Ivette Cejas, PhD & CDaCI Investigative Team

1. Ivette Cejas, PhD & CDaCI Investigative Team Effects of cochlear implants on young deaf children’s language, behavioral, and social development

2. Background Information • Extensive literature exists on the linguistic and auditory benefits of early implantation • Variability in performance • Children have co-morbid diagnoses • Dynamical systems approach • Interactions among several areas of development (e.g. cognitive, emotional and social) (Rubin, Burgess, Kennedy & Stewart, 2003; Smith & Thelen, 1993; Thelen & Smith, 1994) • A deficit in one area may lead to a deficit in another • Example: Language delay leads to more behavior problems • Few studies have evaluated the effects of early implantation on psychosocial outcomes • Behavioral, social, and cognitive benefits

3. Behavior Problems • Children with severe to profound SNHL are at risk for difficulties with: • Communication • Behavior problems • Attention problems • Poor academic achievement • 40-50% of deaf school-age children had behavior problems above the clinical cut-off by parent report1 • 30% of deaf school-age children had behavior problems in the clinical range by teacher report2 • Prevalence of behavior problems range from 19.6% to 22.6% of children with deafness, compared to 2% of hearing population3 (1Barker, et al., 2009; 2Mitchell & Quittner, 1996; 3Van Eldik, et al., 2004)

4. Social Competence • Social competence has been defined as a construct with several sub-domains: • Social adjustment • Social skills • Social performance • Substantial evidence suggests that school-age deaf children have lower social competence than hearing peers • Peer rejection (Cappelli et al, 1995) • Social immaturity (Reivich & Rothrock, 1972) • Less contact overall with peers (Stinson, Whitmire & Kluwin, 1996) • More likely to engage in solitary play (Higginsbotham & Baker, 1981) • Few studies have examined social competence in deaf and hearing children • No studies have compared their longitudinal trajectories over time

5. Childhood Development after Cochlear Implantation Study PI: Niparko External Advisors & Consultants Kirk Rice Thal DCC Wang Carson Vilche Zwolan Arnedt CI: 188 NH: 97 JHU Francis Marsiglia Stephens HRI* UNC UTD Eisenberg Johnson Teagle Woodard Buchman Tobey Geers Britt Hodges Lopez Cejas Balkany PCC Quittner Cejas Hoffman * Researchers & participants from HRI have now moved to USC

6. CDaCI Study Aims • Aim 1: Language Development • Aim 2: Development of Speech Recognition • Aim 3: Cognitive Development • Aim 4: Social & Behavioral Development • Aim 5: Family Adjustment & Parent-Child Interactions • Aim 6: Quality of Life

7. Demographics *p <.05

8. Surgery Activation Cochlear Implant (CI) n = 188 Normal-Hearing (NH) n = 97 Baseline 6 12 18 24 30 36

9. Measures • Language Development • Reynell Developmental Language Scales • MacArthur-Bates Communicative Development Inventories • Behavioral Development • Child Behavior Checklist 1 ½ -5 years (CBCL) • Attention Tasks • Puppet Task • Continuous Performance Task • Child Persistence • Social Development • The Social Competence and Behavior Evaluation (SCBE; LaFreniere & Dumas, 1995) • The Social-Emotional Assessment Inventory (SEAI; Meadow, 1983; 1984)

10. Child Behavior Checklist 1 ½ -5 years (CBCL) • 100 item measure with 6 subscales • 4 subscales assess internalizing behavior problems • Emotional Reactivity • Depression/ Anxiety • Somatic Complaints • Withdrawal • 2 subscales assess externalizing behavior problems • Attention Problems • Aggressive Behaviors • Items are rated on a 0-2 scale (Not true to Very true) Achenbach & Rescorla, 2000

11. Attention Tasks • Puppet Task • Videotaped puppet skits lasting about 15 seconds • Each skit followed by a latency period where no image was shown • Task was presented without sound • The duration of children’s gazes were recorded and classified as On Taskif they were looking at the television screen and Off Task if they were looking elsewhere • Continuous Performance Task (CPT) • Children were presented with different pictures of animals and instructed to press a large red button every time they saw a duck • The task recorded number of correct responses, missed responses and false alarms • Child Persistence • Play was coded during a 5-minute Problem Solving task and a 5-minute Art Gallery task using the NICHD Early Child Care Study codes

12. The Social Competence and Behavior Evaluation (SCBE) • For children ages 30 to 76 months (2 1/2 to 6 years) • 80 items measure with 8 subscales • Basic Scales: Depressive-Joyful, Anxious-Secure, Angry-Tolerant, Isolated-Integrated, Aggressive-Calm, Egotistical-Prosocial, Oppositional-Cooperative, Dependent-Autonomous • Summary Scales: • Social Competence, • Internalizing Problems, • Externalizing Problems • General Adaptation • Items are rated on a 6-point Likert scale - “Never” to “Always”

13. Social-Emotional Assessment Inventory (SEAI) • Deaf-specific measure for children ages 3-7 years • 49 item measure with 4 subscales • Sociable, Communicative Behaviors • Impulsive, Dominating Behaviors • Developmental Lags • Anxious, Compulsive Behaviors • Items are rated as “Very True,” “True,” “False,” or “Very False”

14. CBCL Internalizing Behavior Subscales: Baseline Comparisons ---------------------------------------------------------------------- Clinically Significant ---------------------------------------------------------------------- At-Risk Mean T-Score * * *Statistically significant difference between groups, p < .05

15. CBCL Externalizing Behavior Subscales: Baseline Comparisons ---------------------------------------------------------------------- Clinically Significant ---------------------------------------------------------------------- At-Risk Mean T-Score * *Statistically significant difference between groups, p < .05

16. CBCL: % of Children Above Clinical Cutoff at Baseline *Statistically significant difference between groups X2 ( 2, N = 171) = 4.065, p = .043

17. CBCL: Changes in Withdrawal Over Time * Mean T-Score Post-implantation *Statistically significant difference between groups, p < .05

18. CBCL: Changes in Attention Scores Over Time Mean T-Score * Post-implantation Baseline: Significant group differences 24 months post-implantation: No significant differences

19. CBCL: Changes in % Above Clinical Cutoff in CI

20. CBCL Results Summary • At Baseline, children in the CI group exhibited more externalizing and internalizing problems than NH children • More CI children above the clinical cutoff • Over time, there were trends across both groups indicating decreases in behavior problems • Behavior problems were significantly related to language delays

21. Puppet Task: Off Task Gazes * Baseline 6 months12 months NH CI Average length of off task gazes

22. Continuous Performance Task: Misses Baseline 6 months12 months NH CI Total Misses

23. Child Persistence Baseline 6 months12 months NH CI Child Persistence Rating (1-7)

24. Results: Attention Tasks • Compared to the NH group, children in the CI group showed difficulties with visual attention across all three attention tasks • Attention improved from baseline to 12 months post-implantation • Language was significantly related to performance on CPT and Persistence, but not Puppet Task • Results supported the hypothesis that language development contributes to effortful control, but does not influence the amount of time young, deaf children visually monitor their environment

25. SCBE: Baseline Comparisons * * * Mean T-Score ----------------------------------------------------------------------------- Clinical cutoff *Statistically significant difference between groups, p < .05

26. SCBE: % of Children Above Clinical Cutoff at Baseline *Statistically significant difference between groups X2 ( 2, N = 86) = 5.2852, p = .021

27. SCBE: Changes in Social Competence Post-Implantation Mean T-Score * * Post-implantation *Statistically significant difference between groups, p < .05

28. General Adaptation Over Time in CI vs. NH on SCBE Mean T-Score * * * Post-implantation *Statistically significant difference between groups, p < .05

29. SCBE: Changes In % Above Clinical Cutoff

30. Classifications on SEAI at Baseline in CI Group

31. Changes in Classifications on the SEAI Over Time

32. Social Competence Summary • At Baseline, deaf children had lower social competence relative to hearing norms on the SCBE • No associations were found between social competence and language measures • As a group social competence did not change significantly over time • Language at Baseline was predictive of improvements in social competence at 12 months post-implantation on SCBE • Baseline SEAI scores predicted more growth in expressive language

33. Summary/Future Directions • At Baseline, CI children exhibited worse behavior problems, more attention difficulties, & social skills deficits • Mediated by language • By 24 months post-implantation, CI children were cathcing up to their hearing peers • CI clinics should consider screening children annually for behavior problems and social skills deficits • Research should focus on developing evidenced-based interventions to improve behavior and social skills in children with hearing loss

34. Acknowledgments • Thanks to all the parents and children who participated in this study • The investigators of the CDaCI study, including Clinical Center PI’s, Clinic Coordinators, Audiologists, Speech Pathologists, Surgeons, & the Data Coordinating Center at Johns Hopkins University. • Funding was provided by NIDCD Grant # DC04797