Writing could be one of the most complex tasks for all students, whether being normal-hearing or hearing-impaired students. For Mandarin Chinese students, who use a logographic orthography, they must know the correct spatial arrangements of strokes of a character, the conventions of punctuation, and the use of proper vocabulary and syntactical structures in order to write at a basic level. At a higher level, they have to choose topics and plan and organize their ideas [
It was indicated that early writing patterns during elementary school years are related to spoken language trends [
With the restoration of hearing via a cochlear implant (CI), it is expected that the improvements in spoken language may also lead to the improvements in other language skills such as writing. Spencer et al. [
The problem with written language was not necessarily eased with age. It was found that high-school students with CIs also spelled significantly poorer than the hearing peers, and less than 50% of them scored within 1 SD of the hearing group on the expository writing task [
Nevertheless, to date, most of the studies on the written language skills in the implanted population use only subjects with an alphabetic language background, such as English. There is hardly any study investigating the patient group that uses Mandarin Chinese, a logographical language. While the basic unit for writing in alphabetic languages is segments [
Therefore, this study aimed (1) to examine the narrative writing performance in Mandarin-speaking elementary-school students with cochlear implants and (2) to understand the family/child-related, implant-related, and language-related factors associated with less favorable writing performance.
Forty-five prelingually deafened patients (20 boys, 25 girls) who received CIs in our center participated in this study. They all met the inclusion criteria: (1) the subjects were in grades 2–6 of elementary school; (2) the subjects did not have any developmental problems or additional handicaps (e.g., intellectual disability, attention deficit, language disorders, learning disability, and autism); (3) the subjects used oral communication and Mandarin Chinese as their major language; (4) the subjects went to mainstream schools and were not placed in the resource class; (5) the subjects’ performance intelligence quotient [
The socioeconomic status (SES) of the family was determined based on the Hollingshead two-factor index of social status [
All informed consents signed by participants and guardians were obtained before the test procedures. The study protocol was approved by the Institutional Review Board, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.
The SPSS software (version 17.0; SPSS, Inc., Chicago, IL, USA) was employed to do the statistical analysis. The analysis of the written language ability was performed based on the ranges (normal range = 0; problematic range = 1) rather than on the
The implanted subjects averagely produced
Results of Written Language Ability Diagnostic Test in the children with cochlear implants.
Test results | Range | Mean ± SD |
---|---|---|
Total Number of Words | 22.0–314.0 | 127.0 ± 69.3 |
Total Number of Words ( |
32.0–56.0 | 40.9 ± 6.5 |
Total number of sentences | 3.0–32.0 | 13.2 ± 6.8 |
Words per Sentence | 6.6–13.0 | 9.5 ± 1.7 |
Words per Sentence ( |
35.0–59.0 | 44.7 ± 5.3 |
Morphosyntax ( |
10.0–63.0 | 51.6 ± 12.2 |
Semantics ( |
28.0–77.0 | 42.5 ± 11.3 |
Error rates of each of assessment items on the “Morphosyntax” subscale.
Addition | Omission | Substitution | Transposition | Total | |
---|---|---|---|---|---|
Diction (%) | 1.06 | 0.97 | 0.55 | 0.09 | 2.68 |
Miswritten words (%) | 0.06 | 0.07 | 0.63 | 0.00 | 0.77 |
Punctuation (%) | 0.09 | 1.35 | 0.74 | n/a | 2.18 |
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Total (%) | 1.21 | 2.40 | 1.92 | 0.09 | 5.62 |
Description of each level on the “Semantics” subscale and number (%) of cochlear implanted patients at each level.
Semantic level | Raw score | Number of children (%) | |
---|---|---|---|
(1) Nonsense | 0 | Daubing; nonsensical phrases; unrelated subject to the given picture. | 0 (0) |
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(2) Concrete description | 1 | Using a series of nouns. | 3 (6.7) |
2 | Using verb-noun structure to signal actions; using only one verb. | 6 (13.3) | |
3 | Using nouns, verbs (more than one), and adjectives; able to make categorization. | 11 (24.4) | |
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(3) Concrete imagination | 4 | With a main point and a structure; description of actions and feelings of people in the picture. | 7 (15.6) |
5 | With a consistent main point throughout the story and a better organized structure; description of actions, feelings, and relations of people in the picture. | 7 (15.6) | |
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(4) Abstract description | 6 | With some plot; describing people in the picture as a group. | 4 (8.9) |
7 | With a setting; the entire story being set in one single context (e.g., family, school, playground, and park); structuring the story based on what the storyteller feels and perceives. | 1 (2.2) | |
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(5) Abstract imagination | 8 | With a plot, which is developed based on the picture; description of how people in the story feel and their motivations of taking certain actions. | 3 (6.7) |
9 | Longer story with more details and a more complicated plot; able to show causal relationship; description of events that are imaginary or may happen in the future. | 1 (2.2) | |
10 | Description of abstract concepts that are beyond the picture contents; writing a prose/essay, exposition or fable rather than a story; expressing concerns about moral issues or welfare of human beings. | 2 (4.4) |
The CI subjects had
Individual standard scores for the four subscales of the Written Language Ability Diagnostic Test plotted for 45 children, with subscales including (a) “Total Number of Words,” (b) “Words per Sentence,” (c) “Morphosyntax,” and (d) Semantics. Horizontal lines indicate standard scores within 1 SD of the normal-hearing normative sample.
Stimulus picture for the Written Language Ability Diagnostic Test for children.
However, there were significantly more CI students in the problematic range (i.e., more than 1.5 SD lower than the normative mean) on the subscales of “Total N Words” (
Percentage of patients in the normal range and the problematic range on the four subscales of the Written Language Ability Diagnostic Test and a comparison between the distribution of cochlear implanted subjects and that of the normal-hearing grade-matched normative sample using chi-square goodness-of-fit test.
Subjects for comparison | Range | Total |
Words per Sentence (%) | Morphosyntax (%) | Semantics (%) |
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All subjects | Normal | 24.4 | 55.6 | 77.8 | 62.2 |
Problematic | 75.6 | 44.4 | 22.2 | 37.8 | |
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<0.001 | 0.049 | 0.208 | <0.001 | |
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Lower graders | Normal | 33.3 | 45.8 | 70.8 | 50.0 |
Problematic | 66.7 | 54.2 | 29.2 | 50.0 | |
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<0.001 | 0.01 | 0.85 | <0.001 | |
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Higher graders | Normal | 14.3 | 66.7 | 85.7 | 76.2 |
Problematic | 85.7 | 33.3 | 14.3 | 23.8 | |
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<0.001 | 0.809 | 0.099 | 0.002 |
Demographical data of the cochlear implanted subjects and the outcomes of language skill and speech perception measures.
Parameters | Mean ± SD | Median |
---|---|---|
Child/family-related | ||
Age at implantation (years) | 4.1 ± 2.1 | 3.3 |
Duration of CI use (years) | 6.5 ± 2.7 | 6.9 |
Grade | 4.2 ± 1.6 | 4.0 |
SESa | 2.3 ± 0.6 | 2.0 |
CAP | 6.2 ± 0.5 | 6.0 |
SIR | 4.7 ± 0.6 | 5.0 |
Language/speech-related | ||
Paragraph reading (%) | 59.9 ± 19.6 | 60.0 |
Word recognition ( |
51.4 ± 12.7 | 52.0 |
Receptive language ( |
49.0 ± 12.6 | 48.5 |
Expressive language ( |
52.4 ± 11.8 | 52.0 |
Receptive vocabulary | 90.0 ± 13.5 | 90.0 |
Word perception (%) | 85.7 ± 13.0 | 92.0 |
CI: cochlear implant; SES: socioeconomic status; CAP: Categorical Auditory Performance; SIR: Speech Intelligibility Rating.
aSES of the family (1 = low SES; 5 = high SES) was determined based on the Hollingshead two-factor index of social status that referenced to the parents’ occupational status (1 = unskilled workers; 5 = higher executives/major professionals) and educational level (1 = illiterate; 5 = with a graduate degree or above).
Criteria of Categorical Auditory Performance and Speech Intelligibility Rating scales.
Rating | Criteria of Categorical Auditory Performance | Criteria of Speech Intelligibility Rating |
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7 | Use of telephone with known listener | n/a |
6 | Understanding of conversation without lip-reading | n/a |
5 | Understanding of common phrases without lip-reading | Connected speech is intelligible to all listeners. Child is understood easily in everyday contexts |
4 | Discrimination of some speech sounds without lip-reading | Connected speech is intelligible to a listener who has a little experience of a deaf person’s speech |
3 | Identification of environmental sounds | Connected speech is intelligible to a listener who concentrates and lip-reads |
2 | Response to speech sounds | Connected speech is unintelligible. Intelligible speech is developing in single words when context and lip-reading cues are available |
1 | Awareness of environmental sounds | Connected speech is unintelligible. Prerecognizable words in spoken language, primary mode of communication may be manual |
0 | No awareness of environmental sounds | n/a |
n/a = not applicable.
The factors related to child/family characteristics and language/speech skills were entered into a binary logistic regression analysis. The child/family characteristics included age at implantation, duration of implant use, SES, CAP, and SIR scores. The language-related parameters included paragraph reading, Chinese character recognition, receptive vocabulary, receptive language, expressive language, and word perception. Results showed that lower scores of receptive language (i.e., lower than the median score = 48.5) were independently associated with problematic performance on the “Total N Words” subscale (
Although chronological age and grade were not taken into concern in the regression analysis, we still would like to know how written language ability was developed during elementary-school years in the implanted children. Therefore, the subjects were split into two groups according to their grades (median = 4): the lower graders (those who are in grades 2–4;
Written language ability is essential for academic performance. Yet, it has never been carefully examined in prelingually deaf CI children with a Mandarin Chinese language background. Our preliminary results show that, compared to normal-hearing grade-matched children, significantly more implanted children have problematic performance on “Total N Words” and “Semantics” during narrative writing. Their receptive language skills and auditory performance have a close association with these problems, respectively.
CI children’s narrative writing ability is examined from four perspectives, among which “Total N Words” seems to be the most problematic for the implanted students. Their production is significantly shorter than that of the normal-hearing children. This finding is in line with most of the previous studies on deaf and cochlear implanted children [
However, although the implanted children are less productive, it seems that they have no difficulty forming morphosyntactically correct sentences. Actually, almost 80% of our subjects show normal or better-than-normal performance on the “Morphosyntax” subscale. Only a mean error rate of 5.6% was found in all subjects (Table
This discrepancy occurs not only because our subjects have used the CIs for a long duration of 6.5 years averagely, but also very likely as a result of the logographic orthography used in Mandarin Chinese and the type of test applied in the current study. The written language test administered in this study focuses more on the morphology than the syntax on the “Morphosyntax” subscale. That is, it examines, firstly, whether the subjects make mistakes in words and punctuations and secondly, whether the error with words/punctuations is made because of addition, omission, substitution, or transposition. It remains unknown how well or erroneously these CI children manipulate different lexical categories, such as nouns, verbs, and adverbs, and different structures, such as interrogative and coordinate sentences.
Moreover, when these Mandarin-speaking students write in Chinese, they engage with logographemes rather than phonemes, so their auditory performance may not impede “spelling,” resulting in a mean miswritten word rate of only 0.8% (see Table
Another problem with the stories written by our CI students is that they tend to engage only with concrete description. That is, more than two-fifths (44%) of the subjects write a story that does not have a main point and is not well organized or consistent (Table
The lack of capability of developing a story and expressing themselves fully may be associated with their less satisfactory auditory performance, considering that the CAP score is an independently associated factor of “Semantics” subscale in this study. It suggests that the ability to express oneself and organize a story in writing may develop with the increase in auditory experiences. Special trainings may be needed to improve their narrative writing ability because children with CIs seem to develop such ability at a slower rate than the normal-hearing ones, resulting in their lower scores on this subscale throughout the elementary-school years.
It has to be noted, however, that the structure organization of the story was not taken into concern in the current study. We focus on the semantic and morphosyntactical levels to understand the basic writing ability in students with CIs. Yet, narrative production does have a close association with the ability of linguistic structure organization, that is, the ability to concatenate different parts into a story (e.g., a beginning, a conflict and a corresponding resolution, and an ending), and the productiveness of written narratives is related to the production of oral narratives, as our result shows. It is therefore of particular interest to learn the correlation between oral and written narratives on a discursive level of language in future studies.
Our preliminary results show that children with CIs tend to write shorter stories which are not well organized and without a plot. These weaknesses in narrative writing are associated with their poorer receptive language skills and auditory performance. However, their ability to formulate morphosyntactically correct sentences is as good as the normal-hearing grade mates. Specialists thus are suggested not to focus only on syntactical problems but also on the development of auditory perception and receptive language for they could be the underlying causes of the writing problems. Also, a test that more thoroughly examines different aspects of written language needs to be developed in the future in order to better evaluate the written language problems in Mandarin-speaking patients with CIs.
The authors have no conflict of interests relevant to this paper to disclose. The authors have no financial relationships relevant to this paper to disclose.
This study was supported by the Chang-Gung Memorial Hospital Research Program (CMRPG391121, CMRPG3B1143, and CMRPG3C1402). The authors would like to thank all the children and their parents who participated in the study.