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Language and Emergent Literacy in Preschoolers with Early Cochlear Implantation

Permanent Link: http://ufdc.ufl.edu/UFE0022200/00001

Material Information

Title: Language and Emergent Literacy in Preschoolers with Early Cochlear Implantation
Physical Description: 1 online resource (38 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: cochlear, deaf, implant, language, literacy, preschoolers
Communication Sciences and Disorders -- Dissertations, Academic -- UF
Genre: Communication Sciences and Disorders thesis, M.A.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Profoundly deaf children who receive cochlear implants at an early age have a better prognosis for developing appropriate oral language and, therefore, more proficient emergent literacy skills (Geers, 2003; Kyle & Harris, 2006). Since spoken language as well as emergent literacy skills have been documented to predict later reading proficiency in normal hearing four-year-olds, the question arises as to how strongly spoken language and pre-literacy skills correlate in children with deafness at age four. The present study explores how spoken language behaviors correlate with emergent literacy skills, specifically letter knowledge and rhyme knowledge, in profoundly deaf four-year-olds with a cochlear implant (CI) as compared to their normal hearing (NH) peers. The Assessment of Literacy and Language (ALL) was administered to 14 profoundly deaf cochlear implant users from four centers for oral deaf education between the ages of 48 and 59 months. Their subtest and composite scores for emergent literacy and for language were compared to the composite scores of 14 normally hearing preschoolers with no identifiable risk of language disorder selected from the ALL's normative sample. The groups were matched on gender, SES, grade, ethnicity, and region of the country. Results indicate that language and emergent literacy composite scores were highly correlated in children with early cochlear implantation. There was no significant group effect for emergent literacy; however, a significant group effect for the language composite was found, with the participants from the CI group performing more poorly than children with typical language. When the groups? individual subtest scores were examined, it was observed that a substantial portion of the CI group scored in the clinical range on the rhyme knowledge test (-1.5 SD), one of the two tests that comprise the emergent literacy composite. Their group composite emergent literacy score was inflated by higher than average letter knowledge scores in 6 of the 14 children (+ 1.5 SD). Instructional implications for oral education centers for the deaf are discussed.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (M.A.)--University of Florida, 2008.
Local: Adviser: Lombardino, Linda J.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022200:00001

Permanent Link: http://ufdc.ufl.edu/UFE0022200/00001

Material Information

Title: Language and Emergent Literacy in Preschoolers with Early Cochlear Implantation
Physical Description: 1 online resource (38 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: cochlear, deaf, implant, language, literacy, preschoolers
Communication Sciences and Disorders -- Dissertations, Academic -- UF
Genre: Communication Sciences and Disorders thesis, M.A.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Profoundly deaf children who receive cochlear implants at an early age have a better prognosis for developing appropriate oral language and, therefore, more proficient emergent literacy skills (Geers, 2003; Kyle & Harris, 2006). Since spoken language as well as emergent literacy skills have been documented to predict later reading proficiency in normal hearing four-year-olds, the question arises as to how strongly spoken language and pre-literacy skills correlate in children with deafness at age four. The present study explores how spoken language behaviors correlate with emergent literacy skills, specifically letter knowledge and rhyme knowledge, in profoundly deaf four-year-olds with a cochlear implant (CI) as compared to their normal hearing (NH) peers. The Assessment of Literacy and Language (ALL) was administered to 14 profoundly deaf cochlear implant users from four centers for oral deaf education between the ages of 48 and 59 months. Their subtest and composite scores for emergent literacy and for language were compared to the composite scores of 14 normally hearing preschoolers with no identifiable risk of language disorder selected from the ALL's normative sample. The groups were matched on gender, SES, grade, ethnicity, and region of the country. Results indicate that language and emergent literacy composite scores were highly correlated in children with early cochlear implantation. There was no significant group effect for emergent literacy; however, a significant group effect for the language composite was found, with the participants from the CI group performing more poorly than children with typical language. When the groups? individual subtest scores were examined, it was observed that a substantial portion of the CI group scored in the clinical range on the rhyme knowledge test (-1.5 SD), one of the two tests that comprise the emergent literacy composite. Their group composite emergent literacy score was inflated by higher than average letter knowledge scores in 6 of the 14 children (+ 1.5 SD). Instructional implications for oral education centers for the deaf are discussed.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (M.A.)--University of Florida, 2008.
Local: Adviser: Lombardino, Linda J.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022200:00001


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LANGUAGE AND EMERGENT LITERACY INT PRESCHOOLERS
WITH EARLY COCHLEAR IMPLANTATION


















By

KAMERON CLARK GARDEN


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF ARTS

UNIVERSITY OF FLORIDA

2008






































O 2008 Kameron Clark Carden

































To my sister, Caroline









ACKNOWLEDGMENTS

There are many people who have provided guidance, support, and assistance to me

throughout the completion of my master' s degree and thesis. I must first thank my committee

members without whom this thesis would not have been created. Dr. Linda Lombardino has

taught me so much over the past two years about reading development and disabilities. I would

not have developed an interest in this area without her academic guidance and support. Dr.

Bonnie Johnson has been critical to my development as a clinician and as a researcher. Her

enthusiasm, encouragement, and support have continually brightened my graduate experiences.

She has helped me to become a researcher who looks at data through a clinical lens, and for that I

will always be grateful.

I could not have completed this study without the help of Dr. Wayne King, Christine

Gustus, and Jean Sachar Moog. Dr. King graciously completed all statistical analyses on the data

for this study as well as assistance in deciphering what the data meant. He also created the

beautiful figures displayed in the results section of this thesis thereby creating a visual

description of the data we obtained. Christine Gustus and Jean Sachar Moog of the Moog Center

for Deaf Education in St. Louis, MO facilitated the gathering of participants for this study as well

as insight into oral deaf education and its academic impact on preschoolers with cochlear

implants. I thank you for both your academic guidance and your friendship. I would also like to

thank the directors and staff at the following schools who also allowed me to test their students:

Child's Voice in Chicago, IL; Ohio Valley Voices in Cincinnati, OH; St. Joseph Institute in

Indianapolis, INT.

I would like to thank Dr. Kenneth Gerhardt and Dr. Scott Griffiths for their support and

encouragement during my transition from audiology to speech-language pathology. They never










made me feel like a quitter, and they gave me a second chance. I would not be here today

without them.

Finally, I would like to thank my family for their eternal love and support. Specifically, I

thank my mother, Edie, for always encouraging me to do more and to be better. I thank my sister,

Caroline, for being my muse. And I thank my husband, Nathan, for putting up with my

occasional crankiness throughout this long and arduous thesis process. His friendship and love

make everything worth it.












TABLE OF CONTENTS


page

ACKNOWLEDGMENTS .............. ...............4.....


LIST OF TABLES .........__.. ..... .__. ...............7....


LIST OF FIGURES .............. ...............8.....


AB S TRAC T ............._. .......... ..............._ 10...


CHAPTER


1 INTRODUCTION ................. ...............12.......... ......


Emergent Literacy Skills .............. ...............12....
Language and Emergent Literacy ................. ...............12................
Effects of Cochlear Implantation ................. ...............13................
Literacy and Cochlear Implantation .............. ...............14....
Limitations in Current Research ................. ...............15................

Purpose .............. .... ...............16.
Research Question 1 .............. ...............16....
Research Question 2 ................ ...............17........... ....


2 M ETHODS ................. ...............18.......... .....


Participants ............... ..... ...............18.
Cochlear Implant Group ................ ...............18........... ....
Normally Hearing Participants ................. ...............18................
M material s .............. ...............19....
Proc edure s ................ ...............20........... ....
Desi gn ................. ...............20.................


3 RE SULT S .............. ...............22....


Spoken Language and Emergent Literacy Skill Performance ................. .......................22
Language and Emergent Literacy Correlations .............. ...............24....

4 DI SCUS SSION ................. ...............3.. 1......... ....


Language and Emergent Literacy Skills............... ...............31.
Language and Emergent Literacy Relationships .............. ...............34....

LIST OF REFERENCES ................. ...............36........... ....


BIOGRAPHICAL SKETCH .............. ...............38....










LIST OF TABLES


Table page

2-1 Descriptive information for cochlear implant participant group .............. ....................21

3-1 Mean and standard deviations (SD) of Language and Emergent Literacy subtest and
composite standard scores for the cochlear implant (CI) and normally hearing (NH)
group s ................ ...............30.................










LIST OF FIGURES


Figure page

3-1 Comparison of raw scores between cochlear implant (CI) and normally hearing (NH)
group for Emergent Literacy composite and subtests ................. .......................__25

3-2 Comparison of raw scores between cochlear implant (CI) and normally hearing (NH)
group for Language composite, combined Basic Concepts (BC) and Receptive
Vocabulary (RV) subtests, and combined Parallel Sentence Production (PS) and
Listening Comprehension (LC) subtests ................. ...............26................

3-3 Comparison of relationship between Emergent Literacy composite score
chronological age between cochlear implant (CI) and normally hearing (NH) groups.....27

3-4 Comparison of relationship between Language and Emergent Literacy composite
scores between cochlear implant (CI) and normally hearing (NH) group ................... ......28

3-5 Percentage of participants from the cochlear implant group who scored 1.5 standard
deviations or more below the standard mean across the six ALL subtests
administered: Letter Knowledge (LK), Rhyme Knowledge (RK), Basic Concepts
(BC), Receptive Vocabulary (RV), Parallel Sentence Production (PS), Listening
Comprehension (LC) .............. ...............29....









LIST OF ABBREVIATIONS

CI Cochlear implant group

NH Normally hearing group

ALL Assessment of Language and Literacy

BC Basic Concepts subtest

RV Receptive Vocabulary subtest

PS Parallel Sentence Production Subtest

LC Listening Comprehension subtest

LK Letter Knowledge subtest

RK Rhyme Knowledge subtest









Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Arts

LANGUAGE AND EMERGENT LITERACY INT PRESCHOOLERS
WITH EARLY COCHLEAR IMPLANTATION

By

Kameron Clark Carden

May 2008

Chair: Linda Lombardino
Major: Communication Sciences and Disorders

Profoundly deaf children who receive cochlear implants at an early age have a better

prognosis for developing appropriate oral language and, therefore, more proficient emergent

literacy skills (Geers, 2003; Kyle & Harris, 2006). Since spoken language as well as emergent

literacy skills have been documented to predict later reading proficiency in normal hearing four-

year-olds, the question arises as to how strongly spoken language and pre-literacy skills correlate

in children with deafness at age four.

The present study explores how spoken language behaviors correlate with emergent

literacy skills, specifically letter knowledge and rhyme knowledge, in profoundly deaf four-year-

olds with a cochlear implant (CI) as compared to their normal hearing (NH) peers. The

Assessment of Literacy and Language (ALL) was administered to 14 profoundly deaf cochlear

implant users from four centers for oral deaf education between the ages of 48 and 59 months.

Their subtest and composite scores for emergent literacy and for language were compared to the

composite scores of 14 normally hearing preschoolers with no identifiable risk of language

disorder selected from the ALL's normative sample. The groups were matched on gender, SES,

grade, ethnicity, and region of the country.










Results indicate that language and emergent literacy composite scores were highly

correlated in children with early cochlear implantation. There was no significant group effect for

emergent literacy; however, a significant group effect for the language composite was found,

with the participants from the CI group performing more poorly than children with typical

language. When the groups' individual subtest scores were examined, it was observed that a

substantial portion of the CI group scored in the clinical range on the rhyme knowledge test (-1.5

SD), one of the two tests that comprise the emergent literacy composite. Their group composite

emergent literacy score was inflated by higher than average letter knowledge scores in 6 of the

14 children (+ 1.5 SD). Instructional implications for oral education centers for the deaf are

discussed.









CHAPTER 1
INTTRODUCTION

Emergent Literacy Skills

Traditionally, learning to read has not been a focus of attention until elementary school.

Intensive literacy training is not begun until first grade, so a child who has not been progressing

at a steady rate toward reading fluency is not be detected as having reading difficulties until

second grade or later. Fortunately, the emergent literacy approach has developed an awareness

that reading ability progresses along a continuum beginning long before children start

kindergarten. The concept of emergent literacy has blurred the line between a preschooler who

does not read and a first grader who does. Emergent literacy skills must be in place before

learning to read can progress (Lonigan, Burgess, & Anthony, 2000).

Vast amounts of research have documented that pre-literacy skills such as phonological

awareness and letter knowledge (Ryachew, Ohberg, Grawburg, & Heyding, 2003; Lonigan,

Burgess, & Anthony, 2000), as well as knowledge of print (Crain-Thoreson & Dale, 1992) are

strongly correlated with later reading. These skills appear to emerge around 4 years of age

(Oliver, Dale, & Plomin, 2005; Crain-Thoreson & Dale, 1992). Whitehurst and Lonigan (1998)

argue that three factors are associated with the preschooler' s later ability to decode words, and

thus learn to read: oral language, phonological processing, and print knowledge. The relationship

between oral language and emergent literacy skills in preschoolers is the focus of the present

study .

Language and Emergent Literacy

The relationship between oral language and early predictors of reading ability has been

well documented within the literature of our field. More specifically, the relationship between

oral language and phonological sensitivity, or the ability to manipulate the sound structure of a









language, exists in typically developing preschool-aged children (Foorman, Anthony, Seals, &

Mouzaki, 2002; Lonigan, Burgess, & Anthony, 2000). Phonological sensitivity is critical to the

development of literacy (Wagner & Torgesen, 1987). One method that researchers have used to

document this relationship is to examine how language deficits impact learning to read. Bishop

and Adams (1990) investigated the acquisition of literacy in 83 third graders who had been

diagnosed with a speech or language impairment at age 4. The preschoolers with more global

language deficits at an early age were more likely to have difficulty with both reading and

spelling in third grade. Catts (1993) compared the reading achievement of three groups of second

graders: children with a language impairment, children with normal language but impaired

phonological systems, and children with typically developing language and phonology. The

results indicated that the reading skills of the language impaired group were significantly

depressed, while the reading skills of the group with phonological deficits were within the

normal range. Because the relationship between oral language and emergent literacy is so well-

documented, it seems intuitive that the development of pre-literacy skills, such as phonological

awareness, letter knowledge, and knowledge of print, should be highly monitored in children

with oral language delays and disorders. One tool for documenting and comparing these skills is

the Assessment ofLanguage and Literacy (ALL), developed by Lombardino, Lieberman, and

Brown, which identifies children from preschool to Birst grade who are at risk for reading

difficulties due to weaknesses in one or more areas of language.

Effects of Cochlear Implantation

While the relationship between oral language and emergent literacy has been established

in normal hearing preschoolers, this study attempts to determine whether the same relationship

exists for children with deafness who receive cochlear implants at an early age. Since the average

deaf or hard of hearing student graduates from high school with a fourth grade reading level









(Traxler, 2000), literacy is a chief educational concern with this population. According to Perfetti

and Sandak (2000), the low literacy levels reported among children with severe to profound

deafness may be attributed to the gap between their oral language abilities and the demands of

reading, which is a written system based upon the phonology of our language.

It is important to discuss here how early cochlear implantation affects the oral language

skills of profoundly deaf children, so that a hypothesis can be formed about how implantation

may effect reading in a similar way. Geers, Nicholas, and Sedey (2003) evaluated the oral

language of 8 and 9 year olds who had been implanted before the age of 5. More than half of the

participants exhibited receptive and expressive language skills comparable to their normal

hearing peers. The authors underscored that the oral education provided to these children played

a key role in their well developed language skills. Similar findings show that receiving an

implant by 2 years of age dramatically enhances both spoken language and language

development (Svirsky, Teoh, & Neuberger, 2004; Nicholas & Geers, 2006; Nicholas & Geers,

2007). Research also suggests that children who receive cochlear implants early show faster rates

of language acquisition than children who are implanted at later ages (Svirsky, Robbins, Kirk,

Pisoni, & Miyamoto, 2000).

Literacy and Cochlear Implantation

Because cochlear implants improve rate and quality of oral language acquisition in

children, reading skills should also be positively affected. Most of the research in this area

explores reading development in deaf children without cochlear implants or examines the effects

of cochlear implantation before the age of 5 on reading skills. Kyle and Harris (2006) compared

7 and 8 year old deaf children with age-matched peers on both language and literacy skills. Of

the 29 deaf children, 7 had received cochlear implants. They found that age was the best

predictor of reading ability in the control group, while expressive vocabulary and speech-reading









skills were the best predictors of reading ability in the deaf group. Upon further analysis, the

researchers determined that the children with implants performed significantly worse on reading

tasks than children with hearing aids and attributed this difference to the late implantation of the

implant users.

Studies specifically designed to explore the literacy skills of children with cochlear

implants have produced similar results. Geers (2003) found that out of 181 children implanted by

the age of 5, over half scored within average range for their reading abilities when compared to

normative data for hearing children. Unthank, Rajput, and Goswami (2001) found that children

who received an implant before 3 V/2 years of age had larger vocabularies and higher word

reading scores than children implanted after the age of 5. Similar findings were observed by

Moog and Geers (1999) with children who had been implanted between the ages of 2 and 9.

Because all children in the study were educated in a private oral setting, the researchers

postulated that oral education accelerated the participant's literacy development.

Limitations in Current Research

Most studies that explore literacy in children with cochlear implants enroll participants that

received their implants at 2 years of age or later (Geers, 2003; Moog & Geers, 1999; Unthank,

Rajput, & Goswami, 2001). Today, however, many children are receiving implants as early as 12

months of age. A study has not been completed to address the emergent literacy skills of

preschoolers participating in oral education that were implanted at or before 2 years of age.

Because very young children can now be implanted at the 12 months of age, they have the

opportunity to be exposed to oral language much earlier. Since oral language development

improves with earlier implantation, it is expected that (a) improvement in the development of

pre-literacy skills will occur as well and that, (b) emergent literacy skills in children with early









implantation will develop around the same time that they emerge in normal hearing children,

approximately 4 years of age.

Purpose

The current study seeks to determine whether the same positive correlation between oral

language and emergent literacy skills seen in 4-year-old preschoolers will exist in 4-year-old

profoundly deaf children who received cochlear implants before the age of 2 and are now being

educated in an oral setting. The current study also seeks to explore the emergent literacy skills,

specifically letter knowledge and rhyme knowledge, of preschoolers with early cochlear

implantation (CI) as compared to their normally hearing age-matched peers (NH). The Language

and Emergent Literacy composites from the CI group are compared to composites of the NH

control group to determine whether oral language and emergent literacy correlate in the same

way for both groups and if differences exist between the composite scores of the groups. The

current study seeks to determine if a select group of preschoolers with early implantation are on

track for reading skill development, as well as if that skill development can be predicted from

oral language efficiency.

Research Question 1

How do children with cochlear implants compare to their age-matched peers on their

spoken language composite skills and their emergent literacy composite skills as measured on

the Assessment of Literacy and Language? It was hypothesized that (1) children with cochlear

implants will perform more poorly on spoken language and early literacy measures than their

age-matched peers that require discrete auditory discrimination, such as rhyme knowledge, and,

(2) children with cochlear implants will perform similarly to their typically hearing peers on

tasks that to not require discrete auditory discrimination.









Research Question 2

Will similar correlations exist between the language and emergent literacy skills of

preschoolers with early cochlear implantation when compared to their typically hearing peers? It

was hypothesized that children with cochlear implants will demonstrate the same relation

between spoken language and early literacy skills that is found in the normally hearing group.









CHAPTER 2
IVETHOD S

Participants

Cochlear Implant Group

Fourteen CI preschoolers participated in the study. They were recruited from full day

preschool programs at the following oral education centers: four participants from The M~oog

Center for DeafEducation in St. Louis, MO; two participants from Child's Voice in Chicago, IL;

six participants from Ohio Valley Voices in Cincinnati, OH; and two participants from St. Joseph

Institute in Indianapolis, INT. Selection criteria included that all CI participants (1) have an

unaided severe to profound bilateral sensorineural hearing loss, (2) have received a cochlear

implant between the age of 12 and 30 months, (3) were between the ages of 48 months and 59

months, and (4) did not have a concomitant disorder. Four additional preschoolers were tested

but were excluded because three did not meet the criteria for age of implantation and one had a

concomitant disorder.

Table 2-1 provides descriptive information for the CI participant group. The participants

ranged in age from 48 to 59 months (X=53.71; SD=4.12). The age at which the children were

implanted ranged from 10 to 27 months (X=17.64; SD=5.87). Twelve participants were

unilaterally implanted, while the remaining two were bilaterally implanted. The maternal

education levels were available for 12 of the 14 participants. For those participants, the maternal

education level ranged from 12 to 18 years. Five of the participants were females, and nine were

males.

Normally Hearing Participants

Fourteen NH preschoolers with no identifiable risk of language disorder were selected

from the ALL's normative sample as matches for the experimental group. These typically









developing control children were matched with the CI children on gender, maternal education

level, grade, ethnicity, and region of the country. The 14 control preschoolers were between the

ages of 49 and 58 months (X=51.73; SD=2.73).

Materials

Assessment ofLanguage and Literacy (ALL) by Lombardino, Lieberman, and Brown

(2005) was administered to each child participating in the study. The ALL was used to evaluate

the language development and emergent literacy skills of the 14 preschool participants. The

following six subtests from the ALL were administered separately to each of the children from

the CI group: Letter knowledge, Rhyme Knowledge, Ba~sic Concepts, Receptive Vocabulary,

Parallel Sentence Production, and Listening Comprehension. These same data were available

for all the control subj ects from the normative sample. Each of these tasks is described below.

The Letter Knowledge subtest is comprised of three tasks. In Task 1, the participant points

to letters on a stimulus page as they are named. In Task 2, he or she names letters as they are

pointed to by the researcher. In Task 3, the participant writes letters that the researcher names.

The Rhyme Knowledge subtest is comprised of four tasks. In Task 1, the child judges whether or

not pairs of words rhyme. In Task 2, the participant identifies the one word out of a set that does

not rhyme. In Task 3, he or she provides a word that rhymes with the stimulus word. In Task 4,

the participant completes a sentence by providing a word that rhymes with a stimulus word

within the sentence. The Letter Knowledge and Rhyme Knowledge subtests comprise the

Emergent Literacy composite, because together they represent phonological sensitivity to sounds

and print knowledge, two constructs that are necessary for later reading.

The Ba~sic Concepts subtest requires the participant to point a picture that most closely

represents the concept the researcher describes. The Receptive Vocabulary subtest allows the

child to point to a picture that best resembles the word said by the researcher. For the Parallel










Sentence Production subtest, he or she completes a phrase or sentence that matches the target

structure of the sentence provided by the researcher. The Listening Comprehension subtest

involves two tasks. First, the participant retells a story the researcher has told to him or her.

Then, he or she answers questions about the story after it is repeated again. These subtests

comprise the Language composite.

Procedures

The primary researcher traveled to the four following oral centers for deaf education in

order to administer the ALL to study participants: The M~oog Center for DeafEducation in St.

Louis, MO; Child's Voice in Chicago, IL; Ohio Valley Voices in Cincinnati, OH; St. Joseph

hIstitute in Indianapolis, INT. The primary researcher administered the ALL in each school's

resource room or library. Prior to conducting the language and literacy testing, the examiner

received an audiogram containing aided and unaided pure tone thresholds, as well as speech

perception thresholds, for each implanted child by his or her school. Each child was informed

prior to initiation of testing that he or she could abandon testing at any time and would not be

penalized for doing so. The total testing time per child was approximately 30 to 45 minutes. The

ALL's subtests were administered in the order of appearance within the stimulus book as

follows: Letter Knowledge, Rhyme Knowledge, Ba~sic Concepts, Receptive Vocabulary, Parallel

Sentence Production, and Listening Comprehension.

Design

This study is a between-group, 2 by 2 design. The two independent variables are the

experimental (CI) and the normally hearing (NH) groups. The two dependent variables are the

Emergent Literacy and the Language composite scores from the ALL. The composite scores

between groups were compared to determine if similar relationships between language and

emergent literacy are found for the NH and CI groups.





















17 M


Not reported


16 F Some college

12 F Not reported
Master' s
14 F degree
27 M Some college
18 M College degree
10 M College degree
12 M high school
Master' s
18 M degree
Master' s
16 M degree


Table 2-1. Descriptive information for cochlear implant participant group


V


Maternal
Education
College degree
College degree


Age
(mo)
59
57

48

56

51

57

56


Age at
Implantation (mo)
27
21


Impl antati on
Unilateral
Unilateral

Unilateral

Unilateral

Unilateral

Unilateral

Unilateral

Unilateral
Unilateral
Unilateral
Bilateral
Unilateral

Unilateral

Bilateral


Race School
White Child's Voice
White Child's Voice
Ohio Valley
White Voices
Ohio Valley
White Voices
Ohio Valley
White Voices
Ohio Valley
Asian Voices
Ohio Valley
White Voices
Ohio Valley
White Voices
White St. Josephs
White St. Josephs
White Moog Center
White Moog Center

White Moog Center

White Moog Center


Sex
F
M


12 M Not reported

27 F College degree









CHAPTER 3
RESULTS

Spoken Language and Emergent Literacy Skill Performance

Descriptive statistics were used to address the question how of children with cochlear

implants compare to their age-matched peers on the language skills and emergent literacy skills

evaluated by the ALL. The means and standard deviations for individual subtests language and

emergent literacy and composite scores for language and emergent literacy tests were calculated

and compared between groups.

The Language composite standard scores ranged from 44 to 94 (X=69.07, SD=15.98) for

the CI group and from 80 to 112 (X=94.07; SD=8.83) for the NH group. The Emergent Literacy

composite standard scores ranged from 57 to 116 (X=92.43; SD=20.82) for the CI group and

from 69 to 108 (X=90.79; SD=13.50) for the NH group. As indicated by the standard deviations,

a wide range of variability in composite scores was observed for both language and emergent

literacy skills in the CI group. Box plots, as seen in Figures 3-1 and 3-2, were used to show

differences between the two groups on composite scores, as well as how the subtest scores

comprising those composites differ between groups. Table 3-1 provides the means and standard

deviations of Language and Emergent Literacy subtest and composite standard scores for the

(CI) and (NH) groups.

Descriptively, it is also important to point out that the proportion of CI group participants

with a score of 1.5 SD or more below the mean was > 36% for 5 of the 6 subtests. This means

that at least 36% of the participants are performing significantly below age expectations for

every task except Letter Knowledge. Please refer to Figure 3-5 for the percentage of participants

from the cochlear implant group who scored 1.5 standard deviations or more below the standard

mean across the six ALL subtests administered.










An analysis of variance (ANOVA) was used to compare performance between groups on

the Language composite and Emergent Literacy composite scores in an effort to evaluate the

effects of group, age, gender, and group/age interactions. For the Language composite, a

significant effect for group was discovered (F (1,23) = 24.8, p < 0.001) in which the NH group

performed better on language tasks as a whole than the CI group. A significant effect for age was

also present (F (1,23) = 12.9, p < 0.001), so that the older participants achieved higher language

composite scores despite group. No significant effect for gender or group/age interaction was

present.

For the Emergent Literacy composite, only a significant effect for age was observed (F

(1,23) = 20.73, p < 0.001), so that as the participants got older, their performance on tasks of

emergent literacy improved despite group. In particular, this trend between an increase in age

and improvement in performance was stronger for the CI group. Refer to Figure 3-3 for a

comparison of the relationship between emergent literacy skills and age across the two groups.

No significant effect was found for group, gender, or group/age interaction for the Emergent

Literacy composite. Although no significant group effect for the emergent literacy composite

was observed, a substantial portion of the CI group scored in the clinical range (-1.5 SD) on the

emergent literacy subtest of Rhyme Knowledge. The CI group composite emergent literacy score

was inflated by the subj ects higher than average Letter Knowledge scores for 6 of the 14 children

(+ 1.5 SD).

Differences between groups across individual subtests were examined. When scores were

converted to scaled scores, a significant effect for group was observed for five of the six subtests.

In order maintain a conservative approach to data analyses, independent t-tests were performed









at a significance level of 0.05 using the Bonferoni correction (p < 0.008) to account for the six

variables being analyzed.

Several significant differences were observed when the subtest scores of the two groups

were compared. The NH groups performed better than the CI for Rhyme Knowledge (t = 2.96

(26), P = 0.006), Ba~sic Concepts (t = 3.13 (26), p = 0.004), Receptive Vocabulary (t = 3.2 (26), p

= 0.003), Listening Comprehension (t = 5.38 (26), p < 0.001), and ParallelPPP~~~~PPP~~~PPP Sentence Production

(t = 4.56 (26), p < 0.001). It should be noted that if the p-value had not been adjusted, a

significant group effect would also have been observed for Letter Knowledge, with the CI group

performing better than the NH group.

Language and Emergent Literacy Correlations

Descriptive statistics were used to address the question of whether a similar correlation

exists between the language and emergent literacy skills of preschoolers from the CI group when

compared to their NH peers. Language and emergent literacy are highly correlated among the CI

group (0.81, p<0.001). However, language and emergent literacy were not correlated among the

NH group in this study. Please refer to Figure 3-4 for a comparison of the relationship between

language and emergent literacy skills between the CI and NH groups.












Literacy Score (LK,RK)


Letter Knowledge


Rhyme Knowledge


Cl NH Cl NH




Figure 3-1. Comparison of raw scores between cochlear implant (CI) and normally hearing
(NH) group for Emergent Literacy composite and subtests













Language Score (BC,RV,PS,LC)

~I







Cl NH



Language Score (BC,RV) Language Score (PS,LC)





Cl: NH N


Fiur 3-2 Coprsno a crsbtenccla mln C)adnral ern
(N)gou o Lnug comoie obndBscCocps(C n eetv

Voaulr (RV sutss n obndPrlelSnec rdcin(S n
Litnn CopeesonL)sbet














Literacy Composite (LK+RK)


*
*


48 50 52 54
Age (Months)


56 58


Figure 3-3.


Comparison of relationship between Emergent Literacy composite score
chronological age between cochlear implant (CI) and normally hearing (NH) groups


* 6NH












Literacy Composite vs. Language Composite Scores


f NH




E *


o





o 5 10 15
Literacy Composite


Figure 3-4. Comparison of relationship between Language and Emergent Literacy composite
scores between cochlear implant (CI) and normally hearing (NH) group





100%
80%
60%
40%
20%
0%


LK RK BC RV PS


Figure 3-5.


Percentage of participants from the cochlear implant group who scored 1.5 standard
deviations or more below the standard mean across the six ALL subtests
administered: Letter Knowledge (LK), Rhyme Knowledge (RK), Basic Concepts
(BC), Receptive Vocabulary (RV), Parallel Sentence Production (PS), Listening
Comprehension (LC)


1111










Table 3-1. Mean and standard deviations (SD) of Language and Emergent Literacy subtest and
composite standard scores for the cochlear implant (CI) and normally hearing (NH)
groups
CI group NH group
Mean SD Mean SD
Emergent Literacy
Composite 92. 43 20. 82 90. 79 13.50
Letter Knowledge 11.64 5.02 8.50 2.65
Rhyme
Knowledge 6.50 2.44 8.93 1.86
Language
Composite 69. 07 15. 98 94. 07 8. 83
Receptive
Vocabulary 5.36 2.31 8.43 2.74
Basic Concepts 5.79 3.31 9.36 2.68
Parallel Sentence
Production 5.57 2.85 9.64 1.74
Listening
Comprehension 3.64 2.37 8.57 2.47









CHAPTER 4
DISCUSSION

This study was designed to determine whether the same positive correlation between oral

language and emergent literacy skills seen in 4-year-old preschoolers would exist in 4-year old

profoundly deaf children who received cochlear implants before the age of 2 and were now being

educated in an oral setting. The study also sought to explore the emergent literacy skills,

specifically letter knowledge and rhyme knowledge, of a CI group in comparison to a (NH)

group. The Language and Emergent Literacy composites from the CI group were compared to

composites of the NH control group to determine whether oral language and emergent literacy

correlate in the same way for both groups and if differences exist between the composite scores

of the groups. Individual subtest scores, specifically those related to emergent literacy, were also

compared between groups.

Language and Emergent Literacy Skills

It was hypothesized that children with cochlear implants would perform more poorly than

age-matched peers on spoken language and early literacy measures that required discrete

auditory discrimination, such as rhyme knowledge. However, on tasks that did not require

discrete auditory discrimination, it was expected that children with cochlear implants would

perform similarly to their typically hearing peers.

This hypothesis was confirmed under specific conditions. When the two groups were

compared on their Language and Emergent Literacy composite scores, the NH group showed

superior performance on language measures overall as compared to the CI group, while no group

differences were observed based on their emergent composite scores. However, when the groups

were compared on individual subtest scores, much clearer profiles of their similarities and

differences emerged.









Children with cochlear implants performed more poorly than children with typical

language development on the Language composite score, which is comprised of Basic Concepts,

Receptive Vocabulary, Parallel Sentence Production, and Listening Comprehension. The

language composite subtests that best differentiated children with cochlear implants from their

typical hearing peers were the ParallelPPP~~~~PPP~~~PPP Sentence Production and Listening Comprehension.

These findings are not surprising and are likely to be accounted for by weak phonological

processing skills. Parallel Sentence Production involves discrete auditory discrimination and

subsequent repetition of a parallel syntactic structure with novel semantic content. Listening

Comprehension requires the auditory processing retelling of orally presented passages. Further,

the simultaneous presentation of picture cards and oral story telling for the listening

comprehension tasks may have interfered with the CI group to fully utilize their lip-reading

skills. Thus, the two tasks that required discrete metaphonological discrimination, processing,

and memory differentiated the two groups. Conversely, performance on the Ba~sic Concepts and

Receptive Vocabulary subtests did not differentiate the two groups. This means that the CI group

was not dissimilar in performance when compared with the NH group across these two basic

language domains and supports the hypothesis that early cochlear implantation facilitates early

language development in preschoolers.

Within the group evaluated in this study, performance on measures of receptive language

was, on average, similar between the two groups. However, performance on measures of

expressive language was a much more differentiating modality, with the CI group performing

much more poorly than the NH group. As discussed above, the tasks used to measure expressive

language in the ALL require discrete phonological processing, which is an auditory task. These

results indicate that, while children with cochlear implants being educated in an oral setting are










keeping up with their peers on basic language concepts (e.g., vocabulary) that are not

phonologically taxing, they are still falling behind on tasks that require finer grain phonological

analyses. These findings indicate that these children are still displaying deficits in language tasks

requiring discrete auditory sensitivity despite their early implantation, and intense efforts should

be made to remediate this performance in this risk area.

While no significant group effect was observed for the Emergent Literacy composite,

comprised of the Rhyme Knowledge and Letter Knowledge tasks, the CI group showed different

skill levels on these two tasks. The CI group composite emergent literacy score was inflated by

higher than average Letter Knowledge scores in 6 of the 14 children (+ 1.5 SD). The higher

scores for Letter Knowledge are not surprising for two reasons. First, letter identification is

explicitly taught in preschools for normally hearing children as well as in centers for oral deaf

preschool education. Thus, letter knowledge among preschoolers should be well developed on

average, since it is a skill explicitly taught to these groups. Second, letter recognition is a largely

visual memory task, which is an area of relative strength for children who are deaf. These two

factors may contribute to the average or above average performance for letter knowledge for the

maj ority of the participants from the CI group.

On the other hand, a substantial portion of the CI group scored in the clinical range (-1.5

SD) on the Rhyme Knowledge subtest. Unlike Letter Knowledge, Rhyme Knowledge was an area

of relative weakness for the CI group. Phonological awareness is the underlying construct of

rhyme knowledge. As discussed previously, phonological sensitivity is critical to the

development of literacy (Wagner & Torgesen, 1987). According to the standards on the ALL

(Lombardino, Lieberman, and Brown, 2005), early skills that predict later reading change with

age. Rhyme knowledge is the strongest predictor of later reading achievement at 4 years of age,









whereas, letter knowledge is a better predictor of later reading skill at age 5. Because

phonological processing appears to be a relative weakness for this population, rhyming and other

tasks of phonological discrimination and sensitivity should be explicitly taught to preschoolers

who are deaf in order to secure a foundation for later reading development. We cannot assume

that because this population can identify and produce letters, they will become proficient readers.

If the reading development of children with cochlear implants is to progress along the same

course as their normally hearing peers, then emergent literacy skills should be acquired in the

same order. Therefore, children who are deaf should be explicitly instructed to phonological

awareness in conjunction with alphabetic acquisition.

Language and Emergent Literacy Relationships

It was also hypothesized that children with cochlear implants would demonstrate the same

relationship between spoken language and early literacy skills found in the normally hearing

group. While, surprisingly, a positive correlation was not observed from the control group of

normally hearing preschoolers, it is well documented in the literature (Foorman, Anthony, Seals,

& Mouzaki, 2002; Lonigan, Burgess, & Anthony, 2000). This lack of correlation may have

resulted from a relatively wide range of performance in the skills of the 14 normally developing

children between 49 and 58 months of age. Conversely, a relatively strong relationship between

language and literacy performance was found for the CI group that is more typical of normally

developing children. This finding of similar patterns of language and literacy development in the

CI group supports the hypotheses that the early auditory exposure derived from implantation

before the age of 27 months may contribute to a similar pattern of language and emergent

literacy development for deaf children as compared to normally hearing children, specifically

during the preschool years.










The performance of the CI group on the ALL subtests provides a clear profile of this

group's strengths and weaknesses that span across both language and emergent literacy skills.

The relative areas of strength for the CI group arise in basic syntactic and semantic interpretation

(e.g., Ba~sic Concepts), receptive vocabulary, and letter knowledge. All three of these skill areas

involve naming-type tasks that are quite concrete. In essence, letter knowledge is a visual

memory task, which is an expected area of superior performance for this population. The relative

areas of weakness noted for the CI group were in the areas of listening comprehension, parallel

sentence production, and rhyme knowledge. As with strengths, these areas of weakness are not

surprising. Tasks of rhyming require metaphonological knowledge, story retelling and listening

comprehension require higher level integration of auditorily presented information, and parallel

sentence requires discrete auditory processing and subsequent generation of a parallel syntactic

structure. These areas of weakness are more abstract and require a level of auditory processing,

manipulation, and memory that is difficult even for children implanted at such a young age.









LIST OF REFERENCES


Bishop, D.V.M. & Adams, C. (1990). A prospective study of the relationship between specific
language impairment, phonological disorders and reading retardation. Journal of Child
Psychology and Psychiatry and Allied Disciplines, 31, 1027-1050.

Catts, H.W. (1993). The relationship between speech-language impairments and reading
disabilities. Journal of Speech and Hearing Research, 36, 948-958.

Crain-Thoreson, C. & Dale, P.S. (1992). Do early talkers become early readers? Linguistic
precocity, preschool language, and emergent literacy. Developnzental Psychology, 28(3),
421-429.

Foorman, B.R., Anthony, J., Seals, L., & Mouzaki, A. (2002). Language development and
emergent literacy in preschool. Seminars in Pediatric Neurology, 9(3), 173-184.

Geers, A.E. (2003). Predictors of reading skill development in children with early cochlear
implantation. Ear & HM'arling. 24(1S), 60S-68S.

Geers, A., Nicholas, J., & Sedey, A. (2003). Language skills of children with early cochlear
implantation. Ear andHM aring. 24(Suppl.), 46S-58S.

Kyle, F.E. & Harris, M. (2006). Concurrent correlates and predictors of reading and spelling
achievement in deaf and hearing school children. Journal ofDeafStudies and Deaf
Education, 11(3), 273-288.

Lonigan, C.J., Burgess, S.R., & Anthony, J.L. (2000). Development of early literacy and early
reading skills in preschool children: Evidence from a latent-variable longitudinal study.
Developmental Psychology, 36(5), 596-613.

Moog, J.S. & Geers, A. (1999). Speech and language acquisition in young children after
cochlear implantation. Otolaryngologic Clinics of North America, 32, 1 127-1 141.

Nicholas, J.G. & Geers, A.E. (2006). Effects of early auditory experience on the spoken
language of deaf children at 3 years of age. EarEEEEEE~~~~~~~EEEEEE & HM'arling. 27(3), 286-298.

Nicholas, J.G. & Geers, A.E. (2007). Will they catch up? The role of age at cochlear
implantation in the spoken language development of children with severe to profound
hearing loss. Journal of Speech, Language, and Hearing Research, 50, 1048-1062.

Oliver, B.R., Dale, P.S., & Plomin, R. (2005). Psychological Science, 16(11), 861-865.

Perfetti, C.A. & Sandak, R. (2000). Reading optimally builds on spoken language: Implications
for deaf readers. Journal ofDeafStudies and DeafEducation, 5, 32-50.










Rvachew, S., Ohberg, A., Grawburg, M., & Heyding, J. (2003). Phonological awareness and
phonemic perception in 4-year-old children with delayed expressive phonology skills.
American Journal ofSpeech-Language Pathology, 12, 463-471.

Svirsky, M.A., Robbins, A.M., Kirk, KI., Pisoni, D.B., & Miyamoto, R.T. (2000). Language
development in profoundly deaf children with cochlear implants. Psychological Science,
11, 153-158.

Svirsky, M.A., Teoh, S.-W., & Neuberger, H. (2004). Development of language and speech
perception in congenitally, profoundly deaf children as a function of age at cochlear
implantation. Audiology and Neuro-Otology, 9, 224-233.

Traxler, C.B. (2000). The Stanford Achievement Test, ninth edition: National norming and
performance standards for deaf and hard-of-hearing students. Journal ofDeafStudies
and DeafEducation, 5(4), 337-348.

Unthank, D., Rajput, K., & Goswami, U. (2001). The effect of cochlear implantation on
phonological awareness skills of young deaf children. Eighth Symposium on Cochlear
Implants in Children, Los Angeles.

Wagner, R.K. & Torgesen, J.K. (1987). The nature of phonological processing and its causal
role in the acquisition of reading skills. Psychological Bulletin, 101, 192-212.

Whitehurst, G.J. & Lonigan, C.J. (1998). Child development and emergent literacy. Child
Development, 69, 848-872.









BIOGRAPHICAL SKETCH

Kameron Carden graduated summa cum laude with her Bachelor of Science in education

degree in communication sciences and disorders from the University of Georgia in August of

2005. She completed the requirements for the Master of Arts degree in speech-language

pathology from the University of Florida in May of 2008. Upon graduation, Kameron began a

position as a clinical fellow at the Nashville campus of the Veterans Administration Tennessee

Valley Healthcare System.





PAGE 1

1 LANGUAGE AND EMERGENT LITERACY IN PRESCHOOLERS WITH EARLY COCHLEAR IMPLANTATION By KAMERON CLARK CARDEN A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS UNIVERSITY OF FLORIDA 2008

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2 2008 Kameron Clark Carden

PAGE 3

3 To my sister, Caroline

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4 ACKNOWLEDGMENTS There are many people who have provided gui dance, support, and assistance to m e throughout the completion of my ma sters degree and thesis. I must first thank my committee members without whom this th esis would not have been created. Dr. Linda Lombardino has taught me so much over the past two years abou t reading development and disabilities. I would not have developed an interest in this area withou t her academic guida nce and support. Dr. Bonnie Johnson has been critical to my developm ent as a clinician and as a researcher. Her enthusiasm, encouragement, and support have co ntinually brightened my graduate experiences. She has helped me to become a researcher who looks at data through a clinical lens, and for that I will always be grateful. I could not have completed this study wit hout the help of Dr. Wayne King, Christine Gustus, and Jean Sachar Moog. Dr King graciously completed all st atistical analyses on the data for this study as well as assistance in decipheri ng what the data meant. He also created the beautiful figures displayed in the results sect ion of this thesis th ereby creating a visual description of the data we obtai ned. Christine Gustus and Jean Sachar Moog of the Moog Center for Deaf Education in St. Louis, MO facilitated the gathering of participants for this study as well as insight into oral deaf e ducation and its academic impact on preschoolers with cochlear implants. I thank you for both your academic guida nce and your friendship. I would also like to thank the directors and staff at the following school s who also allowed me to test their students: Childs Voice in Chicago, IL; Ohio Valley Voices in Cincinnati, OH; St. Joseph Institute in Indianapolis, IN. I would like to thank Dr. Kenneth Gerhardt and Dr. Scott Griffith s for their support and encouragement during my transition from audi ology to speech-language pathology. They never

PAGE 5

5 made me feel like a quitter, a nd they gave me a second chance. I would not be here today without them. Finally, I would like to thank my family for their eternal love and support. Specifically, I thank my mother, Edie, for always encouraging me to do more and to be be tter. I thank my sister, Caroline, for being my muse. And I thank my husband, Nathan, for putting up with my occasional crankiness throughout this long and arduous thesis process. His friendship and love make everything worth it.

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6 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 LIST OF FIGURES.........................................................................................................................8 ABSTRACT...................................................................................................................................10 CHAP TER 1 INTRODUCTION..................................................................................................................12 Emergent Literacy Skills....................................................................................................... .12 Language and Emergent Literacy........................................................................................... 12 Effects of Cochlear Implantation............................................................................................ 13 Literacy and Cochlear Implantation....................................................................................... 14 Limitations in Current Research.............................................................................................15 Purpose...................................................................................................................................16 Research Question 1........................................................................................................ 16 Research Question 2........................................................................................................ 17 2 METHODS.............................................................................................................................18 Participants.............................................................................................................................18 Cochlear Implant Group.................................................................................................. 18 Normally Hearing Participants........................................................................................ 18 Materials.................................................................................................................................19 Procedures..................................................................................................................... ..........20 Design.....................................................................................................................................20 3 RESULTS...............................................................................................................................22 Spoken Language and Emergent Literacy Skill Performance................................................ 22 Language and Emergent Literacy Correlations...................................................................... 24 4 DISCUSSION.........................................................................................................................31 Language and Emergent Literacy Skills................................................................................. 31 Language and Emergent Literacy Relationships....................................................................34 LIST OF REFERENCES...............................................................................................................36 BIOGRAPHICAL SKETCH.........................................................................................................38

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7 LIST OF TABLES Table page 2-1 Descriptive information for coch lear im plant participant group....................................... 21 3-1 Mean and standard deviations (SD) of Language and Em ergent Literacy subtest and composite standard scores for the cochlear implant (CI) and normally hearing (NH) groups.................................................................................................................................30

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8 LIST OF FIGURES Figure page 3-1 Comparison of raw scores between cochle ar im plant (CI) and normally hearing (NH) group for Emergent Literacy composite and subtests........................................................ 25 3-2 Comparison of raw scores between cochle ar im plant (CI) and normally hearing (NH) group for Language composite, combined Basic Concepts (BC) and Receptive Vocabulary (RV) subtests, and combined Parallel Sentence Production (PS) and Listening Comprehension (LC) subtests............................................................................ 26 3-3 Comparison of relationship between Em ergent Literacy composite score chronological age between cochlear impla nt (CI) and normally hearing (NH) groups..... 27 3-4 Comparison of relationship between La nguage and Em ergent Literacy composite scores between cochlear implant (C I) and normally hearing (NH) group......................... 28 3-5 Percentage of participants from the co chlear im plant group who scored 1.5 standard deviations or more below the standa rd mean across the six ALL subtests administered: Letter Knowledge (LK), Rhyme Knowledge (RK), Basic Concepts (BC), Receptive Vocabulary (RV), Parall el Sentence Production (PS), Listening Comprehension (LC)......................................................................................................... 29

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9 LIST OF ABBREVIATIONS CI Cochlear implant group NH Normally hearing group ALL Assessment of Language and Literacy BC Basic Concepts subtest RV Receptive Vocabulary subtest PS Parallel Sentence Production Subtest LC Listening Comprehension subtest LK Letter Knowledge subtest RK Rhyme Knowledge subtest

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10 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Arts LANGUAGE AND EMERGENT LITERACY IN PRESCHOOLERS WITH EARLY COCHLEAR IMPLANTATION By Kameron Clark Carden May 2008 Chair: Linda Lombardino Major: Communication Scie nces and Disorders Profoundly deaf children who receive cochlear implants at an early age have a better prognosis for developing appropria te oral language and, therefore, more proficient emergent literacy skills (Geers, 2003; Kyle & Harris, 2006). Since spoken language as well as emergent literacy skills have been documented to predict later reading proficiency in normal hearing fouryear-olds, the question arises as to how strongly spoken language a nd pre-literacy skills correlate in children with deafness at age four. The present study explores how spoken langua ge behaviors correlate with emergent literacy skills, specifically lett er knowledge and rhyme knowledge, in profoundly deaf four-yearolds with a cochlear implant (CI) as compar ed to their normal hearing (NH) peers. The Assessment of L iteracy and Language (ALL) was administered to 14 profoundly deaf cochlear implant users from four centers for oral deaf education betwee n the ages of 48 and 59 months. Their subtest and composite scores for emergent literacy and for language were compared to the composite scores of 14 normally hearing preschool ers with no identifiable risk of language disorder selected from the ALLs normative samp le. The groups were matched on gender, SES, grade, ethnicity, and region of the country.

PAGE 11

11 Results indicate that language and emergent literacy composite scores were highly correlated in children with early cochlear implantation. There wa s no significant group effect for emergent literacy; however, a si gnificant group effect for the language composite was found, with the participants from th e CI group performing more poorly than children with typical language. When the groups individual subtest scores were examined, it was observed that a substantial portion of the CI group scored in th e clinical range on the rhyme knowledge test (-1.5 SD), one of the two tests that comprise the emergent literacy composite. Their group composite emergent literacy score was inflated by higher than average lette r knowledge scores in 6 of the 14 children (+ 1.5 SD). Instructi onal implications for oral edu cation centers for the deaf are discussed.

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12 CHAPTER 1 INTRODUCTION Emergent Literacy Skills Traditionally, learning to read has not been a focus of attention until elem entary school. Intensive literacy training is not begun until firs t grade, so a child who has not been progressing at a steady rate toward reading fluency is not be detected as having re ading difficulties until second grade or later. Fortunatel y, the emergent literacy appro ach has developed an awareness that reading ability progresses along a con tinuum beginning long before children start kindergarten. The concept of emergent literacy has blurred the line between a preschooler who does not read and a first grader who does. Emerge nt literacy skills must be in place before learning to read can progress (L onigan, Burgess, & Anthony, 2000). Vast amounts of research have documented that pre-literacy sk ills such as phonological awareness and letter knowledge (Rvachew Ohberg, Grawburg, & Heyding, 2003; Lonigan, Burgess, & Anthony, 2000), as well as knowledge of print (Crain-Thore son & Dale, 1992) are strongly correlated with later reading. These skills appear to emerge around 4 years of age (Oliver, Dale, & Plomin, 2005; Crain-Thoreson & Dale, 1992). Whitehurst and Lonigan (1998) argue that three factors are associated with the preschoolers later ability to decode words, and thus learn to read: oral la nguage, phonological processing, and print knowledge. The relationship between oral language and emergent literacy skills in preschoolers is the focus of the present study. Language and Emergent Literacy The relationship between oral language and early predictors of reading ability has been well documented within the literature of our fi eld. More specifically, the relationship between oral language and phonological sensitivity, or the ability to mani pulate the sound structure of a

PAGE 13

13 language, exists in typically developing preschool-aged child ren (Foorman, Anthony, Seals, & Mouzaki, 2002; Lonigan, Burgess, & Anthony, 2000) Phonological sensitivity is critical to the development of literacy (Wagner & Torgesen, 1987) One method that researchers have used to document this relationship is to examine how la nguage deficits impact learning to read. Bishop and Adams (1990) investigated th e acquisition of literacy in 83 third graders who had been diagnosed with a speech or language impairment at age 4. The preschoolers with more global language deficits at an early age were more lik ely to have difficulty with both reading and spelling in third grade. Catts ( 1993) compared the reading achievem ent of three groups of second graders: children with a language impairment children with normal language but impaired phonological systems, and children with typi cally developing language and phonology. The results indicated that the reading skills of the language im paired group were significantly depressed, while the reading sk ills of the group with phonological deficits were within the normal range. Because the relationship between oral language and emergent literacy is so welldocumented, it seems intuitive that the development of pre-literacy skills, such as phonological awareness, letter knowledge, and knowledge of print, should be highly monitored in children with oral language delays and disorders. One to ol for documenting and comparing these skills is the Assessment of Language and Literacy (ALL), developed by Lo mbardino, Lieberman, and Brown, which identifies children from preschool to first grade who are at risk for reading difficulties due to weaknesses in one or more areas of language. Effects of Cochlear Implantation While the relationship between oral language and emergent literacy has been established in normal hearing preschoolers, this study attempts to determine whether the same relationship exists for children with deafness who receive cochl ear implants at an early age. Since the average deaf or hard of hearing student graduates from high school with a fourth grade reading level

PAGE 14

14 (Traxler, 2000), literacy is a ch ief educational concern with this population. According to Perfetti and Sandak (2000), the low literacy levels re ported among children with severe to profound deafness may be attributed to the gap between th eir oral language abilit ies and the demands of reading, which is a written system based upon the phonology of our language. It is important to discuss here how early co chlear implantation aff ects the oral language skills of profoundly deaf children, so that a hypothesis can be formed about how implantation may effect reading in a similar way. Geers, Nicholas, and Sedey (2003) evaluated the oral language of 8 and 9 year olds who had been implante d before the age of 5. More than half of the participants exhibited receptive and expressive language skills comparable to their normal hearing peers. The authors underscored that the or al education provided to these children played a key role in their well developed language sk ills. Similar findings show that receiving an implant by 2 years of age dramatically enhances both spoken language and language development (Svirsky, Teoh, & Neuberger, 2004; Ni cholas & Geers, 2006; Nicholas & Geers, 2007). Research also suggests that children who rece ive cochlear implants early show faster rates of language acquisition than children who are im planted at later ages (Svirsky, Robbins, Kirk, Pisoni, & Miyamoto, 2000). Literacy and Cochlear Implantation Because cochlear implants improve rate a nd quality of oral language acquisition in children, reading skills should also be positively affected. Most of the research in this area explores reading development in deaf children without cochlear im plants or examines the effects of cochlear implantation before the age of 5 on reading skills. Kyle a nd Harris (2006) compared 7 and 8 year old deaf children with age-matc hed peers on both language and literacy skills. Of the 29 deaf children, 7 had received cochlear implants. They found that age was the best predictor of reading ability in the control gr oup, while expressive vocabulary and speech-reading

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15 skills were the best predictors of reading abi lity in the deaf group. Upon further analysis, the researchers determined that the children with implants performed significantly worse on reading tasks than children with hearing aids and attributed this difference to the late implantation of the implant users. Studies specifically designed to explore the literacy skills of children with cochlear implants have produced similar results. Geers (2 003) found that out of 18 1 children implanted by the age of 5, over half scored w ithin average range for their read ing abilities when compared to normative data for hearing children. Unthank, Ra jput, and Goswami (2001) found that children who received an implant before 3 years of age had larger vocabularies and higher word reading scores than children im planted after the age of 5. Si milar findings were observed by Moog and Geers (1999) with children who had b een implanted between the ages of 2 and 9. Because all children in the study were educated in a private oral setting, the researchers postulated that oral education accelerated the participants literacy development. Limitations in Current Research Most stud ies that explore literacy in children w ith cochlear implants enroll participants that received their implants at 2 years of age or later (Geers, 2003; Moog & Geers, 1999; Unthank, Rajput, & Goswami, 2001). Today, however, many child ren are receiving implants as early as 12 months of age. A study has not been completed to address the emergent literacy skills of preschoolers participating in oral education that were implanted at or before 2 years of age. Because very young children can now be implanted at the 12 months of age, they have the opportunity to be exposed to oral language much earlier. Since oral language development improves with earlier implantation, it is expected that (a) impr ovement in the development of pre-literacy skills will occur as well and that, (b) emergent literacy skills in children with early

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16 implantation will develop around the same time th at they emerge in normal hearing children, approximately 4 years of age. Purpose The curren t study seeks to determine whether the same positive correlation between oral language and emergent literacy skills seen in 4year-old preschoolers wi ll exist in 4-year-old profoundly deaf children who receive d cochlear implants before th e age of 2 and are now being educated in an oral setting. Th e current study also seeks to expl ore the emergent literacy skills, specifically letter knowledge and rhyme knowle dge, of preschoolers with early cochlear implantation (CI) as compared to their nor mally hearing age-matched peers (NH). The Language and Emergent Literacy composites from the CI group are co mpared to composites of the NH control group to determine whethe r oral language and emergent l iteracy correlate in the same way for both groups and if differences exist betw een the composite scores of the groups. The current study seeks to determine if a select gr oup of preschoolers with early implantation are on track for reading skill development, as well as if that skill development can be predicted from oral language efficiency. Research Question 1 How do children with cochlear implants compare to their age-matched peers on their spoken language composite skills and their emer gent literacy composite skills as measured on the Assessment of Literacy and Language ? It was hypothesized that (1 ) children with cochlear implants will perform more poorly on spoken la nguage and early literacy measures than their age-matched peers that require discrete auditory discrimination, such as rhyme knowledge, and, (2) children with cochlear implants will perfor m similarly to their typically hearing peers on tasks that to not require disc rete auditory discrimination.

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17 Research Question 2 W ill similar correlations exist between the language and emergent literacy skills of preschoolers with early cochlear implantation when compared to their typically hearing peers? It was hypothesized that children with cochlear im plants will demonstr ate the same relation between spoken language and early literacy skill s that is found in the normally hearing group.

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18 CHAPTER 2 METHODS Participants Cochlear Implant Group Fourteen CI preschoolers participated in th e study. They were recruited from full day preschool program s at the following oral ed ucation centers: four participants from The Moog Center for Deaf Education in St. Louis, MO; tw o participants from Childs Voice in Chicago, IL; six participants from Ohio Valley Voices in Cincinnati, OH; and two participants from St. Joseph Institute in Indianapolis, IN. Selectio n criteria included that all CI participants (1) have an unaided severe to profound bilateral sensorineura l hearing loss, (2) have received a cochlear implant between the age of 12 and 30 months, (3 ) were between the ages of 48 months and 59 months, and (4) did not have a concomitant diso rder. Four additional preschoolers were tested but were excluded because three did not meet the criteria for age of implantation and one had a concomitant disorder. Table 2-1 provides descriptive information for the CI participant group. The participants ranged in age from 48 to 59 months (X=53.71; SD=4.12). The age at which the children were implanted ranged from 10 to 27 months (X=17.64; SD=5.87). Twelve participants were unilaterally implanted, while the remaining tw o were bilaterally implanted. The maternal education levels were available for 12 of the 14 participants. For those participants, the maternal education level ranged from 12 to 18 years. Five of the participants were females, and nine were males. Normally Hearing Participants Fourteen N H preschoolers with no identifiable risk of language diso rder were selected from the ALLs normative sample as matches for the experimental group. These typically

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19 developing control children were matched with the CI children on gender, maternal education level, grade, ethnicity, and region of the country. The 14 control preschoolers were between the ages of 49 and 58 months (X=51.73; SD=2.73). Materials Assessment of Language and Literacy (ALL) by Lom bardino, Lieberman, and Brown (2005) was administered to each child participati ng in the study. The ALL was used to evaluate the language development and emergent literacy skills of the 14 preschool participants. The following six subtests from the ALL were administered separately to each of the children from the CI group: Letter knowledge, Rhyme Knowledge, Basic Concepts, Receptive Vocabulary, Parallel Sentence Production, and Listening Comprehension These same data were available for all the control subjects from the normative samp le. Each of these tasks is described below. The Letter Knowledge subtest is comprised of three tasks. In Task 1, the participant points to letters on a stimulus page as they are named. In Task 2, he or she names letters as they are pointed to by the researcher. In Task 3, the participant writes letters that the researcher names. The Rhyme Knowledge subtest is comprised of four tasks. In Task 1, the child judges whether or not pairs of words rhyme. In Task 2, the particip ant identifies the one word out of a set that does not rhyme. In Task 3, he or she provides a word that rhymes with the stimulus word. In Task 4, the participant completes a sentence by providing a word that rhymes with a stimulus word within the sentence. The Letter Knowledge and Rhyme Knowledge subtests comprise the Emergent Literacy composite, because together they re present phonological sensitivity to sounds and print knowledge, two c onstructs that are nece ssary for later reading. The Basic Concepts subtest requires the participant to point a picture th at most closely represents the concept the researcher describes. The Receptive Vocabulary subtest allows the child to point to a picture that best resembles the word said by the researcher. For the Parallel

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20 Sentence Production subtest, he or she completes a phrase or sentence that matches the target structure of the sentence pr ovided by the researcher. The Listening Comprehension subtest involves two tasks. First, the par ticipant retells a story the researcher has told to him or her. Then, he or she answers questions about the story after it is re peated again. These subtests comprise the Language composite. Procedures The prim ary researcher traveled to the four following oral centers for deaf education in order to administer the ALL to study participants: The Moog Center for Deaf Education in St. Louis, MO; Childs Voice in Chicago, IL; Ohio Valley Voices in Cincinnati, OH; St. Joseph Institute in Indianapolis, IN. The primary research er administered the ALL in each schools resource room or library. Prior to conducting the language and literacy testing, the examiner received an audiogram containing aided and una ided pure tone thresholds, as well as speech perception thresholds, for each implanted child by his or her school. Each child was informed prior to initiation of testing th at he or she could abandon testi ng at any time and would not be penalized for doing so. The total testing time per child was approximately 30 to 45 minutes. The ALLs subtests were administered in the order of appearance within the stimulus book as follows: Letter Knowledge, Rhyme Knowledge, Basic Concepts, Receptive Vocabulary, Parallel Sentence Production, and Listening Comprehension. Design This study is a between-group, 2 by 2 desi gn. The two independent variables are the experimental (CI) and the normally hearing (NH) groups. The two dependent variables are the Emergent Literacy and the Language composite scores from the ALL. The composite scores between groups were compared to determine if similar relationships between language and emergent literacy are found for the NH and CI groups.

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21 Table 2-1. Descriptive information fo r cochlear implant participant group Age (mo) Age at Implantation (mo) Sex Maternal Education Race School Implantation 59 27 F College degree WhiteChild's Voice Unilateral 57 21 M College degree WhiteChild's Voice Unilateral 48 12 M Not reported White Ohio Valley Voices Unilateral 56 27 F College degree White Ohio Valley Voices Unilateral 51 17 M Not reported White Ohio Valley Voices Unilateral 57 16 F Some college Asian Ohio Valley Voices Unilateral 56 12 F Not reported White Ohio Valley Voices Unilateral 50 14 F Masters degree White Ohio Valley Voices Unilateral 51 27 M Some college WhiteSt. Josephs Unilateral 48 18 M College degree WhiteSt. Josephs Unilateral 57 10 M College degree WhiteMoog Center Bilateral 58 12 M high school WhiteMoog Center Unilateral 56 18 M Masters degree WhiteMoog Center Unilateral 48 16 M Masters degree WhiteMoog Center Bilateral

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22 CHAPTER 3 RESULTS Spoken Language and Emergent Literacy Skill Performance Descriptive statistics were used to ad dre ss the question how of ch ildren with cochlear implants compare to their age-matched peers on the language skills and emergent literacy skills evaluated by the ALL. The means and standard deviations for individual subtests language and emergent literacy and composite scores for language and emergent literacy tests were calculated and compared between groups. The Language composite standard scores ranged from 44 to 94 (X=69.07, SD=15.98) for the CI group and from 80 to 112 (X=94.07; SD=8.83) for the NH group. The Emergent Literacy composite standard scores ranged from 57 to 116 (X=92.43; SD=20.82) for the CI group and from 69 to 108 (X=90.79; SD=13.50) for the NH group. As indicated by the standard deviations, a wide range of variability in composite scor es was observed for both language and emergent literacy skills in the CI group. Box plots, as seen in Figures 3-1 and 3-2, were used to show differences between the two groups on composite scores, as well as how the subtest scores comprising those composites differ between groups Table 3-1 provides the means and standard deviations of Language and Emergent Literacy subtest and composite st andard scores for the (CI) and (NH) groups. Descriptively, it is also importa nt to point out that the propor tion of CI group participants with a score of 1.5 SD or more below the mean was > 36% for 5 of the 6 subtests. This means that at least 36% of the participants are perf orming significantly below age expectations for every task except Letter Knowledge Please refer to Figure 3-5 for th e percentage of participants from the cochlear implant group who scored 1.5 sta ndard deviations or more below the standard mean across the six ALL subtests administered.

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23 An analysis of variance (ANOVA) was used to compare performance between groups on the Language composite and Emergent Literacy composite scores in an effort to evaluate the effects of group, age, gender, a nd group/age interactions. For the Language composite, a significant effect for group was discovered (F (1,23) = 24.8, p < 0.001) in which the NH group performed better on language task s as a whole than the CI group. A significant effect for age was also present (F (1,23) = 12.9, p < 0.001), so that the older participants achieved higher language composite scores despite group. No significant e ffect for gender or group/age interaction was present. For the Emergent Literacy composite, only a significant effect for age was observed (F (1,23) = 20.73, p < 0.001), so that as the participants got older, their performance on tasks of emergent literacy improved despite group. In partic ular, this trend between an increase in age and improvement in performance was stronger for the CI group. Refer to Figure 3-3 for a comparison of the relationship between emergent literacy skills and age across the two groups. No significant effect was found for group, gender, or group/age interaction for the Emergent Literacy composite. Although no significant group effect for the emergent literacy composite was observed, a substantial portion of the CI gr oup scored in the clinic al range (-1.5 SD) on the emergent literacy subtest of Rhyme Knowledge. The CI group composite emergent literacy score was inflated by the subjects higher than average Letter Knowledge scores for 6 of the 14 children (+ 1.5 SD). Differences between groups across individual su btests were examined. When scores were converted to scaled scores, a significant effect for group was observed for five of the six subtests. In order maintain a conservative approach to da ta analyses, independent t-tests were performed

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24 at a significance level of 0.05 using the Bonfer oni correction (p < 0.008) to account for the six variables being analyzed. Several significant differences were observed when the subtes t scores of the two groups were compared. The NH groups performed better than the CI for Rhyme Knowledge (t = 2.96 (26), P = 0.006), Basic Concepts (t = 3.13 (26), p = 0.004), Receptive Vocabulary (t = 3.2 (26), p = 0.003), Listening Comprehension (t = 5.38 (26), p < 0.001), and Parallel Sentence Production (t = 4.56 (26), p < 0.001). It should be noted that if the p-value had not been adjusted, a significant group effect would also have been observed for Letter Knowledge, with the CI group performing better than the NH group. Language and Emergent Literacy Correlations Descriptive statistics were used to ad dress the question of whether a similar correlation exists between the language and emergent literac y skills of preschoolers from the CI group when compared to their NH peers. Language and emergent literacy are highly correlated among the CI group (0.81, p<0.001). However, language and emerge nt literacy were not correlated among the NH group in this study. Please refe r to Figure 3-4 for a comparison of the relationship between language and emergent literacy skills between the CI and NH groups.

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25 Figure 3-1. Comparison of raw scores between cochlear implant (CI) and normally hearing (NH) group for Emergent Literacy composite and subtests

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26 Figure 3-2. Comparison of raw scores between cochlear implant (CI) and normally hearing (NH) group for Language composite, combined Basic Concepts (BC) and Receptive Vocabulary (RV) subtests, and combined Parallel Sentence Production (PS) and Listening Comprehension (LC) subtests

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27 Figure 3-3. Comparison of re lationship between Emergent Literacy composite score chronological age between cochlear impla nt (CI) and normally hearing (NH) groups

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28 Figure 3-4. Comparison of relati onship between Language and Emergent Literacy composite scores between cochlear implant (CI) and normally hearing (NH) group

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29 0% 20% 40% 60% 80% 100% LK RK BC RVPSLC Figure 3-5. Percentage of partic ipants from the cochlear implant group who scored 1.5 standard deviations or more below the standa rd mean across the six ALL subtests administered: Letter Knowledge (LK), Rhyme Knowledge (RK), Basic Concepts (BC), Receptive Vocabulary (RV), Parall el Sentence Production (PS), Listening Comprehension (LC)

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30 Table 3-1. Mean and standard de viations (SD) of Language and Emergent Literacy subtest and composite standard scores for the cochlear implant (CI) and normally hearing (NH) groups CI group NH group Mean SD Mean SD Emergent Literacy Composite 92.43 20.82 90.79 13.50 Letter Knowledge 11.64 5.02 8.50 2.65 Rhyme Knowledge 6.50 2.44 8.93 1.86 Language Composite 69.07 15.98 94.07 8.83 Receptive Vocabulary 5.36 2.31 8.43 2.74 Basic Concepts 5.79 3.31 9.36 2.68 Parallel Sentence Production 5.57 2.85 9.64 1.74 Listening Comprehension 3.64 2.37 8.57 2.47

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31 CHAPTER 4 DISCUSSION This study was designed to determ ine whether the same positive correlation between oral language and emergent literacy skills seen in 4-year-old preschoolers would exist in 4-year old profoundly deaf children who receive d cochlear implants before th e age of 2 and were now being educated in an oral setting. The study also sought to explor e the emergent literacy skills, specifically letter knowledge and rhyme knowledge, of a CI group in comparison to a (NH) group. The Language and Emergent Literacy composites from the CI group were compared to composites of the NH control group to determine whether oral language and emergent literacy correlate in the same way for both groups and if differences exist between the composite scores of the groups. Individual subtest sc ores, specifically those related to emergent literacy, were also compared between groups. Language and Emergent Literacy Skills It was hypothesized that children with coch lear implants would perform more poorly than age-matched peers on spoken language and early literacy measures that required discrete auditory discrimination, such as rhyme knowle dge. However, on tasks that did not require discrete auditory discrimination, it was expected that children with co chlear implants would perform similarly to their typically hearing peers. This hypothesis was confirmed under specific conditions. When the two groups were compared on their Language and Emergent Literacy composite scores, the NH group showed superior performance on language measures overa ll as compared to the CI group, while no group differences were observed based on their emergent composite scores. However, when the groups were compared on individual subtest scores, much clearer profiles of their similarities and differences emerged.

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32 Children with cochlear implants performed more poorly than ch ildren with typical language development on the Language composite score, which is comprised of Basic Concepts, Receptive Vocabulary Parallel Sentence Production, and Listening Comprehension. The language composite subtests that best differentiated ch ildren with cochlear implants from their typical hearing peers were the Parallel Sentence Production and Listening Comprehension. These findings are not surpri sing and are likely to be accounted for by weak phonological processing skills. Parallel Sentence Production involves discrete aud itory discrimination and subsequent repetition of a pa rallel syntactic structure with novel semantic content. Listening Comprehension requires the auditory processing retelli ng of orally presented passages. Further, the simultaneous presentation of picture card s and oral story tell ing for the listening comprehension tasks may have interfered with the CI group to fully utilize their lip-reading skills. Thus, the two tasks that required discrete meta phonological discrimination, processing, and memory differentiated the two groups. Conversely, performance on the Basic Concepts and Receptive Vocabulary subtests did not differentiate the tw o groups. This means that the CI group was not dissimilar in performance when compar ed with the NH group across these two basic language domains and supports the hypothesis that early cochlear implantation facilitates early language development in preschoolers. Within the group evaluated in this study, pe rformance on measures of receptive language was, on average, similar between the two gr oups. However, performance on measures of expressive language was a much more differen tiating modality, with the CI group performing much more poorly than the NH group. As discussed above, the tasks used to measure expressive language in the ALL require disc rete phonological processing, which is an auditory task. These results indicate that, while children with cochlear implants being educated in an oral setting are

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33 keeping up with their peers on basic language concepts (e.g., vocabul ary) that are not phonologically taxing, they are still falling behind on tasks that require finer grain phonological analyses. These findings indicate that these childre n are still displaying defi cits in language tasks requiring discrete auditory sensitivity despite th eir early implantation, a nd intense efforts should be made to remediate this performance in this risk area. While no significant group effect was obser ved for the Emergent Literacy composite, comprised of the Rhyme Knowledge and Letter Knowledge tasks, the CI group showed different skill levels on these two tasks. The CI group composite emergent literacy score was inflated by higher than average Letter Knowledge scores in 6 of the 14 child ren (+ 1.5 SD). The higher scores for Letter Knowledge are not surprising for two reasons. First, letter identification is explicitly taught in preschools for normally hearing children as we ll as in centers for oral deaf preschool education. Thus, letter knowledge among preschoolers should be well developed on average, since it is a sk ill explicitly taught to these groups. Second, letter recognition is a largely visual memory task, which is an area of relati ve strength for children who are deaf. These two factors may contribute to the av erage or above average performa nce for letter knowledge for the majority of the participants from the CI group. On the other hand, a substantial portion of the CI group scored in the clinical range (-1.5 SD) on the Rhyme Knowledge subtest. Unlike Letter Knowledge, Rhyme Knowledge was an area of relative weakness for the CI group. Phonological awareness is the underlying construct of rhyme knowledge. As discussed previously, phon ological sensitivity is critical to the development of literacy (Wagner & Torgesen, 1987). According to the standards on the ALL (Lombardino, Lieberman, and Brown, 2005), early skil ls that predict later reading change with age. Rhyme knowledge is the stronge st predictor of late r reading achievement at 4 years of age,

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34 whereas, letter knowledge is a better predictor of later reading skill at age 5. Because phonological processing appears to be a relative weakness for th is population, rhyming and other tasks of phonological discrimination and sensitivity should be explicitly taught to preschoolers who are deaf in order to secure a foundation fo r later reading development. We cannot assume that because this population can id entify and produce letters, they will become proficient readers. If the reading developm ent of children with co chlear implants is to progress along the same course as their normally hearing peers, then em ergent literacy skills shou ld be acquired in the same order. Therefore, children who are deaf should be explicitly instructed to phonological awareness in conjunction with alphabetic acquisition. Language and Emergent Literacy Relationships It was also hypothesized that children with cochlear im plants would demonstrate the same relationship between spoken language and early literacy skills found in the normally hearing group. While, surprisingly, a posi tive correlation was not observe d from the control group of normally hearing preschoolers, it is well documented in the lit erature (Foorman, Anthony, Seals, & Mouzaki, 2002; Lonigan, Burgess, & Anthony, 2000). This lack of correlation may have resulted from a relatively wide range of performance in the skills of the 14 normally developing children between 49 and 58 months of age. Conver sely, a relatively stro ng relationship between language and literacy performance was found for the CI group that is more typical of normally developing children. This finding of similar patterns of language and liter acy development in the CI group supports the hypotheses th at the early auditory exposu re derived from implantation before the age of 27 months may contribute to a similar pattern of language and emergent literacy development for deaf children as compar ed to normally hearing children, specifically during the preschool years.

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35 The performance of the CI group on the ALL s ubtests provides a clear profile of this groups strengths and weaknesses th at span across both language a nd emergent literacy skills. The relative areas of stre ngth for the CI group arise in basic s yntactic and semantic interpretation (e.g., Basic Concepts ), receptive vocabulary, and letter know ledge. All three of these skill areas involve naming-type tasks that are quite concre te. In essence, letter knowledge is a visual memory task, which is an expected area of supe rior performance for th is population. The relative areas of weakness noted for the CI group were in the areas of listening comprehension, parallel sentence production, and rhyme kno wledge. As with strengths, these areas of weakness are not surprising. Tasks of rhyming require metaphonologi cal knowledge, story retelling and listening comprehension require higher level integrations of auditorily presented information, and parallel sentence requires discrete auditory processing an d subsequent generation of a parallel syntactic structure. These areas of weakness are more abst ract and require a level of auditory processing, manipulation, and memory that is difficult even for children implanted at such a young age.

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36 LIST OF REFERENCES Bishop, D.V.M. & Adams, C. (1990). A prospectiv e study of the relations hip between specific language impairm ent, phonological diso rders and reading retardation. Journal of Child Psychology and Psychiatry and Allied Disciplines, 31 1027-1050. Catts, H.W. (1993). The relationship between speech-language impairments and reading disabilities. Journal of Speech and Hearing Research, 36, 948-958. Crain-Thoreson, C. & Dale, P.S. (1992). Do early talkers beco me early readers? Linguistic precocity, preschool language, and emergent literacy. Developmental Psychology, 28 (3), 421-429. Foorman, B.R., Anthony, J., Seals, L., & Mouzaki, A. (2002). Language development and emergent literacy in preschool. Seminars in Pediatric Neurology, 9 (3), 173-184. Geers, A.E. (2003). Predictors of reading skill devel opment in children with early cochlear implantation. Ear & Hearing, 24 (1S), 60S-68S. Geers, A., Nicholas, J., & Sedey, A. (2003). Language skills of ch ildren with early cochlear implantation. Ear and Hearing, 24(Suppl.), 46S-58S. Kyle, F.E. & Harris, M. (2006). Concurrent correlates and pr edictors of reading and spelling achievement in deaf and hearing school children. Journal of Deaf Studies and Deaf Education, 11 (3), 273-288. Lonigan, C.J., Burgess, S.R., & Anthony, J.L. (2000). Development of early literacy and early reading skills in preschool children: Evid ence from a latent-variable longitudinal study. Developmental Psychology, 36 (5), 596-613. Moog, J.S. & Geers, A. (1999). Speech and language acquisition in young children after cochlear implantation. Otolaryngologic Clinics of North America, 32 1127-1141. Nicholas, J.G. & Geers, A.E. (2006). Effects of early audito ry experience on the spoken language of deaf childre n at 3 years of age. Ear & Hearing, 27 (3), 286-298. Nicholas, J.G. & Geers, A.E. (2007). Will they catch up? The role of age at cochlear implantation in the spoken language devel opment of children with severe to profound hearing loss. Journal of Speech, Language, and Hearing Research, 50 1048-1062. Oliver, B.R., Dale, P.S., & Plomin, R. (2005). Psychological Science, 16 (11), 861-865. Perfetti, C.A. & Sandak, R. (2000). Reading optimally builds on spoken language: Implications for deaf readers. Journal of Deaf Studie s and Deaf Education, 5 32-50.

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37 Rvachew, S., Ohberg, A., Grawburg, M., & Heyding, J. (2003). Phonological awareness and phonemic perception in 4-year-old children with delayed expressive phonology skills. American Journal of Speech -Language Pathology, 12 463-471. Svirsky, M.A., Robbins, A.M., Kirk, K.I., Pisoni, D.B., & Miyamoto, R.T. (2000). Language development in profoundly deaf ch ildren with cochlear implants. Psychological Science, 11, 153-158. Svirsky, M.A., Teoh, S.-W., & Neuberger, H. (2004). Development of language and speech perception in congenitally, profoundly deaf children as a function of age at cochlear implantation. Audiology and Neuro-Otology, 9 224-233. Traxler, C.B. (2000). The Stanford Achievement Test, ninth edition: National norming and performance standards for deaf and hard-of-hearing students. Journal of Deaf Studies and Deaf Education, 5 (4), 337-348. Unthank, D., Rajput, K., & Goswami, U. (2001). The effect of cochlear implantation on phonological awareness skills of young deaf children. Eighth Symposium on Cochlear Implants in Children, Los Angeles. Wagner, R.K. & Torgesen, J.K. (1987). The nature of phonologica l processing and its causal role in the acquisition of reading skills. Psychological Bulletin, 101 192-212. Whitehurst, G.J. & Lonigan, C.J. (1998). Child development and emergent literacy. Child Development, 69 848-872.

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38 BIOGRAPHICAL SKETCH Ka meron Carden graduated summa cum laude w ith her Bachelor of Science in education degree in communication sc iences and disorders from the Univ ersity of Georgia in August of 2005. She completed the requirements for the Ma ster of Arts degree in speech-language pathology from the University of Florida in May of 2008. Upon graduati on, Kameron began a position as a clinical fellow at the Nashville campus of the Veterans Administration Tennessee Valley Healthcare System.


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