Heliyon 7 (2021) e08507 Contents lists available at ScienceDirect Heliyon journal homepage: www.cell.com/heliyon Research article Differences in picture naming between children with cochlear implants and children with typical hearing C. Cambra a, *, J.M. Losilla b, N. Mena a, E. Perez a a Department of Basic, Developmental and Educational Psychology, Faculty of Psychology. Universitat Autonoma de Barcelona, 08193 Bellaterra, Cerdanyola del Valles, Spain b Department of Psychobiology and Health Sciences Methodology, Faculty of Psychology, Universitat Autonoma de Barcelona, 08193 Bellaterra, Cerdanyola del Valles, Spain A R T I C L E I N F O A B S T R A C T Keywords: Increase in the auditory abilities of children with cochlear implants (CIs) has led to an improvement in naming Picture naming tasks, although divergent results are still being reported; this strongly suggests that further studies are needed. Cochlear implant The study aims to compare the responses in a picture-naming activity between the complete population of Childhood children aged 5 to 7 with cochlear implants in Catalonia -Spain- (N ¼ 31), without developmental problems, and a Education matched sample of 31 children with typical hearing. A picture-naming task was used to assess their lexical naming abilities. The results show that children with CIs provide more non-responses, they produce fewer words correctly, they require a longer reaction time and they commit more picture-naming errors than children with typical hearing. The auditory age does significantly affect the results, but not the type of implant. In spite of the hearing gain achieved with the cochlear implant and the listening experience progressively achieved in distinct contexts, further explicit work on lexical naming in speech-therapy intervention is clearly required. 1. Introduction studying children aged 5 to 8 with CIs immersed in an oral-educational programme, along with the study by Connor et al. (2006), which Technological improvements in hearing devices in the past decade examined a sample of 6-year-old children. Geers and Nicholas (2013) have contributed to improving auditory perception and, consequently, evaluated the linguistic competence of 60 children with CIs when they oral-language development in early-deaf children, especially in the area were 4 and 10 years old and found that the language levels they reached of lexicon (James et al., 2008). correlated significantly with their auditory age; they showed higher There are many variables implicated in the lexical learning of chil- scores in vocabulary than in the other areas, although type of cochlear dren with cochlear implants (CIs), but two of these have been shown to implant, either unilateral or bilateral, bore no influence. The improve- be more strongly associated: the age at which the implants are implanted, ment with cochlear implants in the lexical component takes place known as the age of implantation, and how long the person has worn the regardless of the type of implant, whether unilateral, performed in one of implant, known as the auditory age (Bayes, 2017; Connor et al., 2006; the ears, or bilateral, performed in both ears (Geers and Nicholas, 2013; Convertino et al., 2014; Dettman et al., 2007; Geers et al., 2008; Geers Bayes, 2017). and Nicholas, 2013; Hayes et al., 2009; Holt and Svirsky, 2008; Houston The characteristics of the words generate the same lexical learning et al., 2012; Miyamoto et al., 2008; Nicholas and Geers, 2007; Szagun pattern in children with implants as in children with typical hearing of and Stumper, 2012). Implants performed before the age of two allow the same age. Neither word length nor phonological components in- children to reach similar oral-language levels to their same-age peers fluence word learning, whereas neighbourhood density (the number of with typical hearing, as their age of language acquisition is the same as known words that sound similar to a given word) and word frequency that of children with typical hearing, a variable considered as the greatest do (Kyung Han et al., 2015). The results of the recent study by Lund predictor of success in the ability to name in lexical processing, even (2019) concur that children with CIs tend to know words with both more than the variable of word frequency (Cannard and Kandel, 2008). high density and common probability or sparse density and rare The study by Hayes et al. (2009) reaches this same conclusion after probability. * Corresponding author. E-mail address: cristina.cambra@uab.cat (C. Cambra). https://doi.org/10.1016/j.heliyon.2021.e08507 Received 5 July 2021; Received in revised form 7 October 2021; Accepted 26 November 2021 2405-8440/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). C. Cambra et al. Heliyon 7 (2021) e08507 In addition to the studies indicated, other studies have reported language and children with typical hearing aged between 7 and 12. different results in the areas of lexicon between children with CIs and After a first phase of familiarisation with the words to ensure they were children with typical hearing of the same age. Lund's (2016) review of known by all the children in the sample, and through the use of dis- studies examining the vocabulary of deaf children with CIs (average tractors, the results showed that children with CIs made more precision participant age ranged from 49 to 109 months) found that they still show errors than children with typical hearing, but they did not need more lower expressive and receptive lexical knowledge than their same-age reaction time for production. Schwartz et al. (2013), using distractors peers with typical hearing (Davidson et al., 2014; El-Hakim et al., too, agree that the response time is not a variable that establishes dif- 2001; Nott et al., 2009; Marshall et al., 2018; Svirsky et al., 2004). Le ferences between the population with CIs and the population with Normand et al. (2003) observed a considerable individual variability in typical hearing. lexical acquisition, in the fact that some children obtained a level close to Boons et al. (2013) studied the errors made in the picture-naming task the expected level for their age two or three years after implantation, and compared them with the expressive vocabulary. They used The while others displayed a long delay with little or no production. More- Expressive One Word Picture Vocabulary Test (EOWPVT), a standardised over, the studies also found that a good level in one lexical category does test to study the naming of objects, actions and concepts. The study not predict similar scores in other categories. The influence of age of sample consisted of 70 children with CIs aged 5 to 13 with those of their implantation as a significant variable in learning activities concerning same-age peers with typical hearing. The picture-naming errors were new vocabulary was also questioned by Pimperton and Walker (2018). analysed using 8 categories: (1) No answer; (2) Neologism; (3) Not Along the same lines, Duchesne et al. (2009) showed the heteroge- related; (4) Circumlocution; (5) Related-Meaning-General; (6) neity of the population of deaf children in relation to their levels of Related-Meaning-Neighbour; (7) Related-Meaning-Specific; and (8) language acquisition. The study examined receptive and expressive vo- Related-Sound. The results showed that the most frequent conduct of cabulary and grammar achievement of 27 French-speaking children aged children with CIs was (1)-No answer, and significantly lower results than between 42 and 99 months, who received a CI at the age of one or two children with typical hearing were found only in the number of responses years. As a group, children exhibited language levels within normal limits with a neighbouring word from the same semantic field in all standardized language measures. Nevertheless, examination of in- (6-Related-Meaning-Neighbour). dividual patterns revealed four different language profiles ranging from The goal of this study was to further examine the process of naming normal language levels in all domains to general language delay. production based on the picture-naming task in children with cochlear The picture-naming task is the most consolidated task in determining implants. The aim was to establish whether the lexical naming abilities in linguistic progress (Cannard and Kandel, 2008; Wechsler-Kashi et al., children with CIs are the same as for children with typical hearing. First, 2014) and its use in research serves to determine not only the lexical we studied whether the number of words produced is similar to or less repertoire of the child (words he/she knows), but also whether or not than that of children with typical hearing in order to contribute knowl- there are difficulties in the production process of these new words. edge to the contradictory results generated by previous studies. Second, Perez Perez (2013) indicates that in the process of lexical produc- we wanted to establish whether children with CIs present a difficulty tion, children with typical hearing can make errors (produce the pattern in naming production similar to that presented by children with wrong words) and/or can need more time to access the word (also typical hearing in relation to production errors and latency time. Third, known as reaction or latency time) than what is considered as normal we want to contribute more evidence about whether the auditory age (600 ms, according to Rodriguez-Ferreiro and Cuetos, 2011). The (i.e., the difference between the age and the implantation age) and the result of the work by Logan (1981) reveal a direct correlation between type of implant are relevant variables in the naming production process. production errors and latency time (the more errors, the longer the According to the results of previous works, and considering the latency time). In the production process, word characteristics have characteristics of the sample, the present study presents the following been shown to affect the precision and/or latency time of production hypotheses: (Cycowicz et al., 1997). H1. Analysis of the differences in the number of correct names produced. As The picture-naming task has rarely been used to assess naming pro- indicated by the review of the studies carried out by Lund (2016), in the duction in children with CIs. Some studies have used it to analyse the picture-naming task, it is expected that children with CIs will produce a production of categories (Lund and Dinsmoor, 2016), others to analyse lower number of correct responses than children with typical hearing. the phonology (Grandon et al., 2019). However, it can also help to determine if the learned lexicon is produced following the same pattern H2. Analysis of the differences in the number of names not produced. Ac- as children with typical hearing, which would help to specify the lin- cording to the results of the study by Boons et al. (2013), it is expected guistic benefits of cochlear implants. that children with CIs will remain silent (no answers) more times than Wechsler-Kashi et al. (2014) used the picture-naming task to study children with typical hearing when a name is required, unlike explicit the production of names and the verbal fluency in order to establish responses given when the answer is simply unknown (“don't know”). whether children with CIs have deficits in lexical organisation and ac- H3. Analysis of the differences in production difficulties. Along the same cess that are manifested through reaction time. The sample consisted of line as the study by Wechsler-Kashi et al. (2014), it is expected that 20 children with CIs and 20 children with typical hearing between the children with CIs and children with typical hearing will show the same ages of 7 and 10 years old. They were shown pictures of words varying profile of production difficulties, but children with CIs will have more in length, familiarity and neighbourhood density, and pertaining to difficulties accessing the lexicon, needing more latency time. basic semantic categories and they were asked to quickly name the images. No significant differences were found between the two groups H4. Study of the influence of auditory age and type of implant on the number in the total number of pictures named or the total response time. In the of names produced. According to the results of the study by Geers and production process, the very familiar and shorter words were produced Nicholas (2013), it is expected that the naming production process in more quickly by both groups. These results support the argument that children with CIs of an older auditory age will produce a larger number of the auditory age and age of implantation correlated positively with names, while the type of cochlear implant is not expected to be a relevant naming skills: the deaf children who received their CIs at a younger age variable. and who had an older auditory age were more skilled at naming very H5. Study of the influence of auditory age and type of implant on production familiar bi-syllabic words. difficulties. In children with CIs, fewer difficulties are expected to be In different conditions to those of Wechsler-Kashi et al. (2014), Hoog found in children of an older auditory age while the type of cochlear et al. (2015) analysed the quickness and precision of naming production implant is not expected to be a relevant variable. in children with CIs, hard of hearing children, children who used signed 2 C. Cambra et al. Heliyon 7 (2021) e08507 2. Materials and methods the authors for the phonological study of children from 3 years of age. This ensures that the images are suitable for the age range in our study. In 2.1. Participants addition, in order to increase the sensitivity of the instrument and to make it more discriminative, the name of 13 complementary words that The study sample was comprised of 62 children, 31 deaf children with appear in the test images was also requested (see Appendix A). That is, CIs and 31 children with typical hearing, with 18 girls (58%) and 13 boys the children were asked to say 2 or 3 names for 11 of the images, but only (42%) in each group, and aged between 5 and 7 years (mean of 6.03 years when they correctly named the first one. For example, when the image of and standard deviation of 0.71 in both groups) from public inclusive a “turtle” was shown, the word to name its “shell” was only requested if schools that use Catalan as the working language for all school content. the child had previously said the word “turtle”. Consequently, the All these subjects are children of hearing parents and use exclusively number of words requested ranged from a minimum of 28 to a maximum spoken language to communicate. The deaf-children group constitutes of 41. the entire population of schoolchildren at the indicated ages in Catalonia (Spain). They were enrolled in an oral communication programme in the 2.3. Procedure Resource Centres for Persons with Hearing Impairments (CREDA, in its Catalan acronym). CREDAs are institutions that depend on the Catalan The images were shown by speech therapists who were familiar with Government's Department of Education, whose objective is to provide the usage of the test in the context of children with language disorders. speech therapy at inclusive schools in order to attend to students with Children were asked to name pictures with the following prompt: What is hearing impairment. The specific selection criteria for deaf children were this? They were given a maximum of 4 s to answer, following the criteria having prelinguistic deafness, wearing a cochlear implant (either uni- applied by Wechsler-Kashi et al. (2014). If after this time span the child lateral or bilateral), using oral language as a means of communication; remained silent (no answer) or said that he/she does not know (“I don't having an auditory age equal to or higher than two years old (two or know”), the next image was shown. All responses were recorded in audio more years post CI, whether unilateral or bilateral), and not having any and subsequently transcribed literally by two researchers (judge 1: NM; associated disability that could justify production difficulties itself. A judge 2: CC); this was then revised independently by a third researcher control partner with typical hearing was sought for each deaf child. Each (judge 3: IE). deaf child's tutor selected a partner from the same year group of the same When the image was not automatically recalled, the latency time age and sex, with a similar socioeconomic level and an average academic between the presentation of the image and its naming was recorded. level obtained from school results that was also comparable, who did not present any developmental problems. All the families, whether of the 2.4. Measures deaf or hearing participants, provided their written consent for their children to participate in the study and the study was approved by the Following the Protocolo de An alisis de las Dificultades del Lenguaje Catalan Government's Department of Education. (Protocol of Language Difficulty Analysis) (PADIL) proposals of Perez Perez (2013), the responses were grouped into three categories: number 2.2. Instruments of names correctly produced (“automatic picture naming”, known and automatically produced names, and “latency picture naming”, known The materials used were images of names that differ in frequency of names with a longer latency time of production than expected), number use, length and pertinence to distinct semantic fields (food, animals, of names not produced (“no answer”, in which the children remained objects, transport, musical instruments, professions and personalities). silent, and “don't know”, in which the name is declared unknown), and The differences in the characteristics of the words were not the goal of number of responses with production difficulties (“semantic difficulties”, our study. in which a name produced for the picture was inappropriate due to the On the one hand, we presented the 28-color photos of the AREPA test semantic features of the word activated; “lexical-access difficulties”, in (An alisi del Retard de la Parla) by Aguilar and Serra (2003), prepared by which there was a longer latency time of production than expected, Table 1. Descriptive statistics of the study sample. Children with typical hearing Children with CI Total sample n (%) n (%) n (%) Gender Male 13 (42) 13 (42) 26 (58) Female 18 (58) 18 (58) 36 (58) Type of implant Unilateral 21 (67.7) Bilateral 10 (32.3) Mean (SD) Mean (SD) Mean (SD) Age (years) 6.03 (0.71) 5.97 (0.75) 6.0 (0.72) Age of implantation (months) 26.58 (15.04) Auditory age (months) 52.03 (15.15) Types of responses in the naming task (counts) No answer 0.94 (1.24) 3.94 (3.49) 2.44 (3.01) Don't know 0.68 (1.11) 1.0 (1.27) 0.84 (1.19) Automatic Picture Naming 28.71 (5.14) 22.29 (6.41) 25.5 (6.61) Latency Picture Naming 31.03 (4.95) 26.19 (5.90) 28.61 (5.93) Semantic difficulties 0.36 (0.71) 0.36 (0.80) 0.36 (0.75) Lexical access difficulties 2.45 (2.1) 3.39 (2.70) 2.92 (2.44) Picture Naming errors 4.55 (3.14) 5.71 (3.53) 5.13 (3.37) 3 C. Cambra et al. Heliyon 7 (2021) e08507 Figure 1. Adjusted differences (in percentages) between children with CIs and children with typical hearing in the picture naming task. independently of whether the response was correct or incorrect; and regression models, and gender and age were included as control vari- “picture-naming errors”, in which an incorrect name was produced). The ables. The age at the time of implantation, which some authors also complete coding of the PADIL categories is shown in Appendix B. Distinct include in this type of analysis (Colin et al., 2017), was not considered in works have established that the time from an image being seen and its our case on account of the strong collinearity with the auditory age (r ¼ name being vocalised is 600 ms (Rodriguez-Ferreiro and Cuetos, 2011). .82; p < .001) due to the scarce variability in the age of the participants. In this study, the consideration of difficulty of lexical access is advocated The Incidence Rate Ratio (IRR) was calculated as the measure of relative when the child takes more than a second to produce the word when being risk, as well as its 95% confidence interval (95% CI) and p-values. shown an image. All statistics were processed with Stata/SE v16 (StataCorp, 2019). 2.5. Data analysis 3. Results Considering the measurement scale of the outcomes registered Table 1 summarises the main characteristics of the two groups of (counts/number of instances) and the non-experimental nature of our children studied, as well as the different responses recorded in the study design (cross-sectional), Poisson regressions models were fitted to picture-naming task. investigate the responses of children with CIs and children with typical Results of the analyses conducted are presented below in the same hearing, as well as to analyse the influence of the type of CI, the auditory order as the hypotheses. Figure 1 and Table 2 summarise the main results age in the group of children with CIs (Lindsey, 1995; Long, 1997; Vives of the comparative analyses between children with CIs and children with et al., 2006). Variability in the number of words requested to each typical hearing (hypotheses H1 to H3). Table 3 shows the results of the participant was included as an offset (exposure variable) in all Poisson analyses within the group of children with CIs (hypotheses H4 and H5). Table 2. Comparative analysis between children with CIs and children with typical hearing (reference group) in the Picture Naming task. Measure IRRadj (95% CI) (IRRadj  1)*100 P Automatic Picture Naming 0.783 (0.708–0.864) 21.7% (29.2% – 13.6%) <.001* Latency Picture Naming 0.852 (0.776–0.935) 14.9% (22.4% – 6.5%) .001* No Answer 4.179 (2.786–6.270) 317.9% (178.6% – 527.0%) <.001* Don't Know 1.527 (0.877–2.657) 52.7% (12.3% – 165.7%) .135 Semantic Difficulties 1.026 (0.444–2.371) 2.6% (55.6% – 137.1%) .952 Lexical Access Difficulties 1.368 (1.017–1.839) 36.8% (1.7% – 83.9%) .038* Picture Naming Errors 1.387 (1.112–1.731) 38.7% (11.2% – 73.1%) .004* Note: Adjusted Poisson regression coefficients (IRRadj), 95% confidence intervals (95% CI) and p-values (P). (IRRadj  1)*100 show the differences expressed in per- centage between children with CIs and children with typical hearing. All regression models include sex and age (in years) as adjustment variables. * IRRadj statistically significant. 4 C. Cambra et al. Heliyon 7 (2021) e08507 H1. Analysis of the differences in the number of correct names produced H4. Study of the influence of auditory age and type of implant on the number The number of names that the children knew was analysed in two of names produced conditions. First, we analysed the number of names that children knew The results showed that the auditory age (amount of time the children and produced automatically (automatic picture naming), and second, we had had the implant) has a direct and significant influence, with a analysed the number of names that they knew but did not produce maximum magnitude of 1.2% (IRRadj ¼ 1.006; 95% CI: 1.0–1.012), on automatically but which, instead, involved a latency time in which the the number of names automatically produced without latency (Table 3). presentation of the picture and its naming exceeded 1 s (latency picture However, the type of implant (unilateral or bilateral) did not significantly naming). determine the number of names the children with CIs knew and produced As shown in Table 2, significant differences were found between the either automatically (automatic picture-naming) or with latency time two groups in the two situations studied in relation to hypothesis H1: the (latency picture-naming). The hypothesis on the influence of auditory group of children with CIs knew and automatically produced between age was supported, as was the hypothesis on the influence of the type of 13.6% and 29.2% fewer names than the children with typical hearing implant. As expected, wearing a unilateral or bilateral implant did not (IRRadj ¼ .783; 95% CI: .708–.864), and children with CIs produced lead to significant differences in the number of names that the children between 6.5% and 22.4% fewer names with a latency time less than 1 s knew and correctly produced without latency time. (IRRadj ¼ .85; 95% CI: .776–.935). H5. Study of the influence of auditory age and type of implant on production H2. Analysis of the differences in the number of names not produced difficulties The study of the names that were not produced revealed two different In the group of children with CIs the results showed that the auditory behavioural patterns: remaining silent (No Answer) or verbalizing the age has an inverse and significant influence, with a maximum magnitude fact that the item for production was not known (saying “I don't know”). of 2.5%, on the number of picture-naming errors (IRRadj ¼ .987; 95% CI: As shown in Table 2, and as posited in hypothesis H2, the number of .975–.998), but not in any of the other types of production difficulties names not produced in which the children remained silent was between studied (semantic difficulties and lexical access difficulties). However, no 2.8 and 6.4 times higher in children with CIs than in children with typical significant differences were obtained with regards to the implant in any hearing (IRRadj ¼ 4.179; 95% CI: 2.786–6.270). However, no significant of the production difficulties studied. differences were found in the number of times both groups stated that they did not know the answer. 4. Discussion H3. Analysis of the differences in production difficulties As posited in hypothesis H3, no significant differences between the The objective of this study was to further examine the naming pro- two groups were found in the number of semantic difficulties. However, duction process with the picture-naming task in children with cochlear the results indicate that the hypothesis on lexical-access difficulties was implants and to provide knowledge about the effect of implants. To do so, not supported: we expected to find no significant differences between the we studied the number of words produced, the difficulty patterns pre- two groups in picture-naming time yet the results showed that this is sented in production and the effect of the auditory age and the type of between 3.5% and 86.7% higher in children with CIs than in the children implant as relevant variables in naming production. The results show that with typical hearing (IRRadj ¼ 1.368; 95% CI: 1.017–1.839). That is, deaf children with cochlear implants aged between 5 and 7, compared to children with CIs take more time to name than children with typical children with typical hearing, produce a lower number of words, do not hearing. answer in a higher proportion, present a production time of more than 1 s In accordance with H3, significant differences were found in the (latency time) and make more production errors. The auditory age of picture-naming errors: the number of errors committed by children with children with CIs has proved to be a relevant variable in the production of CIs was between 11.2% and 73.1% higher than children with typical automatic picture-naming and in the reduction of the number of errors, hearing (IRRadj ¼ 1.387; 95% CI: 1.112–1.731) (Table 2). With regard to but not the type of implant, which has not significantly influenced the the type of picture-naming errors, as expected, no significant differences results. were found between those made by children with CIs and by children These results are consistent with some earlier studies, strengthening with typical hearing. the knowledge of the naming production process with the picture- Table 3. Effects of type of implant and auditory age of the children with CIs in the Picture Naming task. Error classification IRRadj (95% CI) (IRRadj  1)*100 P Automatic Picture Naming - Type of Implant (bilateral vs unilateral) 0.904 (0.755–1.082) 9.6% (24.5% – 8.2%) .270 - Auditory Age (months) 1.006 (1.0–1.012) 0.6% (0% – 1.2%) .049* Latency Picture Naming - Type of Implant 1.034 (0.877–1.218) 3.4% (12.3% – 21.8%) .693 - Auditory Age 1.004 (0.999–1.010) 0.4% (0.1% – 1.0%) .127 Semantic Difficulties - Type of Implant 0.455 (0.089–2.314) 54.5% (91.1% – 131.4%) .343 - Auditory Age 1.030 (0.983–1.079) 3.0% (1.7% – 7.9%) .210 Lexical Access Difficulties - Type of Implant 0.965 (0.591–1.576) 3.5% (40.9% – 57.6%) .887 - Auditory Age 0.986 (0.972–1.001) 1.4% (2.8% – 0.1%) .075 Picture Naming Errors - Type of Implant 1.023 (0.713–1.467) 2.3% (28.7% – 46.7%) .901 - Auditory Age 0.987 (0.975–0.998) 1.3% (2.5% – 0.2%) .027* Note: Adjusted Poisson regression coefficients (IRRadj), 95% confidence intervals (95% CI) and p-values (P). (IRRadj  1)*100 shows the effect expressed in percentage of change. All regression models include sex and age (in months) as adjustment variables. * IRRadj statistically significant. 5 C. Cambra et al. Heliyon 7 (2021) e08507 naming task, and they provide data in a different light to those presented This similarity between the two groups shows that children with CIs by other works. have the same awareness of their own knowledge as same-age children When analysing the activated lexicon, significant differences are with typical hearing. This is necessary to advance cognitively and, from found between the two groups in the number of correct responses. an educational-psychology standpoint, it helps the teacher and speech Regardless of whether the picture naming is automatic or takes some therapist employ specific methodological strategies to foster student time to be activated, children with typical hearing produced a larger learning. number of correct responses than the children with CIs, independently of Finally, this current study found no differences in the number of their sex and age. As with some of the preceding studies (see the review words the children knew and could produce according to the type of by Lund, 2016), this study has therefore found a lower knowledge of implant (unilateral-bilateral). This is in accordance with other studies nominal lexicon in children with CIs than in the control group. Moreover, (Bayes, 2017; Geers and Nicholas, 2013). That find, the type of implant unlike the results of the studies by Wechsler-Kashi et al. (2014), Hoog does not affect the number of words that these children know and et al. (2015) and Schwartz et al. (2013), children with CIs needed more correctly produce in the naming task. The fact that various studies time to produce those words than the control children. That is, they analyzing language ability in children with CIs conclude that those with needed latency times because these words were not produced automat- bilateral CIs perform no better than those with unilateral CIs highlights ically. Despite using the same task as in the previous studies, the pro- the need to carefully consider and evaluate the necessity of a second cedure and the characteristics of the sample could explain such implant in each individual case. However, as we expected, the child's discrepancies in the results. For one thing, the Wechsler-Kashi et al. study auditory age (24–71 months) has an effect on the naming task, as found (2014) explicitly requested that participants respond as quickly as in the majority of previous studies (Convertino et al., 2014; Dettman possible, while our study did not require that participants respond et al., 2007; Geers et al., 2008; Geers and Nicholas, 2013; Houston et al., quickly. Furthermore, it was observed in their study that responses were 2012; Holt and Svirsky, 2008; Miyamoto et al., 2008; Nicholas and Geers, slower as a function of the length of the word. While their study only used 2007; Szagun and Stumper, 2012; Wechsler-Kashi et al., 2014). The re- monosyllabic and bisyllabic words, the present study included words of sults of this study show that the auditory age has an effect on the number three and four syllables, which probably contributed to the increase in of names automatically produced without delay and on the number of response times. Another factor that prevents direct comparison between picture-naming errors. the results of the two studies is the age of the participants. Our study Therefore, we can conclude that even though deaf children who comprised younger children (5–7 years old), while Wechsler-Kashi et al. attend inclusive schools receive the same linguistic experiences and are (2014), looked at children from 7–10 years old and Hoog et al. (2015), exposed to the same academic curriculum as their classmates with examined children between 7 and 12 years old. This could explain why typical hearing, they do not construct their nominal lexicon as accu- participants in our study took longer to respond. The analysis of the type rately as their same-age peers with typical hearing. However, through of error produced by the participants with CIs versus children with the technological assistance of a cochlear implant that provides typical hearing revealed no significant differences. Overall, these results good auditory gains, they gradually improve as their auditory age concur with those found by Boons et al. (2013), with the exception that increases. they found that the least frequent picture-naming errors in children with It should be noted that the non-experimental nature of the study may CIs were words named with a neighbouring word from the same semantic limit the scope of our conclusions. Children with typical hearing were field. selected through a process of matching by age, sex, socioeconomic level When children with CIs are asked to name pictures, they do so in a and average academic level to maximise their comparability with the different way to children from the control group. The differences lie in group of deaf children with CIs, thus reducing the potential confounding the behavioural pattern of non-response (remaining silent), which is bias inherent in cross-sectional research designs. In any case, there can significantly more common in children with CIs than in the group of potentially remain certain confusion due to the fact that the information children with typical hearing. These results match those found in the about the socioeconomic status of the participants was collected from the study by Boons et al. (2013) who observed that the most frequent interview with the academic teacher-tutor in relation to the profession of conduct shown by children with CIs when the EOWPVT test was applied the parents and the inference of their income level. Furthermore, only to them were responses of the type “no answer”. There can be different children without any developmental problems were included in the reasons that justify the lack of response, some of which could be related, study. for example, to a reduced lexicon or difficulty accessing the lexicon. A A notable strength of our study is the high representativeness of the possibility could be that they simply do not know the word, in which group of children with cochlear implants included, since they constitute case the cause of differences to the group of children with typical the total population of children with this characteristic in Catalonia hearing would be a lack of lexical knowledge (Lund, 2016). Alterna- within the age range studied. However, the small sample size reduces the tively, they do not respond because they cannot retrieve the word from statistical precision of the estimated effects of the type of cochlear their lexical storage, in which case the differences with the group of implant. children with typical hearing would lie in greater difficulty activating Further research into the lexical knowledge of children with CIs is the word, which then leads them to stop trying (Boons et al., 2013). clearly required, as is the exploration of whether word-form character- These different causes (reduced lexicon or difficulty accessing the istics affect the naming differences observed in our population. lexicon) would require specific types of speech and language therapy. A reduced lexicon will require a focus on increasing lexical learning, while Declarations difficulty accessing the lexicon will require a focus on reducing word finding difficulties. These two objectives will indicate the use of Author contribution statement different intervention strategies and procedures, as should always be the case when considering the individual characteristics of each child with a Cristina Cambra and Encarna Perez: Conceived and designed the CI. Only when the children explicitly state that they do not know the experiments; Performed the experiments; Analyzed and interpreted the word by actually expressing the fact that they do not know the answer data; Contributed reagents, materials, analysis tools or data; Wrote the can we be certain that this is the reason they do not answer, although paper. even in these cases this should be asserted with caution. Counter to the Josep-Maria Losilla: Analyzed and interpreted the data; Contributed hypothesis, the results of our study reveal that there are no significant reagents, materials, analysis tools or data; Wrote the paper. differences between children with CIs and the control group with typical Nereida Mena: Performed the experiments; Analyzed and interpreted hearing in terms of the number of words they say they do not know. the data. 6 C. Cambra et al. Heliyon 7 (2021) e08507 Funding statement Geers, A.E., Tobey, E., Moog, J., Brenner, C., 2008. Long-term outcomes of cochlear implantation in the preschool years: from elementary grades to high school. Int. J. Audiol. 47, S21–S30. This work was supported by the Grant PGC 2018-100675-B-I00 from Grandon, B., Vilain, A., Gillis, S., 2019. The effect of hearing impairment on the the Spanish Ministry of Science, Innovation and Universities. production of prominences: the case of French-speaking school-aged children using cochlear implants and children with normal hearing. First Lang. 39 (2), 200–219. Hayes, H., Geers, A., Treiman, R., Moog, J.S., 2009. Receptive vocabulary development in Data availability statement deaf children with cochlear implants: achievement in an intensive auditory-oral educational setting. Ear Hear. 30, 128–135. The data that has been used is confidential. Holt, R.F., Svirsky, M.A., 2008. An exploratory look at pediatric cochlear implantation: is earliest always best? Ear Hear. 29, 429–511. Hoog, B.E., Langereis, M.-C., Weerdenburg, M.V., Knoors, H., Verhoeven, L., 2015. Lexical Declaration of interests statement access in children with hearing loss or specific language impairment, using the cross- modal picture word interference paradigm. Res. Dev. Disabil. 37, 81–94. Houston, D.M., Stewart, J., Moberly, A., Hollich, G., Miyamoto, R.T., 2012. Word learning The authors declare no conflict of interest. in deaf children with cochlear implants: effects of early auditory experience. Dev. Sci. 15, 448–461. Additional information James, D., Rajput, K., Brinton, J., Goswami, U., 2008. Phonological awareness, vocabulary, and word reading in children who use cochlear implants: does age of implantation explain individual variability in performance outcomes and growth? Supplementary content related to this article has been published J. Deaf Stud. Deaf Educ. 13 (1), 117–137. online at https://doi.org/10.1016/j.heliyon.2021.e08507. Kyung Han, M., Storkel, H.L., Lee, J., Yoshinaga-Itano, C., 2015. The influence of word characteristics on the vocabulary of children with cochlear implants. J. Deaf Stud. Deaf Educ. 20 (3), 242–251. Acknowledgements Le Normand, M.-T., Ouellet, C., Cohen, H., 2003. Productivity of lexical categories in French-speaking children with cochlear implants. Brain Cognit. 53, 257–262. This study was carried out with the support of the Catalan Govern- Lindsey, J.K., 1995. Modelling Frequency and Count Data. Clarendon. Logan, G.D., 1981. Attention, automaticity, and the ability to stop a speeded choice ment's Department of Education (Departament d’Ensenyament de la Gen- response. In: Long, J., Baddeley, A.D. (Eds.), Attention and Performance IX. Erlbaum, eralitat de Catalunya), which provided us with access to the sample Hillsdale, NJ, pp. 209–222. studied. We would like to thank all the speech therapists at CREDA, and Long, J.S., 1997. Regression Models for Categorical and Limited Dependent Variables. Sage. especially all the children with CIs and the children with typical hearing Lund, E., 2016. Vocabulary knowledge of children with cochlear implants: a meta- who were part of this study, for their availability and cooperation. analysis. J. Deaf Stud. 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