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Year : 2017  |  Volume : 23  |  Issue : 4  |  Page : 244-246

Optimizing outcomes in pediatric cochlear implant recipients with coexisting attention deficit hyperactive disorder

Department of ENT and HNS, Army Hospital (R&R), New Delhi, India

Date of Web Publication2-May-2018

Correspondence Address:
Dr. Poonam Raj
Department of ENT and HNS, Army Hospital (R&R), New Delhi - 110 010
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.INDIANJOTOL_83_17

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Introduction: Speech language outcomes are often variable in hearing impaired children managed with cochlear Implantation. Co-existing Attention Deficit Hyperactive Disorder may be responsible in some cases. Active management of these cases may result in improved outcomes in terms of better speech language acquisition. This study compared the progress in speech language acquisition in paediatric cochlear implant recipients with coexisting ADHD before and after intervention with Behaviour Modification Therapy (BMT) and /or pharmacological treatment. Materials and Methods: The study group was of 20 hearing impaired children post cochlear implant with co-existing ADHD who did not show expected results with regular AVT for 3 months post implant. Management of ADHD was instituted as per laid down protocol and CAP scores were compared at 0, 3, 6, 9 and 12 months post implantation. The scores obtained were subjected to a Wilcoxon sign rank test and P value derived. Results: The CAP scores after the inclusion of treatment for ADHD showed a definite improvement with a highly significant P value. Conclusions: Variables such as co-existent ADHD must be actively looked for in hearing impaired children prior to surgery and. Appropriate treatment in the form of BMT and / or medication should be instituted to improve the performance.

Keywords: Attention deficit hyperactive disorder, behavior modification therapy, category of auditory performance, cochlear implant recipients, speech-language outcome

How to cite this article:
Mittal R, Raj P. Optimizing outcomes in pediatric cochlear implant recipients with coexisting attention deficit hyperactive disorder. Indian J Otol 2017;23:244-6

How to cite this URL:
Mittal R, Raj P. Optimizing outcomes in pediatric cochlear implant recipients with coexisting attention deficit hyperactive disorder. Indian J Otol [serial online] 2017 [cited 2023 Feb 6];23:244-6. Available from: https://www.indianjotol.org/text.asp?2017/23/4/244/231649

  Introduction Top

Hearing is critical for the development of speech, language, communication skills and learning.[1] Some hearing impaired children do extremely well while others derive suboptimal benefit from cochlear implants. Many factors are responsible for this difference in outcome including age at implant, pre- and post-implant rehabilitative therapy measures, and coexisting congenital morbidity. Attention deficit hyperactive disorder (ADHD) in the child could be one of these factors.

ADHD is the most common neurodevelopmental disorder in childhood affecting approximately 3%–5% of school-age children.[2] Children with hearing impairment may also have coexistent ADHD. These children may face difficulties in tasks that require a greater degree of sustained attention, inhibition, planning, and organization due to a breakdown of cerebral inhibitory and self-control mechanisms. In addition, central cognitive deficits in ADHD also negatively influence communication.[3] It is, therefore, obvious that outcomes with cochlear implant will be suboptimal in a hearing impaired child suffering from ADHD.

In this study, we have compared the progress in speech-language acquisition in pediatric cochlear implant recipients with coexisting ADHD before and after intervention with behavior modification therapy (BMT) and/or pharmacological treatment.

  Materials and Methods Top

This study was carried out at a tertiary care hospital with a comprehensive cochlear implant program. The study was approved by the institutional ethical committee of the tertiary care center where it was carried out. Written, informed consent was obtained from parents of all participating individuals. The work described was carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans.

The study group was derived from 186 children who received cochlear implant in the period from March 2013 to March 2014. All the recipients were implanted with Nucleus Freedom © implant with straight electrode array using posterior tympanotomy with cochleostomy surgical approach by various cochlear implant surgeons at our tertiary care center. These children were enrolled in the postimplant rehabilitation unit of our tertiary care hospital. The study design was an interventional before and after study.

The criteria used for inclusion to the study group were those pediatric cochlear implant recipients who did not show increase in scores on category of auditory performance (CAP) with 3 months of attending regular auditory-verbal therapy (AVT) sessions' postcochlear implant (on twice a week basis) and showed signs of inattention and hyperactivity. The recipients with incomplete electrode array insertion, inner ear malformation, additional comorbidities, and irregular in habilitation program were excluded from the study. Out of the 186 cochlear implant recipient children, 20 in the age range of 4–6 years with the mean age of 4.63 ± 0.61 years [Table 1] did not show any progress on CAP after taking 3 months of AVT postcochlear implant and showed signs of inattention and hyperactivity. These twenty recipients were referred to a child psychologist and pediatrician for the assessment and management of hyperactivity and inattentive behavior. The diagnosis of ADHD was made using criteria of the Diagnostic Statistical Manual Fourth Edition.[4] Depending on the opinion of the child, psychologist and pediatrician either BMT and/or pharmacological treatment (methylphenidate, 0.5–1.5 ml/kg) were provided to the children along with regular AVT sessions.[5] The progress of these 20 pediatric cochlear implant recipients was monitored using CAP score at intervals of 0, 3, 6, 9, and 12 months' postcochlear implant [Table 2]. These scores were subjected to the Wilcoxon signed-rank test and P value was obtained.
Table 1: Age distribution of 20 cochlear implant recipients who were given treatment for attention deficit hyperactive disorder

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Table 2: Category of auditory performance scores at various intervals of follow-up

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  Results Top

The CAP scores of the recipients after the inclusion of treatment for ADHD showed a definite improvement. The Wilcoxon-signed rank test showed a mean difference of 4.80, sum of positive ranks: 15.5, sum of negative ranks: 210, Z-value: −4.02, and P = 0.0002. Hence, there was a significant difference in the CAP scores before and after intervention with the treatment for ADHD.

  Discussion Top

Children with hearing loss face challenges in developing speech and language skills because of their inability to detect and hear acoustic-phonetic cues that are essential for speech and language acquisition. A hearing impaired child cannot acquire speech and language skills unless specialized methods are used. Cochlear implantation as a treatment option for hearing loss has opened up a new world of listening opportunities for hearing impaired children. A combined AVT with surgery increases the child's chances to benefit from the cochlear implant and helps him in acquiring superior speech and language skills. In this technique, the emphasis is made on listening and natural development of speech, language, and cognition.[6] However, AVT in hearing impaired children is extremely challenging and it becomes even more daunting in children with coexisting ADHD. ADHD may frequently be found to co-occur with language impairment and may play a large role in hampering normal acquisition of speech and language. In an epidemiological study, 30% of children with speech and language impairment had ADHD.[7] A prerequisite of speech and language acquisition is the ability of the child to be attentive toward language stimulation. Attention and central cognitive deficits in ADHD negatively influence the skills required to master communication.[3] This slows down the progress with AVT in pediatric cochlear implant recipients with ADHD.

The clinical evaluation of potential pediatric cochlear implant candidates involves professionals from otolaryngology, audiology, speech-language pathology, education, and psychology. There are various factors which affect the degree of postoperative benefit such as age at implantation and duration of nonstimulation of residual hearing. The symptoms of ADHD may not be apparent when the patient is in a highly structured settings or when engaged in an interesting activity. It is also difficult to observe these when rewards are frequently provided for appropriate responses. Symptoms are more observable in unstructured situations and in tasks requiring sustained attention. It is often difficult to confirm the diagnosis of ADHD in clinical settings.[8] This is especially true in children <3 years of age.[2]

Treatment planning for these children depends on the severity of involvement. The intervention can be in the form of BMT and/or pharmacological support.

In our study, 13 cochlear implant recipients diagnosed with ADHD were managed with BMT and AVT and the remaining 7 received pharmacological treatment and BMT along with similar AVT sessions. The decision to start pharmacological treatment (methylphenidate) or/and BMT was as per the National Institute for Health and Care Excellence guidelines.[5] With the inclusion of treatment for ADHD along with AVT, all the cochlear implant recipients responded well and the CAP scores improved significantly.

Treatment with behavioral management therapy involves identifying problematic behavior and the environmental conditions that evoke this behavior. A strategy is then devised to produce changes in the environment, which ultimately results in a desirable change in behavior. Methylphenidate is central nervous stimulant. Its action involves increasing attention span and decreasing restlessness in children and adults who are overactive, cannot concentrate for very long or are easily distracted, and are impulsive. Recent research suggests that the cerebral dopamine is the main target for methylphenidate in ADHD patients. The neurotransmitters, i.e., dopamine and norepinephrine appear to influence the underlying neurochemistry of ADHD patients. In patients with ADHD, the brain activity in areas controlling planning, attention, foresight considering alternative response, and behavioral inhibition is reduced. Both adults and children with ADHD have increased dopamine transporter binding ratios in the basal ganglia compared with normal participants. Feron et al. demonstrated a reduction of dopamine transporter activity with methylphenidate treatment by imaging the cerebral dopamine system using single-photon emission computed tomography. Methylphenidate had a positive effect on attention span and thus resulted in improved social behavior listening tasks of the reported cases.[9]

In our study, the progress of the cochlear implant recipients was monitored using the CAP score. It is a rating scale that is rapidly applied and assesses the child's auditory outcomes in everyday life situations. CAP scores are based on subjective assessment but have shown to have very high inter-user reliability.[10] Therefore, CAP scoring is a well-established reliable postintervention outcome measure in hearing impaired children.

  Conclusions Top

It is frustrating for both the parents and clinicians to see children who do not achieve the expected results in terms of speech language acquisition with AVT post cochlear implantation. Therefore variables such as co-existent ADHD must be actively looked for prior to surgery and parents must be counselled well in advance regarding expected outcomes. Appropriate treatment in the form of BMT and/or medication should be instituted to improve the performance in these children.

With increasing experience and improvement in technology, cochlear implant patient selection criteria have widened. Our experience shows that co-existent ADHD in children with hearing loss is not a definite contra indication to cochlear implantation. A delay the progress may be anticipated but if managed properly improved outcomes are very much achievable.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Yoshinaga-Itano C, Sedey AL, Coulter DK, Mehl AL. Language of early- and later-identified children with hearing loss. Pediatrics 1998;102:1161-71.  Back to cited text no. 1
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, D.C.: American Psychiatric Association; 2013.  Back to cited text no. 2
Redmond SM. Conversational profiles of children with ADHD, SLI and typical development. Clin Linguist Phon 2004;18:107-25.  Back to cited text no. 3
Patterson GR, Jones R, Whittier J, Wright MA. A behaviour modification technique for the hyperactive child. Behav Res Ther 1964;2:217-26.  Back to cited text no. 4
Kendall T, Taylor E, Perez A, Taylor C. Guidelines: Diagnosis and management of attention-deficit/hyperactivity disorder in children, young people, and adults: Summary of NICE guidance. Br Med J 2008;27:751-3.  Back to cited text no. 5
Lim SY, Simser J. Auditory-verbal therapy for children with hearing impairment. Ann Acad Med Singapore 2005;34:307-12.  Back to cited text no. 6
Beitchman JH, Hood J, Rochon J, Peterson M. Empirical classification of speech/language impairment in children. II. Behavioral characteristics. J Am Acad Child Adolesc Psychiatry 1989;28:118-23.  Back to cited text no. 7
Pundir M, Nagarkar AN, Panda NK. Intervention strategies in children with cochlear implants having attention deficit hyperactivity disorder. Int J Pediatr Otorhinolaryngol 2007;71:985-8.  Back to cited text no. 8
Feron FJ, Hendriksen JG, van Kroonenburgh MJ, Blom-Coenjaerts C, Kessels AG, Jolles J, et al. Dopamine transporter in attention-deficit hyperactivity disorder normalizes after cessation of methylphenidate. Pediatr Neurol 2005;33:179-83.  Back to cited text no. 9
Archbold S, Lutman ME, Nikolopoulos T. Categories of auditory performance: Inter-user reliability. Br J Audiol 1998;32:7-12.  Back to cited text no. 10


  [Table 1], [Table 2]


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