Non-verbal
ment. This has been well established by animal experimentation
development of
children with deafness
with and without
cochlear implants
Emilie Schlumberger*;
Juan Narbona;
Manuel Manrique, Clínica Universitaria de Navarra,
Universidad de Navarra, Unidad de Neurología Pediátrica,
Pamplona, Spain.
*Correspondence to first author at Hôpital Raymond
Poincaré, Service de Médecine Physique et Réadaptation de
l’Enfant, 104 Bd Raymond Poincaré, 92380 Garches, France.
E-mail: emilie.schlumberger@rpc.ap-hop-paris.fr
Deprivation of sensory input affects neurological
development. Our objective was to explore clinically the role
of hearing in development of sensorimotor integration and
non-verbal cognition. The study involved 54 children (15
males, 39 females; 5 to 9 years old) with severe or profound
bilateral prelocutive deafness but without neurological or
cognitive impairment. Of these, 25 had received an early
cochlear implant (CIm). Patients were compared with 40
children with normal hearing. All were given a battery of
non-verbal neuropsychological tests and a balance test, and
were timed for simple and complex movement of limbs.
Deafness, whether treated by CIm or not, resulted in a delay
in development of complex motor sequences and balance.
Lack of auditory input was also associated with lower, but
non-pathological, scores in visual gnoso-praxic tasks and
sustained attention. Such differences were not observed in
children with CIm. Hearing contributes to clinical
development of spatial integration, motor control, and
attention. An early CIm enables good verbal development and
might also improve non-verbal capacities.
Developmental Medicine & Child Neurology 2004, 46: 599–606 599
Sensory perception is a determinant of neurological develop-
and clinical evidence on visual, tactile, and vestibulokines-
thetic modalities. The repercussion of auditory deafferenta-
tion on language development is clear, but there have been few
studies about the effects on extraverbal capacities.
In Europe the prevalence of neonatal cochlear hearing loss
is about 3 to 5 out of every 1000 live births, with a third of
these children having severe to profound bilateral congenital
hearing loss (Davis et al. 1995, Van Naarden et al. 1999). Even
in the absence of other neurological damage, and despite
specially designed educational intervention, deafness is fre-
quently the cause of low academic achievement (Rapin 1979,
Denoyelle et al. 1999). Considerable efforts have been made
over the past few decades to improve the early detection of
deafness (American Academy of Pediatrics 1999), and this has
led to better results from therapeutic interventions from a
young age (Yoshinaga-Itano 1995, Samson-Fang 2000).
It is commonly accepted that motor development is slow-
er in children with deafness, in terms of both coordination
(Myklebust 1964) and speed of movement (Wiegersma and
Van der Velde 1983). The neuropsychological features of
congenital deafness have been studied extensively in adults
and most of the studies deal with visual perception (Neville
and Lawson 1987): the principal support for communication
skills in those with deafness.
A cochlear implant (CIm) can restore the auditory input to
the developing brain. Svirsky (2002) and many others have
reported promising results in terms of improvement in recep-
tive and expressive language in children with deafness who
were given an early CIm combined with subsequent speech
therapy. So far there have been no studies on the repercussions
of CIm on cognitive extraverbal or fine motor development.
The aim of this work is to investigate clinically the neuro-
logical and neuropsychological development of children
with deafness – excepting verbal development – whether they
received an early CIm or not.
Method
The ethics committee of the University Clinic of Navarra
approved our research protocol. All parents gave their informed
consent. The children participated freely in all tasks.
PARTICIPANTS
The study included 94 children, 54 of whom had prelocutive,
bilateral, severe or profound hearing loss defined in accordance
with the norms of the Bureau International d’Audiophonologie
(hereafter we shall use the term ‘deafness’); the remaining 40
were a comparison group of children with normal hearing.
The sample was divided into three groups which are detailed
in Table I. Group A contained 29 children with deafness
between 5 and 9 years of age who were mainly recruited from
outside the region served by Navarra University Hospital. All
children were diagnosed as severely or profoundly hypoacusic
before 2 years of age. All except four children had been enrolled
in early intervention programmes, had begun using hearing
aids soon after diagnosis, and attended regular kindergarten or
school with speech therapy support. Exclusion criteria were
known neurological impairment, or learning disabilities*.
Four of the children in this group underwent motor skill tests
*US usage: mental retardation.
but were excluded from the rest of neuropsychological study
because they did not receive regular schooling.
Group B consisted of 25 children with deafness and the
same age characteristics as those in group A, but group B had
received a CIm and a subsequent intensive speech therapy pro-
gramme. Median age at implantation was 26 months (range 12
to 39 months). Implants were Nucleus 22 or 24 (Cochlear Ltd,
New South Wales, Australia). The coding strategy of the CIm was
spectral-peak (SPEAK). This group comprised all the children
(except one) on the CIm programme at our centre who met the
inclusion criteria.
Group C comprised 40 children with normal hearing
recruited in a local school following authorization by their
parents. Distribution in the different parameters (sex, educa-
tional status of the family, age) allowed a comparison with
group A and B.
Distributions of age, sex, and family education level of the
three groups can be seen in Table I, and diagnosis of deafness
in Table II.
The study was undertaken during the decade in which
cochlear implantation was being adopted in Spain, and
Navarra University Hospital has been a pioneer in the early
application of this technique. This explains why group B chil-
dren received a CIm whereas group A, who had the same
hearing loss characteristics but were mainly recruited from
other regions of Spain, did not.
Familial educational status was categorized as ‘high’ if both
parents had completed university education, ‘medium’ if
both parents had completed secondary education, and ‘low’
if neither parent had completed secondary education. There
is a difference in family cultural/educational levels between
groups A and B: more children with low familial educational
level were in group A and more children with high parental
educational level were in group B. This is an unavoidable
consequence of the method of recruitment (families educat-
ed to a higher level are presumably more likely to demand and
obtain a CIm for their children with deafness). However, we
believe that this difference in cultural level is not relevant to
our results, because of the good quality of special education
resources for all children with deafness in Spain. We know
that the rehabilitation programmes received by both groups of
children with deafness were excellent. The comparison group
lay at an intermediate point between the two other groups in
terms of educational status. The non-verbal IQ determined by
the Raven’s Standard Progressive Matrices test (Raven 1967)
was not different after grouping our participants according to
low, medium, and high parental educational levels.
MEASURES AND ASSESSMENT
Medical records for children in groups A and B were reviewed,
in particular for information about the aetiology of deafness
and age at walking. Children underwent a classical general
neurological examination, to which we added special tasks
(Table III) to evaluate maturation of balance and motor con-
trol. The ‘coordination of legs’ subtest of the McCarthy’s
Scales of Children’s Ability (McCarthy 1972) provided a score
of balance (0 to 13 points). We also used the revised Physical
and Neurological Examination for Soft Signs (Denckla 1985)
to quantify the speed of repetitive, alternating, or sequential
movements of limbs.
The protocol for evaluating cognitive function included non-
verbal IQ measurement and tests of visuospatial perception,

Table I: Characteristics of children according to hearing status, n (%)

Group Sex Educational statusa Age (years)

Males Females Low Medium High 5–<6 6–<7 7–<8 8–9

Group A (–CIm) 7 (24) 22 (76) 18b (56) 6 (24) 5 (20) 8 (28) 6 (21) 7 (24) 8 (27)
Group B (+CIm) 8 (32) 17 (68) 5 (20) 7 (28) 13 (52) 13 (52) 4 (16) 2 (8) 6 (24)
Group C (Comp) 15 (37.5) 25 (62.5) 19 (47) 10 (25) 11 (28) 17 (43) 8 (20) 5 (12) 10 (25)
aEducational status of child’s parents. bFour children in this group were not considered for neuropsychological evaluation because they did

not receive regular schooling. Group A (–CIm), children with deafness; Group B (+CIm) children with deafness and cochlear implant; Group
C (Comp), comparison children with normal hearing.

Table II: Diagnosis of children with deafness

Age (years) Group A Group B

5 7? 10?
1 genetic: deaf parents 1 Waardenburg syndrome
2 genetic: deaf brothers
6 4? 3?
1 genetic: deaf brothers 1 bilateral otitis Pseudomonas and cholesteatoma
1 intrauterine growth retardation
7 6? 1?
1 genetic: deaf brothers 1 meningitis Haemophilus influenzae
8 3? 2?
2 genetic: deaf parents 1 preterm
1 cochlear malformation
9 1? 2?
1 genetic: deaf parents 1 genetic: deaf brothers

Question marks indicate unknown cause of deafness (likely to be genetic).

600 Developmental Medicine & Child Neurology 2004, 46: 599–606

executive function, and visual memory. We used tests that
were appropriate for the child’s age, had been validated for
the Spanish population, and that the children could under-
stand easily without oral instructions. The complete protocol,
described in Table IV was performed by the same person (ES)
for each of the children, usually in a single session. In accor-
dance with our focus in this study on non-verbal skills, lan-
guage abilities will not be discussed here.
Results pooled for each of the three groups were com-
pared by using a two-way analysis of variance with the Tukey
or the Tamhane correction for multiple comparison. In order
to detect maturational changes over time, between group dif-
ferences for children younger than 7 years old and between
group differences for children that were 7 years old or more
were calculated.
To detect more general differences between groups, facto-
rial analysis was applied to the data from both the motor and
neuropsychological tests. As usual, the correlation matrix was
considered adequate if the Kaiser–Meyer–Olkin index was
greater than 0.8. Values of measures of sampling adequacy
for each variable were accepted if greater than 0.5. The three
groups of children were compared for factorial scores with
an analysis of variance. Results were considered significant
when p≤0.05. All statistical analysis was performed with SPSS
(version 10.0).
Results
MOTOR TESTS
Age at walking
The age at which the comparison group started walking (group
C; 11.8 months, SD1.2) was earlier than that for children with
deafness (groups A and B; 14 months, SD2.8; p<0.001). This
was still true even after excluding four children with deafness
who learned to walk only after the age of 18 months (p<0.001).

Table III: Motor tasks

Balance: leg coordination subtesta

Action

Walking forward
Walking on toes
Walking on a line
Standing on right leg
Standing on left leg
Jumping alternately from one leg to the other
Time performance: feet, hands, and fingersb Label used in text and Table V
Action (Twenty repetitions)

Repetitive movements
Foot: tapping of forefoot on floor T1 (right foot), T2 (left foot)
Hand: tapping with one hand on knee T5 (dominant hand), T6 (non-dominant hand)
Finger: tapping thumb and index T9 (dominant hand), T10 (non-dominant hand)
Alternating movements
Foot: heel–toe alternations on floor T3 (right foot), T4 (left foot)
Hand: pronation and supination T7 (dominant hand), T8 (non-dominant hand)
Sequential movements
Fingers: opposing each finger with thumb in sequence T11 (dominant hand), T12 (non-dominant hand)
aMcCarthy’s Scales of Children’s Ability (McCarthy 1972).
bRevised neurological examination for subtle signs (Denckla 1985).

Table IV: Protocol for evaluation of neurological and neuropsychological capacities

Capacity Test

General intelligence Raven’s Standard Progressive Matrices (Raven 1976)

Visuospatial gnosias and constructive praxias Visual Perception (Colarusso and Hamill 1980)
Visual Understanding, ITPA (Von Isser and Kirk 1980)
Visual Association, ITPA (Von Isser and Kirk 1980)
Copy Drawing (McCarthy 1972)
Draw a Child (Harris 1982)a
Copy of Rey’s Figure (Rey 1959)b
Executive function Mazes (Wechsler 1949)
Visual memory Visual Span, ITPA (Von Isser and Kirk 1980)
Reproduction of Rey’s Figures (Rey 1959)b
Handedness Edinburgh Inventory, modified (Oldfield 1971)
aChildren under 7 years old. bChildren 7 years old or more. ITPA, Illinois Test of Psycholinguistic Abilities.

Non-verbal Development and Deafness in Children Emilie Schlumberger et al. 601

Balance
The comparison group (group C) had better balance than
children with deafness (groups A and B; p<0.001). When
balance was compared separately for the children younger
than 7 years old and those 7 years old or more, the compari-
son group had better balance than children with deafness
and without CIm (group A; p=0.005) but there was no differ-
ence between the comparison group and children with CIm
(group B) in either age range.
Repetitive, alternating, and sequential movements of limbs
The three groups of children showed rapid increases in veloci-
ty of movement with age. Exhaustive results of the comparison
between the three groups can be seen in Table V. When move-
ment was compared separately for children younger than 7
years old and 7 years old or more, children in group C were
faster at certain repetitive and sequential movements than
children in group A (see T3, T4, T5 and T6 in Table V). There
was no such significant difference between other groups.

Table V: Timed movements. Comparison of three groups: those with normal hearing, those with deafness and cochlear implants,
and those with deafness but no cochlear implant

Timea (s) <7 years old ≥ 7 years old

Comparison +CIm –CIm p Comparison +CIm –CIm p
(n=25) (n=17) (n=13) (n=15) (n=8) (n=15)

T1 8.65 (2.09) 9.07 (2.25) 9.05 (2.71) 0.810 6.40 (1.21) 7.25 (1.67) 7.62 (1.69) 0.092
T2 9.32 (2.56) 10.18 (1.72) 10.27 (3.14) 0.417 6.78 (1.27) 7.12 (1.42) 8.21 (2.34) 0.096
T3 14.43 (3.44) 13.41 (2.87) 14.64 (3.78) 0.531 9.25b (2.03) 11.03 (2.97) 12.46b (2.90) 0.007
T4 14.28 (3.70) 15.56 (4.08) 14.91 (3.18) 0.547 10.13b (1.69) 12.12 (1.75) 12.38b (2.34) 0.009
T5 5.73b (1.02) 6.39 (1.13) 7.03b (1.41) 0.005 4.24b (0.52) 5.00 (1.12) 5.13b (0.59) 0.004
T6 6.40b (1.06) 7.32 (1.42) 7.38b (1.49) 0.031 5.06 (0.84) 5.47 (1.02) 5.72 (0.90) 0.141
T7 9.09 (1.59) 9.15 (1.44) 9.27 (2.28) 0.898 7.31 (1.13) 6.67 (0.87) 7.29 (1.44) 0.442
T8 8.95 (1.26) 9.88 (1.82) 9.66 (2.02) 0.275 7.74 (0.85) 7.48 (1.39) 8.14 (0.98) 0.325
T9 7.26 (1.09) 8.00 (1.47) 7.74 (1.27) 0.232 6.08 (0.68) 5.93 (0.94) 6.35 (0.95) 0.472
T10 7.91 (0.89) 7.96 (0.99) 8.41 (1.56) 0.870 6.84 (0.93) 6.70 (1.11) 6.82 (1.02) 0.950
T11 14.15 (3.19) 15.09 (3.88) 16.70 (4.04) 0.148 11.08 (2.66) 11.94 (2.20) 12.22 (2.23) 0.422
T12 14.75 (2.08) 14.07 (3.35) 16.86 (4.38) 0.062 10.59 (2.32) 12.63 (2.00) 12.14 (2.49) 0.091

Numbers in parentheses are standard deviations; p values refer to comparison of three groups.
aRefer to Table III for key to T1–T12. bTwo groups are significantly different. Comparison, comparison children with normal hearing (group C).

+CIm, children with deafness and cochlear implant (group A); –CIm, children with deafness and without CIm (group B).

2.0 2.0

1.0 1.0
Factorial score
Factorial score

0.0 0.0

–1.0 –1.0

–2.0 –2.0
n= 25 16 12 15 8 15 n= 25 16 12 15 8 15
<7 years ≥7 years <7 years ≥7 years

Simple movement factor Complex movement factor

Figure 1: Analysis of variance between groups of children for two motor factors. Simple Movement factor: for children younger
than 7 years old, p=0.273; for 7 years old or more, p=0.617. Complex Movement factor: for children younger than 7 years old,
p=0.702; for those 7 years old or more, p=0.008. , comparison children with normal hearing; , children with deafness and
cochlear implant; , children with deafness. aSignificantly different from others.

602 Developmental Medicine & Child Neurology 2004, 46: 599–606

FACTORIAL ANALYSIS OF DATA FROM MOTOR TESTS
The variables of motor tests were found to be grouped into
two factors (Table VI). The first factor, which we call ‘Simple
Movement’, embraces movements that are easily performed
automatically after a few imitative repetitions. The second fac-
tor, which we call ‘Complex Movement’, takes into account
movements that are difficult to learn and require the mobi-
lization of a large panel of muscular groups. In order to com-
pare the three groups within the two age ranges, a factorial
score for each patient was calculated for the two factors, with
a median of 0 and standard deviation (SD) of 1 (the median
and interquartile amplitude are represented in Fig. 1). An
analysis of variance was then used to compare the new values
for each group (Fig. 1). For children 7 years old or more,
there was a difference in the factor ‘Complex Movement’
between the comparison group and both groups of children
with deafness (p=0.008). There was no difference between
groups in the factor ‘Simple Movement’.
COGNITIVE PROFILE : INDIVIDUAL TESTS
The three groups were compared for each cognitive test. There
was no difference between the comparison group and children
with CIm. There were significant differences between the com-
parison group and children with deafness without CIm (group
A) in terms of performance in the following tests: Raven’s
Standard Progressive Matrices (p=0.012), McCarthy’s Scales of
Children’s Ability–Copy Drawing (McCarthy 1972; p<0.001),
Wechsler Intelligence Scale for Children–Mazes (Wechsler
1949; p=0.005), and Visual Perception (Colarusso and Hamill
1980; p=0.018).
We compared cognitive test performances separately for
those children younger than 7 years old and those 7 years old
or more. Children in group A in both age groups, did signifi-
cantly worse than the comparison group at Copying Drawing.
However, with regard to Mazes, group A only performed worse
than groups B and C in the subgroup of children younger than
7 years old (p=0.007).
FACTORIAL ANALYSIS OF DATA FROM COGNITIVE PROFILE
Two factors were identified (Table VII). We call the first
‘Procedural’ because it embraces tests evaluating general intel-
ligence, executive function, and short-term memory (namely
the following tests: Raven’s Standard Progressive Matrices,
Mazes, and Illinois Test of Psycholinguistic Abilities Visual
Span [ITPA]–Visual Span [Von Isser and Kirk 1980]). The sec-
ond factor, which we call ‘Semantic’, encompasses aspects of
meaning in the tests of Visual Perception (Colarusso and Hamill
1980), ITPA–Visual Understanding (Von Isser and Kirk 1980),
ITPA–Visual Association (Von Isser and Kirk 1980), and Copy
Drawing (McCarthy 1972).
After calculating the new score for each child in each factor,
we compared our groups within the two age ranges (Fig. 2).
In the children younger than 7 years old, there was a clear dif-
ference for the ‘Procedural’ factor between the comparison
group and the children with deafness without CIm. This fac-
tor was normalized in the group without CIm that were 7
years old or more; however, for this age range there was a dif-
ference in the ‘Semantic’ factor between the group with
CIm and the group without implants (p=0.031).
Discussion
Deafness is often an isolated pathology, so children with such
sensory impairment but no associated neurological lesion pro-
vide a negative pathological model with which to study the role

2.0 2.0

1.0 1.0
Factorial score

Factorial score

0.0 0.0

–1.0 –1.0
b

–2.0 –2.0
n= 25 17 12 15 7 12 n= 25 17 12 15 7 12
<7 years ≥7 years <7 years ≥7 years
Procedural factor Semantic factor

Figure 2: Comparison between groups of children for two cognitive factors. Procedural factor: for children younger than 7 years
old, p=0.001; for those 7 years old or more, p=0.916. Semantic factor: for children younger than 7 years old, p=0.928; for those
7 years old or more, p=0.031. aSignificantly different from others; bTwo groups marked are significantly different to each other.
, comparison children with normal hearing; , children with deafness and cochlear implant; , children with deafness.

Non-verbal Development and Deafness in Children Emilie Schlumberger et al. 603

of auditory input in neurological development and maturation
(Robinson 1998). However, few studies have been published
so far. Children with deafness and CIm provide a further
opportunity for study in this area (Ponton et al. 1996).
In our study, 50 of the 54 children with deafness had no
anamnestic or clinical elements of neurological involve-
ment in their deafness (despite 10 of them having a clear ele-
ment of genetic deafness). The remaining four patients had
an anamnestic element that might possibly have been relat-
ed to a neurological event (one prematurity, one intrauter-
ine growth retardation, one cochlear malformation, and one
meningitis due to Haemophilus influenzae) but no clinical or
radiological signs of neurological damage and, therefore, we
consider them to be lesion free.
More of the children with deafness but without implants
were from families of lower educational status than the chil-
dren with a CIm. This could be a confounding factor, even if
we deal with a European population of children who are ade-
quately educated by modern rehabilitation specialists. To be
in no doubt, we compared Raven’s Standard Progressive
Matrices test results for those whose parents had low, medi-
um, or high educational status, and this showed no difference
between the three groups of children.
This homogeneous population of children with deafness
all received adequate teaching and speech therapy support,
whether they had a CIm or not, but the two groups (A and B)
truly differ because of the auditory input restored in those with
Table VI: Composition of motor factors
Factors Components
Simple Complex
Movement Movement
T9: Dominant finger repetitive movement 0.832
T10: Non-dominant finger repetitive movement 0.797
T6: Non-dominant hand repetitive movement 0.755
T8: Non-dominant hand alternating movement 0.745
T7: Dominant hand alternating movement 0.717
T5: Dominant hand repetitive movement 0.708
T3: Right foot alternating movement
T4: Left foot alternating movement
T2: Left foot repetitive movement
T12: Non-dominant finger sequential movement
T11: Dominant finger sequential movement
T1: Right foot repetitive
Table VII: Composition of cognitive factors
Factor Components
Procedural Semantic
Mazes: T score 0.860
Visual Span, ITPA: T score 0.740
IQ: Raven’s Standard Progressive Matrices 0.680
Visual Perception: CP 0.653
Visual Understanding, ITPA: T score
Visual Association, ITPA: T score
Copy Drawing: z score
ITPA, Illinois Test of Psycholinguistic Abilities.
604 Developmental Medicine & Child Neurology 2004, 46: 599–606
a CIm. This is the first report of a paediatric population with
those characteristics.
The most evident consequence of deafness on neuropsy-
chological development is language impairment; for that rea-
son, improvement of oral language has been the principal
objective reported in the literature until now. In most cases a
CIm has proved to be sufficient in providing the brain with
the auditory input necessary for the development of recep-
tive and expressive speech. A young age at implantation is
correlated with better results (Manrique et al. 1999,
Nikolopoulos et al. 1999).
Deafness also affects neuropsychological and motor devel-
opment. People with congenital deafness but no neurological
impairment have normal general intelligence (Mayberry 1992).
However, there are some subtle differences. Hemispheric spe-
cialization is atypical for language (Marcotte and LaBarba 1987)
and visuospatial processing, in both childhood (Rapin 1979)
and adulthood (Neville and Lawson 1987). Some studies have
found visuospatial processing to be enhanced, which has been
interpreted as a consequence of training in American Sign
Language (Parasnis et al. 1996). Although some studies suggest
that those with congenital deafness have normal visual span
(Mayberry 1992), others suggest that immediate visual memo-
ry is reduced (Parasnis et al. 1996). A recent study, on a short
follow up of 18 children, suggests that cognitive and behav-
ioural skills of children with deafness start falling behind from a
very young age (Kutz et al. 2003).
In our study, the innovative work of giving a CIm to young
children at the mean age of 26 months – and always before 39
months, which is considered an optimal age range for the lin-
guistic benefit of the CIm – has offered the possibility of
studying different aspects of neurological development.
None of the children with deafness in our study had neuro-
logical lesions or even manifested neuropsychological deficien-
cies other than language impairment. Despite the repercussion
of deafness on cerebral functional differentiation (Hirano et al.
2000) there were adequate educational and neuropsychologi-
cal compensatory mechanisms to enable the children with
deafness to perform normally in all the cognitive tasks put to
them. However, as a group, our series of children with deafness
0.847 presented some subtle differentiating characteristics: although
0.819 within the normal range, IQ (Raven’s Standard Progressive
0.680 Matrices) was lower in the group without implants than in the
0.678 group with implants (p=0.012). In visual tasks the group
0.665 without implants also performed more poorly than both of the
0.591 other groups together (Mazes, p=0.005; copy of drawings,
p<0.001) and more poorly than the group with implants alone
(Colarusso, p=0.018). This poses questions about the detri-
mental effect of a lack of auditory perception on visual percep-
tion, in the context of polymodal development (Bailey 2002).
In terms of motor performance, children with deafness
have been characterized as late in maturing dynamic coordi-
nation (Wiegersma and Van der Velde 1983, Myklebust 1964)
and visuomotor skills. Wiegersma and Van der Velde (1983)
showed that in a video-game task the movements of children
with deafness between 8 and 10 years old were slower than
those of the comparison group. Those authors went on to
0.533
suggest that children with deafness, whether lacking ade-
0.786
quate muscular control or suffering from subclinical neurolog-
0.780
ical defects, might have different motor programmes to
0.630
children with normal hearing. Because of the exclusion of
participants with neurological impairment, our results on
motor development confirm that children with deafness take
longer to develop complex motor sequences, and imply that
this is due to sensory impairment.
The fact that motor development was somewhat delayed
in both the group with and the group without implants raises
the question of why auditory stimulation coming from a CIm
is insufficient to completely normalize it. Some suggestions
can be made but this topic needs further study.
Prolonged auditory deprivation can have permanent delete-
rious effects on the developing auditory system (Moore 1985).
Hearing begins before birth. Maturation (synaptogenesis and
myelinogenesis) of the auditory prethalamic tract is completed
during the first postnatal year, and the post-thalamic tract is
completed by the end of the third year (Yakovlev and Lecours
1967, Brody et al. 1987, Huttenlocher 1990). The children with
a CIm in this study received it at a mean age of 26 months
(range 12 to 39 months). Although this is quite early in compar-
ison with previous published series, it should be considered
late in terms of development of the auditory tract and the inter-
action of sensory input.
Patients usually receive a CIm in one ear only. Such unilat-
eral implantation improves a patient’s ability to localize sounds
but does not normalize it. Further studies of bilateral implan-
tation (Mueller et al. 2000) and a better understanding of the
integration of bilateral auditory information are required
(Moore 2002).
In terms of the cognitive and behavioural functions that it
sustains and also in terms of global maturation of the nervous
system, sensory input participates not only in a simple addi-
tive way but also has a reciprocal influence in that it synergisti-
cally modulates the building of neural networks. Therefore,
although children with deafness can perform normally in cogni-
tive tasks, they still present subtle differences in some function-
al fields, such as abstract thinking and visual/motor integration,
that seem far removed from the auditory function.
Conclusion
Although auditory impairment does not cause a pathological
delay or distortion in non-verbal development, it does pro-
duce subtle differences in certain motor and neuropsycho-
logical functions. This observation is not of major clinical
importance to the management of children with deafness,
but it is an interesting demonstration of the extent of the role
of hearing in the building of the brain. Language impairment
is not the only consequence of deafness on neuropsycholog-
ical development.
It is suggested that damaged auditory input should be
restored as early as possible; neuropsychological development
follows a sequence, and the development of all the neuropsy-
chological abilities linked to hearing should not be delayed.
DOI: 10.1017/S001216220400101X
Accepted for publication 6th February 2004.
Acknowledgements
We thank the children who participated in this study, their parents,
and Nerea Crespo MA for her help with data collection. We also
thank David Burdon MSc for correcting the English.
Non-verbal Development and Deafness in Children Emilie Schlumberger et al. 605
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606 Developmental Medicine & Child Neurology 2004, 46: 599–606