A psychosocial follow-up study of deaf preschool children using cochlear implants

Original Article A psychosocial follow-up study of deaf preschool children using cochlear implants G. Preisler,* A.-L. Tvingstedt† and M. Ahlström* *Department of Psychology, Stockholm University, Stockholm, and †Department of Educational and Psychological Research, School of Education, Malmö University, Malmö, Sweden Accepted for publication 6 May 2002 Abstract Keywords deaf children, cochlear implant, sign language, oral skill, communication The aim of the study was to explore patterns of communication between 22 children with cochlear implants (CI) and their parents, teachers and peers in natural interactions over a 2-year period. The children, between 2 and 5 years old when implanted, had used the implant between 1 and 3.5 years at the end of the study. Analyses of videorecorded interactions showed that meaningful oral communication was more easily obtained in the home setting than in the preschool setting. Patterns of communication between parent–child, content and complexity of dialogues, quality of peer interactions, communicative styles of adults, and the use of sign language in communication turned out to be important factors when explaining the result of the CI on the individual child’s development.The children with the best oral skills were also good signers. Introduction Correspondence: Professor G. Preisler, Department of Psychology, Stockholm University, S106 91 Stockholm, Sweden. E-mail: gp@psychology.su.se The first cochlear implant operations on deaf children in Sweden were made in the beginning of the 1990s. In mid-2001, approximately 180, or 80%, of pre- and post-lingually deaf children had received an implant in this country. The effect of the implant is usually measured in terms of the child’s perception and production of speech in the laboratory setting. The results indicate that the children can profit from the implant when these aspects are measured (see, for example Moog & Geers 1991; Osberger et al. 1991; 1993; Staller et al. 1991; Geers & Moog 1994; Miyamoto et al. 1995; Meyer et al. 1998; Svirsky et al. 2000). However, perceiving or recognizing spoken words and producing or imitating spoken words or sentences do not amount to commanding a language, and it is not equivalent to understanding the symbolic meaning of a particular word or phrase or being able to communicate © 2002 Blackwell Science Ltd orally with others. Measuring the outcome of a CI merely in terms of perception and production of speech is therefore to focus on a limited part of the child’s language development. To give a broader perspective on the development of language and communication in deaf children with CI, a descriptive, longitudinal and qualitative psychosocial study was performed. In total, 22 Swedish deaf preschool children with CI participated, along with their parents and teachers as well the members of two hospital teams, and the results will be presented in this paper. Theoretical background According to Studdert-Kennedy (1991), language is a mode of action into which the child grows because the mode is implicit in the human developmental system. Language learning or language acquisition is about understanding a world of symbols, under- 403 404 G. Preisler et al. standing that something can be represented by something else, that a word or a gesture can represent an object, an event or an idea. Thus, language is a representation of representations (Piaget 1951). Which are the developmental growth paths that lead to language? For a long time, the most common approach to answer this has been to search for the roots of spoken language in the development of the auditory and vocal modalities, and the roots of sign language in the development of the visual–gestural modality. But the most significant things that the infant needs to learn about language from a developmental point of view are written on the face, body, voice and gestures of those who talk (Locke 1995) or sign. The primary contribution of the face to communication is that it reveals the emotional state of the speaker as well as the attitude of the speaker towards the listener. Infants are already from birth attracted to the face, particularly the eyes of the caregiver (Bower 1977). This is adaptive, as the eyes are vital components in the human signalling system conveying emotions and social intentions. Early precursors of language Shared gaze between infants and mothers contributes to the establishment of object reference (Bruner 1975). Infants look at their mothers’ eye gaze and head orientation as if they were attempting to find out what she might be thinking about (Locke 1995). Infants tend to follow an adult’s line of regard as early as 2–4 months, but more consistently so by 8– 10 months of age. This enables infants to appreciate an important concept: the object of the mother’s attention. This might be one of the more important conceptual precursors of lexical acquisition. Mothers also spend a great deal of time looking at the things to which their infants attend. The activity of the face, particularly the movements of the eyes, also conveys some indexical information (Locke 1995). Preverbal abilities in children, such as the use of conventional gestures, pointing and showing, symbolic and combinatorial play, imitation and the use of tools are important precursors of language development (Bates et al. 1979). The sharing of meaning in joyful interactions and early mutual play with turn-taking qualities are crucial prerequisites for language development (Trevarthen 1988). The interdependence of the spoken language and visual cues can be shown in studies of blind children. The early language development in blind children is often delayed, some do not speak for several years, despite perfect hearing ability (Wills 1981; Urwin 1983; McConachie 1990; Preisler 1995). This is probably due to the fact that blind children do not use conventional gestures. It is not possible for them to follow the parent’s direction of gaze, or perceive visually emotional cues from the face of their caregiver, and many blind children do not engage in pretend play until a later age than sighted children (Preisler 1995). The importance of peer interaction The significance of early close relationships for children’s social and emotional development has long been recognized (see, for example Bowlby 1982; Fogel 1993; Stern 1998). Relationships are viewed as the context in which socialization takes place and basic competence emerges (Hartup 1985; 1989) in which communicational skills are acquired (Preisler 1983; Trevarthen 1988), and in which the regulation of emotions develops (Stern 1998). But studies in child development have also shown how children acquire important developmental skills as a result of peer interactions (File 1994). Delays in expressive language abilities affect the development of social skills, which, in turn, can hinder children from becoming involved in more complex forms of peer interaction (Guralnick 1986; Ahlström 2000). The ability to use language as a medium for sharing experiences and feelings, for referring to abstract concepts, and for relating to future and past experiences, enables a child to become involved in fantasy and role play. If preschool children are to be able to take part in fantasy play, it is important that they also are given the opportunity to develop close friendships with other children. Warren & Kaiser (1986) stress the importance of providing the possibility to acquire language for children with specific difficulties. Failure to do so not only has consequences for their language development per se, but also for their emotional, social and cognitive development. © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 Deaf preschool children using cochlear implants Early communication in deaf children During the first year of life, when vision plays a most important role in communication, deaf infants are able to share in the communication with hearing parents much to the same extent as hearing children (Scroggs 1983; Preisler 1990; Harris 1992). The deaf infants also take part in body games, give-and-take and peek-a-boo games with their parents. They explore toys, they imitate their mother’s actions and they start to take part in early pretend play. They show their intentions and they take active part in proto-conversations. The hearing loss is seldom a serious obstacle to communication until the age when hearing children normally begin to talk. If habilitation of the deaf child focuses on the use of communicative signals that are suited to auditory perception and therefore difficult to interpret visually, mutual understanding is often impeded, and breakdowns in communication become the rule rather than the exception causing language development to stall (Nordén et al. 1981; Preisler 1983; Heiling 1995). Several studies of toddlers or preschoolers have shown that hearing parents using an oral/aural approach in communication use more directives and different control techniques in interaction with their deaf child (Schlesinger & Meadow 1972; Meadow-Orlans 1987). The deaf children in these studies were more passive and less attentive than hearing children and they tended to withdraw from social interaction. The idea that sign language could hinder the development of speech, which is still sometimes held, is by no means valid (Marshark 1993). Studies from the two last decades in particular, have clearly shown the positive effects of sign-language learning in deaf children with respect to the children’s communicative, socioemotional development as well as language learning in general and cognitive development (Nordén et al. 1981; Heiling 1995; Preisler & Ahlström 1997; Preisler 1999). Caregiver’s communicative styles As children acquire language in interaction with their caregivers, the parents’ part of the interaction is also important to consider, i.e. the way caregivers meet the needs of their children as well as the reci- 405 procity of the interaction. When analysing the way parents talk to their children, two main patterns have been distinguished; a more adult-centred and directive style and a mainly child-centred and supportive style (Hoff-Ginsberg & Schatz 1982; Barnes et al. 1983; Dale et al. 1987; Moseley 1990). Studies have shown that parents of children with language learning difficulties tend to use a more controlling and directive way of communicating than parents of children without these difficulties (McDonald & Pien 1982; Tiegerman & Siperstein 1984; Konstantareas et al. 1988). Characteristic of a directive adult-centred communicative style is that the dialogues are short, often with one turn only (Ahlström 2000). Adults who adopt a supportive and child-centred communicative style on the other hand, tend to adapt their communication to the interests and linguistic ability of the child. Bruner (1983), Bronfenbrenner (1979) Greenspan (1985) among others, stress the essential role of a balanced relationship, involving joint activity that supports language learning. The way the parents interact with their children is dependent on a variety of factors. The way support systems and habilitation are managed and how parents experience this management are also important variables for the well-being of the child and the family in the future. Attitudes towards children with disabilities in the society can influence the way parents look upon their children’s possibilities to develop. A psycho-social follow-up study of deaf preschool children using cochlear implants In 1981, sign language was acknowledged as the official language of the deaf in Sweden. The objective of habilitation has been to create possibilities for the child to become a competent deaf child and for the parents to become competent in their role as parents of deaf children. Today there is an official consensus that, for a child to be considered a CIcandidate, the family must have established sign language in communication with their child, at least to some extent (Swedish National Board of Health and Welfare 2000). Hence, the situation is quite different from that of most other countries where an © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 406 G. Preisler et al. oral/aural approach to deaf children’s language learning is adopted. Therefore a study of Swedish deaf children with cochlear implants was started in 1995. The results have been published in four separate reports. A summary of the results will be presented in this paper. Aim of the study The primary objective of the study was to explore patterns of communication between children with CI and their parents, teachers and peers in different natural interactional settings over a 2-year period. The questions posed were: How do children with a cochlear implant communicate with their parents and teachers in different activities? Which communicative styles do parents and teachers use? What characterizes the content of the dialogues? How do children with CI communicate with deaf and with hearing peers, and what kind of play are they engaged in? How does communication develop and change over time? Another aim was to study how parents and teachers experienced the encounter with the multidisciplinary teams at the two hospitals performing the implant operations with respect to information, expectations and recommendations given. The purpose of collecting data about the children, the parents, teachers and peers as well as the team members was to explore which factors could be considered to promote a positive development of children with cochlear implants, as well factors being a hindrance of such a development. Methods Subjects between 1990 and 1994 and operated before the summer of 1996. The families were informed about the research project by the surgeons at the two CI teams in the country performing the operations. If the parents declared that they were willing to participate in the study, the researchers made contact with them. The five families who did not participate in the study were all informed by the same hospital team. One child was not using the implant and in one case the parents considered that too many people were already involved in the habilitation of their child. Two families did not want the researchers to contact them, whereas the fifth family did not want to participate after having been informed about the details of the research project by one of the researchers. The 22 families represented all socioeconomic groups and they lived in the big cities and smaller urban areas as well as in rural parts of Sweden. The five families not taking part in the study did not, to our knowledge, differ in these respects from the children and their families participating in the study. The group of children consisted of 11 boys and 11 girls, born between 1990 and 1994. They were between 2 and 6 years old when the study began and between 4 and 8 year old towards the end of the study (see Table 1). All the children had Nucleus/Cochlear mini 22/20 + 2 implants. The majority, 16 out of the 22 children, were prelingually deaf whereas six children became deaf after they had started to use oral language. Out of the 16 prelingually deaf children, 12 were most likely born deaf whereas four became deaf before the age of 1.5 years due to meningitis. Six of the children became deaf between 2 and 4 years of age, four due to progressive hearing loss and two due to meningitis (see Table 2). In total, 22 deaf preschool children took part in the study, out of a total population of 27 children born Table 2. Time and cause of deafness Table 1. Sex and year of birth Date of birth Deafness Number <2 years of age Pre-lingual meningitis Pre-lingual deafness, cause generally unknown 4 12 Sex 1990 1991 1992 1993 1994 Total Boy Girl 3 3 3 5 1 3 2 1 1 11 11 2–4 years of age Post-lingual meningitis Post-lingual progressive hearing loss Total 6 8 1 5 2 22 Total © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 2 4 22 Deaf preschool children using cochlear implants The children were operated when they were between 1 year 11 months and 4 years 10 months old (see Table 3). Thirteen of the children had received their implants before the study began and the remaining nine were operated during the course of the study (see Table 4). At the end of research period, 10 children had used their implants between 2.5 and 3.5 years, whereas 12 had between 1 and 2.5 years of experience. When the children started to take part of the study, 8 out of the 22 children attended preschools for deaf children using sign language and 10 attended preschools for deaf and hard-of-hearing children where both signs and speech were used. Four children were mainstreamed in regular preschools for hearing children; in three cases with and in 1 case without a personal assistant (see Table 5). As the study proceeded, the preschool placement was changed for two of the children. These children Table 3. Time of deafness and age at operation in years and months Age at operation Deafness 1:11–2:11 3:0–3:11 4:0–4:11 Total <2 years 2–4 years 7 4 4 5 2 16 6 Total 7 8 7 22 Table 4. Time of deafness and time with implant in years and months at the end of the study Table 5. Preschool placement at the time of the first visit in the preschools 407 attended a preschool for deaf and hard-of-hearing children some days a week and a regular preschool for hearing children during the rest of the week. Procedure The children were visited every third month and data were collected by direct observations and videorecordings of the children in natural interactions with their parents and siblings, and in their preschool settings with teachers and peers. Between 3 and 7 videorecordings have been made of each child, depending on when they started to take part in the study. Altogether 72 recordings and direct observations were made in the home setting and 57 in the preschool setting. Each visit lasted between 1.5 and 3 h. Between 45 and 60 min of videorecordings were made in the home setting, somewhat longer in the preschool setting. The parents were interviewed as well as the preschool teachers (in all, 28 teachers and personal assistants) about their experiences of pre-, peri- and post-implant treatment as well as their experiences and expectations of the effect of the implant. The teachers were asked questions about information and educational support as well as attitudes and feelings about cochlear implants in deaf children. In addition to this, all of the members of the two multidisciplinary teams engaged in the operation and treatment of the cochlear implants (22 people) were interviewed Time with CI Deafness 1:0–1:5 1:6–1:11 2:0–2:5 2:6–2:11 3:0–3:5 Total <2 years 2–4 years 3 1 5 – 3 – 4 2 1 3 16 6 Total 4 5 3 6 4 22 Preschool placement Number Preschool for deaf children using sign language Preschool for deaf and hard-of-hearing children where sign language and spoken language were used Mainstreamed in a regular preschool with a personal assistant Mainstreamed in a regular preschool without a personal assistant 8 10 Total 22 3 1 © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 408 G. Preisler et al. about their values, ideas, hopes and worries about this new technical device on the development of the deaf children. Their knowledge of child development in general, and about the development of deaf children in particular, was asked for as well as their experiences of the deaf culture and sign language. Analyses The videorecordings were analysed in several steps. For each video recording, an overall description of the content of the video was made, in terms of interactional context. Thereafter, each author made a description as well as codings of approximately one-third of the material. Continuous intercoder agreement controls were made to ensure that the same criteria were used during the coding process. The descriptions and the codings focused on: • Which communicative means the children, their parents, teachers and peers used in different interactional settings, i.e. mainly non-verbal means, signs, speech or speech-like utterances alone or in combination with signs. • The content of the dialogues in terms of level of complexity. • The communicative styles of the adults defined as mainly child-centred and supportive or adultcentred and directive. • Perception and production of speech. • Participation in play with peers and/or adults as well as the content of the play. In the next phase of the analyses, a number of selected dialogues, which illustrated characteristic features in the interactions at the time of the videorecording, were transcribed and analysed in detail. The aim of the codings was to get a comprehensive qualitative description of patterns of communication for each individual child in the different contexts. All of the videorecordings from the preschool settings were further coded and described in detail by a fourth researcher, who had not taken part in the videorecordings, with the aim of analysing the children’s play (Jorup & Preisler 2000). Finally, descriptive, qualitative analyses were made of the content of the interviews with parents, teachers and the members of the two CI teams. Results Communication and interaction in the families From the first videorecordings in the families, it was observed that parents and children mainly communicated in sign language or by using signs in combination with non-verbal means of communication. In two-thirds of the families (15), sign language communication was considered to be well functioning, in the others, less so. Six of the children were postlingually deaf and had already developed a certain comprehension and production of speech. Speech accompanied by signs was the main language used in these families. But, even if several parents in the study group used speech, the use of signs was a natural basis of communication in most of the families. Among the youngest children in the study, it was observed that the parents and children directed their attention to and reached a mutual understanding mainly about the ‘here-and-now’. (As the group of children is small and well known to many practitioners and parents in Sweden, we have chosen not to be exact in number when this has not been considered necessary in interpreting the results, to protect the children’s and their families’ identity.) In most cases, both parents and children established eye contact before signing and maintained it throughout the conversation. There were, however, a couple of families where parents and children had not developed a well functioning communication in signs and hence did not share much common language. Their mutual understanding was reached by means of actions. Patterns of communication between the older children and their parents showed that the content of the dialogues in sign language was more advanced and extended. They could discuss experiences of different kinds as well as share fantasies in playful interactions. As time passed, all of the 22 parents in the study began to introduce more spoken language in their communication with their children. Characteristic of this new way of communicating was that the parents were not paying the same attention to establishing eye contact with their child before starting to communicate as they were at the beginning of the study. This in turn affected the turn-taking pattern © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 Deaf preschool children using cochlear implants and the dialogues were disrupted and misunderstandings occurred. Another observation was that when more speech was introduced the communication could result in the parent using speech and the child using sign language and single spoken words. When the parents did not demand speech as output when using speech as input the result was often a smooth communication without disruptions or misunderstandings. Towards the end of the research period, the majority of the children could take part in simple oral dialogues in the family setting. The children used some words or responded appropriately to their parent’s speech by using non-verbal means such as head nods or pointing. Characteristic of these interactions was that the context was well known and that the content was about the ‘hereand-now’. According to the parents, simple daily conversations in the families had now been facilitated. (A more detailed description of communication in the families was presented by Tvingstedt, Preisler & Ahlström 2001). Five of the children in the study were not observed to use speech at all in natural interactions with their parents. The parents’ way of communicating with their children varied and different styles used could be related to an adult-centred and directive way of communicating and, alternatively, a child-centred and supportive style. When parents used a more adult-centred and directive communicative style, the dialogues between child and parent were generally short, often with one turn only. When using a more child-centred communicative style, the conversations could develop into extensive dialogues with many turns. When the child initiated a new subject, the parents followed, answered and expanded on the subject in relation to the child’s interests and utterances. On several occasions, it was observed that the children started to use sounds and spoken words concurrently with signs as they became more absorbed in the conversations. However, when the content became complicated and difficult to convey they returned to using sign language only. These parents made no demands on the children’s language production, neither in signs nor in spoken words, but focused entirely on the content and answered, irrespective of form. In some cases with the older children, these dialogues devel- 409 oped into the kind of narratives that are a part of the life stories children create. Being able to create an autobiographic narrative is an essential aspect of the child’s development of identity and sense of self (Stern 1998). Communication and interaction in the preschool setting When analysing the interaction between teachers and children as well as between the children with CI and their peers, we focused on interactions where the children were involved in different play activities as well as on training sessions in the three different preschool settings. As the videorecordings were mainly made during the morning sessions and free play was more frequent in the afternoon, the amount of free play was limited in the video observations in all of the three different preschool settings. Activities and play In the preschools for the deaf where sign language was used, the main part of the videorecorded interactions consisted of different structured adultinitiated activities, such as sitting in a circle discussing different events, meal times, playing games, telling stories etc. The conversations registered in these contexts were primarily between teachers and children. The communicative style of the teachers varied. Some used an adult-centred directive style in some situations, whereas others used a more child-centred supportive communicative style. The level of linguistic activity was high, and fantasy and storytelling were frequently occurring. When communicating with one another, the children used sign language and the content of the dialogues was considered adequate for children of their age. They could discuss the here-and-now as well as future or past events. The older children could also share fantasies and there were some symbolic plays observed between the children (see Table 6 for a description of play activities in the preschool setting). Observations from the preschools for the deaf and hard-of-hearing showed that speech was the main language used between the children and the © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 410 G. Preisler et al. Table 6. Content of play in the different preschool settings (with other children and/or adults) Preschool placement/language For the deaf /sign language For hard-of-hearing /sign and speech Mainstream /speech Total Type of play f % f f f Sensorimotor play Symbolic play Rule play Construction play – – 6 5 2 46 39 15 17 13 7 6 40 30 16 14 3 2 2 1 38 25 25 12 20 21 14 9 31 33 22 14 Total 13 100 43 100 8 100 64 100 teachers, often with support of signs. There were also instances when only sign language was used as well as only speech. One problem that occurred in the situations when teachers used speech only or used speech supported by signs was that the adults not always reassured that they had established eyeto-eye contact with the children. Thus, this was the same phenomenon as observed in the family setting. In the preschool setting, the children did not seem aware of that they were addressed, which could be a cause of misunderstandings. The more speech the teachers used, the more uncertain the communication. But, if the context was clearly defined and if the children knew what was expected of them, they could manage to take simple instructions in spoken language. The main communicative means used in communication between the deaf children with CI and children who were not familiar with sign language, was by means of pointing, gestures, eye-contact, i.e. non-verbal. The communication was at a concrete and presymbolic level (for a description of play activities, see Table 6). For the four children in mainstream preschools, the same type of activities was observed as for the children in the other preschool settings. They made paintings and drawings and they were engaged in memory games as well as in construction building. But there was no symbolic communication between the hearing children and the deaf child with CI. The opportunities for the deaf child to take part in dialogues with peers were limited. The child interacted mostly with adults, particularly a signing adult if there was one present, and this adult often took the role of interpreter both for other adults and children. The deaf child was occasionally observed to % % % take part of the hearing children’s play but only in non-communicative roles. The teachers had no prior experience of working with groups of deaf or hard-of-hearing children but considered the situation for the child with CI as satisfying. They seldom experienced that the children were involved in conflicts or that they were exposed to harassment from the other children. Training sessions The children attending preschools for the deaf received speech and hearing training once a week outside the preschool setting during the research period. These sessions were not recorded except for one single occasion. However, the training followed the same curriculum as that for children with CI in other preschool settings. Most of the children in preschools for the deaf and hard of hearing children or in mainstream preschools received speech and hearing training from a special teacher for the hearing impaired or a speech therapist. Half an hour, twice a week, was the most common model used. This special training was aimed at making the children attentive to sounds and to discriminate between different environmental sounds as well as speech sounds. In these adult-centred, speechorientated and often very well structured communicative contexts, most of the children in the study made efforts to utter spoken words. The words were mainly the names of persons or objects, like ‘Mummy’ and ‘apple’. However, it was observed in these training sessions that there was a tendency among teachers to overestimate the children’s ability to perceive sounds, in particular speech © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 Deaf preschool children using cochlear implants sounds, but also environmental sounds played from an audio recorder. On the other hand, there were teachers who often seemed to underestimate the children’s cognitive development. The content of the interaction in these training sessions was often considerably below the children’s intellectual level. A summary of the training sessions showed that: • These sessions were primarily adult-centred and directive. In almost all of the recorded sessions, the children tried to expand the content of the dialogues by associating with their own experiences or to other known facts, as if they wanted to make these situations more interesting. In those cases where the teachers responded to these initiatives, the dialogues developed to a more advanced cognitive level. • The teachers used speech as the starting point, even if they used signs as support. As the visual turn-taking seldom worked in these instances, the information received by the children became restricted. According to the way the children behaved, they had difficulties in understanding the meaning of what was said. However, they made efforts to repair the communication. • When the teachers used an alternative strategy and approached speech by using sign language and joint activities, the children seemed to understand more of what was intended and there were no disturbances in the communication. Hearing, speech and language development In the interviews with the parents, they reported that soon after the implant was tuned in, all of the children reacted to environmental sounds like church bells, aeroplanes, telephone and door bells as well as to other children shouting or calling from the room next door. A majority of them were observed to react when adults were calling from a distance. Parents and teachers reported that all of the children vocalized more since they had started to use their implants. Five out of the 10 children having used their implants between 2.5 and 3.5 years were observed to utter several single words primarily for objects and persons, but also as exclamations or for attracting the attention of adults or peers. Certain words and 411 sentences were well articulated, others more difficult or not possible for an outside observer to understand. Some of the children could utter threeto-five-word sentences, a few even longer ones. According to the parents, the children could understand more words and sentences than they could produce and this was also observed from the videorecordings. For three of the children in the remaining group, the perception and production of speech consisted of single words or exclamations. Two children did not seem to react to speech or to produce speech in natural interaction neither in the family nor in the preschool setting. Among the children having used their implants between 1 and 2.5 years, half of the group were observed to utter single words and even short sentences in natural interactions. The others had a restricted repertoire of oral language. Three of the children did not produce speech at all. Analyses of the videorecorded interactions showed that the children who had developed most oral language also had a well developed sign language. These children seemed to have an awareness of the function of language in communication and they were used to understand and be understood at home as well as in the preschool setting. When misunderstandings occurred, either because the children had not perceived the spoken words, or that the parents or teachers had not understood, the children tried to make repairs. They asked for repetitions or for more information, or they changed their own way of communicating to facilitate for the partner to establish a well functioning dialogue. Sign language in itself, however, was no guarantee for the development of spoken language. But children who had an insufficient command of sign language or whose sign-language development was discontinued also had very little or no spoken language. In three cases, we observed children who had very little sign language to begin with but, as their sign language increased, they also developed more spoken language. The use of the implant At the end of the study, all of the observed children used their implants. A majority (15) used their implants daily and the use of the implant was not © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 412 G. Preisler et al. the cause of any conflict or discussions in this group. The other seven children did not use the implant as regularly. In some of these cases, the use of the implant had been the cause of conflicts between parents and children. In 10 out of the 22 families, there had been some initial problem of implant use during the first months after the processor had been tuned in. These children had protested against wearing the implant, but the protests had gradually ceased. Information, expectations and recommendations given In the interviews, the parents expressed satisfaction with regard to the CI operation. They maintained that it had facilitated communication and interaction in daily family activities. The teachers working in preschools for the deaf and for the hard-ofhearing had on average 15 years of prior experience of teaching deaf and hard-of-hearing children. The teachers in mainstream preschools had, with some exception, no previous experience of children with hearing impairments until the child with CI came to their group. Almost half of the teachers (13) were negative or sceptical to the initial information and advice given by team members about how to perform the speech and hearing training for deaf children with cochlear implants. The same teachers were also critical to the lack of co-operation between them and the team members both pre and post implantation. Two out of the 22 interviewed members from the two multidisciplinary teams had previous experience of deaf children and sign language. The others lacked experience of deaf children. All of the team members declared that they were positive to the use of sign language in communication with deaf children, but not with severely hard-of-hearing children. The parents in the study were content with the way they had been treated by the medical staff at the hospital at their first visits to before the operation. Twelve of the parents were also positive to the pre-, peri- and post-operation treatment at the hospitals. The experiences of the other parents had been more negative, either due to negative reactions from their children or worries of their own in connection with anaesthesia and operation. One conclusion of the interviews was that those with most experience of development in deaf children, i.e. the teachers and many of the parents, were informed and educated by those with less knowledge and experience in these areas, i.e. the team members. Factors facilitating a positive development in deaf children with cochlear implants Analyses of the video interactions showed that there were differences between the children in the study group with respect to development of communication, language and overall psychosocial well-being. Analyses of the interviews in combination with the results of the observations gave reason to believe that these differences could be related to different circumstances in the environment, such as the following: • That a well functioning communication between child and adults was established already before the implantation. • That the adults mainly used a child-centred and supportive communicative style. That there were reasonable demands on the child with respect to oral/aural skills. That there were reasonable demands on the child in relation to age, maturity and capacities. That focus of the dialogues was primarily on the content and not on the linguistic form. • That the child had possibilities to discuss present experiences as well as experiences of past and future events with parents and teachers in order to create ‘narratives’ that there was a joyful and meaningful communication between child and adult, • That the child could take part in age-adequate plays with peers. And also, as a result of the interviews, • That the parents were satisfied and felt confident with the decision of having their child operated. • That the parents, teachers, habilitation staff and implant teams had been able to co-operate with respect to the child. © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 Deaf preschool children using cochlear implants For each individual child it was coded, from the videotranscriptions and the analyses of the interviews, whether the above stated circumstances were present or not. The results showed that for eight of the children in the study, between nine and 10 of the above mentioned circumstances were considered to be present. All of these children displayed a well functioning sign language communication and they could communicate freely with parents, teachers and peers. Parents and teachers mainly exhibited a child-centred communicative style, they seemed to pose reasonable demands on the child’s performance and the children could enter into fantasy and role play with other children and adults. The parents expressed satisfaction with their decision of having an operation for their child and, in most cases, the co-operation with preschool teachers, habilitation staff and team member had been satisfactory. The children who perceived, produced and understood most spoken language belonged to this group. They used spoken words in communication with others, and a couple of them could produce three-to-five-word sentences, and some even longer ones, in well known contexts. The children understood, provided the context was clear, more speech than they could produce. By the end of the study, some children used more spoken language than sign language with their parents. According to our judgements, these children lived in a stimulating communicative environment. The group consisted of three boys and five girls. Five of the children were prelingually deaf and three postlingually deaf. The children were between 2 years 5 months and 5 years when implanted. They had worn their implants for between 1.5 and 3.5 years (see Table 7). For a second group of children, six boys and four girls, the situation was somewhat different. In some Table 7. Group in relation to time of deafness and time with implant 413 cases, there had been difficulties when deciding about the operation or uncertainty whether the child developed normally or not. In some cases, the children exhibited an adequate sign language for their age at the first recordings, but this development was later discontinued. In other cases they had a far less well developed communication. For most of the children, communication with parents and teachers was generally directive and more focused on form than content. Children not communicating the way the parents expect might elicit a directive communicative style, but personality characteristics of the parents can also influence the way they communicate with their child. In some cases, the adults posed high demands on oral/aural skills. In other cases, the demands on the children’s general behaviour were low and the children were treated as younger than their age. Fantasy and story telling as well as pretend and role play were seldom or never observed among the families in this group. Instead of receiving a rich linguistic stimulation, nourishing both sign-language development and the development of spoken language, some of these children were living in a poor linguistic and communicative environment. In this group, some children used their implants daily without problems whereas others did not use their implants as regularly, which became a source of conflict between parents and children. One postlingually deaf child could produce several spoken words and utterances, but could not perceive or understand what the parents or teachers said. Another child did not utter any spoken words, but vocalized frequently. The other eight children uttered single words, occasionally in two-word sentences. Seven of the children in this group were prelingually deaf and three were postlingually deaf. The Deafness Group I Group II Group III <2 years: Time with CI < 2.5 years Time with CI 2.5–3.5 years 4 1 4 3 3 1 2–4 years Time with CI < 2.5 years Time with CI 2.5–3.5 years – 3 1 2 – – Total 8 10 4 © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 414 G. Preisler et al. time for operation and fitting of the processor varied between 2 and 5 years. The children had used their implants between 13 months and 3 years 5 months (see Table 7). Finally, there was a third group of children, two boys and two girls, who received a rich signlanguage stimulation in their preschool setting and could communicate in sign language with teachers and peers. In some of the families, a wellfunctioning sign-language communication was established whereas in others, communication was mainly based on non-verbal expressions in combination with speech and single signs. Two of the children in this group did not use their implants regularly, which was a source of conflict in the families. Most of the circumstances considered beneficial to the children’s development were not, or only partly, present. In these children, speech perception and speech production was practically non-existent. They were considered by the researchers as well as by their teachers to be just as deaf after the implantation as before. They were all prelingually deaf, having used their implants between 20 and 36 months. One child was 3 years old, the others were between 4 years 5 months and 4 years 9 months old at the time of the operation (see Table 7). Discussion The results of this study showed that all of the children could perceive environmental sounds after implantation. The majority of the children could take part in simple oral conversations in a well known context. This was more easily obtained in the more quiet home setting than in preschool setting. Observations from the preschools showed that the children in the study having used their implants between 1 and 3.5 years did not interact with other children or adults by means of speech and hearing. They did not take an active part in role or fantasy play with peers who did not command sign language. As peer interactions were limited, they mostly interacted with signing adults, and these adults often took the role of interpreter for both other adults and children. Therefore, the children were considered as socially deaf. The results of the present study reflect some of the difficulties to interact socially with hearing peers as was found in a study by Boyd (1999). The aim of Boyd’s study was to determine whether cochlear implants used by prelingually deaf children would result in improved competence as measured with a peer group entry task. The results did not show any improvement of the social competence of these children. The conclusion was that they experience the same difficulties in this situation as other deaf and hardof-hearing children and adolescents (Tvingstedt 1993; Ahlström 2000) and this is also what hard-of-hearing adults have reported in interviews about experiences from their childhood (Ahlström & Svartholm 1998). The children in this study developed differently with their implants. There were no clear patterns registered regarding the effects of variables such as time for and cause of deafness, time with implant or age of operation, on the children’s ability to perceive and produce spoken language after 2 years of study. But the group of children in this study is small and heterogenous and the conclusions of the results must be considered as tentative. Variables such as time for and cause of deafness, and time with implant or age of operation, are often used as important predictors of a successful effect on implant use (Miyamoto et al. 1993; Ganz et al. 1994; Walzman et al. 1994; 1995). But the results have not been unequivocal. According to Ganz et al. (1994), age when receiving the implant had a minor effect on the result concerning the prelingually deaf children. There were, however, differences if the children were implanted between the age of 2–5 years or after the age of 8 years. The former had better results than the latter. The same researchers maintain that aetiology had more effect on the results than age. Waltzman et al. (1994) found better results if the children were implanted before the age of 3 years compared with those implanted at an older age, whereas aetiology did not seem to have effect when the children had received an implant at an early age. In a French study, the linguistic progression in 21 prelingually deaf children having used their implants for at least 24 months was compared with the standard development in normally hearing children (Cochard et al. 1998). Three types of development were distinguished. For nine of the children, © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 Deaf preschool children using cochlear implants 415 Table 8. School placement and time of deafness School placement Deafness <2 years 2–4 years Total Sign-language class for the deaf Class for the hard-of-hearing Regular class Total 9 1 2 2 5 3 16 6 10 4 8 22 the language development was rapid and homogenous; for a group of eight children it was slower and more heterogeneous, whereas three children showed diverse problems with their language development. Thus, these results are in line with those presented in this study. The results of the present study indicate the importance of using a somewhat broader perspective on children’s development when discussing predictors of a successful result of the implant in terms of improving communicative skills. Studies in child development have shown that the roots of language are found in the early preverbal communication where parent and child can share focus of attention in a joyful and meaningful interaction. For language to develop, symbolic play has shown to play an important role. The significance of early close relationships for children’s social and emotional development has also been stressed and to be able to interact with peers is important for the child’s language development. Therefore, the situation for the deaf children with CI in preschools where speech was the main language, gave cause for apprehension. To have an adult as a mediator or interpreter seldom promotes friendship, as normal peer relations become almost impossible. The children will also lack opportunities to discuss important matters with peers. The importance of considering children’s total social reality and their own experiences in this reality in relation to later developmental outcomes is maintained by many developmental psychologists (see, for example Belsky 1990). What is further stressed is that single cause and effect explanations of development have not been very useful (Rutter 1991; Schaffer 1990). Instead, a network of factors is involved. We cannot predict the future development of a particular child using a single-variable design (Leeber 1998). This seems most valid in studies of language development. The possibilities for the child to engage in meaningful interaction is, to a great extent, dependent on the ability of an adult to adapt to a child and to give space for the child to take an active part in the interaction. As a consequence, in future research on cochlear implants in deaf children a variety of qualitative as well as quantitative evaluations ought to be used. These could include level and quality of peer interactions, play activities, communicative styles of adults, content of dialogues in terms of degree of complexity as well as the child’s possibility to create a narrative. This would enable a more comprehensive understanding of the consequence of a cochlear implant on individual children’s psycho-social as well as cognitive development. Today, the children in this study have started school. They are now taking part in a continued longitudinal follow-up study in their different school settings (see Table 8 for a description of school placement). The results of this study will be presented shortly. Out of the 22 children, 10 receive their education in sign-language classes, mainly at the schools for the deaf. Four children are placed in classes for the hard-of-hearing where spoken Swedish is used, sometimes with sign support, and sign language may also be offered as a special school subject. Eight children attend regular classes for hearing children supported by a personal assistant using sign language. When the data collection in the school study is terminated, the children will have used their implants for between 5 and 7.5 years. Thus, this study will give us more detailed information on the development of individual children with cochlear implants from a longitudinal perspective. Acknowledgement This research was supported by grants from the Swedish National Board of Health and Welfare. © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 416 G. Preisler et al. References Ahlström, M. (2000) Hörselskadade barn i kommunikation och samspel. [Hard-of-hearing children in communication and interaction]. PhD Dissertation, Stockholm University, Department of Psychology, Stockholm. Ahlström, M. & Svartholm, K. (1998) Barndomshörselskadades erfarenheter och upplevelser av tvåspråkighet. En pilotstudie [Experiences of bilingualism among adults, hard-of-hearing from childhood]. Forskning Om Teckenspråk XXI, (Sign Language Studies). Stockholm University, Department of Linguistics, Stockholm. Barnes, S., Gutfreund, M., Satterly, D. & Wells, G. (1983) Characteristics of adult speech which predict children’s language development. Journal of Child Language, 10, 65–84. Bates, E., Benigni, L., Bretherton, I., Camaioni, L. & Volterra, V. (1979) Cognition and communication. From nine to thirteen months. In: The Emergence of Symbols: Cognition and Communication in Infancy (ed. E. Bates), Academic Press, New York. Belsky, J. (1990) Parental and nonparental child care and children’s socioemotional development: a decade in press. Journal of Marriage and the Family, 52, 885–903. Bower, T. G. R. (1977) A Primer of Infant Development. Freeman, San Francisco. Bowlby, J. (1982) Attachment and Loss, Vol. 1. Hogarth, London. Boyd, R. C. (1999) Peer group entry behavior of hearingimpaired and hearing children. Dissertation Abstracts International; Section B: The Sciences & Engineering, 59 (9-B), 5131. Bronfenbrenner, U. (1979) The Ecology of Human Development. Harvard University Press, Cambridge, MA. Bruner, J. (1975) The ontogenesis of speech acts. Journal of Child Language, 2, 1–19. Bruner, J. (1983) Child Talk. W.W. Norton, New York. Cochard, N., Vidal, M. F., Baciocchi, D., Cormarey, X., Honeger, A. & Fraysse, B. (1998) Development of different linguistic systems in children with a cochlear implant. Review of Laryngological Rhinological (Bord), 119 (44), 277. Dale, P. S., Greenberg, M. T. & Cernic, K. A. (1987) The multiple determinants of symbolic development: evidence from preterm children. New Directions for Child Development, 36, 69–86. File, N. (1994) Children’s play, teacher–child interactions, and teachers beliefs in integrated early childhood programs. Early Childhood Research Quarterly, 9 (2), 223–240. Fogel, A. (1993) Developing Through Relationships Origins of Communication, Self and Culture. Harvester Wheatsheaf, New York. Ganz, B. J., Tyler, R. S., Woodworth, G. C., Tye-Murray, N. & Fryauf-Bertschy, H. (1994) Results of multichannel cochlear implants in congenital and acquired prelingual deafness in children: Five-year follow-up. American Journal of Otology, 15 (Suppl. 2), 1–8. Geers, A. & Moog, J. (1994) Effectiveness of cochlear implant and tactile aids for deaf children: The sensory aids study at Central Institute for the Deaf. Volta Review, 96 (5), (Monograph). Greenspan, S. (1985) First Feelings: Milestones in the Emotional Development of Your Baby and Child. Viking Penguin, New York. Guralnick, M. J. (1986) The peer relations of young handicapped and non handicapped children. In: Children’s Social Behavior (eds P. S. Strain, M. J. Guralnick & H. M. Walker), Academic Press, New York. Harris, M. (1992) Language Experience and Early Language Development Essays in Developmental Psychology. Lawrence Erlbaum Associates, Hove (UK). Hartup, W. (1985) Relationships and their significance in cognitive development. In: Social Relationships and Cognitive Development (eds R. A. Hinde, A. N. PerretClermont & J. Stevenson-Hinde), Clarendon Press, Oxford. Hartup, W. (1989) Social relationships and their developmental significance. American Psychologist, 44, 120–126. Heiling, K. (1995) The Development of Deaf Children Academic Achievement Levels Social Processes. Signum, Hamburg. Hoff-Ginsberg, E. & Schatz, M. (1982) Linguistic input and the child’s acquisition of language. Psychological Bulletin, 92, 3–26. Jorup, B. & Preisler, G. (2000) Att Göra Gemensamt I Leken–Om Lekens Kommunikativa Villkor [Sharing in Play–About the Communicative Premises in Play], Reports no. 111. Stockholm University. Department of Psychology, Stockholm. Konstantareas, M. M., Mandel, L. & Homatidis, S. (1988) The language patterns mothers and fathers employ with autistic boys and girls. Applied Psycholinguistics, 9 (4), 403–414. Leeber, J. (1998) How much brain does a mind need? Scientific, clinical and educational implications of ecological plasticity. Developmental Medicine and Child Neurology, 40, 352–357. Locke, J. (1995) Development of the capacity for spoken language. In: The Handbook of Child Language (eds P. Fletcher & B. MacWhinney), Blackwell Ltd, Oxford. Marshark, M. (1993) Psychological Development of Deaf Children. Oxford University Press, New York. McConachie, H. (1990) Early language development and © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 Deaf preschool children using cochlear implants severe visual impairment. Child: Care, Health and Development, 16 (1), 55–61. McDonald. L. & Pien, D. (1982) Mothers’ conversational behaviour as a function of interactional intent. Journal of Child Language, 9, 337–358. Meadow-Orlans, K. (1987) Deaf and hearing mothers of deaf and hearing infants: interaction during the first year. Paper Presented at the World Conference of the Deaf, Helsinki, Finland. Meyer, T., Svirsky, M., Kirk, K. & Miyamoto, R. (1998) Improvements in speech perception by children with profound prelingual hearing loss: effects of device, communication mode and chronological age. Journal of Speech, Language and Hearing Research, 41 (4), 846–858. Miyamoto, R. T., Osberger, M. J., Robbins, A. M., Myres, W. A. & Kessler, K. (1993) Prelingually deafened children’s performance with the Nucleus multichannel cochlear implant. American Journal of Otology, 14, 437–445. Miyamoto, R., Robbins, A., Osberger, M. J., Todd, S., Allyson, I., Riley, M. & Kirk, K. (1995) Comparison of multichannel tactile aids and multichannel cochlear implants in children with profound hearing impairments. American Journal of Otology, 16 (1), 8–13. Moog, J. S. & Geers, A. E. (1991) Educational management of children with cochlear implants. American Annals of the Deaf, 136 (2), 69–76. Moseley, M. J. (1990) Mother–child interaction with preschool language-delayed children: Structuring conversations. Journal of Communication Disorders, 23 (3), 187–203. Nordén, K., Preisler, G., Heiling, K., Hülphers, E. & Tvingstedt, A.-L. (1981) Learning processes and personality development in deaf children. International Journal of Rehabilitation Research, 4 (3), 393–395. Osberger, M. J., Robbins, A. R., Miyamoto, R. T., Berry, S. W., Myres, W. A., Kessler, K. S. & Pope, M. L. (1991) Speech perceptions abilities of children with cochlear implants, tactile aids, or hearing aids. The American Journal of Otology, 12 (Suppl.), 105–115. Osberger, M. J., Maso, M. & Sam, L. K. (1993) Speech intelligibility of children with cochlear implants, tactile aids or hearing aids. Journal of Speech and Hearing Research, 36, 186–203. Piaget, J. (1951) Play, Dreams and Imitation in Childhood. Heinemann, London. Preisler, G. (1983) Deaf Children in Communication. PhD Dissertation, Stockholm University, Department of Psychology, Stockholm. Preisler, G. (1990) Development of communication in deaf infants. Augmentative and Alternative Communication, 6 (2), 122–123. Preisler, G. (1995) The development of communication 417 in blind and in deaf infants: similarities and differences. Child: Care, Health and Development, 21 (2), 79–110. Preisler, G. (1999) The development of communication and language in deaf and severely hard-of-hearing children: implications for the future. International Journal of Pediatric Otorhinolaryngology, 49 (Suppl.), 39–43. Preisler, G. & Ahlström, M. (1997) Sign language for hard-of-hearing children: a hindrance or a benefit for their development? European Journal of Psychology of Education, XII (4), 465–477. Rutter, M. (1991) A fresh look at the ‘Maternal deprivation’. In: The Development and Integration of Behaviour (ed. P. Bateson), Cambridge University Press, Cambridge. Schaffer, H. R. (1990) Making Decisions About Children Psychological Questions and Answers. Basil Blackwell Ltd, Oxford. Schlesinger, H. & Meadow, K. (1972) Sound and Sign. University of California Press, Berkeley. Scroggs, C. L. (1983) An examination of the communication interactions between hearing impaired infants and their parents. In: Language in Sign (eds J. Kyle & B. Woll), Croom-Helm, London. Staller, S. J., Beiter, A. L., Brimacombe, J. A., Mecklenburg, D. J. & Arndt, P. (1991) Pediatric performance with the Nucleus 22-channel cochlear implant system. The American Journal of Otology, 12 (Suppl.), 126–136. Stern, D. (1998) The Interpersonal World of the Infant. Karnac Books, London. Studdert-Kennedy, M. (1991) Language development from an evolutionary perspective. In: Language Acquisition: Biological and Behavioral Determinants (eds N. Krasnegor, D. Rambaugh, R. Schiefelbusch, M. & M. Studdert-Kennedy), Lawrence Erlbaum, Hillsdale. Svirsky, M., Robbins, A. K., Kirk, K. I., Pisoni, D. B. & Miyamoto, R. T. (2000) Language development in profoundly deaf children with cochlear implants. Psychological Science, 11 (2), 153–158. Swedish National Board of Health and Welfare. (2000) Vårdprogram för barn med cochlea implantat [Directions for habilitation of children with cochlear implants]. Report no. 2000:06. Tiegerman, E. & Siperstein, M. (1984) Individual patterns of interaction in the mother-child dyad: implications for parent intervention. Topics in Language Disorders, 4 (4), 50–61. Trevarthen, C. (1988) Infants trying to talk. In: Children’s Creative Communication (ed. R. Söderbergh), Lund University Press, Lund. Trevarthen, C. (1990) Signs before speech. In: The Semiotic Web (eds T. A. Sebeok & J. Umiker-Sebeok), © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418 418 G. Preisler et al. Mouton de Gruyter, Berlin, New York, Amsterdam. Tvingstedt, A.-L. (1993) Sociala betingelser för hörselskadade elever i vanliga klasser. [Social conditions for hard-of-hearing pupils in classes with hearing children]. Doctoral Dissertation, Almqvist & Wiksell International, Stockholm. Tvingstedt, A.-L. (2000) Communication with deaf pre-school children using cochlear implants. Paper presented at the 19th International Congress on Education of the Deaf. Sydney, 9–13 July 2000. (Available on CD-ROM.). Tvingstedt, A.-L., Preisler, G. & Ahlström, M. (2001) Pre-school children with cochlear implants: a psychosocial follow-up study in Sweden. Paper presented at the Conference: ‘Sign language as a guide to Dutch’, Groningen, The Netherlands, 15–16 November 2001. Urwin, C. (1983) Dialogue and cognitive functioning in early language development of three blind children. In: Language Acquisition in the Blind Child (ed. A. E. Mills), Croom-Helm Ltd, Beckenham, Kent. Waltzman, S., Cohen, N., Gomolin, R. H., Shapiro, W. H., Shelly, R. O. & Hoffman, R. A. (1994) Long-term results of early cochlear implantation in congenitally and prelingually deafened children. Journal of Otology, 15 (Suppl. 2), 9–13. Waltzman, S., Cohen, N. & Shapiro, W. H. (1995) Effects of cochlear implantations on the young deaf child. In: Advances in Oto-Rhino-Laryngology (eds A. S. Uziel & M. Mondain), pp. 125–128, Karger, Basel. Warren, S. & Kaiser, A. P. (1986) Incidental language teaching. A critical review. Journal of Speech and Hearing Disorders, 51 (4), 291–299. Wills, D. M. (1981) Some notes in the application of diagnostic profile to young blind children. Psychoanalytic Study of the Child, 36, 217–240. © 2002 Blackwell Science Ltd, Child: Care, Health & Development, 28, 5, 403–418