Lindsey Edwards*Foluso Thomas§

Kaukab Rajput*

*Cochlear Implant Department, GreatOrmond Street Hospital for Children,London, UK§Audiology Department, East KentHospitals University NHS Trust,Canterbury, UK

Key WordsCochlear implant

Paediatric

Speech perception

Psycho-social/emotional

AbbreviationsChIP: Children’s implant profile

E2L: English as a second language

GOSHChIP: Great Ormond Street

Hospital ChIP

MJWL: Manchester junior word list

MPT: Manchester picture test

SIR: Speech intelligibility rating

Original Article

International Journal of Audiology 2009; 48:554�560

Use of a revised children’s implant profile

(GOSHChIP) in candidacy for paediatric

cochlear implantation and in predicting

outcome

AbstractThe aims of this study were to investigate statistically theway a revised version of the children’s implant profile(GOSHChIP) is used to inform candidacy decisions andexplore its utility in predicting outcomes in the first threeyears of implant use. A retrospective case series analysisdesign was employed. Data were collated for 127 childrenwith a mean age of 4.7 years at implantation. Concerns ina number of areas of the child’s pre-implant functioningas rated on the GOSHChIP (spoken or manual commu-nication skills, cognitive abilities, family structure andsupport, and use of hearing aids) were associated withspeech perception and intelligibility outcomes followingimplantation. In terms of non-verbal cognitive abilities,the score on tests of fluid reasoning skills (sequencing),that contributes to the cognitive factor on the GOSH-ChIP, was found to significantly predict speech percep-tion and speech intelligibility post implant. TheGOSHChIP is a useful tool in making paediatric cochlearimplant candidacy decisions, and in forming a guide forcounselling parents about the potential benefit their childmay receive from an implant.

SumarioLos objetivos de este estudio fueron investigar estadısti-camente la forma en la que la version revisada del perfilpara implantes en ninos (GOSHChIP) es utilizada parainformar las decisiones sobre la candidatura y paraexplorar su utilidad en predecir los resultados de losprimeros tres anos de uso del implante. Se empleo undiseno de analisis serial retrospectivo de casos. Secolectaron datos de 127 ninos con una media de edadde 4.7 anos al momento de ser implantados. Inquietudessobre diferentes areas de los ninos antes del implante(habilidades de comunicacion manual o hablada, habili-dades cognitivas, estructura y apoyo familiar y uso deauxiliares auditivos), como se relatan en el GOSHChIP,fueron asociadas con los resultados de la percepcion y lainteligibilidad del lenguaje despues del implante. Enterminos de las habilidades cognitivas no-verbales, lapuntuacion en una prueba de razonamiento fluido(secuenciacion) que contribuye al factor cognitivo en elGOSHChIP, se encontro que predice significativamentela percepcion del lenguaje y la inteligibilidad del lenguajepost-implante. EL GOSHChIP es una herramienta utilpara tomar decisiones sobre la candidatura al implantecoclear en ninos y para formar una guıa para elasesoramiento de los padres sobre el beneficio potencialque su hijo podrıa recibir de un implante.

The children’s implant profile (ChIP) was developed by Hellman

and colleagues (1991) and has been widely adopted by paediatric

cochlear implant programmes as a tool to guide candidacy

decisions. In its original form it had 11 factors, including for

example chronological age, multiple handicap, functional hear-

ing, and family structure and support, each of which were rated

as being of ‘no concern’, ‘mild-moderate concern’, or ‘great

concern’ for a particular child and their family. The profile is not

scored, and therefore there is no cutoff score beyond which the

child is considered ‘unsuitable’; rather, the profile is used to

highlight areas that are likely to result in the benefit from a

cochlear implant being compromised or less than optimal.

In the 16 years since the ChIP was first conceived, the field of

paediatric cochlear implantation has changed dramatically, with

advances in technology and a greater understanding of the

variables associated with better speech and language outcomes.

In particular, there is now a substantial body of evidence

indicating that the younger the child is when they receive the

implant, the better the outcome (e.g. Nicholas & Geers, 2007;

Tait et al, 2007; Dettman et al, 2007). As a result, candidacy

criteria have also evolved, most clearly seen in the reduction in

the age limit for the procedure, aided by the newborn hearing

screening programmes in many countries. Equally, ‘older’

congenitally deaf children (i.e. aged around 5 to 7 years) who

would previously have been offered a cochlear implant may now

be thought unlikely to derive significant benefit from an implant

in terms of spoken language development, and therefore not be

considered an ideal candidate. Also, notably, children with

complex needs including significant physical, medical, cognitive,

and developmental problems are now far more likely to be

implanted than previously, despite the sometimes limited bene-

fits (Edwards, 2007; Edwards et al, 2006).

Since its first publication, the ChIP has been modified both in

terms of the factors included in the profile, and the criteria used

to determine the ratings of concern for the factors. A limited

number of studies have presented data relating to the ChIP and

its utility in identifying those children most likely to benefit from

a cochlear implant. The first, that of Daya et al (1999), found

that when the ratings on the ChIP factors were assigned scores,

the total score derived from the profile predicted improvements

in speech perception outcomes, with one factor, duration of

deafness, accounting for 24% of the variance. More recently,

ISSN 1499-2027 print/ISSN 1708-8186 onlineDOI: 10.1080/14992020902894533# 2009 British Society of Audiology, InternationalSociety of Audiology, and Nordic Audiological Society

Received:September 16, 2008Accepted:March 12, 2009

Lindsey EdwardsCochlear Implant Department, Great Ormond Street Hospital for Children, GreatOrmond Street, London, WC1N 3JH, UK.E-mail: Edwarl@gosh.nhs.uk

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Nikolopoulos, Gibbin & Dyar (2004) described their modifica-

tion of the ChIP (the Nottingham children’s implant profile;

NChIP) and its use in informing candidature in 200 children. In

a second study of the NChIP, Nikolopoulos Gibbin & Dyar

(2004) examined its predictive value in the outcome of implanta-

tion over a four-year period in 51 children with a profound

hearing loss. They found that concerns about the child’s learning

style (ability to cope with change, novelty or ambiguity,

engagement in adult-directed activities, locus of control, and

temperament in learning situation) was the most consistent

predictor of speech perception outcomes three and four years

after implantation, with duration of deafness, age at implanta-

tion, and family structure and support also contributing

significantly to the amount of variance explained, which ranged

between 29 and 42% across the different time intervals and

outcome measures.

The cochlear implant team at Great Ormond Street Hospital

has used the ChIP, or a version of it, since the programme’s

inception in 1992. In 2003 we published data from the first 147

children who had been assessed for implantation, examining the

consistency with which the ChIP (with one additional factor)

was being used to determine candidacy. Ratings for each factor

were assigned scores such that ‘no concern’ was scored 0, ‘mild-

moderate’ concern 1, and ‘great concern’ 2. It was found that the

total score for the profile was highly predictive of the decision to

implant, and five of the individual factors together significantly

predicted the decision, accounting for 52% of the variance.

Concern about the child’s speech and language abilities was the

strongest single predictor of whether the child was considered a

suitable implant candidate. Similarly in terms of outcomes, the

speech and language ability factor was the most consistent

predictor of speech perception and speech production outcomes.

Following the study, the ChIP underwent significant modifica-

tion increasing the number of factors to 19. To distinguish it

from the original ChIP, we have named it the Great Ormond

Street Hospital ChIP (GOSHChIP) and it is presented here with

kind permission of the ChIP’s authors.

The revisions to the ChIP were made on the basis of the

clinical experience of the implant team professionals and their

observation of factors likely to be important in influencing

outcomes, along with the need to clarify some of the factors and

make them more specific. Thus the following changes were

made:

1. ‘Chronological age’ became ‘chronological age for pre-

lingual hearing loss’.

2. ‘Duration of deafness’ became ‘duration of deafness for

post-lingual, progressive, and acquired hearing loss’.

3. ‘Medical/radiological’ became two separate factors, with

‘medical’ encompassing multiple handicap.

4. The ‘functional hearing’ factor was defined as specifically

related to the consistency between the child’s aided hearing

levels and their use of that hearing to respond to environ-

mental sounds and develop spoken language skills.

5. ‘Audiological opinion’ was added, to reflect criteria relating

to aided and unaided hearing thresholds and speech

discrimination scores.

6. ‘Use of hearing aids’ was added, reflecting the consistency

with which the child used their conventional hearing aids.

7. ‘Multiple handicap’ was removed and replaced by ‘cognitive/

non-verbal abilities’.

8. ‘Speech and language abilities’ was separated into two

factors: ‘communication skills: spoken/oral’, and ‘commu-

nication skills: manual/sign’. In both cases, the rating is

based on the degree of progress in each communication

mode in light of exposure (duration and extent), and residual

aided hearing levels.

9. ‘Behaviour’ was added, and related to the appropriateness of

the child’s behaviour for their age, behaviour problems, and

the appropriateness and consistency of parents’ behaviour

management strategies.

10. ‘Availability of support services’ was separated into two

factors: ‘availability of teacher of the deaf services’, and

‘availability of speech and language therapy services’.

11. ‘Record of attendance’ was added. This provides an indica-

tion of the family’s commitment to the process of implanta-

tion, through a measure of the number of missed

appointments.

One of the most potentially significant changes to the profile

was the inclusion of a factor specifically looking at the child’s

cognitive abilities or global development, as distinct from their

learning style. There were two main reasons for this. Firstly,

there is increasing evidence that cognitive factors play an impor-

tant role in the development of speech and language skills after

cochlear implantation, including overall cognitive ability and

specific cognitive functions such as attention and memory (e.g.

Fagan et al, 2007; Horn et al, 2005; Horn et al, 2006; Horn et al,

2007; Pisoni & Cleary, 2003). Secondly, on our cochlear implant

programme, the non-verbal cognitive ability or global develop-

ment (depending on the age of the child), of all children is

routinely assessed as part of the assessment protocol for

implantation. Therefore, it is possible to examine the relation-

ship between cognitive functioning and the candidacy decision,

as well as between cognitive functioning and outcome.

Thus this study has four aims:

1. To determine whether the GOSHChIP is consistent in

identifying which children are considered likely to benefit

from a cochlear implant.

2. To examine the predictive value of the individual GOSH-

ChIP factors in the candidacy decision.

3. To see whether concerns identified on the GOSHChIP are

related to speech perception and speech production out-

comes.

4. To examine the relationship between pre-implant non-verbal

cognitive abilities and speech perception and production

outcomes.

Method

DesignThe methodology used in this study is essentially the same as

that of our earlier study (Edwards, 2003). A retrospective case

series design was employed. Data were collated from the case

records of all the children referred to our cochlear implant

programme during the period March 1999 to February 2004, who

Use of a revised children’s implant profile(GOSHChIP) in candidacy for paediatriccochlear implantation and in predictingoutcome

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underwent the full assessment for a cochlear implant (i.e. medical,

radiological, audiological, psychological, speech and language,

and educational assessments). As previously, information was

recorded regarding the child’s hearing loss*duration of deafness

prior to implantation, cause of deafness, and mean aided

thresholds; (the age at which the decision to implant was taken,

and the age at which those children who received an implant had

the procedure performed).

The ratings on the GOSHChIP were recorded, such that the

categories ‘no concern’, ‘mild to moderate concern’ and ‘great

concern’ were given scores of 0, 1, and 2 respectively. Note that

these ratings are based on defined criteria, which are available on

request. Where a factor was considered not applicable for a

particular child (for example where the childwas tooyoung to be in

any form of educational setting, the factor ‘educational environ-

ment’ would be rated not applicable), a score of 0 was also given.

This gives a possible range of scores on the GOSHChIP of 0�57.

Speech perception and production outcomes were also recorded

from pre-implant assessment and yearly reviews of progress at one,

two, and three years post implantation.

Finally, in contrast to the earlier study, the results of the non-

verbal cognitive assessment of the children aged two years and

older were also collated.

SubjectsData were available for 127 children, 88.2% of whom were two

years or older at the time of assessment of candidacy. All

children were implanted unilaterally, and only two children did

not receive a full insertion of electrodes. Table 1 summarizes the

demographic and other characteristics of the sample.

Measures

SPEECH PERCEPTION

A number of tests of speech perception of increasing difficulty

are used to monitor progress. Given the age range of the children

pre-implant, and their prior speech and language skills, no one

test is appropriate for all children, or covers the range of

attainments over the first three years after implantation. There-

fore three measures were used in the analyses*the E2L (Bellman

et al, 1996), the Manchester picture test (MPT; Hickson, 1987)

and the Manchester junior word lists (MJWL; Watson, 1957).

The first two are closed-set tests requiring the child to chose a

toy or point to a picture of an object in response to a single live

voice presentation. The third is an open-set test comprising 10

monosyllabic words, again presented by a live voice. More

comprehensive details of these tests are given in Edwards (2003).

SPEECH INTELLIGIBILITY

Speech intelligibility ratings (SIRs) were made by speech and

language therapists with specialist qualifications in working with

children with hearing losses, on a six point scale, with demon-

strated reliability (Parker & Irlam, 1995; Dyar, 1994; Allen et al,

2001). Definitions of the ratings are presented in Table 2.

NON-VERBAL COGNITIVE ABILITY

The Leiter international performance scale-revised (LIPS-R;

Roid and Miller 1997) was used to assess the non-verbal

intellectual ability of those children within the age range of the

test (2.0 to 20.92 years), as part of the assessment of candidacy.

The LIPS-R comprises two major batteries of subtests: visuali-

zation & reasoning (V-R), and memory & attention (M-A). A

non-verbal intelligence quotient (IQ) can be derived from the

scores on six subtests from the V-R battery, as well as two

composite scores, reflecting different cognitive abilities: (1) fluid

reasoning (FR), and (2) fundamental visualization (FV). These

two composite scores are used in the statistical analyses since

previous research has suggested that hearing-impaired children

may have poorer fluid reasoning abilities compared with the

more straightforward visualisation skills. In terms of non-verbal

memory and attention skills, two scores were derived from the

battery subtests. The first, the memory screen, comprises scores

from two subtests, assessing immediate recall of paired stimuli

(e.g. mushroom � dog, hat � mittens) and visual memory span.

The other score used in this study is a measure of visual

attention, assessed using a cancellation task in which the child

has to locate and cross out specific stimuli (e.g. circles), among

Table 1. Characteristics of the 127 implant candidates includedin the study

Mean age at decision to

implant

4.7 years

(range 0.5�16.3 years)

Mean age at implantation 4.7 years

(range 1.02�16.75 years)

Mean duration of deafness 1.8 years (range 0�3.0 years)

Male:Female 1:0.8

Aetiology of deafness

Acquired 22%

Congenital 69%

Progressive 6%

Additional disabilities* 25%

Mean non-verbal IQ

pre-implant

97.8 (range 52�135)

Mean aided threshold

pre-implant (500�4000 Hz)

74.4

Implant device Nucleus CI 24

*Additional disabilities includes those conditions known to be presentpre-implantation, for example cerebral palsy, autistic spectrum disorder,significant developmental delay or learning disabilities, or visual impair-ment.

Table 2. Definitions of speech intelligibility ratings

Category 1 Pre-recognizable words in spoken language

Category 2 The primary mode of communication is

manual. The speech vocalization patterns

which accompany the use of sign/gesture

may give some additional information at the

lipreading level.

Category 3 Speech unintelligible. All experienced

listeners can follow a known topic via

lipreading and context cues. It is not possible

to follow an audiotape sample.

Category 4 Speech intelligible to a listener who

concentrates and lipreads

Category 5 Speech intelligible to listeners with little

experience of the speech of a deaf speaker

Category 6 Speech intelligible to all listeners

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an array of various shapes (e.g. squares, triangles, stars,

diamonds, and crescents).

The results of the non-verbal cognitive assessment are used

to complete factor 10 of the GOSHChIP, based on the follow-

ing criteria: no concern: abilities consistent with chronological

age; mild-moderate concern: mild learning difficulties/delay/

specific area of weakness/minor inconsistencies in test results;

great concern: significant learning difficulties/delay/many speci-

fic areas of weakness/ gross inconsistencies in test results.

Results

Of the 127 children in the study, 105 were offered cochlear

implants and went on to receive one. At the time of data analysis,

data were available for 74 children one year post-implant, 61

children at two years, and 51 children at three years. SPSS

version 15 was used for the analyses. Chi-square analyses

indicated no difference in the proportions of males and females

offered implants, or in the proportion of children whose deafness

was congenital compared with progressive or acquired. Table 3

presents the mean scores on the tests of speech perception and

intelligibility before and after implantation.

Candidacy decisionThe sum of scores derived from the GOSHChIP (Total GOSH-

ChIP) ranged from 0 to 22. The relationship between the Total

GOSHChIP and the candidacy decision is represented graphi-

cally in Figure 1. This suggests three groups of candidates, based

on the ration of yes/no decision for each Total GOSHChIP score.

Those who scored 8 or less are more likely to be considered

candidates for a cochlear implant, those who scored 16 and above

are not offered a cochlear implant, and of those scores in the

range 9 to 15, 50% are considered suitable candidates.

A logistic regression with ‘decision’ (yes/no) as the dependent

variable, and ‘Total GOSHChIP’ as the independent variable,

confirmed a highly predictive relationship between the GOSH-

ChIP ratings and the decision whether to offer a cochlear

implant (p�0.000), accounting for 36% of the variance. Using

the regression equation to predict ‘decision’ for any given total

GOSHChIP score, results in 96% correct ‘yes’ decisions and 55%

correct ‘no’ decisions.

A second logistic regression with the individual GOSHChIP

factors as the independent variables, again predicting ‘decision’,

indicated four factors as significant predictors: communication:

manual (p�0.000), audiological opinion (p�0.000), radiologi-

cal and anatomical (p�0.003), and communication: spoken

(p�0.052). Together, these variables account for 45% (Cox and

Snell R2) of the variance in ‘decision’.

The reasons for a decision not to offer a cochlear implant to a

child scoring less than 8 on the GOSHChIP (three children) were

hearing thresholds out of criteria, and malformation of the inner

ear identified radiologically which precluded surgical insertion

of the device.

Speech perception outcomesStepwise linear regression analyses were performed with the

speech perception test scores at one, two, and three years post

implant as the dependent variables, and the individual GOSH-

ChIP factors as the independent variables. In addition, the

pre-implant speech perception test score was also included as

an independent variable (for the test used pre-implant, most

typically the E2L), to account for the fact that children who

score relatively highly pre-implant have less ‘room for improve-

ment’ on a test compared with those who achieve lower scores

pre-implant. Table 4 presents the significant findings. At one

year post-implant, E2L scores were predicted by ratings on the

audiological opinion factor, the MPT scores were predicted by

family support and duration of deafness factors, and the MJWL

scores were predicted by the family support and educational

environment factors. At two years post-implant concerns about

manual communication predicted outcomes on all three speech

perception tests, and concerns about use of hearing aids pre-

dicted outcomes on the MPT and MJWL. Finally, at three years

post implant, E2L scores were predicted by concerns about

manual communication skills, MPT scores were predicted by

concerns on the medical factor, and MJWL scores were

predicted by both the manual communication skills factor and

radiological/anatomical factor.

Speech intelligibility outcomesSIRs were analysed using the CROSSTABS procedure since both

these ratings, and those of the GOSHChIP factors are categori-

cal. The Somer’s d statistic was employed, as both SIR and

GOSHChIP factor ratings are ordinal*the SIR categories reflect

increasingly intelligible speech, and the GOSHChIP ratings

reflect increasing levels of concern about the potential benefit to

be derived from a cochlear implant. At one year post-implant,

significant relationships were found between speech intelligibi-

lity and the following GOSHChIP factors: functional hearing

(p�0.043), use of hearing aids (p�0.017), communication:

spoken (p�0.003), communication: manual (p�0.001), cogni-

tive/non-verbal ability (p�0.000), behaviour (p�0.001), family

structure and support (p�0.010), expectations (p�0.015),

availability of speech and language therapy (p�0.011), learning

style (p�0.000), and ease of access to the centre (p�0.046).

At two years post implantation, the following GOSHChIP

factors were significant predictors of speech intelligibility: med-

ical (p�0.000), use of hearing aids (p�0.001), communication:

spoken (p�0.002), communication: manual (p�0.001),

cognitive/non-verbal ability (p�0.001), behaviour (p�0.005),

Table 3. Scores on tests of speech perception and speech intelligibility pre-implant and at one, two, and three years post-implant

Mean (s.d.)

Pre-implant

Mean (s.d.) One year

post-implant

Mean (s.d.) Two years

post-implant

Mean (s.d.) Three

years post-implant

E2L test 2.69 (3.86) 7.22 (4.72) 9.87 (3.86) 10.92 (2.65)

Manchester picture test 31.73 (27.06) 59.32 (35.93) 80.81 (30.61) 91.97 (20.46

Manchester junior word list * 31.28 (42.71) 63.04 (40.55) 84.00 (26.53)

Speech intelligibility rating 1.91 (1.51) 2.77 (1.66) 3.26 (1.50) 3.61 (1.40)

*This cell is empty because no child was able to undertake this test pre-implant.

Use of a revised children’s implant profile(GOSHChIP) in candidacy for paediatriccochlear implantation and in predictingoutcome

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family structure and support (p�0.008), and learning style (p�0.012).

A number of GOSHChIP factors remained as significant

predictors three years after the children had received their

cochlear implants: medical (p�0.001), use of hearing aids

(p�0.000), communication: manual (p�0.001), cognitive/non-

verbal ability (p�0.003), behaviour (p�0.000), family structure

and support (p�0.009), and learning style (p�0.004).

Non-verbal cognitive abilitiesFour cognitive variables were used in two sets of regression

analyses, predicting post-implantation speech perception and

speech intelligibility outcomes. In the first set, separate stepwise

multiple regression analyses were performed with the speech

perception tests (E2L, MPT, and MJWL) as the dependent

variables, and pre-implant fluid reasoning, fundamental visua-

lization, memory screen, and visual attention scores as the

independent, predictor variables. In these analyses, fluid reason-

ing was found to predict E2L scores at three years post-implant

(p�0.008), MPT scores at three years post implant (p�0.018),

and MJWL scores at both two and three years post (p�0.040

and p�0.010, respectively). In these analyses fluid reasoning

accounted for between 52% and 83% of the variance in speech

perception outcomes.

0

2

4

6

8

10

12

14

16

18

Freq

uenc

y

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22GOSHChIP Total Score

YesNo

Figure 1. Frequency of the decision to offer a cochlear implant (‘yes’ or ‘no’) for each total score on the GOSHChIP.

Table 4. Significant predictors of speech perception outcomes at one, two, and three years post implantation (stepwise multipleregression analyses)

Dependent variable Predictor variable df b Adjusted R2 p

One year post-implant:

E2L Audiological opinion 1,60 0.273 0.059 0.032

MPT Pre-implant MPT 1,53 0.316 0.083 0.019

Family support 2,52 �0.264 0.054 0.043

Duration of deafness 3,51 0.275 0.06 0.031

MJWL Family support 1,50 �0.323 0.087 0.019

Educational environment 2,49 0.337 0.099 0.010

Two years post-implant

E2L Communication: manual 1,41 �0.634 0.388 0.000

Pre-implant E2L 2,40 0.281 0.064 0.021

MPT Communication: manual 1,42 �0.548 0.284 0.000

Use of hearing aids 2,41 �0.378 0.08 0.003

MJWL Communication: manual 1,47 �0.574 0.315 0.000

Use of hearing aids 2,46 �0.293 0.074 0.013

Three years post-implant

E2L Communication: manual 1,31 �0.752 0.552 0.000

MPT Medical 1,27 �0.622 0.364 0.000

MJWL Communication: manual 1,30 �0.684 0.450 0.000

Radiological and anatomical 2,29 0.321 0.0838 0.015

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In the second set of stepwise regression analyses the depen-

dent variables were the speech intelligibility ratings at one, two,

and three years post-implantation, and the independent vari-

ables were again the fluid reasoning, fundamental visualization,

memory screen, and visual attention scores. Here, speech

intelligibility outcomes at one year post-implant were predicted

by fundamental visualization and fluid reasoning scores (p�0.003), accounting for 62% of the variance. At two and three

years post-implant fluid reasoning scores predicted speech

intelligibility ratings (p�0.003 and p�0.001, respectively),

accounting for 53% and 73% of the variance respectively.

Discussion

The ChIP, or a version of it, has been found to be a useful tool

by many paediatric cochlear implant programmes in guiding

candidacy decisions and predicting potential benefit for a

particular child. In this study we examined the predictive value

of our version of the ChIP (the GOSHChIP). The first aim of

the study was to determine whether the GOSHChIP is used

consistently in guiding candidacy decisions. Overall, considering

the GOSHChIP as a whole, there was a very strong relation-

ship between the level of concern identified by the profile and

whether a cochlear implant was considered an appropriate

intervention for a particular child. This implies that the profile

is being used with a high degree of consistency. However, there

appears to be much greater consistency in the use of the profile

when the decision is to offer an implant, than when the decision

is not to. In other words, when the total score derived from the

profile is low, the decision is almost certainly yes, but when the

total score is higher (8 or above), there is much greater variability

in the decision. This reflects the complexity of some cases in

terms of disabilities in addition to the deafness, for example

where there is also a visual impairment or some degree of

learning disability. Here, although only limited benefit may be

expected in terms of spoken language, an implant may result in

improved communication and quality of life, and in the case of

visual impairment, this may be given greater weight than other

factors in the decision-making.

Considering the contribution of individual profile factors,

four factors were found to account for 36% of the variance in

the decision whether or not a cochlear implant was an

appropriate intervention. This is somewhat less than with

the earlier version of the ChIP, where five factors accounted

for 52% of the variance in ‘decision’. However, the focus of

the factors was similar on both occasions, with an emphasis

on concerns regarding communication skills, whether spoken

or signed, being predictive of the candidacy decision. Con-

cerns regarding residual hearing (i.e. being out of current

criteria) were also again significantly associated with the

decision to offer an implant. Not surprisingly, concerns about

the child’s radiological or anatomical status were also asso-

ciated with the decision regarding implantation. The fact that

only four factors were predictive of the decision to offer an

implant could be interpreted as suggesting that the remainder

are not useful or informative. However, as with previous

versions of the ChIP, clinically no score is derived from it, and

many of the factors highlight areas where children and

families can be supported by the implant team to maximize

their use of an implant.

The third aim of the study was to examine the ability of the

individual GOSHChIP factors to predict speech outcomes

following paediatric cochlear implantation. In our sample of

children speech perception abilities in the first three years post-

implantation were consistently predicted by concerns about the

child’s manual communication abilities pre-implant. Indeed, at

three years post implant, more than half the variance in E2L

scores was accounted for by this factor. Pre-implant concerns

about the child’s use of hearing aids (in terms of behavioural

consistency of use) were significantly associated with speech

perception outcomes at 2 and 3 years. In addition, in the first

year after receiving a cochlear implant greater concerns about

the extent to which the child’s family would be able to support

and optimize the child’s use of the implant, were associated with

poorer speech perception skills.

In terms of speech intelligibility, a number of consistent

themes emerged throughout the first three years of implant

use. Pre-implant concerns about the child’s communication

abilities, cognitive abilities or developmental status, family struc-

ture and support, behaviour and learning style consistently

predicted speech intelligibility ratings one, two, and three years

after implantation. It is interesting to speculate as to why

concerns rated on the cognitive abilities factor may be related

to speech intelligibility outcomes, but not speech perception

outcomes. One possibility is that the ability to discriminate

speech sounds is more ‘automatic’ and relies less on higher-level

cognitive processing skills, than producing speech. In addition,

the rating on this factor is largely based on the overall non-

verbal IQ, resulting in a categorization with only three possible

alternatives, thereby ‘losing’ the more subtle information con-

veyed by the wide range of individual scores possible on the

separate tests of cognitive skills. This may have led to a true

relationship between speech perception and cognitive abilities

being obscured, which indeed seems likely given the results of the

additional analyses of the relationship between specific types of

cognitive skill and speech outcomes.

Although different outcome measures were employed by

Nikolopoulos et al (2004), some similarity between the findings

of that study and this one is evident. In particular, in both

studies, concern regarding the child’s learning style pre-implant

was significantly associated with speech outcomes, although in

the Nikopoulos et al study, they were associated with speech

perception rather than speech production outcomes.

The final aim of this study was to explore the relationship

between pre-implant cognitive functioning and post-implant

speech outcomes in more detail. The results suggested that,

of those cognitive skills tested, one particular aspect of cogni-

tive ability is predominantly associated with speech perception

and speech intelligibility outcomes: non-verbal fluid reasoning.

Scores on this variable accounted for very substantial propor-

tions of the variance in speech outcomes. The tests comprising

this measure assess the child’s understanding of visual sequences,

in terms of repeated patterns (e.g. circle-square-triangle-circle-

square-?-?), and putting visual stimuli in sequential order (e.g.

from smallest to largest, or rotating a geometric figure one step

at a time). The understanding of sequential information is

known to be an area of difficulty for many children with a

significant hearing loss. It is therefore interesting to note that

this specific type of cognitive process predicted speech percep-

tion and speech intelligibility skills up to three years post

Use of a revised children’s implant profile(GOSHChIP) in candidacy for paediatriccochlear implantation and in predictingoutcome

Edwards/Thomas/Rajput 559

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implantation. If difficulties processing sequential visual informa-

tion are linked to more general difficulties with processing

sequential information, i.e. auditory information as well, this

could account for the significant predictive relationship between

the fluid reasoning score and the speech outcomes. Also,

previous research (Khan et al, 2003) has suggested that

non-verbal fluid reasoning skills significantly improve after

implantation, further indicating the importance of this cognitive

process in the development of speech and language.

In conclusion, the GOSHChIP can be considered a useful tool

for guiding candidacy decisions in children being considered for

cochlear implantation, as a number of the factors are predictive

of the development of speech perception and speech intellig-

ibility in the early years post implantation. These factors should

be emphasized when counselling parents about the potential

benefits of implantation for their child. In addition, this study

identified some specific non-verbal cognitive abilities as being

associated with speech perception and intelligibility outcome in

the first three years post implant*in particular fluid reasoning

(sequencing). This information will also be of use in counselling

parents regarding the benefit their child may receive from a

cochlear implant, particularly in terms of maintaining realistic

expectations when there is evidence for learning disabilities or

global developmental delay.

References

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