Abstract
Outcomes of cochlear implantation (CI) are generically assessed using standard validated measures like CAP, SIR, MAIS and MUSS scales. Although this reflects the improvement in auditory verbal skills among the implantees with habilitation over one year, the overall perception of their skill development may vary between the parents of these children and the clinicians who provide the habilitation. This study aimed to compare the CAP and SIR scores sequentially over habilitation and further analyzes the correlation between clinician assessment (with CAP/SIR scores) and parental perspective (with MAIS/MUSS scores), at the end of one year of habilitation. 388 children aged 1–6 years who underwent unilateral CI were included in the study. Their baseline CAP and SIR scores were recorded post implantation. All children received 1 year of intensive auditory verbal therapy and their 12 month CAP, SIR, MAIS and MUSS scores were then recorded. The baseline CAP/SIR scores were compared with 12 month CAP/SIR scores and then their 12 month CAP/SIR scores were correlated with 12 month MAIS/MUSS scores respectively. There was significant difference between baseline and the 12 month CAP/SIR scores (p < 0.001). There was strong positive correlation between CAP and SIR scores after 12 months of habilitation (r = 0.7), while there was moderate positive correlation between CAP and MAIS scores (r = 0.59) and between SIR and MUSS scores (r = 0.49) respectively. Though the parents note significant improvement in child’s communication abilities, the parental perspective of final outcomes does not always match with the clinician’s assessments at the end of habilitation, as highlighted by the moderate correlations. A more precise method of holistic assessment is lacking currently and stands warranted.
Keywords: Cochlear implant (CI), Categories of auditory performance (CAP), Speech intelligibility rating (SIR), Meaningful Auditory Integration Scale (MAIS), Meaningful Use of Speech Scale (MUSS)
Introduction
Cochlear implantation (CI) is established as the standard of care for restoration of hearing in children with bilateral profound hearing loss. Clinical outcomes following CI is measured by scoring systems like CAP [1] (Categories of auditory performance) for audiological outcome and SIR [2] (Speech intelligibility rating) for speech outcome. There are other outcome measures which are parental perspective based namely, MAIS [3] (Meaningful Auditory Integration Scale) and MUSS (Meaningful Use of Speech Scale).
These various outcomes may vary among children at the end of auditory verbal habilitation. The parental perspective outcomes are not always in agreement with the clinician’s perspective, resulting in disparity between the various scoring scales. There have been studies done earlier to assess parental satisfaction after implantation, to highlight this issue. The objective of this study was to study the correlation between the clinician and parent perspective of outcomes, based on the four scoring systems and infer upon the strength of association between these scales.
Study Method
The study was conducted at a tertiary care cochlear implant center. 388 children who underwent cochlear implantation at the center were included in the study. All children had hearing loss and speech, language delay. The age of children ranged from 1 to 6 years (Mean = 3.5 years). All children had normal inner ear anatomy and no other associated disabilities apart from deafness. They underwent unilateral cochlear implantation under general anaesthesia uneventfully. The standard procedure of 'switch-on' of CI was done after 3 weeks. Their baseline CAP and SIR cores were recorded. All children underwent regular auditory verbal habilitation for one year 'in-house' in the CI clinic under experienced professionals. Their CAP, SIR, MAIS and MUSS scores were recorded after completion of a year of habilitation. The baseline CAP and SIR scores were compared with their 12 month scores using paired t-test. The CAP scores were correlated with corresponding SIR scores. CAP scores were then correlated with MAIS scores and similarly the SIR scores were correlated with MUSS scores at 1 year post-habilitation. Results were tabulated by the biostatistician and conclusions derived to assess the strength of association between the clinical and parental scores.
Results
The average baseline CAP score was 0.52 (at switch-on) and this score at 12 months was 4.52 (p < 0.01)—Table 1. Similarly the baseline SIR at switch-on was 0.5 and at 12 months it was 3.49 (p < 0.01)—Table 2. There was a strong positive correlation between CAP scores and SIR scores at 12 months of habilitation (r = 0.78). The average MAIS & MUSS scores at 12 months is depicted in Table 3. There was a moderate positive correlation between CAP and MAIS scores (r = 0.538) and similarly, to a lesser extent there was a moderate positive correlation between SIR and MUSS scores (r = 0.49)—Table 4.
Table 1.
Mean values of Baseline and 12 month CAP scores
| SCORE | Baseline CAP | 12 Month CAP | |
|---|---|---|---|
| Mean values | 0.525773 | 4.520619 |
Table 2.
Mean values of Baseline and 12 month SIR scores
| SCORE | Baseline SIR | 12 Month SIR |
|---|---|---|
| Mean values | 0.51546 | 3.497423 |
Table 3.
Mean values of MAIS and MUSS scores at the end of 12 months
| SCORE | MAIS | MUSS |
|---|---|---|
| Mean values | 32.80412 | 23.71649 |
Table 4.
Correlation between the clinical and parental scores
| 12 month mean Clinical Score |
12 month Mean Parental Score | Correlation coefficient (r) |
|---|---|---|
| CAP (4.520619) vs | MAIS (32.80412) | = 0.53832607 |
| SIR (2.497423) vs | MUSS (23.71649) | = 0.492797284 |
Discussion
Outcomes following CI depend on various factors of which the most important is intensive speech and language habilitation. It is important to ensure that children attend therapy classes regularly and also their progress needs to be periodically assessed through standardized scoring methods. The commonly used clinical scales by the habilitationist to measure audiological outcome is CAP [1] (Categories of auditory performance) score and similarly SIR (Speech intelligibility rating) is a scoring method to measure speech outcome. [2]
MAIS and MUSS, are standardized parental reporting scales [3] which help to evaluate a child's auditory and speech abilities in a meaningful, real-world situation from the parental perspective. The MAIS mainly concentrates on auditory behavioural information, whereas the MUSS is based on the speech production behaviour.
In the current study it was noticed that the CAP scores at the end of 12 months of habilitation were greater than the baseline CAP scores and similarly the 12 month SIR scores were greater than the 12 month SIR scores which shows that CI significantly improves audiological and speech outcomes in children over the period of intensive habilitation. A study by Beadle EA et.al [4] had a similar result where they found that cochlear implantees showed significant progress in speech perception and production with habilitation. The positive correlation between the CAP and SIR scores at the end of 12 months shows that the speech outcomes directly depended on audiological outcomes, which forms the basis of combined auditory-verbal therapy. However, the degree of improvement in the auditory verbal skills differed from child to child and the parental perception of the child’s progress does not always agree with the scoring given by the clinician. [5] Hence the MAIS and MUSS scores (parental questionnaires) are utilized to indicate the parental perspective of audiological and speech outcomes of the child respectively. [5, 6]
In the study, CAP scores were correlated with MAIS and SIR scores with MUSS respectively, to identify a moderate positive correlation, implying that improvement in communication skills was perceived by both clinicians and parents, but the degree of improvement from the clinician’s perspective was not exactly the same but different from the parents’ perspective. This may be due to two reasons, one being parents see their children all day and have a better perspective of their child’s performance under different circumstances including natural environments, whereas the clinician gets a very short time to assess the child who maybe in a not so comfortable mood or environment to produce the best outcomes.
The other reason is the varied expectation of parents. Parents with higher intellect, motivation and understanding who had been counseled well preoperatively knew what to expect of their child at different intervals of therapy and they were found to be more in tune with the clinician's scoring. A study by Hyde et al. [7], which studied the comparison of preoperative and postoperative experience of parents of cochlear implantees showed that most patients felt that their expectations were met after the procedure. The importance of preoperative counseling by health professionals to have realistic expectations is thereby paramount. A study by Dev et al. [8], which analysed parental perspectives with CI showed that 50% of parents felt their child had some difficulty in hearing, but were able to lead life as a near-normal child, while 30% felt their child was like any other normal child after implantation. According to a study by Christiansen et al. [9], a large proportion of parents were satisfied with their child’s performance after CI, but they observed that it takes time to notice improvement in the child's communication ability after implantation and that the parental satisfaction was largely dependent on their preoperative expectations. A similar study by Pinto et al. [10], comparing Infant Toddler-MAIS and MUSS responses with simultaneous video recording of children showed that the MAIS scores correlated well as per the video, but there was a deviation in the MUSS responses with video observation.
In this study, the MAIS and MUSS scores were used as guides to parental perspective as these are based on parent questionnaires and are proven to be valid and reliable [11]. Looking at their moderate correlation to the clinician's CAP and SIR scores, we infer that the currently existing clinical and parental scoring systems are not perfect and there should be future focus on developing a comprehensive universally accepted precise scoring system which will encompass both clinician's as well as parent's perspectives for assessing auditory and speech performance outcomes of cochlear implantation.
Conclusion
CI improves audiological and speech abilities of children significantly, when intensive auditory verbal therapy is provided in a systematic and customized way. The role of the habilitationist along with parental support are both essential to achieve the best outcomes. Both clinicians and parents note significant improvement in audiological and speech performance, but the degree of improvement varies among children. Also, the degree of improvement according to clinicians may not be the same as that perceived by parents. Hence, a universal scoring system needs to be developed to take into consideration both the clinicians and parental inputs together, to precisely conclude on the holistic improvements achieved by the child at the end of auditory-verbal habilitation.
Funding
No funding received.
Compliance with ethical standards
Conflict of interest
All authors declares that have no conflict of interest.
Ethical approval
Approved by institutional ethics committee.
Footnotes
Publisher's Note
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