ORIGINAL ARTICLE

Assessment of Vocabulary Development in Children

After Cochlear Implantation
Hamdy El-Hakim, FRCS (ORL); Josée Levasseur, MSc S; Blake C. Papsin, MD, MSc, FRCSC;
Jaswinder Panesar, FRCS; Richard J. Mount; Derek Stevens; Robert V. Harrison, PhD, DSc

Objectives: To assess vocabulary development in chil-
dren following cochlear implantation and to evaluate the
effect of age at implantation on performance.
Design: Retrospective study (mean follow-up, 31⁄2 years).
Setting: Tertiary center.
Patients: Children with prelingual deafness provided
with a cochlear implant between 1988 and 1999, who
serially performed the Peabody Picture Vocabulary Test–
Revised (60 patients) and the Expressive One-Word Pic-
ture Vocabulary Test–Revised (52 patients). The chil-
dren were subgrouped into those receiving implants at
younger than 5 years and at 5 years or older.
Outcome Measures: Age-equivalent vocabulary test
score and gap index (chronological age minus the age-
equivalent score, divided by the chronological age at the
time of testing) were calculated. For each test, the fol-
lowing were performed: calculation of rate of change for
age-equivalent score; comparison of earliest and latest gap
indices means (the cohort and intergroup and intra-
group comparison); and multiple regression analysis dem-
onstrating the effect of age at implantation, sex, commu-
nication mode, etiology of deafness, and residual hearing
on the rate of vocabulary development.
Results: Expressive and receptive vocabulary develop-
ment rates were 0.93 and 0.71 (age-equivalent scores
per year), respectively. Subgrouped by age at implanta-
tion, the children’s rates (for both vocabularies) were not
statistically different (Peabody Picture Vocabulary Test–
Revised, P=.90; Expressive One-Word Picture Vocabu-
lary Test–Revised, P =.23). The global latest gap indices
were significantly less than the earliest (Peabody Pic-
ture Vocabulary Test–Revised, P=.048; Expressive One-
Word Picture Vocabulary Test–Revised, P,.001), indi-
cating an improvement in age-appropriate vocabulary
development over time. The age subgroups demon-
strated similar results, except for the younger group’s
receptive gap index. On multiple regression analysis,
the significant predictive variables were residual hear-
ing (Expressive One-Word Picture Vocabulary Test–
Revised) and male sex and oral communication mode
(Peabody Picture Vocabulary Test–Revised).
Conclusions: Children with cochlear implants devel-
oped their vocabularies at rates that were sufficient to
prevent an increase in their gap indices as related to
ideal scores at testing. A late age at implantation does
not singularly preclude beneficial development of
vocabulary.
Arch Otolaryngol Head Neck Surg. 2001;127:1053-1059

From the Departments of
Otolaryngology (Drs El-Hakim,
Papsin, Panesar, and Harrison
and Mr Mount) and
Epidemiology (Mr Stevens),
and the Cochlear Implant
Laboratory (Ms Levasseur),
The Hospital for Sick Children,
Toronto, Ontario. Dr El-Hakim
is now with the Ear, Nose, and
Throat Department, Aberdeen
Royal Infirmary, Scotland.
D
URING THE past decade,
investigations have at-
tempted to assess the
effect of cochlear implan-
tation on oral commun-
ication in children with severe to pro-
found deafness. 1-8 These studies have
generally demonstrated that, in children
with prelingual deafness, the age-equivalent
scores (on norm-referenced tests of expres-
sive and receptive language or vocabu-
lary) increased significantly over time.
However, the subjects maintained a con-
siderable linguistic delay after cochlear
implantation. To our knowledge, this de-
lay, or gap between the children’s perfor-
mance and the ideal performance for their
chronological age, has not been quanti-
fied in any investigation. In some stud-
ies,5,6 inferences have been made about
how the rates of language development in
children with implants compare with
those of children without hearing abnor-
malities, or children with deafness with-
out implants. These investigations did
not include similarly assessed and con-
current control subjects, and some results
were drawn from cross-sectional data.
Also, the type of habilitation of these chil-
dren after implantation may not have
been necessarily equivalent to that of the
other groups. Moreover, the follow-up
time in the reported studies is generally
short, not allowing for the fact that lan-
guage growth in children may fluctuate
over time.9
Dawson2 and Robbins5,6 and their col-
leagues tried to identify factors that may

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 MATERIALS AND METHODS
PATIENTS
The database of the Cochlear Implant Program at The Hos-
pital for Sick Children contains information on 133 chil-
dren who underwent implantation between 1988 and 1999.
Only children with prelingual deafness who performed the
2 vocabulary tests detailed in the next subsection, “Lan-
guage Tests,” were considered for this retrospective study.
Of these, the patients whose performance could be quan-
tified by the tests were included. Because the scores before
implantation were not available for all patients and repre-
sented variable time points before implantation, none of
these scores were included in the analysis. Consequently,
only patients with scores on at least 2 occasions after im-
plantation were included (Peabody Picture Vocabulary Test–
Revised [PPVT], 60 patients; Expressive One-Word Pic-
ture Vocabulary Test–Revised [EOWPVT], 52 patients).
LANGUAGE TESTS
The PPVT 12 is an individually administered, norm-
referenced test to estimate receptive (hearing) vocabulary
for standard American English. The test format contains 5
training items, followed by 175 test items arranged in or-
der of increasing difficulty. Each item has 4 simple black-
and-white illustrations arranged in a multiple-choice for-
mat. The subject’s task is to select the picture considered
to illustrate the best meaning of a stimulus word pre-
sented orally by the examiner. The raw scores are con-
verted to age-referenced norms (age-equivalent scores). This
test was designed for subjects aged 2 to 40 years who can
see and hear reasonably well and understand standard En-
glish to some degree.
The EOWPVT13 is an individually administered,
norm-referenced test to estimate a child’s expressive vo-
cabulary in standard scores. It is composed of 143 items,
and the child is required to perform a naming task. Again,
the raw scores are converted to age-referenced norms (age-
equivalent scores). This test was designed for children aged
2 to 12 years (maximum score achievable at 11.9 years
equivalent age).
In both tests, the stimulus was only presented orally
(the stimulus word was not presented with signed sup-
port for children whose primary mode of communication
was signing). For the expressive vocabulary test, only spo-
ken answers were considered to determine the child’s score.
During testing, all children were using amplification (co-
chlear implants with or without hearing aids).
significantly affect language development as an out-
come measure for cochlear implantation, but found
none of the factors studied to be significant. Recently,
Nikolopoulos et al10 noted the absence of robust statis-
tical evidence supporting claims that age at implanta-
tion is a significant predictor of speech perception and
intelligibility after pediatric cochlear implantation.
After searching the literature, we similarly found no
evidence in relation to oral language development out-
comes. Therefore, we aimed to address the effect of
age at implantation as a predictive factor of vocabulary
development.
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OUTCOME MEASURES
An age-equivalent score was calculated for each patient af-
ter every assessment. For the purpose of this investiga-
tion, an additional value was derived, the gap index. This
was calculated by subtracting the age-equivalent score from
the chronological age of the child and then dividing by the
chronological age (at the time of the test). This index pro-
vides a measure of the linguistic gap in relation to age at
the time of testing (or to ideal score at the time of testing).
If language develops favorably, the gap index should ap-
proach zero.
The other variables we documented were age at
implantation, duration of follow-up (in years), sex, com-
munication mode, etiology of deafness (if known), and
residual hearing (mean of the preoperative unaided thresh-
old for the ear receiving the implant at 250, 500, 2000, and
4000 Hz) expressed as a percentage of maximum thresh-
old (120 dB).
IMPLANTS USED AND HABILITATION
A multichannel cochlear implant (Nucleus; Cochlear Ltd,
Lane Cove, Australia) was used in all children. All im-
plants were programmed using SPEAK code strategy from
1994 onward, before which the MPEAK strategy was used.
The children had various types of habilitation programs and
educational placements before and after implantation. Some
of the children had changes in educational placement over
the years.
ANALYSIS
For each vocabulary test, we:
1. Determined the rates of change of the age-
equivalent scores (regression coefficients for scores of in-
dividual patients over time) for all patients (mean, SD, and
95% confidence interval [CI]).
2. Compared the mean rates of change of the age-
equivalent scores of older and younger children by age at
implantation (2-tailed t test with unequal variance).
3. Compared the means of the earliest and latest avail-
able gap indices of the whole population (2-tailed paired
t test).
4. Performed multiple regression analysis (analysis of
covariance) using the rate of change of the age-equivalent
scores as a dependent variable, and age at implantation,
mode of communication, percentage of residual hearing (in
the ear receiving the implant), sex, and etiology of deaf-
ness as independent variables.
We concur with Robbins and colleagues6 that a
comprehensive analysis of serially measured age-
equivalent scores should include measures of the per-
formance of the children over time and the language
skills achieved by the end of the follow-up period. In
addition, the method should relate the actual perfor-
mance to that ideally expected, so that one can com-
pare the relative performance of individuals at differ-
ent time points.
We retrospectively reviewed our database of
patients with prelingual deafness who received implants
over a 12-year period in The Hospital for Sick Children,
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 Toronto, Ontario,11 and documented the rates of acqui-
sition of vocabulary (receptive and expressive). We
used a novel method to judge the change in vocabulary
age gap from the earliest to the latest assessment. Fur-
thermore, we evaluated the effect of age at implantation
on these outcomes and explored the predictive value of
residual hearing, communication mode, sex, and etiol-
ogy of deafness on rates of vocabulary acquisition.
RESULTS
As part of the Cochlear Implant Program protocol,11
all patients undertake vocabulary tests preoperatively
for baseline assessment, then postoperatively every 6
months for the first 2 years and once yearly thereafter.
Therefore, at a given time after implantation, every
patient should have performed both language tests an
equal number of times. As this was not achieved
because of several constraints (mainly missed appoint-
ments and relocated families), 2 patient populations
are described.
Satisfying the inclusion criteria were 60 children
(28 boys and 32 girls) for the PPVT and 52 children
(27 boys and 25 girls) for the EOWPVT (Table 1).
Table 1. Characteristics of Prelingually Deaf Patients
Included in the Study*
Characteristic PPVT
No. (boys:girls) 60 (28:32) 52 (27:25)
Age at implantation, y, 5.1 (2.2) [1.9-11.6] 5.3 (2.2) [1.9-11.6]
mean (SD) [range]
Mode of communication 51:8:1
(oral:total communication:
American Sign
Language), No.
Follow-up y, 3.4 (2.2) [1-9] 3.5 (2.1) [1-9]
mean (SD) [range]
*PPVT indicates Peabody Picture Vocabulary Test–Revised; EOWPVT,
Expressive One-Word Picture Vocabulary Test–Revised.
Thirteen patients had postlingual deafness and did not
qualify for inclusion in the study. Of 120 patients with
prelingual deafness, 60 were excluded from the PPVT
group and 68 were excluded from the EOWPVT
group. Exclusion criteria included patients who did
not possess 2 or more assessment scores after implan-
tation, either because of their not being tested or
because the obtained scores fell outside the sensitive
range of the language tests.
The mean age at implantation was 5.1 years for the
PPVT group and 5.3 years for the EOWPVT group
(range, 1.9-11.6 years for both groups). Accordingly, on
subgrouping the populations by age at implantation, we
chose a cutoff point of 5 years. These subgroups (,5
years and $5 years) are referred to as “younger” and
“older” groups.
The subgroups were not different statistically in fol-
low-up duration (PPVT, P=.40; EOWPVT, P =.63) or in
proportions of sex (PPVT, P=.51; EOWPVT, P=.28), com-
munication mode (PPVT, P =.72; EOWPVT, P =.48), or
etiology of deafness (PPVT, P=.42; EOWPVT, P=.31).
There was a significant difference between the sub-
groups in mean residual hearing in the EOWPVT group
(P =.03), but not in the PPVT group (P =.06). These re-
sults are given in Table 2.
All children used their implant devices consis-
tently. They had been followed up for a mean of 3.5 years
(range, 12 months to 9 years for both groups). Most were
oral communicators (85% of both groups), with only 1
EOWPVT
child using American Sign Language. The remainder used
total communication (Table 1).
Figure 1A is a plot of the mean PPVT age-equiv-
44:7:1 alent scores against time after implantation for the whole
group that performed the test and for the younger and
older subgroups. Four observations can be made. First,
there is a consistent rise in the age-equivalent scores of
both tests over time. Second, the rise is uneven between
consecutive time points, indicating a fluctuating rate
of growth. Third, the older group of patients has scores
that were higher than those of the younger ones at any

Table 2. Comparison of Characteristics of Subgroups by Age of Implantation in the Studied Populations*

PPVT EOWPVT

,5 y $5 y P ,5 y $5 y P
Characteristic (n = 37) (n = 23) Value (n = 30) (n = 22) Value
Boys:girls† 19:18 9:14 .51 18:12 9:13 .28
Mode of communication 32:5:0 19:3:1 .72 26:4:0 18:3:1 .48
(Oral:total communication:American Sign Language), No.‡
Etiology of deafness† .42 .31
Usher syndrome 1 1 1 1
Cytomegalovirus 2 0 2 0
Genetic 6 4 6 4
Meningitis 2 0 2 0
Mondini 2 0 1 0
Congenital 24 18 18 17
Follow-up, y, mean (SD) 3.2 (2.3)§ 3.7 (2.0) .40 3.4 (2.2) 3.7 (2.0) .63
Residual hearing, %, mean (SD)§ 8.2 (5.8) 11 (5.3) .06 8.1 (5.2) 11.4 (5.6) .03

*For explanation of abbreviations, see footnote to Table 1.

†x2 Test.
‡Fisher exact test.
§t Test (2-tailed, unequal variance).

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 A 14 1.8
Whole Group PPVT Rates, Mean
Younger Group 1.6 EOWPVT Rates, Mean
Older Group
12

Rate of Age-Equivalent Score

1.4

1.2
10
Age-Equivalent Score, Mean

1.0

0.8
8
0.6

0.4
6
0.2

4 0.0
Whole Younger Older
Group
2
Figure 2. Rates of change in Peabody Picture Vocabulary Test–Revised and
Expressive One-Word Picture Vocabulary Test–Revised in all groups.

12
Table 3. Rates of PPVT and EOWPVT
B
Age-Equivalent Scores*

10 PPVT EOWPVT

No. of Age- No. of Age-

Age-Equivalent Score, Mean

8
Group Patients Equivalent Patients Equivalent
Whole 60 0.71 (0.50) 52 0.93 (0.66)
Younger 37 0.72 (0.45) 30 0.83 (0.55)
6 Older 23 0.69 (0.58) 22 1.06 (0.77)
P value† .90 .23
95% CI −0.22 to 0.31 −0.59 to 0.15
4
*Data are given as mean age-equivalent score per year (SD) unless
otherwise indicated. CI indicates confidence interval; for explanation of other
2 abbreviations, see footnote to Table 1.
†t Test (unpaired, 2-tailed, unequal variance).

0 2 4 6 8 10 Although the mean PPVT rates are not notably differ-

Duration After Implantation, y
Figure 1. A, Mean age-equivalent scores of the Peabody Picture Vocabulary
Test–Revised. B, Mean age-equivalent scores of the Expressive One-Word
Picture Vocabulary Test–Revised over time after implantation. After 7 years,
the number of patients followed up decreases significantly for both tests.
time point. Finally, the growth pattern of the scores of
the younger and older groups do not appear different.
Figure 1B is a plot of the EOWPVT age-equivalent scores
against time after implantation. It has been constructed
in a similar fashion to Figure 1A, and the same observa-
tions can be made on it, the major difference being the
steeper growth curve of the mean EOWPVT scores.
However, because the growth curves were con-
structed using mean scores at separate time points, with
variable numbers of patients at each point, caution is ad-
vised on interpretation, as many of the details of the data
are lost in this representation.14 The results of the method
of summary statistics we used for the definitive analysis
follow.
RATE OF CHANGE OF
THE AGE-EQUIVALENT SCORES
Figure 2 illustrates the mean rates of change in the age-
equivalent score per year in the 2 vocabulary tests for the
whole group and for the older and younger subgroups.
ent, the older group has a greater mean EOWPVT rate
than the younger group; however, this difference is not
significant (P..05). The details of the results are given
in Table 3. The mean PPVT rate for the whole group
was 0.71 age-equivalent score per year (SD, 0.50; 95%
CI, 0.20), while the EOWPVT rate was 0.93 age-equiv-
alent score per year (SD, 0.66; 95% CI, 0.99). For the
PPVT, the older group’s mean rate was less than that of
the younger group (0.69 vs 0.72), but the difference was
not significant (P = .90). For the EOWPVT, the older
group’s rate was higher (1.06 vs 0.83), and again this dif-
ference was not significant (P=.23).
THE GAP INDEX
Figure 3A shows histograms representing means of the
earliest and latest PPVT gap indices for the whole group
and for the older and younger subgroups. There is a sig-
nificant decrease in the older group’s gap index (P,.01).
Figure 3B shows the mean earliest and latest gap indices
of the EOWPVT. There is a similar and statistically sig-
nificant decrease in gap index, over time, for each of the
3 groups.
The results comparing the earliest and latest gap in-
dices of the PPVT and EOWPVT are given in Table 4
and Table 5. The gap index value is expressed as a frac-
tion of the ideal score for age at the time of testing. A

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 A 1.0
Early Gap Indices Table 4. Intragroup Comparison of Early and
0.9 Late Gap Indices Late Gap Indices*
0.8
0.7 PPVT EOWPVT
Gap Index Value

0.6
No. of No. of
0.5 Group Patients Gap Index Patients Gap Index
0.4
Whole
0.3 Earliest 60 0.53 (0.17) 52 0.45 (0.21)
0.2 Latest 60 0.49 (0.14) 52 0.38 (0.2)
P value .05 ,.001
0.1
95% CI −0.0002 to 0.08 0.04-0.10
0.0 Younger
Earliest 37 0.47 (0.19) 30 0.43 (0.23)
B 1.0
Latest 37 0.46 (0.14) 30 0.37 (0.22)
0.9 P value .57 .009
0.8 95% CI −0.04 to 0.07 0.02-0.10
Older
0.7
Earliest 23 0.62 (0.07) 22 0.47 (0.18)
Gap Index Value

0.6
Latest 23 0.55 (0.12) 22 0.38 (0.16)
0.5 P value .005 .001
0.4 95% CI 0.02-0.12 0.04-0.14
0.3
*Data are given as mean gap index (SD) unless otherwise indicated.
0.2 CI indicates confidence interval; for explanation of other abbreviations,
0.1 see footnote to Table 1.
†t Test (paired, 2-tailed).
0.0
Whole Younger Older
Group
Table 5. Intergroup Comparison of Early and
Figure 3. A, Comparison of 52 early and late Peabody Picture Vocabulary Late Gap Indices*
Test–Revised gap indices (whole group, P = .05; younger group, P =.57; older
group, P,.01). B, Comparison of 60 early and late Expressive One-Word
Picture Vocabulary Test–Revised gap indices (whole group, P,.001; PPVT EOWPVT
younger group, P,.01; older group, P,.001).
No. of No. of
Index Value Patients Gap Index Patients Gap Index
significant difference was demonstrated between the Earliest
means of the earliest and latest available gap indices of Younger 37 0.47 (0.19) 30 0.43 (0.23)
the whole population. The PPVT gap indices changed Older 23 0.62 (0.07) 22 0.47 (0.18)
from 0.53 to 0.49 (P=.05; 95% CI, −0.0002 to 0.08) and P value .0001 .45
95% CI 0.26-0.10 −0.06 to 0.17
those of the EOWPVT from 0.45 to 0.38 (P,.001; 95% Latest
CI, 0.04-0.10). Younger 37 0.46 (0.14) 30 0.37 (0.22)
Within the younger and older groups, compari- Older 23 0.55 (0.12) 22 0.38 (0.16)
sons of earliest and latest available gap indices demon- P value .01 .83
strated significance. The PPVT gap indices of the older 95% CI 0.16-0.02 −0.12-0.10
group changed significantly from 0.62 to 0.55 (P,.01;
95% CI, 0.02-0.12), while the younger group had a non- *Data are given as mean gap index (SD) unless otherwise indicated.
CI indicates confidence interval; for explanation of other abbreviations,
significant change from 0.47 to 0.46 (P = .57). For the see footnote to Table 1.
EOWPVT, the gap indices of the older group also changed †t Test (2-tailed, unequal variance).
significantly from 0.47 to 0.38 (P = .001; 95% CI, 0.04-
0.14), while for the younger group gap indices changed respectively). For the EOWPVT, running a best subset
significantly from 0.43 to 0.37 (P,.01; 95% CI, 0.02-0.10). model demonstrated residual hearing as the only signifi-
An intergroup comparison of the younger and cant predictive factor (P=.03). Table 6 contains the re-
older groups’ earliest available and latest available indi- sults of the multiple regression analysis for the 2 test groups.
ces demonstrated that, while the younger patients had
significantly lower gap indices for receptive vocabulary, COMMENT
the 2 groups showed no significant difference with
respect to expressive vocabulary (earliest index, P=.45; Presentation of the results in the form of a gap index and a
latest index, P = .83). The details of these results are rate is necessary to provide as extensive an evaluation as
found in Table 5. possible of the evolving vocabulary skills of these chil-
dren. The rate (calculated as the coefficient of regression
MULTIPLE REGRESSION ANALYSIS of the age-equivalent scores over time) represents perfor-
mance over time and takes into consideration every score
For the PPVT, multiple regression analysis using a back- for the individual patient. At the same time, the gap index
ward stepwise model showed male sex and oral commu- allows an evaluation of the end product and compares it
nication mode to be significant factors (P=.04 and .03, with the state at a starting point. It is our view that neither

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Table 6. Significant Factors on Multiple Regression
Analysis (Analysis of Covariance) of Age-Equivalent
Scores of Both Tests*
Independent
Test Variable Coefficient
PPVT Sex 0.17
Communication mode 0.25
EOWPVT Residual hearing 0.02
*For explanation of abbreviations, see footnote to Table 1.
is exclusive to the other, especially given that the rate of
language acquisition demonstrates considerable intersub-
ject and intrasubject variation.
In our study, rates of vocabulary development of chil-
dren with cochlear implants demonstrated considerable
individual variation, as evidenced by the wide SDs (Fig-
ure 2 and Table 3). This is in agreement with previous
reports.4,6 In the absence of a concurrent control group,
our findings cannot support those of other reports5,6 that
children with cochlear implants equate or supersede rates
of vocabulary acquisition of their counterparts without
hearing abnormalities.
On analyzing the subgroups by age at implanta-
tion, there was no demonstrable difference in vocabu-
lary growth rates. The older group tended to acquire ex-
pressive vocabulary faster, but this may be partly explained
by their significantly higher residual hearing, especially
as it was the only significant predictor for the EOWPVT
on multiple regression analysis. Comparison of the cor-
responding gap indices (Table 5) showed that the recep-
tive vocabulary indices of younger patients were signifi-
cantly better than those of the older children, whereas
the expressive indices were similar for the 2 groups. Al-
though this supports the notion that earlier implanta-
tion may reduce the receptive vocabulary loss caused
by the duration of auditory deprivation, as others have
suggested,4 expressive vocabulary may not be similarly
affected. In addition, the younger children did not im-
prove their receptive indices to any demonstrable de-
gree, whereas the children who underwent implanta-
tion after a longer period of auditory deprivation
demonstrated benefit over time.
There was a reduction in the gap index as a propor-
tion of the ideal score for age at testing. This can be il-
lustrated by a hypothetical example (Figure 4) of a child
aged 3 years at implantation and followed up for 31⁄2 years.
According to mean gap indices, the PPVT gap would
change from 1.65 years at the 6-month assessment after
implantation to 2.99 years after 31⁄2 years of follow-up.
On the other hand, the child’s EOWPVT gap of 1.51 years
would change to 2.41 years. Although the rates of vo-
cabulary growth prevented a perpetual increase in the ini-
tial delays and led to their decrease in the expressive test,
the gaps amounted to 46% of the age-appropriate PPVT
scores for age and 37% of the EOWPVT scores.
The only significant predictive variables were re-
sidual hearing for the EOWPVT and male sex and oral
communication mode for the PPVT. Although the sex
effect has not been found previously in investigations on
children undergoing implantation for deafness, another
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Hypothetical Example Gap = Gap Index × Age
Age-Equivalent Score = Age–Gap
Child With Prelingual Deafness
PPVT EOWPVT
Implanted at Age 3 y
P
SE Value
0.08 .04 Tested 6 mo After Implantation Tested 6 mo After Implantation
Age 3.5 y Age 3.5 y
0.11 .03 Gap = 0.47 × 3.5 = 1.65 Gap = 0.43 × 3.5 = 1.51
0.01 .03 Age-Equivalent Score = 3.5–1.65 = 1.85 Age-Equivalent Score = 3.5–1.51 = 1.99
Tested 3.5 y After Implantation Tested 3.5 y After Implantation
Age 6.5 y Age 6.5 y
Gap = 0.46 × 6.5 = 2.99 Gap = 0.37 × 6.5 = 2.41
Age-Equivalent Score = 6.5–2.99 = 3.51 Age-Equivalent Score = 6.5–2.41 = 4.09
Figure 4. Hypothetical example of a child with prelingual deafness who
underwent implantation at the age of 3 years. The example assumes 6-month
and 31⁄2-year assessments after implantation using the Peabody Picture
Vocabulary Test–Revised and the Expressive One-Word Picture Vocabulary
Test–Revised. The calculation of the expected language gaps and
age-equivalent scores is explained.
author15 found a similar result in a population without
deafness with respect to the same test. Meanwhile, chil-
dren with oral communication did better, probably be-
cause our testers administered the tests only in the oral
mode, irrespective of the communication mode of the
child. This is slightly different from the findings of Mi-
yamoto et al,4 most likely because they administered their
tests in the preferred mode of the child. Age at implan-
tation was not a significant predictive factor, irrespec-
tive of prior expectations.
Despite the retrospective design, there are several
strengths of our investigation. It is one of the larger stud-
ies of communication in children undergoing implanta-
tion for prelingual deafness, and its follow-up has ex-
tended longer than that of most others. Regarding the tools
of the investigation, the tests were administered only in
the oral mode, unlike those of Dawson,2 Miyamoto,4 Rob-
bins,6 and Bollard7 and their colleagues and most other
investigations. Using only the oral mode eliminated all
nonauditory sensory inputs from the results as far as fea-
sible, allowing more credible extrapolation of our re-
sults. Our elimination of the data before implantation is
well-founded, because it was only available for some pa-
tients and hard to accurately designate on a time scale.
This limits our conclusions to the course of events after
implantation.
As an effectiveness study, we introduce the use of
the gap index as a potential outcome measure that sim-
plifies the analysis of serial measurements of scores that
grow over time. It allows comparison of different age
groups and assessment of end stage in relation to the ini-
tial one.
Further research should be directed at conducting
prospective longitudinal clinical trials that compare con-
current groups of children with profound deafness: those
who have been fitted with hearing aids, those who re-
ceived cochlear implants, and those who received nei-
ther. The credibility of such trials would be enhanced if
the outcome measures used are reflective of real-life com-
munication and the extent of inclusion of these chil-
dren in mainstream activities.
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CONCLUSIONS
The evaluation of language development of children with
deafness after cochlear implantation should include, in
addition to the rate of such development over time, an
expression of the language gap at the latest point in the
follow-up. Age at implantation, on its own, cannot pre-
clude a beneficial outcome but may suggest a different
pattern of development.
Accepted for publication February 7, 2001.
Presented at the American Society of Pediatric Oto-
laryngology meeting, Orlando, Fla, May 18, 2000.
Corresponding author and reprints: Hamdy
El-Hakim, FRCS (ORL), Ear, Nose, and Throat Depart-
ment, Ward 45, Aberdeen Royal Infirmary, Foresterhill,
Aberdeen AB9 2ZB, Scotland (e-mail: helhakim@aol.com).
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