Braz. j. . vol.81 número3

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Hearing

rehabilitation

in

cerebral

palsy:

development

of

language

and

hearing

after

cochlear

implantation

夽

,

夽夽

Anacléia

Melo

da

Silva

Hilgenberg

a

_,

_Carolina

_Costa

_Cardoso

a

_,

Fernanda

Ferreira

Caldas

a

_,

_Renata

_de

_Sousa

_Tschiedel

a,b

,

Tatiana

Medeiros

Deperon

c

_,

_Fayez

_Bahmad

_Jr.

a,∗

a_Department_of_Health_Sciences,_Universidade_de_Brasília_(UnB),_Brasília,_DF,_Brazil

b_Department_of_Psychology,_Centro_{Universitário}_Planalto_do_Distrito_Federal_(UNIPLAN),_Brasília,_DF,_Brazil c_Division_of_Audiology,_University_College_of_London_(UCL),_London,_England,_United_Kingdom

Received10November2013;accepted9March2014 Availableonline19October2014

KEYWORDS Cerebralpalsy; Cochlearimplants; Hearingloss

Abstract

Introduction:Auditoryrehabilitationinchildrenwithbilateralsevere-to-profound sensorineu-ral hearinglosswith cochlearimplanthasbeen developedinrecent decades;however,the rehabilitationofchildrenwithcerebralpalsystillremainsachallengetootolaryngologyand speechtherapyprofessionals.

Objective:Toverifytheeffectivenessofcochlearimplantsinthedevelopmentofauditoryand languageskillsinchildrenwithcerebralpalsy.

Methods:Aprospectiveanalyticalstudy.Theevaluationofauditoryresponsestospeechtest was applied to thechildren inthisstudy atregularintervals following implantation. Stan-dardizedteststhatassessandquantifythedevelopmentofauditoryandlanguageskillswere administeredandspeechtherapyvideorecordsandspeechtherapyfileswereanalyzed.All chil-drenwentthroughindividuallytailoredintensiveaudiologicalrehabilitationprogramsfollowing cochlearimplantation.

Results:Twoparticipantshadgradualauditoryandlanguagedevelopmentwhencomparedto otherparticipantswhoreachedadvancedlevelsinhearingandorallanguageclassifications.

夽 _Please_cite_this_article_as:_Hilgenberg_AM,_Cardoso_CC,_Caldas_FF,_Tschiedel_RS,_Deperon_TM,_Bahmad_Jr._F._Hearing_{rehabilitation}_in

cerebralpalsy:developmentoflanguageandhearingaftercochlearimplantation.BrazJOtorhinolaryngol.2015;81:240---7.

夽夽_Institution:_{Post-Graduation}_Program_in_Health_Sciences_of_Universidade_de_Brasília,_Brasília,_DF,_Brazil.

∗_{Corresponding}_author.

E-mail:cleiana23@hotmail.com(F.BahmadJr.). http://dx.doi.org/10.1016/j.bjorl.2014.10.002

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Conclusion: TheuseoftheCochlearimplantenabledparticipantstoreachadvancedstagesof hearingandlanguageskillsinthreeofthefiveparticipantswithcerebralpalsyinthisstudy. Thiselectronicdeviceisaviabletherapeutic optionforchildrenwithcerebralpalsytohelp themachievecomplexlevelsofauditoryandlanguageskills.

PALAVRAS-CHAVE Paralisiacerebral; Implantecoclear; Perdaauditiva

Reabilitac¸ãoauditivanaparalisiacerebral:desenvolvimentodaaudic¸ãoelinguagem apósimplantecoclear

Resumo

Introdução: Areabilitaçãoauditivaemcriançascomdeficiênciaauditivaneurossensorialsevera aprofundabilateralcomoImplanteCoclearfoiconsagradonasúltimasdécadas,contudo,ainda permaneceumdesafioparaaotorrinolaringologiaeafonoaudiologiaareabilitaçãodoportador deparalisiacerebral.

Objetivo: VerificaraefetividadedoImplanteCoclearnodesenvolvimentodashabilidades audi-tivasedelinguagememcrianc¸ascomparalisiacerebral.

Método: Estudo analítico prospectivo. Foram aplicados testes padronizados que avaliam e quantificam o desenvolvimentodas habilidadesauditivase delinguagem. Foramanalisadas asfilmagensdasterapiasfonoaudiológicaseosregistrosdescritosaotérminodecadasessão deterapia.

Resultados: Ascriançasanalisadasapresentaramdesenvolvimentoauditivoedelinguagem sat-isfatório quandocomparado àsdemais crianças que alcançaram níveis mais complexos nas categoriasdeaudiçãoeevoluçãosignificativanodesenvolvimentodalinguagemoral.

Conclusão:OusodoImplanteCoclearfavoreceuoalcancedeetapasavançadasdashabilidades deaudiçãoelinguagememtrêsdascincocriançascomparalisiacerebraldesseestudo.Esse dispositivoeletrônicotemsidoumaopçãoterapêuticaviávelparaquecriançascomparalisia cerebralalcancemetapascomplexasnoqueserefereàshabilidadesauditivasedelinguagem. ©2014AssociaçãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.Publicado por ElsevierEditoraLtda.Todososdireitosreservados.

Introduction

Cerebral palsy (CP) is a non-progressive motor disorder resultingfrombrainimpairmentintheearlystagesofchild development.Thebasicneurologicalsymptomsare charac-terizedbymotordisordersthatdevelopovertime,causing delay or disruption of sensory motor development, with insufficient postural mechanism, presence of reflexes at timeswhentheyshouldbeinhibited,alterationsinmuscle tone,andincapacitytoperformmovements.1

Possibledisordersofhighercorticalfunctionscan gener-ateimportantimpactonactivitiesofdailyliving.Moreover, languageacquisitionmaybedelayedandthechildwithCP may exhibit changes in articulation, speech, fluency, and prosody. Its clinical manifestations may change over the courseofdevelopmentduetobrainplasticity,particularlyin theimmaturebrain.Duetothisplasticity,uninjuredareasof thebraincanassumesomeofthefunctionsofthedamaged areas.

Inadditiontomotorimpairment,otherdisabilitiesmay bepresent,suchashearing,visualandcognitivedeficits,as wellaslanguage,behavioral,andlearningalterations.1

The literatureshowsseveralcommonetiologicalagents for both CP and sensorineural hearing impairment.

Among them are congenital infections, hyperbilirubine-mia,prematurity,lowbirthweight,perinatalhypoxia,and cytomegalovirus,amongothers.

Thecochlearimplant(CI)isahigh-technologyelectronic device developed toperform the functionof damaged or absentcochlearhaircells,andtoprovideelectrical stimu-lationoftheremaining auditorynervefibers. The CIdoes notcuredeafness,butprovidesasenseofhearingwiththe requiredqualityfortheperceptionofspeechsounds.2

Currently,theCIisconsideredaviabletherapeuticoption incasesofchildrenwithCPandsevere/profoundbilateral sensorineuralhearinglosswhohavenotshownbenefitswith theuseofhearingaids.3---7

Thereareotheraspectstoconsider,whenother condi-tionsarepresentinthechildinadditiontohearingloss.Each disabilitythatisaddedtothedeafness,willpresentdistinct clinicalfeaturesthatwillinfluenceboththediagnostic eval-uation and the rehabilitation of the hearing impairment. Among other factors, hearing results will depend on the child’spotentialforhisorheroveralldevelopment.6

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The sooner the brain receives meaningful sounds, the bettertheconditionsforittoproducegoodresults,because ofitsfunctionalplasticityandtheresultantdecreasein sen-sorydeprivation.

The work with CIs in children has transformed and improvedthespeechtherapyprocessduetotheimproved abilitytoperceivespeechsoundsfromtheelectrical stimu-lation.Thepossibilityofsuchprosthesestoprovideaccess toauditory experiences,suchasthe patternsof linguistic auditorycode,effectivelyinfluencestheearlyyearsoflife, whichdeterminethechild’sconstitution.8

The auditory system is the natural pathway to learn speech,andauditoryskillsareessentialforthedevelopment oforallanguageandspeechproduction;thus,effectivework is necessary for them todevelop. This work shouldoccur withina meaningful linguistic context for the child, asa natural result of incidental learning in situations of daily living.9

Itisthroughhearingthatinfantsacquirelanguage.The auditorystimuluscancomefromseveralsources:thehuman voice,householdsounds,toysounds,andmusic.10

Standardized tests and classifications of development areimportantasdescriptorsofthedevelopmentofachild withhearingloss,suchasthe:(1)Infant-Toddler Meaning-fulAuditoryIntegrationScale(IT-MAIS);(2)MacArthur-Bates Communicative Development Inventory (CDI); (3) Classifi-cationofauditory skills;and(4)Classificationof language skills.

IT-MAISwasproposedbyZimmerman-Phillipsin1997and is a test adapted for children younger than 4 years that evaluates responses to speech and environmental sounds thataremediatedexclusivelybytheauditorysensory path-way.This scale has alsobeen used toassess post-surgical outcomes of children with CI. The test consists of ten closed questions that must be answered by parents or guardians.

TheCDI:WordsandGesturesisatoolusedinspeech ther-apytoevaluateandmonitorthelanguagedevelopmentof youngchildrenaged8---16months.Thistoolisadministered totheparentsorguardiansinaninterview.InthePortuguese version,theinventoryassessesthechild’sdevelopmentof lexical comprehension and production. It is divided into threeparts: the first corresponds to the first words, and thesecond corresponds toactions andgestures. The first part is subdivided into: A (first signs of comprehension), B(comprehensionof 28sentences), C (startingtospeak), andD(vocabularylist). ItemDissubdivided into22 cate-gorieswithatotalof415words.Thesecondpartofthetest isdividedinto:A(firstcommunicativegestures),B(games androutines),C(actionswithobjects),D(pretendingtobe theparents),E(imitationofotheradults’activities),andF (actionswithanobjectintheplaceofanother).Thethird partcorrespondstogeneralinformationaboutthechild.

Tables 1 and 2 describe the skills by classifications of hearingandorallanguageskills.

This study aimed to analyze, through standardized testing, the classifications of development, and clinical observations, the improvement of auditory and language skillsinchildrendiagnosedwithCPandprofoundbilateral sensorineural hearing loss using CIs, aiming to assess the effectiveness of the CI as a therapeutic resource in this population.

Table1 Summary ofclassificationofauditory skills pro-posedbyGeers(1994)11_.

Classification Auditoryskills

0 Thischilddoesnotdetectspeechinnormal conversation.

1 Detection:Thischilddetectsthepresence ofspeechsignal.

2 Perceptionpattern.Thischilddetectsthe presenceofthespeechsignal.

3 Startingwordidentification. 4 Wordidentificationthroughvowel

recognition.

5 Wordidentificationthroughconsonant recognition.

6 Wordidentificationinopen-setspeech recognition.

Table2 Classificationoforallanguageskillsproposedby Bevilacquaetal.(1996)12_.

Classification Languagedevelopment

1 Doesnotspeak,onlyproduces undifferentiatedvocalizations. 2 Speaksonlyisolatedwords.

3 Constructsimplesentences,withtwoor threewords.

4 Constructssentenceswithfourorfive words.

5 Childisfluentinorallanguage.

Methods

The study was approved by the Research Ethics Commit-teeofFundac¸ãodeEnsinoePesquisaemCiênciasdaSaúde FEPECS(Brasília,DF,Brazil),underprotocolnumber480/09. Caregiversprovidedwritteninformedconsent.

Theresearch wascharacterizedasa longitudinal, ana-lytical, and prospectivestudy. Fivechildren younger than 6years,onefemaleand fourmales,wereincludedin the study.

AllchildrenhadadiagnosisofCPassociatedwith prelin-gual bilateralprofound sensorineuralhearingloss andhad undergoneCIs.Allparticipantsattendspeechtherapy ses-sions with therapeutic approach based on the aural---oral method twice weekly. Three participants attend speech therapy in a specialized philanthropic institution and the twoothersinprivatespeechtherapyclinics.Both establish-mentsarelocatedinBrasília/DF---Brazil.Table3describes thedataofthestudyparticipants.

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Table3 Characterizationofthestudyparticipants.

Subjects ParticipantA ParticipantB ParticipantC ParticipantD ParticipantE Chronologicalagea ₄_years_and₁₁

months

4yearsand5 months

3yearsand11 months

3yearsand7 months

5yearsand6 months Typeofpalsy Diplegia Diplegia Hemiplegia Quadriplegia Hemiplegia Degreeof

cognitive impairment

Marked b _Moderate b b

Typeanddegree ofhearingloss

Profoundbilateral sensorineural Profoundbilateral sensorineural Profoundbilateral sensorineural Profoundbilateral sensorineural Profoundbilateral sensorineural Timeofspeech

therapyusing the

aural---oral method

4yearsand3 months

3yearsand2 months

2yearsand2 months

1yearand10 months

3yearsand6 months

Chronologicalage atthetimeofCI surgery

3yearsand8 months

2yearsand6 months

3yearsand1 month

1yearand7 months

2yearsand7 months

Cityinwhichthe high-complexity centerwas locatedwhere theCIsurgery wasperformed Brasília(DF) Privateinstitution Natal(RN) Publicinstitution Bauru(SP) Publicinstitution Natal(RN) Publicinstitution Natal(RN) Publicinstitution

Implantedear Right Right Left Bilateral Right

Brandandmodel ofspeech processorand internal componentofCI

AdvancedBionics Platinum HiRes®₉₀_K

Cochlear Freedom Nucleus®₂₄_K

AdvancedBionics Harmony HiRes®₉₀_K

Cochlear FreedomBaby Nucleus®₂₄_K

Cochlear Freedom Nucleus®₂₄_K

Brainauditoryage withtheCIa

14months 20months 9months 22months 2yearsand9

months

CI,cochlearimplant.

a _At_data_collection.

b _Children_B,_D,_and_E_did_not_have_their_cognitive_development_assessment_attached_to_their_records,_but_speech_therapy_records

suggestthattheircognitivedevelopmentappearstobebetterthaninchildrenAandC.

parents/guardiansofstudyparticipants.Theserecordswere accessedafterobtainingpermissionfromtheparticipants’ parentsorguardiansandtheheadsoftheaforementioned institutions,whosignedtheinformedconsent.

Results

Theresultsof theIT-MAISandCDItestsandthe classifica-tionsofhearingandspeechofparticipantsA,B,C,D,andE areshowninTables4---8,respectively.

InparticipantA,itisobservedthatninemonthsafterthe tests were first administered, therewas an improvement of 37.5%in theIT-MAIS, andan increaseof 25 words that wereunderstood and 20words that werespoken, bothin theCDI.Indevelopmentofauditoryandlanguageskillsafter usingtheCIfor24months,thechildshowedfewsignificant advances.

ParticipantBexperiencedanincreaseof32.5%inIT-MAIS. Progressinthehearingandlanguageclassificationswasan evidenceofbetterperformancein hearingcomprehension andanincreaseinthelinguisticrepertoire.

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Table4 ResultsofIT-MAISandCDItestsandclassificationsofhearingandlanguageofparticipantA. AuditoryagewithCI IT-MAIS CDI

(comprehension)

CDI(linguistic repertoire)

Classificationof hearing

Classificationof language 1month 25% --- --- 1 1 6months 32.5% 20words --- 1 1 10months 60% 25words 13words 2 1 14months 62.5% 31words 16words 3 1 24months 62.5% 44words 20words 3 1

IT-MAIS,Infant-ToddlerMeaningfulAuditoryIntegrationScale;CDI,MacArthur-BatesCommunicativeDevelopmentInventory.

Table5 ResultsofIT-MAISandCDItestsandclassificationsofhearingandlanguageofparticipantB. AuditoryagewithCI IT-MAIS CDI

(comprehension)

Classificationof language 1month 32.5% --- --- 2 1 8months 55% 83words 31words 3 2 12months 62.5% 216words 53words 4 2 20months 65% 247words 86words 5 3

Table6 ResultsofIT-MAISandCDItestsandclassificationsofhearingandlanguageofparticipantC. AuditoryagewithCI IT-MAIS CDI

(comprehension)

Classificationof language 1month 12.5% --- --- 2 1 8months 22% 23words --- 2 1 16months 55% 140words 3words 3 1 24months 62.5% 147words 11words 3 1

Table7 ResultsofIT-MAISandCDItestsandclassificationsofhearingandlanguageofparticipantD. AuditoryagewithCI IT-MAIS CDI

(comprehension)

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Table8 ResultsofIT-MAISandCDItestsandclassificationsofhearingandlanguageofparticipantE. AuditoryagewithCI IT-MAIS CDI

(comprehension)

Classificationof language 2months 27.5% 15words 6words 2 2 4months 65% 43words 14words 3 3 11months 90% 107words 32words 4 3 16months 97.5% 154words 77words 4 3 20months 100% 236words 121words 4 3 34months 100% 454words 378words 6 4

As a result of moving to another house,participant D onlyjoinedthespecializedspeechtherapyserviceinwhich thisresearchwasdevelopedafter15 monthsofCI activa-tion.The researcherdidnothaveaccesstotherecordsof theinstitutionwherethechildpreviouslyunderwentspeech therapy.Thus,itwasnotpossibletoassesspreviousdata.

ParticipantEobtaineda72.5%increaseintheIT-MAIStest responses when compared with the first test application. This child has reached satisfactory levelsof performance inhearingandlanguageskills,whichcanbeprovenbythe numberofspokenandunderstoodwordsdocumentedonthe CDI.Thisperformanceallowedthechildtoreachthe max-imumclassificationofauditoryskillsandconstructphrasal structureswithfourorfivewords,whichcharacterizesthe fifthclassificationoflanguageskills.

It was not possible to perform the statistical analysis considering theclinicalheterogeneity ofCPandthesmall numberofparticipants;theanalysiswouldnotprovide accu-ratedataforresults.Consequently,oneofthechallengesfor futureresearchismeasuringandquantifyingtheresultsof theCIindifferentmanifestationsofCP.

Discussion

Allfiveoftheparticipantsexperiencedanoxiaatbirth asso-ciated with prematurity as the etiology of their CP. The etiologyofthesensorineuralhearinglosswaslikelyrelated totheuseofototoxicdrugsandaprolongedICUstayin par-ticipantsA,B,andC,pneumococcalmeningitisinchildD, andseverejaundiceinparticipantE.

Inastudyof40,000children,lowbirthweightandanoxia weregivenasthecausesofCP,butthesetwofactorsalone would not explain the existence of the different clinical pictures.13_It_is_now_known_that_there_are_many_factors_that

candamageadevelopingbrain.

Astudyof67CPpatientsofbothgendersfoundthat51% ofthesamplehadhearingimpairment.14

Because of the chronological age of the study partici-pants,theywouldnotordinarilybeadministeredthe CDI. However,wedecidedtousethistoolforevaluationbecause ofthehearingdeficitcausedbytheprofoundsensorineural hearinglossinallparticipants.

When thereis a languagedisorder associated with CP, twopossibilities must be considered: the firstis that the associated intellectual disability and, in this case, lan-guagealterations,areworsenedbythemotordeficit,which would likely make verbal interactions more difficult. In

the second scenario, the individual with CP has normal overallcognitivedevelopment,butwithsomedegreeof lan-guageimpairment, whichmay bein the phonologicaland morphosyntacticdevelopment,orinthesemanticand psy-cholinguisticaspects.13 _Another _facet _to_be _considered _in

thecommunicationcontextofchildren withCPis speech; itscomponentsrelatedtovocal productioncanbegreatly affected,therebyalteringlanguageacquisition.

ChildrenwithCPmaymissopportunitiestoenabletheir linguisticrepertoire,astheperceptivedevelopmentoccurs throughthebody’sownintegratedactionstopsychomotor measures,influencing the maturationprocess and, conse-quently, the development of the processing of auditory, visual,andsomestheticinformation.14

A recent study reported that in children with other disordersincludingCP in additionto hearingimpairment, languagedevelopmentmaybeclosetothatofnormal chil-dren ifthe impairmentis mild. In contrast,children with more severe disorders may show a lower-than-expected development.15

Currently,thereisconsiderablediscussioninimplant cen-tersregarding theindication of CIsin children withother disordersassociated withhearing impairment.Those that chooseimplantationaimtominimizetheauditory sensory deprivationbyimprovinginteractionwiththeenvironment, languagecomprehension,andconsequently,thequalityof life.15

Accordingtoindicationandcontraindicationcriteria,at thenationalandinternationallevels,disordersinadditionto hearingimpairment,asinthecaseofCP,donot contraindi-catecochlearimplantation.6,7_In_this_sense,_the_participants

assessedinthisstudymettheindicationcriteriafortheCI becausethecriteriaconsidered ascontraindications were not observed in these patients --- there were no medical conditionsthatcontraindicatedsurgery;noagenesisofthe cochleaoroftheauditorynerveorcentralauditorylesions; andnoactivemiddleearinfections.AlthoughCPisa neuro-logicalimpairment,itdoesnotgenerateanyimpedimentto theuseofCI,becausetheaffectedarea,inthiscase,refers tothemotorarea.6

The useof ICallowed theimprovement inspeech per-ception in children with additional needs, although this improvement is often significantly lower than in children whodonothaveadditionaldisorders.16

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Children with CP and hearing loss are very heteroge-neous.Thesimilarityamongthemliesinthefactthatthey havehearingimpairment.Theother characteristicsofthe motorandcognitive picturearedissimilar andcan poten-tiallypresentasvariablesintheevaluationprocessandthe rehabilitationapproachwithCI.6

Animportantpieceofinformationthatmayinfluencethe performanceof auditoryskills is the chronological age of the children at the time of surgery, as this identifiesthe durationofbrainauditorysensorydeprivationthatthechild experienced.When comparingthefive studyparticipants, participantDreceivedanimplantattheearliestage,while participantAwastheoldestwhenimplanted.

It is a known fact in preventive psychology that the youngertheageofthechildforanintervention,thebetter theresults.Thus,theidealtimeforCIsurgeryisduringfirst2 yearsoflife.Thisisbecauseofthegreaterneuralplasticity, whichfacilitatesbrainreorganizationtonewstimuliandis complementedbytheneedforverballearningintheperiod ofnormallanguageacquisition---from1to2yearsofage. Thisprovidesaneffectivemechanismtoallowdevelopment that is appropriate to the child’s developmentalprocess, whileavoidingalongerdurationofauditorydeprivation.18

Studiesshowthatchildrenimplantedbeforethreeyears ofagehavebetterperformanceinauditoryperceptionfor speechsoundsthanchildrenimplantedlater.18 _In_our_study

participantsimplantedbefore3yearsofagewerecase:B, at2yearsand6months;D,at1yearand7months;andE,at 2yearsand7months.Earlychildhoodisthemostimportant periodfor neuronal plasticity;therefore, the tendency is thatthesechildrenwillachievebetterresultswiththeCI.2

Betweenages3and6theindicationfor theCIismore complicated,sincethepost-surgicalimprovementsaremore limited,duetolongerauditorysensorydeprivation.2

Partic-ipantsAandCwerenotimplanteduntilages3yearsand8 months,and3yearsand1month,respectively.

Theinitiationofaudiologicalawarenessintheimplanted childbeginswithhelpingherunderstandthemeaningofthe soundsshehearsbymakingherawareofthesoundsource. Asthisoccurs,shewillbecomeincreasinglyconfidentinher auditory sensory pathway. Upon activation of the CI, the child’shearingdevelopmentshouldoccurfollowingthesame stagesthroughwhichchildrenwithout hearingimpairment go.However,oneaspectshouldbetakenintoconsideration inrelationtoparticipantsAandC:thereiscognitive impair-mentassociatedwiththeneurologicalsymptomsofCPthat mayslowthedevelopmentofauditoryskillwiththeCI.

Inonestudyof60childrentreatedwithCI,27children reachedauditoryskilldevelopmentclassifications5and6, themostadvancedlevelsofauditorydevelopment. Twenty-three children achieved classifications 3 and 4, while 10 childrenreachedonlyclassifications1and2.19

Inthepresentstudy,at20and36monthsofbrain audi-toryagewithCI,participantsDandEreachedclassification 6of hearing.At 20months ofbrain auditoryage, partici-pantBreachedclassification5.At14and16monthsofbrain auditoryage,participantsAandCwereinclassification3.

Inastudywiththreedeafchildrenyoungerthanage3, oneofthetoolsusedtomonitorthedevelopmentof audi-toryandlanguageabilitieswastheCDI---WordsandGestures version.20_Although_this_tool_is_indicated_to_evaluate_children

agedbetween8and16months,theauthorchosetouseit

duetothechildren’slanguagegapfromdecreasedauditory acuity.Wemadethesamedecisioninourstudyforthe chil-drenwhosechronologicalagewas5yearsand6months,and 3yearsand7months.

Atcloseto2yearsofbrainauditoryage,participantsB, D,andEwereactivelydevelopinghearingskills,particularly in relation tothemore complexskillof auditory compre-hension.Atthistime,considering hislinguisticrepertoire, participantDunderstood172wordsaccordingtotheCDI.At 2yearsofage,thechildhadauditorymemoryfortwowords, understoodavarietyofsentences,discriminateddescriptive sentences, followed orders in two directions, recognized by categorization, understood action sentences, under-stood questions, imperatives, and routine and situational statements,understoodpersonalpronouns,understoodthe negative‘‘no’’,andunderstoodsomeconceptsand approx-imately250---300words.21,22

TakingintoaccountthebrainauditoryagewiththeCI, the study shows that in participants B, D, and E, whose speech therapy records suggest better cognitive develop-mentthanthoseofparticipantsAandC,theCIhashelped thedevelopmentofhearingskillsatstagessimilartothose observedinchildrenwithnormalhearing.

When comparing the auditory age of participant C to childrenwithnormalhearingofthesameage,shehas devel-opedauditoryskills, inspiteofthesmallgap.Incontrast, participant A,whohas marked cognitive impairment,has developedauditoryskillswithasignificantlag.

ChildrenwithcognitivedelaycanbenefitfromtheCI,but willhavelimitedresultswhencomparedtotheirpeerswith normalhearingwithoutcognitiveimpairment.18 _This

scien-tificfindingagreeswiththeresultsobservedinparticipants AandCofthisstudy.

Anotherstudyof achild withaCIand CPshowedthat neurologicalalterationwasnotanimpedimentforthechild toreachthemoreadvancedclassificationsofauditoryand languageskilldevelopment.23

Conclusion

Although there is a paucity of studies in the literature addressing the use of CI in children with CP, this study demonstratesthattheuseofthiselectronicdevicehas con-tributedtothedevelopmentofauditoryandlanguageskills intheparticipants.

TheCIhasbeenaviabletherapeuticoptionforchildren withhearingimpairmentassociatedwithCP,asthedevice allowschildrentoachievemoreadvancedstagesofauditory andlanguageskills,althoughatamoregradualrate.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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