Long-Term Outcomes, Education, and Occupational
Level in Cochlear Implant Recipients Who Were
Implanted in Childhood
Angelika Illg,1 Marius Haack,1 Anke Lesinski-Schiedat,1 Andreas Büchner,1,2
and Thomas Lenarz1
Objectives: To document the long-term outcomes of auditory perfor-
mance, educational status, vocational training, and occupational situa-
tion in users of cochlear implants (CIs) who were implanted in childhood.
Design: This retrospective cross-sectional study of 933 recipients of CIs
examined auditory performance, education and vocational training, and
occupational outcomes. All participants received their first CI during their
childhood between 1986 and 2000. Speech comprehension results were
categorized using the categories of auditory performance (CAP) arranged
in order of increasing difficulty ranging from 0 to 8. 174 of the 933 pedi-
atric recipients of CIs completed a self-assessment questionnaire regard-
ing their education and occupational outcomes. To measure and compare
school education, qualifications were converted into International Standard
Classification of Education levels (ISCED-97). Occupations were converted
into International Standard Classification of Occupation-88 skill levels. Data
from the German General Social Survey (Allgemeine Bevölkerungsumfrage
der Sozialwissenschaften/ALLBUS) for 2012 were used as a basis for com-
paring some of the collected data with the general population in Germany.
Results: The results showed that 86.8% of the 174 participants who com-
pleted the survey used their devices more than 11 hr per day. Only 2% of
the surveyed individuals were nonusers. Median CAP was 4.00 (0 to 8).
Age at implantation was significantly correlated with CAP level (r = −0.472;
p < 0.001). The mean ISCED level of the 174 surveyed recipients was 2.24
(SD = 0.59; range: 1 to 3). A significant difference (p = 0.001) between
users’ ISCED levels and those of ALLBUS 2012 respondents was found.
Participants’ ISCED levels and maternal educational levels were sig-
nificantly correlated (r = 0.271; p = 0.008). The International Standard
Classification of Occupation-88 skill levels were as follows: 5% achieved
skill level 1; 77% skill level 2; 16% skill level 3; and 5% skill level 4. The
average skill level achieved was 2.24 (range 1 to 4; SD = 0.57) which was
significantly poorer (t(127) = 4.886; p = 0.001) than the mean skill level of
the ALLBUS 2012 respondents (mean = 2.54; SD = 0.85).
Conclusions: Data collection up to 17.75 (SD = 3.08; range 13 to 28)
years post implant demonstrated that the majority of participants who
underwent implantation at an early age achieved discrimination of speech
sounds without lipreading (CAP category 4.00). Educational, vocational,
and occupational level achieved by this cohort were significantly poorer
compared with the German and worldwide population average. Children
implanted today who are younger at implantation, and with whom more
advanced up-to-date CIs are used, are expected to exhibit better auditory
performance and have enhanced educational and occupational opportu-
nities. Compared with the circumstances immediately after World War
II in the 20th century, children with hearing impairment who use these
implants have improved prospects in this regard.
1
Department of Otolaryngology, Hannover Medical School, Hannover,
Germany; and 2Cluster of Excellence, Hearing4All, Hannover Medical
School, Germany.
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<zdoi; 10.1097/AUD.0000000000000423>
Key words: Auditory performance, Children, Cochlear implant,
Education, Long-term results, Occupation, Training route, Work.
(Ear & Hearing 2017;XX;00–00)
INTRODUCTION
The Hannover cochlear implant (CI) program in children
started in 1986 after experience had been gained, and good out-
comes achieved, in the implantation of postlingually deafened
adults (Lenarz et al. 2012). Since the 1990s, these implants
have been effective in the rehabilitation provided to profoundly
deaf children in many programs all over the world. Studies have
reported on outcomes, with follow-up limited to 2 to 5 years (as
stated in the editorial by Kaplan & Puterman (2010)). Examples
are the publications by Nikolopoulos et al. (1999a, b), Sharma
et al. (2002), Lesinski-Schiedat et al. (2004), and Connor et
al. (2006). During the past 10 years, many studies have also
yielded long-term speech perception results in children with
more than 7 years of CI experience (Waltzmann et al. 2002;
Haensel et al. 2005; Uziel et al. 2007; Roland et al. 2009; Col-
letti et al. 2011; Geers & Sedey 2011; Geers & Nicholas 2013;
Geers et al. 2013; Peixoto et al. 2013; Black et al. 2014; Dunn
et al. 2014). Roland et al. (2009) described the long-term safety
and efficacy of cochlear implantation in 50 very young children
after a period of 7 years of CI use. They concluded that cochlear
implantation in children under the age of 12 months is safe and
efficacious over an extended period of time.
Reports in the literature on educational and occupational
benefits are very rare. Spencer et al. (2004) reported on a
10-year follow-up in a first cohort of 27 of prelingually deaf
children, which yielded scores in speech perception and speech
production, reading, and academic and vocational achievement.
There was also a prospective longitudinal study by Beadle et al.
(2005) on long-term functional outcomes and academic-occu-
pational status in implanted children (mean age at implantation
5.2 years) after 10 to 14 years of CI use. The authors investi-
gated 30 profoundly deaf children using the category of audi-
tory performance (CAP) index and speech intelligibility rating,
and documented training routes and the occupational situation.
Only 4 of these 30 individuals were in work. All others were in
training, on vocational courses or at universities.
Fazel and Gray (2007) described a retrospective analysis in
80 recipients who were older than 19 years of age when they
received their CIs. The aim of this research was to examine
the effect on employment and employee perception of career
opportunities subsequent to cochlear implantation. The job sat-
isfaction rating rose from 5.56 to 6.82 (range 1 to 10) following
cochlear implantation. The authors concluded that a CI helped
2 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX
in terms of improved job satisfaction, as well as improving
employees’ perception of their career prospects. With regard to
education and training, Huber et al. (2008) compared their find-
ings for participants using CIs (age at implantation: 5.2 years)
with a group of normal-hearing peers. They found that 40%
of the users of CIs (aged 12 to 21 years) who completed high
school received advanced education, a proportion similar to that
of their normal-hearing peers. Their publication also described
parental expectations of the child’s future. Parents of partici-
pants using CIs were significantly less optimistic in this respect
than those of normal-hearing children.
In their prospective study, Venail et al. (2010) also compared
their results from children with CIs (age at implantation younger
than 6 years) with those from normal-hearing peers. They ana-
lyzed data on educational and employment achievements in 100
prelingually deaf children who received CIs. The authors con-
cluded that their participants ultimately achieved educational
and employment levels similar to those of their normal-hear-
ing peers. Tanamati et al. (2012) documented device use and
function in 10 postlingually deaf children implanted before 18
years of age, as well as the recipients’ academic/occupational
status. They found that, even many years after surgery, cochlear
implantation proves to be a safe and reliable procedure. Speech
intelligibility (single-word intelligibility) was between 62.2 and
100%. Eight of the 10 participants were in work at the time of
their interview, with their pay varying between R$ 400.00 and
R$ 2000.00. The authors did not describe the different occupa-
tions concerned. To summarize the literature, there were few
authors who reported long-term data in terms of correlation
with the educational and occupational situation. In most stud-
ies, the numbers of users investigated were small. In only two
studies (Huber et al. 2008; Venail et al. 2010) did the authors
compare their findings with those for normal-hearing peers.
Due to the advanced technology of CIs and early access to
hearing, as well as habilitative and educational interventions
during childhood, it should be expected that early-implanted
children would achieve the same educational goals as their
normal-hearing peers (Lesinski-Schiedat et al. 2004; Huber et
al. 2008, 2015). To date, there have been no studies which have
examined auditory performance and long-term educational,
vocational, and occupational outcomes for a large cohort of
pediatric CI recipients.
For other disciplines, too, there have been few studies about
the education of people with disabilities (Broersen et al. 2012;
Karoly et al. 2013; Luciano & Meara 2014). These authors iden-
tified job opportunities, or provided an overview of employment
status, but did not compare their results to those of people with-
out disabilities.
Nevertheless, the children’s CI program at our center started
very early, in 1986. Therefore, long-term observations, as well
as auditory and speech data, were available for a large cohort of
recipients of CIs with congenital or early childhood acquired
deafness.
The first aim of this retrospective cross-sectional study was
to explore the auditory performance outcomes for an unselected
group of 933 CI recipients, and examine the influence of known
variables such as age at CI, presence of additional diagnoses,
and use of oral versus sign communication. The second aim
was to describe the long-term educational status, type of voca-
tional training and occupational outcomes for a subset of 174
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
participants, and to compare these outcomes to that of the gen-
eral population in Germany.
Specifically, it was hypothesized that
a. participants who received CIs earlier, who had no addi-
tional comorbid diagnoses and used spoken language,
would demonstrate better auditory performance and
higher CAP scores compared with those who received
CIs at an older age;
b. educational and occupational attainment for participants
using CIs would be poorer than that of their matched
hearing peers, because of weaker auditory performance;
c. auditory performance (i.e., CAP) would be correlated
with educational and occupational attainment.
MATERIALS AND METHODS
Questionnaires were sent to 933 recipients of CIs who were
implanted in childhood and received their first CIs between
1986 and 2000 (mean age at CI was 5.4 years; range 0.4 to 18.9).
There were 174 returned questionnaires (18.65% response rate).
At the time the questionnaire was completed, the participants
were, on average, aged 23.6 years (range 14.2 to 44.6 years).
The majority (81.05%) had prelingual onset of profound hear-
ing loss and received a unilateral CI (83.49%). Participants’
auditory and speech perception was rated according to the CAP.
The demographic data for the full group of 933 CI recipients,
the subgroup of 174 respondents, and the subgroup of 759 non-
respondents are summarized in Table 1.
Demographic, medical, auditory performance and speech
perception data were obtained from paper files, the electronic
database at Hannover Medical School (Medizinische Hoch-
schule Hannover/MHH), and the Cochlear Implant Center
“Wilhelm Hirte,” Hannover. Functional gain curves or other
audiological findings were not included.
All other variables were recorded using a newly created self-
assessment questionnaire (see Appendix). The questions were
generally multiple choice, with respondents invited to add their
own comments where the category “other” was chosen. The mul-
tiple-choice scales differ from question to question. Several ques-
tions were open ended, including those regarding occupational
activities and workplace arrangements, as well as questions elicit-
ing numerical responses in units such as hours or years.
The questionnaire was refined by discussing it with medical
and educational professionals at our center. For pretesting pur-
poses, the questionnaire was given to young adult recipients of
CIs (20 to 25 years) at our center. They were willing to respond
and give comments in written form.
The questions were grouped into eight main categories:
living conditions and environment, therapy, educational back-
ground of the parents, school education, vocational training,
occupation, job satisfaction, and workplace. Questions on job
satisfaction were derived from the questionnaire for the study
entitled “Education and training of young people who grew up
with CIs” (Huber et al. 2008).
Finally, the questionnaire was sent out via postal and elec-
tronic mail to the participants, advising that respondents use
a link to an online version created by using the online tool
­SurveyMonkey (http://links.lww.com/EANDH/A337).
To assess auditory performance, the CAP were chosen
as these were described as a measure of everyday auditory
 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX 3

TABLE 1.  Demographic data and auditory performance

174 Respondents 759 Nonresponder p-Values From Tests

933 Participants Using (18.65% of All 933 (81.35% of All 933 Between Responder
CI From MHH Participants) Participants) and Nonresponder
Female N (%) 444 (47.59) 95 (54.60) 349 (45.98) p = 0.040
Male N (%) 489 (52.41) 79 (45.40) 410 (54.02)
Mean age at survey date in years (SD; 23.61 (5.19; 14–44) 22.99 (5.38; 14–43) 23.75 (5.15; 14–44) t(931) 1.74; p = 0.083
min–max)
Unilaterally implanted N (%) 779 (83.49) 126 (72.41) 106 (13.97) p < 0.001
Bilaterally implanted N (%) 154 (16.54) 48 (27.59) 653 (86.03)
Mean age at onset of deafness in years 0.7 (2.03; 0–18) 0.81 (2.21; 0.00–18.00) 0.68 (1.98; 0.00–15.33) t(876); p = 0.438
(SD; min–max)
Mean duration of deafness in years (SD; 4.6 (3.45; 0.14–18.83) 4.09 (3.49; 0.16–17.08) 4.74 (3.43; 0.14–18.83) t(665) −1.97; p = 0.049
min–max)
Prelingually deafened N (%) 740 (81.05) 128 (73.99) 612 (82.81) p = 0.027
Perilingually deafened N (%) 45 (4.93) 11 (6.36) 34 (4.60)
Postlingually deafened N (%) 127 (13.91) 34 (19.65) 93 (12.58)
State of speech missing values 21 1 20
Causes of deafness N (%)
 Meningitis 142 (15.22) 32 (18.39) 110 (14.49)
 Genetic 42 (4.50) 8 (4.60) 34 (4.48)
  Other disease 241 (25.83) 41 (23.56) 200 (26.35)
 Unknown 508 (54.45) 93 (53.45) 415 (54.68)
Mean age at first implantation in years 5.4 (3.98; 0.4–18.9) 4.86 (4.08; 0.00–18.00) 5.51 (3.95; 0.00–18.00) t(931) = −1.95; p = 0.052
(SD; min–max)
Period of CI use in years (SD; min–max) 17.75 (3.08; 13–28) 17.64 (3.33; 13–25) 17.78 (3.03; 13–28) p = 0.631
Additional disability N (%) 231 (29.88) 32 (21.47) 199 (31.89) p = 0.013
German native speakers N (%) 768 (91.21) 157 (98.13) 611 (89.59) p = 0.001
Mean CAP level (SD; min–max) 4.63 (2.04; 0–8) 5.41 (1.96; 0–8) 4.43 (2.02; 0–8) t(786) = 5.48; p < 0.001
Median CAP level 4.00 5.00 4.00
Mode CAP level 4.00 8.00 4.00
CAP missing values 145 15 130
Implants manuf. by MedEl N (%) 6 (0.64) 0 (0.0) 6 (0.7)
Implants manuf. by Fa. Advanced 417 (44.69) 83 (47.7) 332 (43.9)
Bionics N (%)
Implants manuf. by Fa. Cochlear N (%) 510 (54.66) 91 (52.3) 419 (55.4)

CAP, categories of auditory performance; CI, cochlear implant.

performance which reflects the “real-life” progress of children
in developing the use of audition (Nikolopoulos et al. 1999a, b,
2000; O’Donoghue et al. 1999; O’Neill et al. 2002; Beadle et
al. 2005). The choice of these categories maintains the continu-
ity of auditory assessment for the pediatric population as they
progress through adolescence to adulthood.
To assess the participants’ auditory performance, results of
previous hearing and speech perception tests at MHH and the
Cochlear Implant Center were used. At the outset of the CI pro-
gram, the Food and Drug Administration test battery (Lesinski-
Schiedat et al. 1999) was employed, which included live-voice
spoken closed-set material (pattern perception, mono- and
disyllabic word recognition, minimal pairs), cued open-set
material (Common Phrases and Mr. Potato Head) and open-set
material (Test of Auditory Perception of Speech for Children
and Glendonald Auditory Screening Procedure; Erber 1982).
Other questionnaires used were Meaningful Auditory Integra-
tion Scale (MAIS; Robbins et al. 1991) and Meaningful Use
of Speech Scale (Robbins & Osberger 1990). Recorded-speech
comprehension tests for numbers and monosyllables (Lehnhardt
2001) were also employed, as were sentences in quiet and noise
(Hochmair-Desoyer et al. 1997).
The most recent test results for each individual were con-
verted into the CAP (Archbold et al. 1998), arranged in order of
increasing difficulty (Table 2) to take into account different age-
related test results and for greater comparability. For conversion
purposes, there are clear guidelines available at our center on
how to categorize results for children and adults. Because of
this clear definition, the most recent hearing and speech com-
prehension test results were coded into CAP by a single person.
For example, if an adult scored 50% or more in the German
speech comprehension sentence test, the result would be coded
into CAP level 5; if a subject achieved 90% or more in the same
test, the result would be coded into CAP level 6.
The CAP index consists of a nonlinear, hierarchical scale of
auditory receptive abilities. Its lowest level denotes no awareness
of environmental sound, and the highest level describes conver-
sational ability within a group in a reverberant room or where
there is some interfering noise, such as a classroom or restaurant.
The CAP scale was chosen because it can be administered to a
variety of age ranges, from very young to adults. The reliability
of this scale has been formally confirmed (Archbold et al. 1998).
To examine educational outcomes, survey data were con-
verted to the International Standard Classification of Education
levels (ISCED-97; OECD 1999). ISCED is a scale designed by
United Nations Educational, Scientific and Cultural Organiza-
tion for benchmarking educational performance across coun-
tries (Table 3). German schools fall within the jurisdiction of the

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4 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX
TABLE 2.  Categories of auditory performance
Category Criterion
8 Follows group conversation in a reverberant room or
where there is some interfering noise, such as a
classroom or restaurant
7 Use of telephone with known speaker
6 Understanding of conversation without lipreading
5 Understanding of common phrases without lipreading
4 Discrimination of speech sounds without lipreading
3 Identification of environmental sounds
2 Response to speech sounds
1 Awareness of environmental sounds
0 No awareness of environmental sounds or voice
country’s federal states. This leads to differences between states
in the organization of the school system. Basically, there is a
distinction between primary education, level I secondary edu-
cation, level II secondary education and certification. Primary
education mainly comprises the elementary schools (Grund-
schule; grades 1 to 4 without certification). Level I secondary
education is provided at general schools (Hauptschule), middle
schools (Realschule), comprehensive schools (Gesamtschule),
and academic high schools (Gymnasium; grades 5 to 10), lead-
ing to a subject-related entrance qualification for technical col-
lege/universities of applied science (Fachhochschule). Level II
secondary education (Gesamtschule, Gymnasium, Fachober-
stufe) involves grades 11 to 13 in academic high schools and
qualifies the student for university. Vocational training can be
chosen in mainstream or special schools for those with hearing
impairment or deafness.
To examine occupation outcomes, survey data were con-
verted into International Standard Classification of Occupa-
tions-88 skill levels (ISCO), conceived by the International
Labor Office which uses four hierarchical categories (Table 4,
International Labor Office 1990).
Data from the German General Social Survey (ALLBUS)
for 2012 were used as a basis for comparing school education,
occupation, and employment status with those of the general
population in Germany (GESIS 2012). ALLBUS 2012 is a
biennial survey on attitudes, behaviors, and social structure in
Germany, designed to obtain a representative cross-sectional
statistical analysis of the population. ALLBUS 2012 data which
was age matched to the survey respondents (18 to 44 years)
were used for comparison.
TABLE 3.  ISCED-97 level and options for further education
No. of
Type of School Respondents (%) ISCED Level
General qualification for university entrance 23 (19.39)
Subject-related entrance qualification 19 (11.52)
Secondary school 65 (39.39)
Secondary school 27 (16.36)
Not (yet) graduated 13 (7.88)
“Type of school” for the missing 5.45% of the patients is unknown or others.
ISCED, International Standard Classification of Education.
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Data Analysis
All statistical analysis was performed using Microsoft Excel
2010 and IBM SPSS Statistics (version 22) software. Vari-
ables correlated with the CAP levels, ISCO-88 skill levels and
ISCED levels were identified by means of Spearman correla-
tion analysis. The relationship between the following variables
(collected via questionnaire responses) and CAP were exam-
ined using t tests: native language, multiple disabilities, status
of speech at implantation, bilateral implantation, understanding
of spoken language without lipreading, reading skills, writing
skills, preferred means of communication, status of job, and
educational institutions. To ensure the results were not biased,
only data from those participants were used who are German
native speakers without additional disabilities; this applies to all
t tests, as well as to all Spearman correlation analysis performed
in this study and described here.
Statistical significance was set to p < 0.05 (*p < 0.05,
†p < 0.01, ‡p < 0.001).
RESULTS
Device Use and Auditory Performance
Of the 174 respondents to the questionnaire, 86.8% regularly
used their CIs for more than 11 hr per day and 2% were nonus-
ers (Fig. 1; the questionnaire contained an open-ended ques-
tion about the number of hours they wore their CIs daily). The
remaining 11.2% indicated they wore their devices for between
1 and 10 hr each day. When asked if they need to use their device
“in the family,” 88% selected “always” from the answer set for
this question; the figures for “in school” and “in their jobs”
were 94 and 68%, respectively. The questionnaire revealed that
only 14% of the surveyed individuals could not understand any
spoken language. (Thirty-nine percent replied that they could
and 47% stated that they could, but only partially.) The survey
also asked participants if they could understand spoken lan-
guage without lipreading, with three possible answers: “yes,”
“partially,” and “no.” The respondent had to choose his answer
between these three possibilities.
The median CAP for respondents to the questionnaire was
5.41 (SD 1.96; Table 2) in contrast to the median CAP for non-
respondents which was 4.43 (SD 2.02). This difference was sta-
tistically significant (t(786) = 5.48; p < 0.001). The CAP level
for the entire group (i.e., respondents and nonrespondents) was
4.63 with a SD of 2.04. Relevant data (numbers of recipients,
medians, or modes) are given in Table 1. For further evalua-
tion, data were divided into different subgroups with special
characteristics (Table 5). Examples are male and female (only
German native speakers without additional disabilities); Ger-
man native speakers and individuals with other first languages
Options for Further Education
3 College, university
3 College, university
2 Recognized higher-level occupations requiring formal training
2 Vocational training
1
 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX 5
TABLE 4.  ISCO-88 major groups and skill level
ISCO-88 Skill
ISCO-88 Major Group
1 Legislators, senior officials, and managers
2 Professionals
3 Technicians and associate professionals
4 Clerks
5 Service workers and shop and market sales
workers
6 Skill agricultural and fishery workers
7 Craft and related workers
8 Plant and machine operators and assemblers
9 Elementary occupations
0 Armed forces
ISCO, International Standard Classification of Occupation.
(without additional disabilities); and participants with and with-
out additional disabilities (only German native speakers). The
nature of the groups in question is described in the fourth col-
umn of Table 5. Individuals for whom the current status was not
known were excluded, thus decreasing the quantity of subject
data. The number of recipients in each subgroup is given in the
second column; as these numbers are small, statistical calcula-
tions could not be performed for every subgroup.
Outcomes differed for the various subgroups. No significant
differences in CAP levels were found for survey respondents for
gender (t(412) = 0.893; p = 0.372). Significant differences in CAP
levels were found for survey respondents for mother tongues, age
at implantation, onset of deafness, and use of spoken language.
German native speakers (participants with additional disabilities
excluded) showed significantly higher CAP scores than did indi-
viduals with other mother tongues (t(35) = 2.794; p = 0.008).
Age at implantation exhibited a significant and strong inverse
correlation with CAP level (r = −0.575; p < 0.001). Children
implanted below 3 years of age and children implanted at 3 years
or above showed significant differences in auditory performance
(t(203) = 7.121; p < 0.001). Younger children achieve a CAP
score of 6.0, with older children obtaining a CAP score of 4.6.
Fig. 1. Daily CI use in hours. CI indicates cochlear implant.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The auditory performance of bilaterally implanted partici-
pants (CAP: 6.2) was significantly better than that of unilaterally
Level
implanted individuals (CAP: 4.7; t(144) = 6.865; p < 0.001).
Significant differences in CAP could not be evaluated
—
between perilingually deafened (CAP: 5.6) and prelingually
4
deafened participants (CAP: 4.9) because the number of perilin-
3
2
gual recipients was low (n = 16). Furthermore, the numbers of
2 perilingually deafened and postlingually deafened (CAP: 5.5)
individuals were too small for statistical analysis.
2 Participants with postlingual acquired hearing loss using CIs,
2 however, showed significantly higher CAP scores than participants
2 with prelingual acquired hearing loss (t(103) = −2.792; p = 0.006).
1 Participants using CIs who could understand spoken language with-
— out lipreading obtained better hearing-test results than participants
who could partially understand spoken language (t(120) = 5.312;
p < 0.001).
One question in the survey addressed participants’ preferred
means of communication with their friends and acquaintances. Of
the participants, 81% used spoken language, 6 individuals used a
combination of spoken language and 6 individuals used German
sign language. Due to the unequal distribution, statistical tests of the
difference were not performed. There were differences in auditory
performance for participants who underwent their vocational train-
ing in mainstream institutions compared with those who received
vocational training in institutions for those with hearing impair-
ment or deafness. Those who attended mainstream establishments
tended to demonstrate auditory performance that was categorized
higher (e.g., categories 6, 7, and 8) but small participant numbers
precluded statistical analysis of this difference.
The questionnaire also asked participants for a self-assess-
ment of their reading and writing skills. Participants who
affirmed the section of the questionnaire where it states “that
they can read books and newspapers without any problems”
did not demonstrate auditory performance that was catego-
rized higher than that of participants who did not tick this box.
With regard to writing skills, however, those who affirmed they
“can easily record personal experiences in writing” attained
significantly higher categories than those who can responded
“only partially” to this section (t(82) = 5.124; p < 0.001).
6 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX

TABLE 5.  CAP results for the subgroups

Subgroups Quantity (%) Mean CAP Level (SD; Min–Max) Characteristic of Subgroups
Female 210 (49.53) 5.1 (1.9; 0–8) n.s. German, no additional disability
Male 204 (48.11) 5.0 (1.8; 0–8)
German native speakers 414 (93.24) 5.1 (1.9; 0–8)* No disability handicap
Other first language 30 (6.76) 4.2 (1.6; 0–8)
Additional disability 178 (30.07) 4.0 (2.2; 0–8) German
No additional disability 414 (69.93) 5.1 (1.9; 0–8)†
Unilaterally implanted 321 (77.5) 4.7 (1.8; 3–8) n.s. German, no additional disability
Bilaterally implanted 93 (22.5) 6.2 (1.7; 0–8)
Prelingually deafened 333 (80.8) 4.9 (1.9; 0–8) n.p. German, no additional disability
Perilingually deafened 16 (3.9) 5.6 (1.9; 3–8)
Prelingually deafened 333 (80.8) 4.9 (1.9; 0–8) German, no additional disability
Postlingually deafened 63 (15.3) 5.5 (1.5; 3–8)‡
Perilingually deafened 16 (3.9) 5.6 (1.9; 3–8) n.p German, no additional disability
Postlingually deafened 63 (15.3) 5.5 (1.5; 3–8)
Implantation age < 3 years 122 (29.47) 6,0 (1.9; 0–8) German, no additional disability
Implantation age ≥ 3 years 292 (70.53) 4.6 (1.7;0–8)†
Employed 37 (82.2) 4.9 (1.6; 3–8) n.p German, no additional disability
Unemployed 8 (17.8) 5.0 (1.5; 3–8)
Institutions for vocational training German, no additional disability
  Mainstream institutions 45 (69.2) 6.1 (1.6; 3–8) n.p.
  Inst. for the deaf 20 (30.8) 4.3 (0.7; 3–5)
Preferred means of communication in contact with friends and acquaintances German, no additional disability
  Spoken language 62 (83.8) 6.2 (1.7; 3–8) n.p
  German sign language 6 (8.1) 3.8 (1.0; 3–5)
  Spoken language 62 (83.8) 6.2 (1.7; 3–8) n.p German, no additional disability
  Sound-accomp. signs 6 (8.1) 4.2 (1.0; 4–6)
  German sign language 6 (8.1) 3.8 (1.0; 3–5) n.p German, no additional disability
  Sound-accomp. signs 6 (8.1) 4.2 (1.0; 4–6)
Self-assessment of understanding spoken language without lip reading German, no additional disability
  Can understand 37 (35.9) 6.8 (1.6; 4–8)†
  Can understand partly 53 (51.5) 5.3 (1.5; 3–8)
  Can understand 37 (35.9) 6.8 (1.6; 4–8) n.p German, no additional disability
  Can not understand 13 (12.6) 3.7 (0.8; 3–8)
  Can understand partly 53 (51.5) 5.3 (1.5; 3–8) n.p German, no additional disability
  Can not understand 13 (12.6) 3.7 (0.8; 3–8)
Self-assessment of reading skills (“Can you read and understand books and newspapers?”)
 Yes 68 (66.0) 6.1 (1.8; 3–8)‡ German, no additional disability
 Partly 33 (32.0) 4.7 (1.4; 3–8)
 Yes 68 (66.0) 6.1 (1.8; 3–8) n.p German, no additional disability
 No 2 (1.9) -
 Partly 33 (32.0) 4.7 (1.4; 3–8) n.p German, no additional disability
 No 2 (1.9) -
Self-assessment of writing skills (“Can you express personal experiences in writing?”) German, no additional disability
 Yes 69 (66.3) 6.2 (1.8; 3–8)†
 Partly 30 (28.8) 4.6 (1.2; 3–8)
 Yes 69 (66.3) 6.2 (1.8; 3–8) n.p German, no additional disability
 No 5 (4.8) 3.6 (0.5; 3–4)
 Partly 30 (28.8) 4.6 (1.2; 3–8) n.p German, no additional disability
 No 5 (4.8) 3.6 (0.5; 3–4)

CAP, categories of auditory performance; n.p., statistical calculation not possible; n.s., not significant.

Education
The mean ISCED level achieved by the 174 respondents
to the questionnaire was 2.24 (SD = 0.59; range: 1 to 3). This
ISCED level was significantly lower (t(1457) = 3.723; p <
0.001) than data from ALLBUS 2012 participants. Specific
information about their qualifications and related options
for further education are shown in Table 3. Figure 2 shows
educational qualification and ISCED-97 level compared with
ALLBUS 2012.
In this study, the ISCED levels were not correlated with audi-
tory performance (p = 0.155). There was a positive correlation
between ISCED levels and maternal educational levels (r =
0.271; p = 0.008) but not paternal education level (p = 0.223) as
recorded on the questionnaire. The type of school attended (i.e.,
mainstream or special schools for those with hearing impairment
or deafness) differed across the age range. Sixty-four percent
attend/attended schools for individuals with hearing impair-
ment or deafness. The remaining 36% attended “integrated or

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX 7
Fig. 2. School education.
mainstream schools.” Most of the participants (95%) stated that
they needed their CIs daily for communication in school, and
83% of the respondents reported using spoken language as their
preferred means of communication while in school.
Occupation
When asked how necessary the CIs were for their on-the-job
communication, up to 97% of participants selected the choice
“permanently” with regard to using their CIs at work, 68%
selected “always,” and 29% selected “sometimes.” This related
to another section of the questionnaire, where 94% of partici-
pants using CIs, selected “spoken language” as the preferred
means of communication in the workplace.
Only 6% of the respondents used an frequency modulation
system at work. Special technical support for participants using
CIs was reported in only 19% of workplaces. At the time of the
survey, 57% of the respondents had finished their education,
with 43% still in school, in vocational training or studying.
Figure 3 shows the ISCO-88 skill level of the recipients of
CIs compared with those of ALLBUS 2012 respondents. At
the time of the survey, 57% of the respondents had finished
Fig. 3. ISCO-88 skill level comparison between surveyed recipients of CIs and ALLBUS 2012 respondents. CI indicates cochlear implant; ISCO, International
Standard Classification of Occupation.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
their education, with 43% still in school, in vocational training
or studying. Respondents of our survey achieved an average
ISCO-88 skill level of 2.24 (SD = 0.57; range: 1 to 4), which
was significantly poorer (t(127) = 4.886; p = 0.001) than that of
the ALLBUS 2012 respondents (mean = 2.54; SD = 0.85). No
correlation was found between ISCO-88 skill levels and CAP
level, or ISCO-88 skill levels and maternal or paternal ISCO-88
skill level.
With regard to institutions attended for vocational training,
71% of the respondents attended mainstream institutions at
least once, with only 44% attending institutions for the disabled
at least once (Fig. 4). Of the total, 65% completed this educa-
tion successfully, with 32% still undergoing training at the time
of the survey.
Of the respondents, 74% replied that they had been able to
obtain the occupation they wanted, and 8% said they had not.
The remaining 19% replied that they had, to an extent, been able
to obtain the occupation they wanted.
Most of the respondents (98%) felt that they did their job
well, 60% were satisfied with their pay, 83% said they had a
good relationship with their supervisor, and 82% reported hav-
ing a good relationship with their colleagues. At the time of
the survey, 41% of the participants using CIs and 77% of the
ALLBUS 2012 respondents were in work, whereas 43% of the
recipients of these implants surveyed were still in school or
vocational training.
Forty-nine percent of the users of CIs and only 29% of the
ALLBUS 2012 respondents (p < 0.001) have been unemployed
at least once during their life (Fig. 5).
DISCUSSION
This retrospective study examined auditory performance,
educational status, vocational training, and occupational out-
comes for recipients of CIs who were implanted in childhood, and
compared these with outcomes for peers with normal hearing.
Auditory Performance
Auditory performance depended on the use of the device.
Our data supported the findings by Beadle et al. (2005), namely
that young people used their CIs throughout their lifetime, espe-
cially during critical life periods such as adolescence. Two per-
cent of those who completed the survey were nonusers (with
8 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX
Fig. 4. Institutions for vocational training.
Beadle et al. reporting a figure of 3%). Most of our participants
used their device all day, including for social contact. The real-
life auditory situation was that the surveyed participants were
able to understand common phrases without lipreading (CAP:
5.41). The recipients of CIs who did not respond to the sur-
vey were able to understand speech sounds without lipreading
(CAP: 4.43). It may be that the individuals surveyed were more
highly motivated and bring greater understanding to their read-
ing and writing. The better placed an individual is in terms of
various factors—such as additional handicap, age at implanta-
tion, time of deafness, implantation mode, use of spoken lan-
guage, and use of sign language—the better his or her auditory
performance. Adolescents attending mainstream schools dur-
ing vocational training show higher CAP levels (CAP: 6) than
their peers in special schools for people who are deaf (CAP: 4).
In addition, Huber et al. (2015) and Langereis and Vermeulen
(2015) reported that mainstreamed students had superior audi-
tory performance compared with those in special schools for
those with hearing impairment. Spencer and Tomblin (2009)
described the input from the CI as a prerequisite for phonologi-
cal awareness and phonological processing which is needed to
decode words and it is, therefore, an important requirement for
the development of oral language. For participants using sign
language, CI input did not favor such good outcomes. Users
Fig. 5. Proportion of participants using CIs and ALLBUS 2012 respondents unemployed at some point in their lives. CI indicates cochlear implant.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
who were unable to understand spoken language, or to read and
write (Geers & Hayes 2011), also had poorer auditory perfor-
mance. In these instances, early listening and speaking skills
were in no participant a predictor of long-term reading skills
(Spencer & Oleson 2008; DesJardin et al. 2009) necessary in
mainstream schools. In the present study, early listening was
a predictor of higher auditory and speech comprehension.
Auditory outcomes tended to be poorer with increasing age at
implantation. Moreover, among those children who to an extent
had developed language skills after receiving hearing aids
previously, those implanted at an earlier age showed superior
results; this is, once again, evidence in favor of early implanta-
tion. Children implanted in recent years had been assessed for
implantation (with reference to the indication criteria) before
the age of 1. Auditory performance and speech comprehension
relating to the first implanted side may be influenced by the high
degree of plasticity in central auditory pathways in early child-
hood and the “sensitive period,” an aspect frequently discussed
by different authors (Sharma et al. 2002; Lesinski-Schiedat et
al. 2004; Sharma et al. 2005; Kral & O’Donoghue 2010; Kral &
Sharma 2012; Illg et al. 2013). This knowledge concerning the
“sensitive periods” involving maturation of the neural auditory
pathway was unavailable in the early years of pediatric implan-
tation, when only deaf children with long experience of hearing
aids received CIs. Therefore, the mean implantation age of our
study group was high (Table 1) compared with that in recent
studies.
Education
A further aim of this study was to evaluate education sub-
sequent to cochlear implantation. In general, there was no
difference between participants using CIs and German normal-
hearing peers in terms of educational qualifications achieved at
secondary school (GESIS 2012); there was, however, a differ-
ence compared with the German deaf population.
The GINKO study (Weber & Schlenker-Schulte 2011) sur-
veyed about 5000 German adult deaf persons with or without
hearing devices concerning their educational qualifications and
other parameters. Compared with the present CI data, 11.7%
more deaf individuals from the GINKO study attended second-
ary school and 2.4% more obtained a secondary-school certifi-
cate than users of CIs in the present study.
 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX 9
What was particularly striking was the difference between
participants using CIs and the normal-hearing group in subject-
related entrance qualifications for technical college and general
qualifications for university entrance. The cochlear-implanted
adolescents did not achieve the same educational level as nor-
mal-hearing German peers, 15% of whom achieved a general
qualification for university entrance (GESIS 2012). This con-
firmed hypothesis b, namely: “Adolescents or adults with pedi-
atric cochlear implantation have a poorer level of education than
their normal-hearing peers.”
However, if the data are compared with outcomes for the
German deaf population, 2.9% more participants using CIs had
a subject-related entrance qualification for technical college and
4.9% more had a general qualification for university entrance
(Weber & Schlenker-Schulte 2011). In Austria, the educational
level of the 52 CI-using students did not differ from that of the
hearing population (Huber et al. 2008). However, it should be
noted that most participants had residual hearing at least in the
second ear, because the duration of hearing-aid use was 10.1
(2.5) years for adolescents and 11.4 (2.5) years for adults in
this study. Furthermore, the maximum age at onset of deafness
was 24 years. Some adolescents or adults in this study benefited
from their first 2 years with hearing. As with the Austrian popu-
lation, the level of school education among German participants
using CIs was found to correlate with the maternal educational
background. This was also found for normal-hearing students
(Davis-Kean 2005).
These comparisons showed that, right from the start, pediat-
ric users of CIs had had better educational possibilities than deaf
people who lacked these implants. Their educational opportuni-
ties will increase because of new technologies and the current
trend toward early implantation.
Occupation
The third aim was to evaluate the occupational situation of
participants using CIs. The results showed that the majority of
users of CIs were able to choose their own occupational path,
unlike in times before World War II, when the deaf had access
only to noncommunication-based handicrafts (Bohms 1999).
Bohms (1999) assumed that deaf persons were not offered
integral education on a universal basis area-wide until the 20th
century. Therefore, many children and adolescents with hearing
impairment had educational deficiencies and could work only in
low-level occupations. There will certainly be many differences
between countries in the educational and occupational status of
adolescents and adults who are hearing impaired. For example,
1041 deaf people working in high-level occupations in United
States between 1871 and 1963 (Geisberger 1963) were success-
ful because they underwent lengthy vocational training up to the
age of 27, involving small classes (5 to 8 students) and special
methods.
Most of the respondents to this study were satisfied with
their job and pay, as well as their relationship with their super-
visor and colleagues. This substantiates the findings of Fazel
and Gray (2007), who reported that CIs helped to improve job
satisfaction and career prospects.
Based on the results of this retrospective study, it could also
be assumed that nowadays good CI performers have the same
opportunities as their normal-hearing peers, but other early pedi-
atric users of CIs were underprivileged in their occupational
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
situation. The data from this present study on occupations reflect
the educational situation. Without university entrance certifi-
cates, it is rare that recipients of CIs receive tertiary education
and achieve high-level occupations, both in Germany and in
other European countries. More users of CIs than normal-hear-
ing peers worked in level 2 areas; this includes service workers,
shop, and market sales workers, skilled agricultural and fishery
workers, craft and related workers, plant and machine operators,
and assemblers or clerks. This supports hypothesis c: Adoles-
cents or adults with pediatric cochlear implantation have poorer
occupational prospects than their normal-hearing peers. Ruben
(2000), too, reported on the general experience that deaf persons
without implants were largely excluded from tertiary educa-
tion. This had a knock-on effect in terms of lower-level employ-
ment. Another crucial question was that of which occupations
were nowadays open to students. To those attending mainstream
classes, the full range of options is available, but often only a
restricted selection is on offer to students in schools for those
with deafness or hearing impairment. At the turn of the millen-
nium, Bohms (1999) reported that only 46 possible occupations
were available to deaf people in Germany, whereas young people
without disabilities had over 400 options. Our literature search
revealed a great paucity of studies on this.
Nevertheless, the present data showed that the employment
rate of participants using CIs (41%) is much lower than that of
the general population (77%), although 65% of recipients of
CIs had concluded their vocational training with a certificate.
In one study (GESIS 2012), the proportion of normal-hearing
peers with work-related qualifications was 93.6%. In the pres-
ent study, 9% of users of CIs were unemployed, and during their
lifetime they have been affected by unemployment to a sig-
nificantly greater extent (49%) than their normal-hearing peers
(Fig. 5). In contrast to the present data, Bohms (1999) assumed
that the unemployment rate was about 75% in deaf adults,
whereas Weber and Schlenker-Schulte’s (2011) survey revealed
that 68.4% were in work and 12.1% unemployed. Because, in
this current investigation, 43% of the surveyed participants
using CIs were still in school—with 32% of these in vocational
training—further studies on employment and unemployment
were required to obtain conclusive data allowing comparison
of recipients of CIs with normal-hearing peers. Furthermore,
the unemployment rate among people with hearing impairment
varies between countries. It is, for example, almost four times
as high as the general unemployment rate in the United King-
dom (Hear-it AISBL 2015). In Denmark, unemployment levels
among job seekers who are hearing impaired were twice the
general rate. Notwithstanding variations from country to coun-
try, the general trend is clear: Individuals with hearing impair-
ment face numerous barriers in the labor market. In a survey on
obstacles to employment, 70% of the respondents believed that
they were taken out of consideration for jobs they had applied
for because of their hearing impairment or deafness (Hear-it
AISBL, undated).
The correlation between auditory performance and both age at
implantation and school type would appear to play an important
part in determining career success. A positive linear correlation
found between CAP and ISCO-88 skill level confirms hypothesis
c, namely that the lower the auditory performance level, the lower
the chance someone has of attending mainstream schools and
gaining access to higher-status careers. Early detection of hear-
ing loss and early cochlear implantation were important if deaf
10 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX
children were to be provided with the best educational and occu-
pational opportunities (Spivark, undated). Not only can cochlear
implantation improve the quality of life of deaf children it is also
expected to save society about $53,000 over a given child’s life-
time, including both direct and indirect costs (Cheng et al. 2000;
Schulze-Gattermann et al. 2002; Shield 2006).
However, the current dataset revealed a wide range of
educational levels among those early pediatric recipients of
CIs who were in work. An investigation into employment rate
would be highly useful in shedding light on this topic. The
surveyed group, however, was too small to draw any conclu-
sions about this (response rate 18.65%). Furthermore, there
is a need for more detailed studies into which children attain
which occupations. With the group being very heteroge-
neous, these data were able to reveal more common relation-
ships between hearing outcome, education, and occupation. A
study with a more homogeneous group could yield informa-
tion about different developmental routes chosen by pediatric
users of CIs. Similarly, it will be necessary to evaluate the
next generation of children who received their implants very
early in life, and with more advanced technology involved.
CONCLUSIONS
The first pediatric recipients of implants showed stable audi-
tory outcomes across a medium range based on the conversion
of age-related test results to CAP, depending on different indi-
vidual factors. Age at implantation was one of the most impor-
tant of these.
Educational and occupational levels were found to be sig-
nificantly poorer than for the general population in Germany.
Compared with the findings of a German study involving about
5000 deaf people (GINKO), more participants using CIs had
qualifications for university-level education.
Our data showed a positive linear correlation between CAP
and the occupational ISCO-88 skill level. CAP levels depended,
inter alia, on the age at implantation. Because age at implanta-
tion decreases, and because of new CI technology, further stud-
ies with a population of children implanted before the age of
one or two will probably demonstrate that both school educa-
tion and occupational levels are comparable with those of the
normal-hearing population.
APPENDIX
See Questionnaire in Supplemental Digital Content (http://
links.lww.com/EANDH/A337).
ACKNOWLEDGMENTS
We are grateful to Barbara Esser-Leyding, PhD, and her team at Cochlear
Implant Centrum “Wilhelm Hirte,” Hannover, Germany, for their support
in this study.
This research was funded by the Geers Foundation and the International
Hearing Foundation.
The authors have no conflicts of interest to disclose.
Address for correspondence: Angelika Illg, Department of
Otorhinolaryngology, Medical University Hannover, German Hearing
Center, Karl-Wiechert-Allee 3, 30625 Hannover, Germany. E-mail: illg@
hoerzentrum-hannover.de
Received October 6, 2015; accepted January 5, 2017.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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