International Journal of Pediatric Otorhinolaryngology (2005) 69, 175—186

www.elsevier.com/locate/ijporl

Young deaf children with hearing aids or cochlear

implants: early assessment package for
monitoring progress
Thomas P. Nikolopoulos*, Sue M. Archbold, Susan Gregory

Nottingham Pediatric Cochlear Implant Programme, 113 The Ropewalk, Nottingham NG1 6HA, UK

Received 23 April 2004; received in revised form 25 August 2004; accepted 29 August 2004

KEYWORDS Summary
Cochlear implant;
Hearing aid; Background: Very few assessment measures exist for evaluating progress in young
Speech perception; deaf children with hearing aids and cochlear implants.
Children; Objective: To introduce and describe an early assessment package that covers
Auditory perception; auditory perception, communication/language development, and speech production
Assessment; in very young deaf children.
Evaluation; Main outcome measures: Seven of the assessment measures (Listening Progress
Outcome; Profile, Categories of Auditory Performance, Tait Video Analysis, Stories–—Narratives
Speech; Assessment Procedure, Profile of Actual Linguistic Skills, Speech Intelligibility Rating,
Communication; and the Profile of Actual Speech Skills) have been specifically developed at the
Preverbal; Nottingham Cochlear Implant Programme, and a further one (Meaningful Auditory
Language Integration Scale) was modified for use within the package. Moreover, two commer-
cially available tests (Pragmatics Profile of Everyday Communication Skills and Pre-
school Language Scale) are included to complete the package.
Methods: The present paper describes each measure, how to use it, and its time
frame. In addition, two case studies demonstrate the usefulness of the package as a
whole.
Results and conclusions: The Nottingham Early Assessment Package (NEAP) offers a
framework with which to assess in young deaf children the use of audition and
language and communication in real-life situations. Being simple, reliable, and time
effective can be used in everyday clinical practice. NEAP is innovative in design and
offers a structured approach to monitor very young deaf children, both in short and
long term. In addition, it allows the identification of additional problems and areas of
difficulty as well as specific abilities and skills. This enables the clinician to determine
appropriate intervention strategies.
# 2004 Elsevier Ireland Ltd. All rights reserved.

* Corresponding author. Present address: 116 George Papandreou Street, Nea Philadelphia, Athens 143-42, Greece.
Tel.: +30 210 25 13 312; fax: +30 210 69 94 904.
E-mail address: [email protected] (T.P. Nikolopoulos).

0165-5876/$ — see front matter # 2004 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2004.08.016
176 T.P. Nikolopoulos et al.

1. Introduction when most tests are limited in their application or

require more formal assessment procedures. Some
The advent of pediatric cochlear implantation of the assessments included in NEAP can be used
necessitated the development of assessment mea- regardless of mode or language, and focus on com-
sures appropriate for very young deaf children to munication itself. The development of the package
inform the decision making process, to monitor took place within a multi-disciplinary context and
device functioning, the appropriateness of support it reflects this philosophy in working with young
and help identify the presence of any additional children.
learning difficulties. The Nottingham Early Assess-
ment Package (NEAP) is a collection of measures
which have been chosen to meet this need. Having 2. The package
been initially developed for use within an implant
programme, the package focuses on the use of The measures developed by Nottingham Pediatric
audition in the development of communication Cochlear Implant Programme over the years for
and spoken language skills. However, it is an impor- assessing young deaf children both before and after
tant feature of the package that the development of cochlear implantation, now form the Nottingham
audition is not viewed in isolation, but in its role in Early Assessment Package. NEAP can be used from
the development of communication and language by the first months of life, providing useful markers in
the child. that early period, guiding decision making about
The package is particularly useful in providing a appropriate intervention and providing a tool for
structured way of looking at development at continuing assessment and monitoring. The package
the pre-lexical and early word stage, before the uses video analyses, observational profiles, inter-
period when most standardized tests of linguistic views, and questionnaires. Some of the measures
skills can be used. NEAP offers a range of assess- can be used from early infancy right through to
ments providing a profile of the child at a stage adulthood, providing continuity and the basis for

Fig. 1 The measures used in the Nottingham Early Assessment Package (NEAP).
Early assessment for hearing aids, cochlear implant 177

long-term comparisons in the various areas of devel- language development. The measures used in this
opment. area have been chosen to cover the range of areas of
NEAP covers the following areas: early communication skills, from the preverbal
stage through to the development of spoken lan-
 communication and language development; guage. They are:
 auditory perception; and
 speech production.  Tait Video Analysis: preverbal communication
skills;
Fig. 1 illustrates the measures used in these areas of  Preschool Profile of Early Communication Skills
focus. Fig. 2 demonstrates the use of the measures (PPECS): pragmatic skills;
over time, and the time-scales for which they are  Story/Narrative Assessment Procedure (SNAP Dra-
applicable, showing the range of each. Seven of the gons): story/narrative development;
assessments have been specifically developed at the  Profile of Actual Linguistic Skills (PALS): develop-
Nottingham programme, and a further scale (MAIS) ment of spoken language; and
was modified for use within the package. Two com-  Preschool Language Scale (PLS): developmental
mercially available tests are included to complete language pre-cursors.
the package.
The present paper describes each measure and 3.1.1. Tait Video Analysis (TVA): developed by
concludes with two case studies, which demonstrate Margaret Tait (Nottingham Pediatric Cochlear
the usefulness of the package as a whole. Implant Programme)
Tait Video Analysis assesses, in a video sample,
deaf children’s preverbal communication skills:
3. The measures responses in an interaction with a known adult,
eye contact, turn-taking, vocal initiative, gestural
3.1. Communication and language initiative, and auditory awareness.
development TVA is very useful in the early stages of assessing
communication skills is a sensitive measure which
Fundamental to any early assessment of young can monitor changes over short time frames, months
children is a consideration of communication and rather than years. It measures the developments

Fig. 2 Nottingham Early Assessment Package (NEAP) time frame in children’s life (months) for the use of the assessment
measures.
178 T.P. Nikolopoulos et al.

which take place before understanding of spoken 3.1.3. Stories/Narratives Assessment Procedure
language is evident and certainly before the emer- (SNAP Dragons): developed by Helen Starczweski
gence of speech. and Hazel Lloyd (Nottingham Pediatric Cochlear
Preverbal development is measured in four areas: Implant Programme)
turn-taking, initiative, eye contact and auditory Stories/Narratives Assessment Procedure (SNAP Dra-
awareness. Turn-taking can be either ‘vocal’, with gons) is a child centered assessment which has been
or without the addition of sign/gesture, or ‘ges- specifically developed for deaf children in order to
tural’ without vocalization. Initiative, which can monitor their narrative abilities. Using picture-
also be vocal or gestural, is judged to be shown if based stories, written and illustrated specifically
a child’s turn contains elements that cannot be for preschool deaf children, children are asked to
predicted from the adult’s preceding turn. Eye con- retell a story using their preferred communication
tact notes when the child looks at the adult and mode and language and this is video-recorded.
when the child looks elsewhere. Auditory awareness SNAP Dragons consists of a set of 14 picture-based
of the adult’s voice is considered to be shown if the stories, written and illustrated specifically for pre-
child ‘replies’ when they have not been looking at school deaf children. The books feature a family of
the adult for the adult’s last few words. Such a reply dragons involved in every day events throughout the
might be an attempted repetition of a recognized year which are familiar and appealing to this age
word, or just a vocalization. This is termed a non- group. The narrative analysis of the video is carried
looking vocal turn [1]. out in two stages: (a) story grammar analysis; (b)
TVA has been shown to be repeatable and been narrative stage (Table 1).
found to predict to a significant extent the later Story grammar analysis looks at the structure of
development of speech perception in children with information in the child’s story. It is particularly
cochlear implants [1—3]. Thus, in this difficult area concerned with the identification of setting infor-
of preverbal assessment, it is a proven tool. mation, initiating events, actions of the characters,
consequences and any internal responses of the
3.1.2. The Pragmatics Profile of Everyday characters in the story. Each utterance of the child’s
Communication Skills: preschool version: story is coded on the transcription. Analysis then
developed by Hazel Dewart and Susie Summers goes on to determine whether a complete episode is
(NFER—NELSON Publishing Co. Ltd., Widsor Be, present. This is a story unit or episode represented
UK, 1995) by the presence of an initiating event, action and
The Pragmatics Profile of Everyday Communication consequence [4,5]. The developmental sequence is
Skills (PPECS preschool version) is an informal inter- described elsewhere [6—8].
view carried out to explore a child’s communication An inter-rater reliability study has been carried
in everyday interactions at home or at school. The out on the SNAP rating with excellent results. The
information is obtained indirectly through inter- SNAP rating is easily undertaken and shows high
view. The person responding is encouraged to inter-observer reliability. Moreover, the progress
describe in his or her own words the way the child of young implanted children in the narrative skills
typically behaves and this description is recorded on using SNAP as the assessment method has been
the PPECS interview schedule. The child’s current demonstrated and a shift towards more speech
communication strategies are recorded under four orientated communication modes following
main headings: cochlear implantation has been found [8].

A. Development of Communicative Functions: the 3.1.4. Profile of Actual Linguistic Skills (PALS):
way the child comes to express a range of inten- developed by Dee Dyar (Nottingham Pediatric
tions, such as requesting, greeting and giving Cochlear Implant Programme)
information. The Profile of Actual Linguistic Skills is a criterion-
B. Response to Communication: the way the child referenced procedure that assesses a deaf child’s
reacts to and understands communication from ability to use oral language, effectively, in every day
other people. linguistic and learning environments. The PALS pro-
C. Interaction and Conversation: how the child par- file looks at the child’s rate of progress at five inter-
ticipates in social interactions involving initia- related linguistic levels: social and pragmatic skills,
tion, turn-taking and repair strategies when receptive skills, expressive skills, voice skills, and
communication breaks down. speech skills.
D. Contextual Variation: how the use of pragmatics PALS has been found to be a sensitive means of
is affected by variations in context, such as time ‘profiling’ changes in the spontaneous communica-
and place and the people involved. tion/linguistic skills of profoundly deaf children who
Early assessment for hearing aids, cochlear implant 179

Table 1 Narrative stages (‘‘SNAP Dragons rating’’)

Narrative Story grammar Narrative behavior
stage
1 Pre-analysis Child is not ready to respond to the task
2 Pre-analysis Child is happy to look at the book while
the adult tells the story, but is not ready
to retell the story
3 Child labels or comments Child needs prompting/scaffolding to retell
on pictures the story (>3 prompts)
4 One or two story categories Some prompting needed (<3)
used. Not a complete episode
5 One complete episode Spontaneous retelling. No prompting needed.
Can include a ‘‘verbatim’’ stage
6 One episode complete and second Verbatim stage may persist
nearly complete (2/3 categories)
7 Two complete episodes Confident story telling
8 Greater than two episodes. Confident and creative story telling
Internal responses used increasingly
to show reasoning of characters

are functioning at the pre-lexical stage of language ple, a child’s shared attention abilities, and also at
acquisition. expressive language pre-cursors, for example,
The developmental framework approach of PALS social communication and vocal development.
makes it an appropriate pre-cursor to norm-refer- This commercially available test can be used by
enced language performance measures. It can pro- speech and language therapists, educational psy-
vide global data on the linguistic status of children chologists, specialist teachers and other profes-
and identifying ‘‘gaps’’ enables the user to plan sionals who may work with communication
immediate communication priorities and goals for impaired children in the preschool years, and has
the deaf child. a comprehensive manual.
The PALS profile is usually completed by a speech
and language therapist. After preliminary training, 3.2. Auditory perception
it can be used by other experienced professionals.
The outcomes obtained on the five inter-related The relationship between degree of deafness and
levels of the PALS individual profile can be collated auditory perception is not a simple one and the
further to provide an overall classification of the ability to use hearing aids or cochlear implants
child’s current linguistic effectiveness in a spoken effectively will vary considerably. In order to com-
language at a specified assessment interval: (1) plement the formal audiological measures taken
preverbal; (2) transitional; or (3) functional lan- within the clinic, indicators of the functional use
guage (Table 2) [9]. of audition in everyday life are necessary. The three
measures of auditory perception are:
3.1.5. Preschool Language Scale: 3 (UK):
developed by I.L. Zimmerman, V.G. Steiner and  Listening Progress Profile (LIP): measuring early
R.E. Pond, UK, adaptation by J. Boucher and V. listening skills.
Lewis (Psychological Corporation Limited,  Categories of Auditory Performance (CAP): mea-
London, 1997) suring auditory performance in everyday life.
The Preschool Language Scale (PLS3) measures the  Meaningful Auditory Integration Scale (MAIS):
pre-cursors to language as well as a broad range of measuring everyday use of sound and hearing
early language skills; early interaction and early aid or implant.
vocal development. It can be used to test children
aged from 3 months to 6 years 11 months or for older 3.2.1. Listening Progress Profile (LIP) developed
children functioning developmentally within this by Sue Archbold (Nottingham Paediatric Cochlear
age range. This scale has been included to enable Implant Programme)
us to evaluate the deaf child’s relative ability in The Listening Progress Profile measures the devel-
receptive and expressive language when compared oping listening skills in young deaf children, in
to a hearing peer (UK and US norms are available). everyday situations. Specific activities are used to
It looks at receptive language pre-cursors, for exam- enable completion of the profile, in observation and
180 T.P. Nikolopoulos et al.

Table 2 PALS: outcome categories preverbal, transitional and functional language

Preverbal Transitional Functional language
The deaf child is functioning at Recognisable words and simple The deaf child demonstrates the ability
the ‘pre-lexical’ stage of oral formulaic expressions are reported to use language(s) spontaneously and in
language acquisition by the deaf child’s parents/carers/ a systematic way. A knowledge of
support professionals. Some single meaning and the rules of the ambient
words or phrase patterns may be spoken language is apparent
elicited on a minimum of two
occasions in an assessment context

play, rather than by testing. It covers a range of 3.2.3. Meaningful Auditory Integration Scale:
abilities from first response to environmental sounds developed by Amy McConkey-Robbins, modified
and first response to voice, through to discrimina- with permission by Nottingham Pediatric
tion of environmental sounds and discrimination of Cochlear Implant Programme
voice, to identification of the child’s own name [10— The Meaningful Auditory Integration Scale was
12]. developed to evaluate the meaningful use of sound
A prospective and longitudinal study found that in everyday situations by profoundly deaf children
all the children studied following implantation could [20]. Nottingham Pediatric Cochlear Implant Pro-
be assessed by LIP; no child scored 0 as early as 3 gramme has extended it to include the opinion of
months post-operatively. The study included chil- their teachers as well as parent. Ten questions are
dren implanted under the age of two. LIP has also given ranging from the child’s initial adaptation to
been useful in highlighting those children who may using the hearing aid or cochlear implant, through
have a potential device problem [10,11]. response to name, to sounds in the environment
The inter-observer reliability on LIP as a measure through to more sophisticated levels of hearing such
of auditory perception has been formally validated as identifying speakers and the ability to identify
and has shown high levels of agreement between emotions from vocal tone.
different observers [13]. In the early days after the fitting of hearing
aids or cochlear implants, the MAIS may provide
early evidence of the use of the system, when other
3.2.2. Categories of Auditory Performance signs are few. Parents and carers can be encouraged
(CAP): developed by Sue Archbold (Nottingham to consider the ways in which their child is using
Pediatric Cochlear Implant Programme) the hearing system in everyday life, and to be
The Categories of Auditory Performance is a global observant of changing behaviors. Its use may alert
outcome measure of the developing auditory skills carers and professionals to early signs of the child
in deaf children, designed to give a readily acces- not adapting to the use of the system; for example,
sible measure for non-specialists. It is carried out by where the child is not happy wearing the device, or
observation, using standard criteria, and assesses not aware where there are any problems with its
the functioning of the child in everyday situations at functioning. Similarly, its use over the long term may
home and at school covering a range of abilities from highlight a child who may be becoming an intermit-
awareness of environmental sounds to discrimina- tent user.
tion of speech sounds and from understanding com-
mon phrases and conversation without lip-reading to Table 3 Categories of Auditory Performance (CAP)
telephone use with a known speaker. Table 3 shows
the categories. CAP is useful in all the stages of Category Criteria
assessing hearing skills, whether use of hearing aids 7 Use of telephone with known listener
or cochlear implants. When used following implan- 6 Understanding of conversation without
tation it shows changes over the short and long term lip-reading
[11,14—18]. 5 Understanding of common phrases
without lip-reading
CAP is simple, easily undertaken, and easily
4 Discrimination of some speech
understood by professionals, parents and ordinary sounds without lip-reading
people who have no experience in tests or other 3 Identification of environmental sounds
assessment methods for deaf children. 2 Response to speech sounds (e.g. ‘‘go’’)
The inter-observer reliability of CAP has been 1 Awareness of environmental sounds
formally validated and has shown high levels of 0 No awareness of environmental sounds
agreement between different observers [19].
Early assessment for hearing aids, cochlear implant 181

3.3. Speech production 3.3.2. Speech Intelligibility Rating (SIR):

developed by Dee Dyar (Nottingham Paediatric
It is important to monitor the developing speech Cochlear Implant Programme)
skills, from the early stages of vocalization in com- Speech Intelligibility Rating measures speech intel-
munication through to the emergence of spoken ligibility of deaf children who use hearing aids or
language. The two measures in this area cover cochlear implants. SIR is a five-point hierarchical
speech production from the earliest vocalizations scale (Table 4) describing various degrees of speech
through to intelligible speech. They are: intelligibility from unintelligible speech through to
speech that is intelligible to all listeners.
 Profile of Actual Speech Skills (PASS): early speech SIR measures progress in speech intelligibility
production video analysis. from before the first words until connected speech
 Speech Intelligibility Rating (SIR): a profile of is established over the long term. It is not intended
speech intelligibility. to monitor small changes in intelligibility over a
short time frame. SIR is a rating of a child’s everyday
3.3.1. Profile of Actual Speech Skills (PASS): de- spontaneous speech and has been found to be a
veloped by Dee Dyar (Nottingham Paediatric Co- practical clinical measure which can be readily
chlear Implant Programme) applied to large groups of young deaf children over
The Profile of Actual Speech Skills is a systematic time irrespective of children’s age and speech abil-
recorded sampling technique that enables a speech ities [22], and has been shown to be reliable
and language therapist to establish a developmen- between observers [23]. There is no need for chil-
tally and linguistically appropriate baseline mea- dren to have language skills or to be able to produce
sure of speech production in profoundly deaf a speech sample. Moreover, the overall pattern of
children, and to transcribe and analyze any changes development produced is easily understood by par-
that occur at the speech production level. A key ents and non-professionals, fostering realistic
emphasis of the PASS is to describe the actual expectations.
spontaneous speech patterns produced by deaf chil-
dren at the pre-lexical stage of spoken language 3.4. Case studies
development.
The PASS summary of findings consist of three The two case studies below of contrasting young
quantitative level outcomes and two qualitative deaf children implanted below the age of two,
level outcomes. The quantitative level outcomes illustrate the use of the measures described above.
include the change in quantity of overall tokens These case studies demonstrate the use of these
over time through the transition from silent articu- assessments to establish base-line measures before
lation postures through non-speech through speech- implantation, and to monitor progress over the
like to speech. The qualitative level outcomes look following year, or longer if necessary.
at changes in the child’s vowel and consonant reper-
toire. 3.4.1. Case study 1
PASS is a developmentally and linguistically The first (C) is an example of a child who has made
appropriate technique for ‘profiling’ the sponta- good progress with her implant. She was born pro-
neous speech patterns of young profoundly deaf foundly deaf and received a cochlear implant with
children. It can influence the choice of short term full insertion of the electrode array at the age of 19
(re)habilitation goals for individual deaf children months. Her preimplant assessments took place
[21]. over the preceding 3 months. The only reliable

Table 4 Speech Intelligibility Rating criteria

Connected speech is intelligible to all listeners. Child is understood Category 5
easily in everyday contexts
Connected speech is intelligible to a listener who has a little Category 4
experience of a deaf person’s speech
Connected speech is intelligible to a listener who Category 3
concentrates and lip-reads
Connected speech is unintelligible. Intelligible speech is developing Category 2
in single words when context and lip-reading cues are available
Connected speech is unintelligible. Pre-recognisable words in Category 1
spoken language, primary mode of communication may be manual
182 T.P. Nikolopoulos et al.

response to sound observed before implantation was ‘intelligible to familiar listeners who know the con-
an elicited response to drum; no responses to envir- text’.
onmental sounds or to the sound of voice were To summarize, C’s ratings on all the assessments
observed. She was therefore rated on the lowest are at a high level by the 12-month interval. Two
category of the CAP (‘no awareness of environmen- ratings (LIP and MAIS) have already reached the
tal sounds’), and scored only 5% on the LIP (elicited maximum level by the 6-month interval; in children
response to drum). She scored 0% on the MAIS, both of this age the majority would be expected to take 1
parent and teacher versions, as she had no interest year to achieve these levels. Clearly, C has not only
in her acoustic hearing aids, being unaware of sound reached a high 12-month level, but her 6-month
through them. ratings show that the rate of progress has been
Her preverbal communication skills were well rapid.
established. Tait Video Analysis showed her to be
taking all her conversational opportunities, but to 3.4.2. Case study 2
be as likely to do so silently (53%) as vocally (47%). The case study of the second child, R, gives an
She had begun to show initiative, again both silently example of monitoring a child who has made slow
and vocally. No auditory response to the sound of the progress with her implant over the first 12 months.
adult’s voice was observed (NLVT 0%). On the PALS She became profoundly deaf following meningitis
she was rated as ‘preverbal’. Her SIR level was with resulting ossification of both cochleas. In addi-
category 1 (pre-recognisable words) and her PASS tion, cerebral palsy was identified after meningitis.
rating showed 10% speech sounds, 26% speech-like She received a cochlear implant at the age of 10
sounds and 63% non-speech sounds. months, with partial insertion of the electrode array
By the 6-month interval C had made rapid pro- (6 electrodes). She had no response to sound before
gress in her listening skills. On the CAP she had gone implantation and was therefore rated at the lowest
up four levels (to ‘discriminates some speech sounds level on the CAP (‘no response to environmental
without lip-reading’) and on the LIP she scored sounds’) and at 0% on the LIP. She was reluctant to
100%: for example, she was observed to be recog- wear acoustic hearing aids and did not respond to
nizing, and spontaneously repeating, all Ling’s five sound through them, so scored 0% on the MAIS also.
sounds without lip-reading, and recognizing family Tait analysis showed that at this stage there was
names, again from the sound alone. She also scored little real turn-taking. Her mother followed the
100% on the MAIS (parent and teacher versions), for normal procedure with young infants, i.e. waiting
example, knowing who had spoken to her by the for any vocalization or body-movement from the
sound of their voice, and recognizing the sound of a child and then responding ‘as if’ R had communi-
cross or excited voice from the vocal tone, without cated. It was estimated that communication from
looking. PALS and SIR are not used at this interval, the child had taken place in 39% of the possible
but PASS showed her to be using far more speech opportunities, evenly divided between vocal turn-
(58%) and speech-like (7%) than non-speech (25%) taking (20%) and gestural (19%). No instances of
sounds. Tait Video Analysis showed her to be becom- initiative or auditory awareness were observed.
ing predominantly vocal in her turn-taking (76% She was rated as preverbal on the PALS and category
vocal compared with 12% gestural) and to be begin- 1 on SIR (pre-spoken language). PASS showed her to
ning to respond vocally to the sound of the adult’s have 0% speech sounds, 0% speech-like sounds, 89%
voice (NLVT 35%). Vocal initiative remained at a low non-speech sounds and 3% other.
level at this stage. By the 6-month interval it was possible to observe
At the 12-month interval the 100% ratings on the some changes. R was at this stage responding to the
LIP and the MAIS were maintained, and she had sound of voice and turning if called, and could
moved up a further category on the CAP (‘under- therefore be given the CAP rating of ‘responds to
stands common phrases without lip-reading’). Tait speech sounds’. On the LIP she scored 36% as she was
analysis showed her to be taking 100% of her con- responding to musical instruments and (sometimes)
versational turns vocally, with 68% of vocal initiative to her own name. She scored 40% on the MAIS (both
and 58% of non-looking vocal turns. By this stage the parent and teacher versions) as she clearly liked to
vocal turns were not simply vocalizations, but con- wear the speech processor, responded to some
sisted mainly of phrases such as ‘Where she gone?’, environmental sounds, and sometimes alerted to
‘There it is!’, ‘What is it?’ and so on. On PALS she was the sound of her name. Tait analysis showed her
rated as transitional, with some functional language turn-taking to have increased to 59% vocal plus 41%
features. On PASS she had 77% speech sound, 21% gestural, with some display of initiative (29% vocal),
speech-like sounds and only 2% non-speech sounds. but with no vocal responses to the sound of the
Finally, her SIR rating had improved to category 3: adult’s voice when not looking (NLVT 0%). However,
Early assessment for hearing aids, cochlear implant 183

by this stage R’s vocalizations and gestures were

becoming more clearly communicative, and there
was less need for the adult to ‘engineer’ the turn-
taking structure. Her PALS rating remained ‘prever-
bal’, but PASS showed her to be using sounds which
were more speech-like in quality: 23% speech and
58% speech-like.
The 12-month assessment showed further
improvement on all profiles. R had gone up one
level on the CAP, to ‘recognizes environmental
sounds’. Her LIP score had increased to 52%, as
her responses to musical instruments, to the sound Fig. 4 Progress of children C and R using listening pro-
of voice and to Ling’s five sounds had become reli- gress profile (LIP).
able. Her MAIS score had gone up to 83% (parent) and
68% (teacher), as she was by this stage showing clear
indications that she liked the speech processor, for Figs. 3—5 compare the progress of the two chil-
example, clapping her hands and getting excited dren on the three measures of auditory perception
when it was put on, and looking at the adult’s face used: CAP, LIP and MAIS, from before implantation
with a puzzled expression if the battery went flat. until 6 and 12 months later. Both children make
Tait analysis showed more positive and purposeful progress in this area, although there are clear dif-
turn-taking with a definite vocal bias (75% vocal ferences. Before the implant, neither child shows
compared with 25% gestural). Her vocal initiative evidence of significant auditory perception,
remained at a similar level to the 6-month interval, although child C registers a score on the LIP, using
and she still displayed no vocal indications of audi- what little residual hearing she has. After implant,
tory processing, preferring to maintain eye contact the benefits of this residual hearing become clear, as
with the adult. PASS showed a continued improve- by 6 months she has reached ceiling performance in
ment in her vocalizations, with 43% of her tokens both the MAIS and the LIP, and on the CAP, progresses
now being classified as ‘speech’. from a score of 4 at 6 months to a score of 5 at 12
months. However, while child R shows steady
3.4.3. Comment on case studies improvement in all areas, it is at a much slower rate.
The implant situation was different for these two The TAIT Video Analysis of developing communi-
children from the start, in ways that were like to cation skills is shown for each child separately. Fig. 6
affect progress. Child C was born profoundly deaf shows development for child C, and Fig. 7 for child
and received her implant at 19 months, when full R. Child C shows a decrease in gestural turns which
insertion of the electrode array was achieved. Child start at 60% prior to implant, and decreased to zero
R was born hearing, and became deaf due to menin- by 12 months after implantation. However, vocal
gitis, which also resulted in cerebral palsy. She turns and non-looking vocal turns (NLVT) increase
received her implant at 10 months but only partial over the 12-month period. By contrast, although
insertion of the implant was achieved. Significantly, child R increases her vocal turns over the same
she was younger at the time of the various assess- period, she still uses gestural turns and has not
ments than child C. developed non-looking vocal turns. The relationship

Fig. 3 Progress of children C and R using categories of Fig. 5 Progress of children C and R using Meaningful
auditory performance (CAP). Auditory Integration Scale (MAIS).
184 T.P. Nikolopoulos et al.

Fig. 8 Progress of children C and R using Profile of Actual

Fig. 6 Child’s C progress using Tait Video Analysis. Speech Skills (PASS).

between the various turn-taking responses is com- monitor the pattern of the development of her
plex, but the analysis indicates that child C’s devel- listening and speech and language skills. The assess-
oping communication skills are encouraging, while ments lead us to have confidence of device func-
child R requires further careful monitoring. tioning, but the slow progress in some areas such as
Figs. 8 and 9 compare progress for both children no vocal indication of auditory processing or use of
using PASS and SIR, measures of speech production. auditory initiative indicate areas that need continu-
SIR measures at 6 months are not available. Neither ing monitoring. However, there are measurable
child has any intelligible speech before implant but changes, and it is particularly important in the case
child C shows progress over 12 months on both of slower progress to be able to document these
measures, and has some speech tokens before early indications that the implant is providing access
implant. One year after implant, she has progressed to sound.
to SIR category 3, which means she has speech
intelligible to an experienced listener. While child
R is beginning to develop speech tokens over the first 4. Discussion
12 months, she is not yet developing spoken lan-
guage and therefore remains at category 1 of SIR. NEAP offers a framework with which to assess lan-
This is consistent with her results of assessments in guage and communication in real-life situations. It is
the other two areas of communication and language innovative in design and offers a structured
development and of auditory perception. approach to the behavior of very young deaf chil-
Overall, child C is making good progress and we dren. Although designed for use within a cochlear
would expect this to continue, although of course implant programme, it can be used with a range of
monitoring will continue. Child R is making much deaf children where information is required about
slower progress than child C, and the assessments their development in auditory development and
will need to be used for at least a further year to speech production as well as aspects of communica-

Fig. 9 Progress of children C and R using Speech Intellig-

Fig. 7 Child’s R progress using Tait Video Analysis. ibility Rating (SIR).
Early assessment for hearing aids, cochlear implant 185

tion and language development. It also provides a information obtained from the assessments included
means of monitoring development both in the short in NEAP provide clear, objective and accessible
term, looking in detail at small changes in behavior; information on an individual child’s development.
and in the long term, looking at significant changes As a more general resource, it provides both parents
over time, an essential requirement when consider- and professionals with information on large groups
ing young deaf children. The package is not time- of children in terms of expected rate of progress as a
consuming and can be incorporated into standard basis for management decisions for an individual
practice and procedures. child. This information may also help highlight areas
NEAP includes observational reports involving in which progress does not meet expectations and
parents and other caregivers, with a focus on inter- which may need further investigation. For local
action. This means it does not depend only on professionals working with deaf children it is very
elicited behaviors which can be unreliable with very helpful to have means to measure change; one
young children. It is most suitable for deaf children strength of NEAP is that many of its measures can
from 12 months although there is some flexibility be used in a variety of settings, at home in the
and many of the assessments can be used from 6 nursery, or in school, where formal assessments are
months or even earlier. Some assessments are often not appropriate or are difficult to undertake.
designed to monitor progress in the short term Moreover most of the measures are easily under-
(TVA, LIP, PASS) although the actual age span over stood by non-professionals and can be translated
which they are used would depend on the develop- into other languages making international compar-
ment of the child. Other assessments, such as CAP, isons possible. The data obtained from the package
SIR, and SNAP, are designed to look at changes over also contributes to the more general information
the long term. required concerning the children’s progress for
Within the cochlear implant programme itself, audit and predictive purposes.
NEAP can be used to assist in the assessment of Although these measures are based on observa-
candidates for cochlear implantation. It is particu- tion, rather than formal testing and clinic-based
larly valuable with very young children and those assessments, they have been demonstrated to have
who are audiologically borderline. Following clinical application and to be robust. Reliability and
implantation it is also essential to monitor progress validity for many of them are well established as
in order to inform the tuning process. In young deaf described previously in this paper. Moreover, a num-
infants it is very difficult to monitor the functioning ber of the assessments have already been shown to
of the device, and one of the uses of this package is have the ability to predict outcomes and work con-
that it can help to identify areas of difficulty to tinues in this area.
explore further. NEAP has thus been shown to be innovative, time-
The package is useful because it focuses on a effective, user friendly, informative, reliable and
child’s strengths as well as weaknesses, providing a valid assessment for young deaf children with
comprehensive assessment as a basis for manage- cochlear implants. Because its strengths lie in the
ment. In addition, in monitoring the child’s devel- assessing of development of spoken language and
opment, it allows the identification of additional use of audition it is clearly significant for all young
problems and areas of difficulty as well as specific deaf children. However, it may need to be modified
abilities and skills. This enables the clinician to in some circumstances. In other contexts a more
determine appropriate intervention strategies, detailed look at language development would
and modify them according to the observed pro- require the assessment of sign language skills and
gress. It also provides indications of where other the use of gesture and vision in communication. A
assessments may be necessary to explore areas of more comprehensive assessment would require
difficulty further. For example, a child may not be assessment of cognitive development and consid-
demonstrating good auditory skills, but communica- eration of symbolic and other play and social and
tion skills not be developing as expected, warrant- emotional development. In future it may be possible
ing further investigation. In another child, auditory to extend NEAP to cover these areas.
and communication development may be progres- In this paper we demonstrated the use of NEAP
sing well but no speech be emerging, again requiring with two significantly different young children and
further, more detailed, assessment. shown its sensitivity in monitoring changes in devel-
Clear information about a young deaf child’s opment. The use of a variety of assessments allows a
progress is needed for a number of purposes. For more comprehensive view of the child and their
example, parents of young deaf infants require strengths and weaknesses. Such profiles can alert
information on which to base the decisions they us to any particular problems or areas requiring
make about the management of their child. The further investigation.
186 T.P. Nikolopoulos et al.

performance in young implanted children, Deaf Educ. Int.

Acknowledgements 2 (3) (2000) 142—151.
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