Computer-assisted reading intervention for children with sensorineural hearing loss using hearing aids: Effects on auditory event-related potentials and mismatch negativity

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Abstract

Objectives

The primary aim was to investigate whether computer-assisted reading intervention somehow can affect event-related potentials (ERP) and mismatch negativity (MMN) in hearing impaired (HI) children with hearing aids (HAs) and normal hearing (NH) children.

Methods

The study included 15 HI children with sensorineural hearing loss (SNHL) using bilateral HAs and 14 NH children as a reference group; all children between the ages of 5 and 8. A multi-feature MMN-paradigm, Optimum-1, with a standard stimulus alternating with 5 different deviants was used. ERPs were recorded pre and post intervention, i.e. one month of repeatedly computer-assisted training (GraphoGame). MMN was calculated from the average ERP of each deviant minus standard. Data were based on samples within a specific time interval, 80–224 ms, and repeated measures ANOVA was used to analyze possible interactions.

Results

There was a significant difference between groups before training, though, the mean obligatory responses or MMN was not statistically significantly different before versus after training, neither among the NH nor the HI children. Further, the HI children did generally achieve lower levels in GraphoGame compared to the NH children. Altogether, our findings indicate differences between the groups and that training may affect the neurophysiological processing in the brain, gaining the HI children. Both MMN and positive mismatch response (pMMR) were seen among both the HA and NH children, irrespective to deviant type. Individually, changes of the MMN and pMMR after training seem unpredictable.

Conclusion

There are statistically significant differences in both the obligatory responses in ERP and the MMNs between the NH and HI groups before the computer-assisted training. Though, these differences disappear after the intervention. This suggests possible training effects regarding the central auditory processing among the HI children.

Introduction

Children with a sensorineural hearing loss (SNHL) using hearing aids (HAs), electrophysiological recordings and a computer-assisted reading intervention are the three main parts in this study. Here follows a background to each topic, starting with the hearing impaired (HI) children.

Children with hearing impairment show a generally reduced academic performance compared to normal hearing (NH) children, despite equal learning capacity [1]. Nearly half of the children with mild-to-moderate SNHL show phonological impairment [2]. Speech and language development in preschool children with a moderate to severe SNHL are delayed 1.5–2 years [3]. Neither HAs nor cochlear implants (CIs) can fully compensate this deprivation of auditory developmental processes. Thus, it is highly relevant to identify those HI children needing extra support and enhance their phonological processing ability. Training programs that address phonological skills could be of great value. A previous study has shown that a computer-assisted training of phoneme-graphene correspondence can improve phonological processing skills in some HI children [4]. Central auditory processing and changes related to training [5,6] can objectively be evaluated by event-related potentials (ERP) and mismatch negativity (MMN).

The MMN is a component of ERPs that was first described by Näätänen in 1978 [7], nearly 50 years after the first introduction of electroencephalogram (EEG) [8]. MMN is an automatic brain response to any discriminable change in auditory stimulation, irrespective of attention. MMN testing is time-consuming but thanks to the fast multi-feature paradigm called Optimum-1 [9] it is possible to record MMNs to five different deviant types (gap, intensity, pitch, location and duration) in a more feasible way. This paradigm enables studies of awake children [10] and it is also applicable on children with HAs [[11], [12], [13]]. Nowadays, guidelines and recommended recording conditions for MMN are compiled [14] along with practical toolkits [15].

MMN can be elicited with high reliability [16,17]. However, the MMN undergoes maturational changes during life. Considerable work has been made to outline the normal development; prior to birth [18], infancy and childhood [[19], [20], [21], [22]] and adolescence [23], to mention some. Amplitude and latency of the MMN change through development. However, Cheour inferred that MMN, in comparison with other ERP components, is quite stable during childhood [24]. Both a negative (i.e. a typical adult-like MMN) and a positive mismatch response (pMMR) are observed in 4- to 6-years old children, in fact, it is in general positive under the age of 5.5 years [21]. This positivity is not yet clearly understood but seems to reflect an immaturity and must not be mistaken for an inverted MMN. A more mature discrimination process is thought to have both an increased amplitude and an earlier latency in MMN and this might overlap and mask the pMMR [21,25]. The results regarding MMN in children are thus mixed and contradictory; despite the reliability of the method, there are difficulties in interpretation due to maturational changes.

MMN studies are being used to shed further light on several diseases, chiefly and above all, neuropsychiatric, neurological and neurodevelopmental disorders, for a review see Ref. [26]. One specific example is children with reading-impairment, i.e. dyslexia [[27], [28], [29], [30]], for a review, see Ref. [17]. An immaturity of auditory processing is thought to underlie poor language abilities in some children with specific language impairment [31]. Abnormal ERPs are also seen in congenital deaf children [32] and a delay, or deficit, in central auditory processing also exists in children with peripheral hearing loss [12]. The presence of either MMN or pMMR (half of each) is also shown in terms of HI children with HAs [13]. Yet, the studies using MMN to access the central auditory processing in HI children are still scarce. In summary, the development, or maturation, of the ERPs and MMN component complicates interpretation of data and it is essential to take this into account when considering atypical or absent MMNs in medical conditions. Reverse the issue, more knowledge about different medical conditions might help us understand the normal complexity better.

A computer-assisted reading intervention with a phonics approach, GraphoGame, is a child-friendly computer game, which aims to help children with the learning-process of reading [33]. GraphoGame has been evaluated regarding its effectiveness for reading development and has been found to be beneficial for children at risk for reading difficulties [34], and dyslexia [35,36]. It focuses mainly on phoneme-graphene correspondence training. GraphoGame is available on the internet and the children can do the training at home, supported by their parents. GraphoGame enables an individual intervention, since it adapts itself to each child's level of performance. The game starts with basic letters and sounds. Gradually, the child learns how to combine letters into words. GraphoGame has been translated into standard Swedish, a Germanic language [36]. The Swedish version is structured in three themes and ends with seven-letter words including initial consonant clusters and bi-graphs. It is suitable for beginning readers and one of the reasons it is fitting the children in present study, see Refs. [4,37].

Changes in MMN after phonological training have been seen in NH adults [5] and MMN has been enhanced after audiovisual training in dyslexic children [6]. Together, it is reasonable to believe that ERP and MMN changes might be detectable in HI children accomplishing a reading program with a phonics approach. Moreover, a likely assumption is that the normal age-related maturation of ERPs and MMN will not interact with possible changes during a relatively short training period (one month). Thus, the aim of this study is to investigate whether a computer-assisted training program (GraphoGame) can affect ERP and MMN in HI children with HAs. NH children are tested as a reference group.

Section snippets

Eligibility and recruitment

This study, focusing on electrophysiological recordings in HI children with HAs, is part of a more comprehensive intervention study, which also included deaf children with CIs. Despite ERP recording, emphasizing not only MMN [13] but also N400 [38], behavioral effects and phonological processing skills were studied [4,37,39,40], and, in addition, there was a three-year follow-up.

In total, 138 medical notes of 5–7 years old HI children were studied at the Department of Audiology and Neurotology,

Results

The results of the obligatory responses in ERP and the corresponding MMN are presented separately below. The results are compared between the groups (NH and HI children), training (before and after), and all stimuli (standard and deviants; gap, intensity, pitch, location and duration) have been taken into consideration. No significant correlations, such as sex, age, age of hearing, hearing thresholds or type of hearing loss were observed, no matter obligatory responses in ERP, MMN or

Discussion

Based on recordings of ERPs and MMNs using the fast multi-feature paradigm Optimum-1 [9], our overall results suggest that there are no significant changes after computer-assisted phonological training. However, our findings imply differences between the HA and NH groups. There was a statistically significant difference in both obligatory responses and MMN between groups before training, but this difference disappeared after training. One explanation might be the better preconditions to hear

Conclusion

The main findings in our study are the statistically significant differences in both the obligatory responses in ERP and the MMNs between the NH and HI groups before the computer-assisted training, which, disappear after the intervention. This suggests possible training effects among the HI children, even if we cannot statistically prove any changes after training in each group. The number of HI children with HAs is limited overall, which hamper the possibilities of statistically significances,

Conflicts of interest

No conflict of interest is declared, including financial, personal, or other relationships with other people or organizations for any of the authors in this study. All authors have approved the final article.

Funding

This work was supported by the Swedish Research Council for Working Life and Social Sciences (Forskningsrådet för Arbetsliv och Social Vetenskap); Linnaeus Centre HEAD at Linköping University; and Cognition, Communication and Learning (CLL) at Lund University. EE was also supported by the Foundation of Helga Hjerpstedt/Swedish Association for Otorhinolaryngology Head and Neck Surgery (SFO-HH) and by a grant from the Foundation of Hearing Research, Hörselforskningsfonden, Hörselskadades

Acknowledgements

The authors want to thank the Phonetics Laboratory at the Department of Linguistics, Stockholm University, the Humanities Laboratories at Lund University, Professor Risto Näätänen for giving access to Optimum-1 and the developing team of the GraphoGame at the University of Jyväskylä.

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    1

    Present address: Department of Neuroscience, Unit for Speech and Language Pathology, Uppsala University, BMC, Box 593, 751 24 Uppsala, Sweden.

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