as expected in receptive
language ability. There is strong evidence from teachers that
some children using cochlear implants have poor short-term
auditory memory ability, which may be impeding their lan-
guage development. Temporal ordering and short-term mem-
ory storage capacity involve higher order processing. Severe
auditory deprivation prior to implantation may have caused
auditory processing deficits at a cortical level.
When cochlear implant implantation will be carried out
especially at the very critical period of language development
(before age of four), this will help the child, in his/her future
life, not only with his/her hearing skills and communication
but for his/her attention skills and behavior.5 The causes of
these apparent differences in the success of treatment among
HI & CI children are poorly understood. Therefore, early iden-
tification, understanding the nature of the disorders and prop-
er intervention is warranted. However, to our knowledge, there
have been no studies done to assess short term memory of Ara-
bic speaking children with HI and CI. In this study we tried to
have answers for the former questions, why there is a wide var-
H.E. Hassan et al.
Allied Sciences.
iation in outcomes of rehabilitation of HI & CI regarding A-
STM & V-STM.
1.1. Aim of the work
The aim of this study was to assess the Psycholinguistic skills
in Arabic speaking children with either SNHL or CI in com-
parison to controls in order to estimate the nature and extent
of any specific deficit in these children that could explain the
different prognostic results of language intervention.
1.2. Subjects and methods
This study was conducted on children presented with delayed
language development to Phoniatrics clinic, King Fahd Hospi-
tal Jeddah, during the period from October 2011 to July 2012.
Three groups were selected, according to Language test,
Pure tone audiometry (PTA) & Auditory brain stem response
(ABR). Group I included fourteen children with severe and/or
severe to profound SNHL aided with proper hearing aids.
Group II consisted of fourteen children with CI (MED-EL
& Nuleus) and group III included fourteen children with nor-
mal hearing.
All children included in this study were subjected to a com-
prehensive language assessment protocol.6
- Patient’s interview.
- Audiological evaluation including Auditory Brain Stem
Response (ABR), Otoacoustic Emissions (OAEs) and
Cochlear Microphonic (CM).
- Psychometric evaluation by using Wechsler intelligence
scale.8
- Objective language assessment was done using Standard
Arabic language test to calculate Receptive, Expressive
and total language quotients.6
- Assessment of psycholinguistic abilities was done using the
Arabic version of the Illinois Test of Psycholinguistic
Abilities.7
- Inclusion criteria: Individuals with severe and/or severe to
profound SNHL, aided with proper hearing aids more than
5 years. Individuals using CI more than 5 years duration.
- Exclusion criteria: Subjects with mental retardation (MR),
below average mentality or any subject with behavioral
problems, pervasive developmental disorders or with audi-
tory neuropathy were excluded from the study.
Children with Hearing Impairment (HI) were 8 boys and 6
girls. Their mean age was 8.3 ± 1.3 and age ranged from 6 to
12 years. The mean duration of H.As fitting was 5 ± 2 years.
Children with Cochlear Implant (CI) were 7 boys and 7
girls. The mean age was 7.9 ± 0.9 years and age ranged from
6 to 12.6 years. The mean duration of CI was 5 ± 1 year. Both
Psycholinguistic abilities in cochlear implant and hearing impaired children
groups of children (HI & CI) were attending regular individual
language therapy sessions (two sessions per week, each session
for 30 minutes for 2 years). Family counseling was given to the
parents every three months to enhance the language abilities of
the children.
Control group (normal hearing children) were 7 boys and 7
girls. The mean age was 8.5 ± 1.2 and age ranged from 6 to
11.9 years. These children were selected randomly from mem-
bers not suffering from any language and speech disorders.
They were selected from outpatient clinic; King Fahd Hospital
Jeddah, during the same period after taking their parents’ con-
sent and they were used as a reference for their language devel-
opment. They were attending because of other communication
disorders as voice disorders.
2. Procedures and clinical tools
2.1. Assessment of short term memory
Assessment of auditory and visual short term memory tasks
was done for all children, using the Arabic version of the Illi-
nois Test of Psycholinguistic Abilities.7
2.1.1. Auditory short-term memory
1- Auditory sequential memory (ASM): Sequences of digits
(1–9) were presented verbally to the child and the child
had to recall each digit sequence verbally. The task
was presented using both auditory and visual cues; the
child is allowed to see the face of the examiner.
2- Sound blending (SB): Combinations of 2–6 CV syllables
were used. The child had to repeat each syllable combi-
nation in the right order
3- Auditory closure: List of 30 words. The examiner pro-
nounced each word with one or more deleted sound.
The child had to pronounce each word correctly.
4- Auditory association: Incomplete phrases analogues. The
child had to complete the missed parts of this analogue
verbally.
5- Verbal expression: 5 different objects were used and the
child had to give full description of each object alone.
2.1.2. Assessment of Visual short-term memory
1- Visual sequential memory (VSM): Sequences of 2–8
abstract symbols presented to the child for 5 seconds.
The child had to place the plates in the right order.
2- Visual reception: The child sees one picture for 3 seconds
and he had to choose the one related to the former one.
3- Visual closure: Sheets of pictures. The examiner named a
picture of an object, while the child was looking at it,
then the child had to look at the full sheet of pictures
and point to the biggest number of pictures similar to
the former one.
31
4- Manual expression: The child looks at 15 pictures of
tools each presented lonely, and then he asked to imitate
the function of the tool manually.
The raw scores for each subtest were used to drive scaled
scores for each task. The raw scores for each subtest were used
to obtain the psycholinguistic age norms. The scaled scores are
linear transformation of raw scores for each subtest according
to the age levels.
Statistical methods: Statistical package for social Sciences
version 11 (SPSS, INC, Chicago, IL) under windows was used
for data entry and data analysis. Descriptive statistics were
done for continuous variables by mean, standard deviation
(± SD) and range; and for qualitative data by number and
percent. Student ‘t’ test and ANOVA test were used to com-
pare continuous variables in various groups. Pearson’s correla-
tion used to assess the association between the different
parametric data. For all tests a probability (P) value less than
0.05 was considered significant.
3. Results
Comparison between the hearing impairment group (HI), co-
chlear implant group (CI) and control group regarding the dif-
ferent demographic data revealed insignificant statistically
differences (>0.05) between the three groups regarding the
age, gender distribution and IQ scores as shown in Table 1.
Results of the Arabic language test indicated that CI chil-
dren showed significant differences (<0.05) in all language
parameters (Receptive, Expressive and total language age) in
comparison to HI children. Control group showed highly sig-
nificant differences (<0.01) in comparison to both CI and HI
groups in all language parameters (Receptive, Expressive and
total language age) as shown in Table 2.
Results of auditory short-term memory subtests revealed
significant differences (<0.05) in CI group in comparison to
HI Group regarding all parameters of auditory short term
memory (sound blending, auditory association, auditory clo-
sure and verbal expression). Also there were highly significant
differences (<0.01) between control group and CI and HI
groups in all auditory short term memory, as shown in Table 3.
Results of visual short-term memory subtests revealed
insignificant differences (>0.05) between HI group and CI
group in all parameters of visual short memory (Visual sequen-
tial, visual reception, visual closure and manual expression).
However, there were significant differences (<0.05) in all sub-
tests of visual short memory (Visual sequential, visual recep-
tion, visual closure and manual expression) between HI and
CI groups in comparison to control group as shown in Table 4.
4. Discussion
The world we live in is overwhelmingly rich and complex. As
human agents living in such a world we are constantly bom-
barded with large amounts of sensory information through
multiple channels such as audition and vision. The outcome
of language acquisition and learning is much different in hear-
ing impaired children and normal hearing individuals, some
hearing impaired and cochlear implant children showed con-
siderable achievement regarding language development and
32 H.E. Hassan et al.

Table 1 Comparison between the hearing impairment groups (HI), cochlear implant group (CI) and control group regarding the
different demographic data.
Variables HI CI Control ANOVA
Mean ± SD Mean ± SD Mean ± SD P value
Chronological age (years) 8.3 ± 1.3 7.8 ± 0.9 8.5 ± 1.2 >0.05
Gender
Boys 8 (57.2%) 7 (50%) 7 (50%) >0.05
Girls 6 (42.8%) 7 (50%) 7 (50%)
IQ 100.5 ± 6 102.2 ± 5 101.9 ± 4 >0.05
There were no statistically differences (>0.05) between the three groups regarding the age, gender distribution and IQ scores.

Table 2 Comparison between the hearing impairment group (HI), cochlear implant group (CI) and control group regarding
Language assessment.
Variables HI CI Control ANOVA t-Test
Mean ± SD Mean ± SD Mean ± SD P value P value
Receptive language quotient 55.5 ± 6 75.3 ± 4 98.2 ± 6 <0.001** <0.05 * (a)
<0.001** (b)
<0.001** (c)
Expressive language quotient 53.4 ± 4 71.7 ± 5 97.8 ± 4 <0.001** <0.05 * (a)
<0.001** (b)
<0.001* (c)
Total language quotient 54.7 ± 4 73.2 ± 3 97.3 ± 5 <0.001** <0.05 * (a)
<0.001** (b)
<0.001** (c)
(a) HI vs. CI, (b) HI vs. control, (c) CI vs. control.
*
Significant.
**
Highly significant.

Table 3 Comparison between the hearing impairment group (HI), cochlear implant group (CI) and control group regarding auditory
short-term memory subtests.
Variables HI CI Control ANOVA t-Test
Mean ± SD Mean ± SD Mean ± SD P (sign.) P (sign.)
Auditory sequential memory 33 ± 2 34 ± 6 40.4 ± 5 <0.001** <0.05 * (a)
<0.001** (b)
<0.001** (c)
Sound blending 34 ± 6 35 ± 2 43 ± 4 <0.001** <0.05 * (a)
<0.001** (b)
<0.001** (c)
Auditory closure 27 ± 2 29 ± 6 37 ± 3 <0.001** <0.05 (a)
<0.001** (b)
<0.001** (c)
Auditory association 26 ± 4 30 ± 3 42 ± 5 <0.001** <0.05 * (a)
<0.001** (b)
<0.001** (c)
Verbal expression 24 ± 3 27 ± 2 49 ± 2 <0.001** <0.05 * (a)
<0.001** (b)
<0.001** (c)
(a) HI vs. CI, (b) HI vs. control, (c) CI vs. control.
*
Significant.
**
Highly significant.
Psycholinguistic abilities in cochlear implant and hearing impaired children
Table 4 Comparison between the hearing impairment group (HI), cochlear implant group (CI) and control group regarding visual
short-term memory subtests.
Variables HI CI
Mean ± SD Mean ± SD
Visual sequential memory 47 ± 3 46 ± 4
Visual reception 45 ± 2 44 ± 4
Visual closure 64 ± 4 47 ± 2
Manual expression 46 ± 3 46 ± 5
(a) HI vs. CI, (b) HI vs. control, (c) CI vs. control.
*
Significant.
**
Highly significant.
academic achievement, others fail to reach satisfactory results
(Rose et al., 2008). Because of the wide variation between the
results, authors tried to investigate other parameters as audi-
tory short term memory and visual short term memory and
their effects on language development and academic
achievement.
Rose et al. (2008) have examined the memory skills of co-
chlear implant users. Children with cochlear implants have
been found to have shorter auditory digit spans compared to
their normal-hearing. Moreover, they mentioned that Children
using cochlear implants have also been found to perform
worse than their normal-hearing on immediate memory tasks
even when the stimuli are not presented auditory and recall
does not require a verbal response.
In this study attention was directed toward auditory and vi-
sual short-term memories, which seems to be related to cogni-
tive processing tasks & language development. Thus, all
children of the three groups were selected to be free from
any neurological, behavioral deficits and within average men-
tality. In This study children with cochlear implantation were
significantly better in all language skills in comparison with HI
children. However all language parameters were significantly
lower in HI and CI groups in comparison to normal control
group. This finding could be explained by the increased ability
of the children with CI to comprehend speech and improve
their speech intelligibility in addition to faster acquisition of
speech production and language development. Aline et al.9
highlighted the advantages of CI over hearing aids. They sta-
ted that cochlear implants were demonstrated to be the best
current alternative for bilateral severe or profound hearing
loss, achieving better results in speech perception and develop-
ment in prelingual children when compared to conventional
hearing aids.
Prezbindowski and Lederberg10 and most (2012) revealed
that normal language development depends on intact sensory
channels and early hearing impairment has its impact on lan-
guage acquisition & competence. Also, they have pointed out
that early identification of hearing loss & early intervention
services have a positive effect for both language and cognitive
33
Control ANOVA test t-Test
Mean ± SD P value P value
36 ± 4 <0.05* >0.05 (a)
<0.05* (b)
<0.05* (c)
34 ± 6 <0.05* >0.05 (a)
<0.05* (b)
<0.05* (c)
37 ± 1 <0.05* >0.05 (a)
<0.05** (b)
<0.05** (c)
38 ± 3 <0.05* >0.05 (a)
<0.05* (b)
<0.05* (c)
development. Spencer and Marschark11 reported that Children
with HI were found to have small size of their vocabulary, less
semantic skills, slower rate of acquiring new vocabulary and
less easily develop new word meaning acquisition processes.
5. Findings of Auditory short term memory
In the current study, auditory short term memory tasks (sound
blending, auditory association, auditory closure and verbal
expression) were better in normal hearing children in compar-
ison to CI & HI groups. These results coincide with that ob-
tained by Bavelier12 who reported poor memory for
sequential information among HI in relation to hearing indi-
viduals. These findings may point to the fact that early lan-
guage development may enhance different auditory memory
skills in HI individuals due to brain plasticity. Furthermore,
introduction of verbal and non verbal materials to the child
environment during infancy and early childhood has its effect
on the development of A-STM.
Laurie et al.13 stated that, from a theoretical standpoint,
emergence of auditory perceptual milestones in young children
would be expected to follow a trajectory of general perceptual
development. This model describes the following three stages
of development: sensory primitives (Level I), which characterizes
basic sensory perceion; perceptual representations (Level II),
which represents complex coding at higher neural levels;
and higher order representations (Level III), which denotes
cognitive/linguistic processing.
However, Wilson et al.14 compared memory span perfor-
mance of HI children with that of hearing children. Their re-
sults revealed that both groups were found to have
comparable forward and backward digit span tasks suggesting
that encoding of serial information does not entail directional
dominance. Also they found that the HI children showed bet-
ter auditory memory than hearing children. They suggest that
memory in HI individuals who are fluent in sign language may
have different characteristics than that of hearing individuals
and perhaps HI individuals who rely on spoken language.
34
These diverse results may be explained by the difference in
the nature of the task and to-be-remembered materials during
application of different subtests. Those differences can lead to
HI individuals having equal or worse auditory memory as
compared with hearing individuals.
In the current study, the mean scores of auditory associa-
tion, auditory closure and verbal expression were better in
CI groups in comparison to HI group. Fallon et al.15 men-
tioned that the evoked recorded potentials of early cochlear
implant children suggest near-normal maturation of cortical
layers of the brain and near normal development of auditory
system; moreover they have better speech perception scores
than HI children who are using hearing aids.
Aline et al.9 mentioned that, based on several studies, co-
chlear implants were demonstrated to be the best current alter-
native for bilateral severe or profound hearing loss, achieving
better results in speech perception and development in prelin-
gual children when compared to conventional hearing aids.
6. Findings of Visual short term memory
On testing the visual short term memory, all children who are
normal hearing and hearing impaired were assessed with tasks
that did not demand speech, to avoid absence of answers due
to language impairments.
The results were comparable for HI & CI groups regarding
all subtests of V-STM. However, all subtests of V-STM (Visual
Sequential memory, Visual reception, Visual closure & Manual
expression) were better in HI and CI groups in comparison to
normal control group. Also visiomotor skills as tested by man-
ual expression subtest are better in HI & CI individuals than
hearing individuals. These results coincide with that obtained
by Bavelier16 and Sladen et al.17
Pelz and Canosa18 showed no differences between the HI
groups & Hearing individuals regarding visual skills. Studies
by Todman and Cowdy19 and Todman and Seedhouse20 found
that HI children surpassed hearing peers in their memories for
complex visual figures, but that the advantage disappeared
when the figures were presented in parts and had to be recalled
visually and/or verbally in sequential manner. Recently, Bou-
tla et al.21 confirmed earlier findings suggesting that HI and
normal hearing individuals have comparable working memory
capacities, even if HI individuals tend to have shorter memory
spans. Hay-McCutcheon et al.22 demonstrated that HI individ-
uals have a variety of visuospatial advantages over hearing
individuals, although some of those differences are a function
of sign language fluency rather than auditory deprivation per
se. Engel-Yeger et al.23 assumed that, whereas in hearing indi-
viduals’ attention is at its peak in the center of the visual field,
HI individuals show greater attention at peripheral locations.
They found enhanced peripheral processing in HI people and
enhanced central processing in hearing people.
7. Conclusions
 HI and CI individuals have V-STM better than normal
hearing individuals.
 Visuomotor skills are more better in HI and CI individuals
than hearing individuals.
H.E. Hassan et al.
 HI and CI individuals have decreased auditory verbal-STM
which may be due to associated language impairment.
8. Recommendations
For HI and CI individuals, multisensory training is needed
both in therapy sessions and classrooms with more focusing
on visual stimuli.
Auditory training program should include tasks to enhance
and improve auditory short term memory span.
Conflict of interest
None declared.
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