International Journal of Pediatric Otorhinolaryngology 113 (2018) 240–247

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Relationship between working memory and comprehension and expression T

of grammar in Farsi-speaking children with cochlear implants
Soodeh Khoramian, Zahra Soleymani∗
Department of Speech Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Iran

A R T I C LE I N FO A B S T R A C T

Keywords: Objectives: Grammar is one of the most fundamental components of language and working memory (WM) is one
Children of the most important cognitive features. These two skills play a vital role in learning, literacy and commu-
Cochlear implant nication. Children with cochlear implants (CIs) experience delays in both of these skills. The aim of this study
Farsi was to investigate the relationship between these two skills in children with CIs.
Working memory
Subjects and methods: The sample consisted of 20 Farsi-speaking children with CIs. WM was estimated by for-
Grammar
ward and backward auditory digit spans (FBS and BDS) from the Persian (Farsi) version of the Wechsler
Intelligence Scale for Children, 4th edition. The comprehension of grammar by participants was evaluated using
the Persian Syntax Comprehension Test. Grammar expression was assessed using the Photographic Expressive
Persian Grammar Test. Pearson's correlation and simple linear regression were used for data analysis.
Results: The results of linear regression and correlation showed a strong correlation between comprehension of
grammar and FDS (r = 0.61; p = 0.004) was obtained, between BDS and comprehension of grammar (r = 0.161;
p = 0.080). FDS and expression of grammar (r = 0.163; p = 0.222) showed a positive but insignificant corre-
lation.
Conclusion: The results indicate that WM decisively effects grammar. Enhancement of the phonological loop can
improve grammar, especially comprehension of grammar. The effect of the central executive in grammar re-
quires further research.

1. Introduction patients with PL impairment are incapable of learning a new language

The Baddeley model (Baddeley, 2000) [1] states that working
memory (WM) is a multi-component system and each component is
responsible for a different function. This model contains four compo-
nents; the phonological loop (PL), visuospatial sketchpad, central ex-
ecutive (CE) and episodic buffer. The growth of the PL and CE have a
direct relationship with the development of vocabulary, comprehen-
sion, reading and speech production [1,2]. The forward digit span
(FDS) is used for assessment of the PL and the backward digit span
(BDS) for the executive system [3,4]. Numeric stimuli are a reliable tool
for measuring WM [5].
CI, grammar, WM, and short term memory were the keywords that
we searched in Google Scholar, PubMed, Web of Science, Scopus and
publisher databases (Springer, Science Direct) to find related studies.
Several studies have investigated the relationship between language
and WM in normal individuals and individuals experiencing language
impairment [2,6–8]. Neuropsychological evidence suggests that
[9–12]. Service (1992) studied learning of English as a second language
by young Finnish children and found that those with good WM acquired
syntax and vocabulary better than the others [13]. The ability to repeat
a non-word or digit or word span as a task for assessment of the PL has
been linked to vocabulary and grammatical skills in normally devel-
oping children [14–16]. Gathercole found that learning of new voca-
bulary by normal children, especially in the early stages of language
acquisition, is dependent on the PL of WM [17].
Most children who are born with severe to profound hearing loss
have significant delays when compared with their normal growth
counterparts for language development and cognitive skills such as
memory, attention and learning [18–20]. Language delays in children
who receive cochlear implants (CIs) has been confirmed by several
studies [21–25]. A delay in access to language, especially in grammar,
has negative consequences that CI children cannot easily overcome
[26]. Tomblin reported a significant difference between CI users and
their normal hearing (NH) peers in terms of sentence comprehension

∗
Corresponding author. Department of Speech Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Enghelab Avenue, Pitch-e-shemiran,
Tehran, 11489, Iran.
E-mail address: Soleymaniz@sina.tums.ac.ir (Z. Soleymani).

https://doi.org/10.1016/j.ijporl.2018.08.006
Received 19 February 2018; Received in revised form 4 August 2018; Accepted 4 August 2018
Available online 08 August 2018
0165-5876/ © 2018 Elsevier B.V. All rights reserved.
S. Khoramian, Z. Soleymani International Journal of Pediatric Otorhinolaryngology 113 (2018) 240–247

and correct use of grammar [27]. They produced more simple syntactic Table 1
structures than their NH peers and they had difficulty perceiving and Demographic details of samples.
expressing complex syntactic structures [27–29]. Measures Min Max Mean (SD)
Children with CIs have various problems understanding and ex-
pressing grammatical morphology [26] in different languages, in- age at implantation 6 (months) 52 (months) 37 (11.78)
(months)
cluding French and German [30,31]. Studies have shown that the ac-
age at testing 70 (months) 90 (months) 78.95 (6.19)
quisition of language skills requires more time in children with CI (months)
compared to NH children and complex grammatical skills are acquired hearing age 24 (months) 72 (months) 42 (13.59)
much later than other linguistic aspects [32]. Although the purpose of a (months)
CI for hearing-impaired children is to provide an auditory experience to Speech recognition thresholds 74 dB 79 dB 75.7 (1.47) dB
(SRT) pre implantation
achieve a desirable language level [33,34], the study of cognitive skills
Speech recognition thresholds 63 dB 66 dB 64.02 (0.97) dB
makes it possible to discover the relationship between these skills and (SRT) post implantation
the language development by CI children [35] and to consider it when Language score 51 91 67 (17.41)
planning therapy.
In addition to language problems in children with CIs, studies have
addressed the cognitive problems of these children, including attention, were to be 70–90 months of age, exhibit congenital hearing loss, re-
memory and learning [14,36]. To indicate the importance of WM, ceived a CI below 5 years of age, be a native speaker of Farsi, have
Gathercole, and Alloway found WM impairment of up to 10% below received a CI at least two years previously, the hearing loss should not
normal levels causes 80% of reading and math problems in normally been caused by a syndrome or neuromuscular disorder, unilateral CI on
developing children [37]. Some studies on WM in CI children have right ear, right-handed and 24-channel nucleus prosthesis. They were
shown that these children show poor performance in this skill. None of almost at the same level as hearing thresholds; Speech recognition
these studies showed a prevalence of WM impairment in these children, thresholds (SRT) prior to implantation (Rang = 74–79 dB HL) and at
but they all confirmed that children with CI experience WM delay test (Rang = 63–66 dB HL).
compared to NH children [38–40]. Because of disturbed phonological All samples had passed pre-primary school then familiar with the
representations of verbal input and a history of reduced hearing, chil- numbers. These children use the total communication method. In terms
dren with CIs are at high risk for WM impairment [39,41–44]. Nittrouer of language abilities, CI children scored severely weak to moderately
et al. [42] tested NH and CI children in phonological awareness/pro- (mean = 67, SD = 17.41, Min = 51, Max = 91) according to Test of
cessing, serial recall of words, vocabulary, reading and grammar. They Language Development-Primary: third edition (TOLD-P: 3) [58].
concluded that non-word repetition tasks could be used to evaluate Ethical approval for the study was obtained from the ethics com-
language acquisition for school-age children with CIs. Dawson et al. mittee of Tehran University of Medical Sciences in Iran
[44] demonstrated that children with CI performed more poorly in the (IR.TUMS.REC.1394.1971). The purpose of the study was explained to
short-term and in WM relative to the control group. Soleymani et al. parents. All parents signed informed consent forms and filled out case
[43] investigated WM in Farsi-speaking children with CI and NH. They history forms about their children.
found that children with CI also show disturbances in encoding, prac- The demographic details of the subjects and descriptive data are
ticing and repeating phonological units resulting from WM impairment. presented in Table 1.
Dawson et al. [44] stated that some WM subsystems, such as serial
recall and FDS, have direct links to word recognition and vocabulary 2.2. Materials
respective.
All of this points to the fact that many studies have been conducted WM was estimated using FDS and BDS from the Farsi version of the
on either grammar [28,29] or WM of children with CI [43,45]. All of Wechsler Intelligence Scale for Children, 4 t h edition (WISC-IV) [59].
these studies have shown that children with CI experience delays in The grammar comprehension of the participants was evaluated using
these skills. To the best of our knowledge, there has been no study on the Persian Syntax Comprehension Test [60]. Grammar expression was
the relationship between grammar and WM in children with CI. Related assessed using the Photographic Expressive Persian Grammar Test [61].
studies in this regard have examined the relationship between WM and
language as a unit concept [42,44,46–48] or speech [41,49,50] in 2.2.1. Working memory test
children with CI, but did not focus on grammar. It remains to be de- The WM was evaluated using the FDS and BDS subtests of the
termined whether or not grammar and WM in children with CIs. If such Wechsler test. The digit spans were presented by means of a live voice
a relationship exists, it must be determine which memory component at a rate of one item per second. Digit span tasks are simple tasks
(PL, CE) is associated with the comprehension and expression of generally used to evaluate WM skill. The FDS tasks asked subjects to
grammar. repeat a sequence of random digits between 1 and 9 in forward order.
Studies have investigated the interface between WM and language The BDS tasks as subjects to repeat the sequences in inverse order. Both
in normal children [11,51,52] and often have confirmed the positive tasks begin with a two-digit sequence. If the child responds correctly,
relationship between these two skills, so the existence of this connec- the sequence length is increased until the child responds incorrectly to
tion is evident. Studies such as that by Ibertsson [53] did not consider two items of the same sequence length. FDS and BDS scores were used
NH children as a control group. Despite the many studies that have as measures of auditory WM. The digit span is an appropriate tool for
surveyed the correlation between WM and a component of language assessing the WM of hearing-impaired children and children with CI
such as vocabulary [54–56], its relation to grammar is not clear. [25,41,45].

2. Methods 2.2.2. Persian syntax comprehension test

2.1. Participants
The present study appraised the WM and grammar skills of 20
children (8 males and 12 females) with profound pre-lingual deafness
that received CIs at under two years of age. Because this was a corre-
lation study, there was no control group [57]. The inclusion criteria
The Persian Syntax Comprehension Test was developed and stan-
dardized by Mohamadi et al. for Farsi-speaking children. This test
contains 24 syntactic structures involving 96 items and was used to
assess grammar comprehension in children. The test has a strong in-
ternal consistency and good content validity. The content validity index
(CVI) of the syntactic comprehension test was 0.81, the criterion va-
lidity of the test was 0.57 and the internal consistency of the test was

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S. Khoramian, Z. Soleymani International Journal of Pediatric Otorhinolaryngology 113 (2018) 240–247

0.89. The syntax comprehension test has been used as a valid and re- Table 2
liable instrument for assessment of syntactic feature assessment of the Minimum, maximum and mean SD of WM, comprehension and expression of
children 4–6 years of age [60]. According to the test instruction, this grammar.
test can be discovering syntax comprehension disorders in children Comprehension of grammar Expression of FDS BDS
aged 4 years and older. The syntax comprehension test detects syntax grammar
comprehension disorders in children aged 4 years and older. This test
Mean 67.60 9.20 3.90 1.65
contains four images for each item that are set on one page (see an item
SD 9.762 6.638 1.619 2.007
of the test in Appendix.1). The stimulant statement is provided by the Minimum 51 0 2 0
examiner and the child should indicate the related image. The child's Maximum 88 24 8 5
response is registered and then scored.

2.2.3. Expressive Persian grammar test Table 3

The Photographic Expressive Persian Grammar Test for Farsi- Pearson Correlation Pearson's sig. (2-tailed) correlations for comprehension and
speaking children was used to investigate grammatical expression. The expression of grammar and WM scores (FDS and BDS) in CI children.
test contains 40 items which exclusively and accurately evaluate Comprehension of Expression of FDS BDS
grammatical structures of 4–6 year-old normally developing Farsi- grammar grammar
speaking children. It also is a valid and reliable test for older children
Comprehension of –
with language disorders. The content validity of each item was between grammar
0.8 and 1 and the content validity of the overall scale was 0.86. The expression of 0.834∗∗ (0.000) –
test-retest reliability and inter-rater reliability were (r = 0.91; grammar
p < 0.0001) and (r = 0.98; p < 0.0001), respectively. The FDS 0.610∗∗ (0.004) 0.404 (0.078) –
BDS 0.401 (0.080) 0.286 (0.222) 0.232 –
Photographic Expressive Persian Grammar Test has a good validity and (0.326)
reliability making a valid and reliable assessment tool for expression of
syntactic features. This test uses a stimulus sentence and a picture to **Correlation is significant at the 0.01 level (2-tailed).
evaluate each structure (see an item of the test in Appendix.2). As the
child looks at the image, the examiner expresses the stimulus sentence Table 4
and asks the question. The response of the child will be recorded and Regression analysis of effect of FDS and BDS scores on comprehension and
scored on an answer sheet [61]. expression of grammar of children with CI.
FDS BDS
2.3. Procedure
R 2
β t R2 β T
A total of 73 children were observed for sampling and 43 were
comprehension 0.0372∗ 0.610 3.26 0.161 0.401 1.856
excluded for non-compliance with all inclusion criteria. The subjects expression 0.163 0.404 1.871 0.082 0.286 1.266
were selected from children who had surgery for CI in the Amir Alam
and Rasool Akram Hospitals. Because correlation studies do not require *p < 0.05.
a control group, the study population only contained children with CIs **p = 0.05.
[57]. All children were evaluated in their schools or rehabilitation
center. To avoid fatigue, each child was individually evaluated in two/
three separate assessment sessions lasting about 1 h. The child was fa-
miliarized with the test with one or two initial samples and then the test
was administered. The test was carried out by a speech and language
pathologist who had enough experience of using target tests. To elim-
inate the effect of fatigue, the order of the tests run was random for the
different children.
SPSS version 19 was used for data analysis. The normal distribution
of data was derived from skewness and kurtosis tests [62]. The mean,
standard deviation, minimum and maximum descriptive measures were
used. Pearson correlation was used to find the correlation between WM
and grammar comprehension and expression by Farsi-speaking children
with CI. The correlation was interpreted as follows: 0.00 to
0.20 = negligible, 0.20 to 0.40 = low, 0.40 to 0.60 = moderate, 0.60
to 0.80 = substantial and 0.80 to 1.00 = high-to-very-high [63]. Re-
gression (simple linear regression) analysis was used to determine
which FDS and BDS scores were predictive of comprehension and ex-
pression of grammar in CI children.

3. Results Fig. 1. Scatterplot of regression for FDS vs. comprehension of grammar.

Descriptive statistics for all variables are presented in Table 2. between variables. Fig. 1 shows a significantly positive correlation of
Table 3 presents the correlations of the WM scores (FDS and BDS) and comprehension of grammar and FDS, Figs. 2 and 3 show non-significant
comprehension and expression of grammar measures for the CI chil- positive correlations and Fig. 4 shows a weak correlation between BDS
dren. and expression of grammar.
Table 4 reports the regression analysis of the effect of BDS and FDS
on the comprehension and expression of grammar of children with CI.
FDS can be seen to be predictive of the level of comprehension of
grammar in CI children (Beta = 0.61). Figs. 1–4 show regression

242
S. Khoramian, Z. Soleymani
Fig. 2. Scatterplot of regression for FDS vs. expression of grammar.
Fig. 3. Scatterplot of regression for BDS vs. comprehension of grammar.
Fig. 4. Scatterplot of regression for BDS vs. expression of grammar.
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International Journal of Pediatric Otorhinolaryngology 113 (2018) 240–247
4. Discussion
Grammar is one of the main components of language and WM is one
of the basic skills of cognition. Many studies have been done on either
the language or the WM of CI children and have demonstrated inter-
ruptions in these skills. These studies investigated language in children
with CI as a unit concept, regardless of the language components (se-
mantic, pragmatic, syntax). The present study surveyed the relationship
between WM (as an underlying cognitive skill), comprehension and
expression of grammar (as components of language skills) and the effect
of WM on grammar in children with CIs. This study hypothesized that
comprehension and expression of grammar can affect WM.
The hypothesis of a positive relationship between the comprehen-
sion of grammar and WM. As mentioned, many studies have stated that
the PL that is evaluated by FDS is directly related to the growth of
vocabulary and grammar [3,9,10,12,64]. Studies on normal individuals
and patients with WM impairment have shown that the PL contributes
to new phonological learning, especially for children [2] and processing
of syntactic complexities and complex sentence comprehension
[1,9–12]. The hypotheses of this study were confirmed in as much as
strong correlations between comprehension of grammar and FDS
(r = 0.61, p = 0.004) were obtained.
Previous studies concerning the expression of grammar suggest that
children with high WM produce longer and more complicated utter-
ances than children with poor WM [65,66]. Adams and Gathercole
[65,67] and Blake et al. [63] found evidence of a relationship between
memory span, mean length of utterance of morphemes, and syntactic
complexity produced in the spontaneous speech of 3 year-old children.
In accordance with other studies, the present study found a moderate
positive significant relationship between expression of grammar and
FDS (r = 0.4) and expression of grammar and WM (r = 0.43).
BDS evaluates the CE [3], is moderately associated with the com-
prehension of grammar (r = 0.40) and mildly linked with expression of
grammar (r = 0.28), but these relationships were not significant. The
relation of the PL with expression and comprehension are stronger than
that of the CE.
The lack of a strong link between comprehension/expression and
the CE may be due to the close relationship between the CE and at-
tention. Studies have produced contradictory results about this re-
lationship. Several studies have reported that the CE, including the PL,
has a close relationship with language [1,68,69]. Other studies have
stated that this component of WM is not associated language processing
[70–72]. Still other research found that the CE does not interfere with
simple linguistic processing and is only involved in complex processing
and information integration [73]. These studies assert that the task of
the episodic buffer in language processing is integration and processing
of the variation of information from different sources. This includes
retrieval and integration of visual and semantic codes from the se-
mantic memory and the spatial-visuospatial sketchpad resource
[73,74]. The episodic buffer also integrates long-term memory with
short-term memory information [75], which requires further in-
vestigation using different linguistic tasks.
The present investigation found no significant relationship between
the CE and grammar skills. The results of the studies on the relationship
between CE and grammar are contradictory. Baddeley believes that the
CE is involved in the processing of complex structures [1]. Many re-
searcher such as Montgomery, Alloway and Gathercole, have confirmed
this view [65,66,76–78]. Montgomery et al. stated that there is no re-
lation between CE and simple structures comprehension, but CE has a
direct relationship with complex structures processing. They claimed
that CE predicts the extent of comprehension of complex structures in
SLI children. This relationship was not found in normally developing
children [76,77]. Alloway et al. also announced that both CE and PL
play an important role in comprehension sentences [78]. Adams and
Gathercole argue that WM plays a role in both production and com-
prehension of complex structures [65,66].
S. Khoramian, Z. Soleymani
On the other hand, studies have ruled out the existence of the re-
lationship between CE and grammar. Several studies have been con-
ducted by Caplan to examine the relationship between WM and com-
prehension in patients whose CE was damaged. Caplan and Waters
found that these patients had no significant difference with the control
group despite CE damage in simple and complex sentences compre-
hension. As a result, they asserted that there is no correlation between
CE and grammar [71,72]. Boyle and colleagues also confirm this view
in SLI children [79]. The result of the present study, about CE, is not
consistent with the results reported by Baddeley, Montgomery and Al-
loway [2,76–78], but is consistent with those by Caplan and Boyle
[71,72,79]. The reason for these contradictions may be due to the age,
clinical conditions of the subjects under study, and different assign-
ments used in these studies.
Despite the importance of the CE, the role of this component re-
mains unclear and requires further research, specifically on the effect of
the various tasks of the CE component, such as counting and listening
recall. Perhaps future study can provide neural evidence to clarify the
role of this component, such as that by Wager [80] that investigated
WM through neuroimaging.
The results of this study suggest that grammar skills (comprehension
and expression) and WM, especially the PL, are closely interrelated. The
WM processes sentences and aids in the understanding and expression
of other syntactical structures [1,81]. Grammar acquisition requires the
programming and storage of the linguistic elements and the processing
of paralinguistic cues in order to understand meaning from other sys-
tems and integrate these items [81]. For all of these, WM is essential for
acquiring language [82].
This study has limitations that may be addressed in future research.
One limitation was the relatively small sample size, which affects ex-
tension of findings. Duplicating this research with a larger sample is
recommended. Another limitation is that it was carried out at a single
point in time. Because grammar skills and WM change during preschool
and the early school years, longitudinal studies are proposed to de-
termine how grammar skills and WM develop and how these skills are
Appendix.1. An item of Persian syntax comprehension
The girl has sat [In Persian/doxtӕr nešӕste/]
Appendix.2. An item of photographic expressive persian grammar test
What does mom do? [In Persian/maman či kar mikone?/]
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International Journal of Pediatric Otorhinolaryngology 113 (2018) 240–247
interrelated. Another limitation was the absence of different tasks for
WM. This was not possible because of the lengthy language tests and
time limits. One additional limitation was the absence of a normal-
hearing control group because of time constraints, but we have cited
many studies with results from NH children, such as that of Pisoni [48].
Despite these limitations, the results of the current study can pro-
vide important contributions to clinical activity. The PL has a direct
relationship with grammar and children with CIs have problems with
WM and grammar. Consequently, in clinical practice, this connection
should be considered in order to facilitate treatment. A high WM level
improves the understanding and production of multiple and more
complex structures. Reinforcement of WM may improve grammar skills.
Clinical therapists who work with CI children on grammar should also
consider WM in their treatment plans.
5. Conclusion
FDS has a direct and positive relationship with the comprehension
and expression of grammar in children with CIs. The PL plays a role in
comprehension and expression of grammar in such children. BDS
showed no significant relationship with the comprehension and ex-
pression of grammar in children with CIs. The CE does not correlate
with the comprehension and expression of grammar in CI children.
Further research is needed to determine relationship between CE and
grammar in children with CIs (Box 1).
Conflicts of interest
This article has no conflict of interest.
Acknowledgements
This article was obtained from a PhD thesis in speech therapy that
accepted financial support from the Tehran University of Medical
Sciences, School of Rehabilitation in Tehran, Iran.
S. Khoramian, Z. Soleymani
Box 1
Glossary of acronyms:
Children with Cochlear Implants: CIs
Cochlear Implant: CI
Normal Hearing: NH
Working Memory: WM
Phonological Loop: PL
Central Executive: CE
Backward Digit Span: BDS
Forward Digit Span: FDS
Wechsler Intelligence Scale for Children, 4 t h edition: WISC-IV
Speech Recognition Thresholds: SRT
Content Validity Index: CVI
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