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- Key words: Auditory performance, Children, Cochlear implant,
mance, educational status, vocational training, and occupational situa- Education, Long-term results, Occupation, Training route, Work.
tion in users of cochlear implants (CIs) who were implanted in childhood. (Ear & Hearing 2017;XX;00–00)
Design: This retrospective cross-sectional study of 933 recipients of CIs
examined auditory performance, education and vocational training, and INTRODUCTION
occupational outcomes. All participants received their first CI during their
childhood between 1986 and 2000. Speech comprehension results were The Hannover cochlear implant (CI) program in children
categorized using the categories of auditory performance (CAP) arranged started in 1986 after experience had been gained, and good out-
in order of increasing difficulty ranging from 0 to 8. 174 of the 933 pedi- comes achieved, in the implantation of postlingually deafened
atric recipients of CIs completed a self-assessment questionnaire regard- adults (Lenarz et al. 2012). Since the 1990s, these implants
ing their education and occupational outcomes. To measure and compare have been effective in the rehabilitation provided to profoundly
school education, qualifications were converted into International Standard deaf children in many programs all over the world. Studies have
Classification of Education levels (ISCED-97). Occupations were converted reported on outcomes, with follow-up limited to 2 to 5 years (as
into International Standard Classification of Occupation-88 skill levels. Data
stated in the editorial by Kaplan & Puterman (2010)). Examples
from the German General Social Survey (Allgemeine Bevölkerungsumfrage
der Sozialwissenschaften/ALLBUS) for 2012 were used as a basis for com- are the publications by Nikolopoulos et al. (1999a, b), Sharma
paring some of the collected data with the general population in Germany. et al. (2002), Lesinski-Schiedat et al. (2004), and Connor et
al. (2006). During the past 10 years, many studies have also
Results: The results showed that 86.8% of the 174 participants who com- yielded long-term speech perception results in children with
pleted the survey used their devices more than 11 hr per day. Only 2% of more than 7 years of CI experience (Waltzmann et al. 2002;
the surveyed individuals were nonusers. Median CAP was 4.00 (0 to 8).
Haensel et al. 2005; Uziel et al. 2007; Roland et al. 2009; Col-
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
letti et al. 2011; Geers & Sedey 2011; Geers & Nicholas 2013;
(SD = 0.59; range: 1 to 3). A significant difference (p = 0.001) between Geers et al. 2013; Peixoto et al. 2013; Black et al. 2014; Dunn
users’ ISCED levels and those of ALLBUS 2012 respondents was found. et al. 2014). Roland et al. (2009) described the long-term safety
Participants’ ISCED levels and maternal educational levels were sig- and efficacy of cochlear implantation in 50 very young children
nificantly correlated (r = 0.271; p = 0.008). The International Standard after a period of 7 years of CI use. They concluded that cochlear
Classification of Occupation-88 skill levels were as follows: 5% achieved implantation in children under the age of 12 months is safe and
skill level 1; 77% skill level 2; 16% skill level 3; and 5% skill level 4. The efficacious over an extended period of time.
average skill level achieved was 2.24 (range 1 to 4; SD = 0.57) which was Reports in the literature on educational and occupational
significantly poorer (t(127) = 4.886; p = 0.001) than the mean skill level of benefits are very rare. Spencer et al. (2004) reported on a
the ALLBUS 2012 respondents (mean = 2.54; SD = 0.85). 10-year follow-up in a first cohort of 27 of prelingually deaf
Conclusions: Data collection up to 17.75 (SD = 3.08; range 13 to 28) children, which yielded scores in speech perception and speech
years post implant demonstrated that the majority of participants who production, reading, and academic and vocational achievement.
underwent implantation at an early age achieved discrimination of speech There was also a prospective longitudinal study by Beadle et al.
sounds without lipreading (CAP category 4.00). Educational, vocational, (2005) on long-term functional outcomes and academic-occu-
and occupational level achieved by this cohort were significantly poorer pational status in implanted children (mean age at implantation
compared with the German and worldwide population average. Children 5.2 years) after 10 to 14 years of CI use. The authors investi-
implanted today who are younger at implantation, and with whom more gated 30 profoundly deaf children using the category of audi-
advanced up-to-date CIs are used, are expected to exhibit better auditory
tory performance (CAP) index and speech intelligibility rating,
performance and have enhanced educational and occupational opportu-
nities. Compared with the circumstances immediately after World War
and documented training routes and the occupational situation.
II in the 20th century, children with hearing impairment who use these Only 4 of these 30 individuals were in work. All others were in
implants have improved prospects in this regard. 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
1
Department of Otolaryngology, Hannover Medical School, Hannover,
received their CIs. The aim of this research was to examine
Germany; and 2Cluster of Excellence, Hearing4All, Hannover Medical
School, Germany. the effect on employment and employee perception of career
Supplemental digital content is available for this article. Direct URL cita-
opportunities subsequent to cochlear implantation. The job sat-
tions appear in the printed text and are provided in the HTML and text of isfaction rating rose from 5.56 to 6.82 (range 1 to 10) following
this article on the journal’s Web site (www.ear-hearing.com). cochlear implantation. The authors concluded that a CI helped

0196/0202/16/XXXX-0000/0 • Ear & Hearing • Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved • Printed in the U.S.A.

1
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<zdoi; 10.1097/AUD.0000000000000423>
2 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX

in terms of improved job satisfaction, as well as improving participants, and to compare these outcomes to that of the gen-
employees’ perception of their career prospects. With regard to eral population in Germany.
education and training, Huber et al. (2008) compared their find- Specifically, it was hypothesized that
ings for participants using CIs (age at implantation: 5.2 years) a. participants who received CIs earlier, who had no addi-
with a group of normal-hearing peers. They found that 40% tional comorbid diagnoses and used spoken language,
of the users of CIs (aged 12 to 21 years) who completed high would demonstrate better auditory performance and
school received advanced education, a proportion similar to that higher CAP scores compared with those who received
of their normal-hearing peers. Their publication also described CIs at an older age;
parental expectations of the child’s future. Parents of partici- b. educational and occupational attainment for participants
pants using CIs were significantly less optimistic in this respect using CIs would be poorer than that of their matched
than those of normal-hearing children. hearing peers, because of weaker auditory performance;
In their prospective study, Venail et al. (2010) also compared c. auditory performance (i.e., CAP) would be correlated
their results from children with CIs (age at implantation younger with educational and occupational attainment.
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- MATERIALS AND METHODS
cluded that their participants ultimately achieved educational Questionnaires were sent to 933 recipients of CIs who were
and employment levels similar to those of their normal-hear- implanted in childhood and received their first CIs between
ing peers. Tanamati et al. (2012) documented device use and 1986 and 2000 (mean age at CI was 5.4 years; range 0.4 to 18.9).
function in 10 postlingually deaf children implanted before 18 There were 174 returned questionnaires (18.65% response rate).
years of age, as well as the recipients’ academic/occupational At the time the questionnaire was completed, the participants
status. They found that, even many years after surgery, cochlear were, on average, aged 23.6 years (range 14.2 to 44.6 years).
implantation proves to be a safe and reliable procedure. Speech The majority (81.05%) had prelingual onset of profound hear-
intelligibility (single-word intelligibility) was between 62.2 and ing loss and received a unilateral CI (83.49%). Participants’
100%. Eight of the 10 participants were in work at the time of auditory and speech perception was rated according to the CAP.
their interview, with their pay varying between R$ 400.00 and The demographic data for the full group of 933 CI recipients,
R$ 2000.00. The authors did not describe the different occupa- the subgroup of 174 respondents, and the subgroup of 759 non-
tions concerned. To summarize the literature, there were few respondents are summarized in Table 1.
authors who reported long-term data in terms of correlation Demographic, medical, auditory performance and speech
with the educational and occupational situation. In most stud- perception data were obtained from paper files, the electronic
ies, the numbers of users investigated were small. In only two database at Hannover Medical School (Medizinische Hoch-
studies (Huber et al. 2008; Venail et al. 2010) did the authors schule Hannover/MHH), and the Cochlear Implant Center
compare their findings with those for normal-hearing peers. “Wilhelm Hirte,” Hannover. Functional gain curves or other
Due to the advanced technology of CIs and early access to audiological findings were not included.
hearing, as well as habilitative and educational interventions All other variables were recorded using a newly created self-
during childhood, it should be expected that early-implanted assessment questionnaire (see Appendix). The questions were
children would achieve the same educational goals as their generally multiple choice, with respondents invited to add their
normal-hearing peers (Lesinski-Schiedat et al. 2004; Huber et own comments where the category “other” was chosen. The mul-
al. 2008, 2015). To date, there have been no studies which have tiple-choice scales differ from question to question. Several ques-
examined auditory performance and long-term educational, tions were open ended, including those regarding occupational
vocational, and occupational outcomes for a large cohort of activities and workplace arrangements, as well as questions elicit-
pediatric CI recipients. ing numerical responses in units such as hours or years.
For other disciplines, too, there have been few studies about The questionnaire was refined by discussing it with medical
the education of people with disabilities (Broersen et al. 2012; and educational professionals at our center. For pretesting pur-
Karoly et al. 2013; Luciano & Meara 2014). These authors iden- poses, the questionnaire was given to young adult recipients of
tified job opportunities, or provided an overview of employment CIs (20 to 25 years) at our center. They were willing to respond
status, but did not compare their results to those of people with- and give comments in written form.
out disabilities. The questions were grouped into eight main categories:
Nevertheless, the children’s CI program at our center started living conditions and environment, therapy, educational back-
very early, in 1986. Therefore, long-term observations, as well ground of the parents, school education, vocational training,
as auditory and speech data, were available for a large cohort of occupation, job satisfaction, and workplace. Questions on job
recipients of CIs with congenital or early childhood acquired satisfaction were derived from the questionnaire for the study
deafness. entitled “Education and training of young people who grew up
The first aim of this retrospective cross-sectional study was with CIs” (Huber et al. 2008).
to explore the auditory performance outcomes for an unselected Finally, the questionnaire was sent out via postal and elec-
group of 933 CI recipients, and examine the influence of known tronic mail to the participants, advising that respondents use
variables such as age at CI, presence of additional diagnoses, a link to an online version created by using the online tool
and use of oral versus sign communication. The second aim ­SurveyMonkey (http://links.lww.com/EANDH/A337).
was to describe the long-term educational status, type of voca- To assess auditory performance, the CAP were chosen
tional training and occupational outcomes for a subset of 174 as these were described as a measure of everyday auditory

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

All statistical analysis was performed using Microsoft Excel
Category Criterion
2010 and IBM SPSS Statistics (version 22) software. Vari-
8 Follows group conversation in a reverberant room or ables correlated with the CAP levels, ISCO-88 skill levels and
where there is some interfering noise, such as a
ISCED levels were identified by means of Spearman correla-
classroom or restaurant
tion analysis. The relationship between the following variables
7 Use of telephone with known speaker
6 Understanding of conversation without lipreading
(collected via questionnaire responses) and CAP were exam-
5 Understanding of common phrases without lipreading ined using t tests: native language, multiple disabilities, status
4 Discrimination of speech sounds without lipreading of speech at implantation, bilateral implantation, understanding
3 Identification of environmental sounds of spoken language without lipreading, reading skills, writing
2 Response to speech sounds skills, preferred means of communication, status of job, and
1 Awareness of environmental sounds educational institutions. To ensure the results were not biased,
0 No awareness of environmental sounds or voice 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
country’s federal states. This leads to differences between states in this study and described here.
in the organization of the school system. Basically, there is a Statistical significance was set to p < 0.05 (*p < 0.05,
distinction between primary education, level I secondary edu- †p < 0.01, ‡p < 0.001).
cation, level II secondary education and certification. Primary
education mainly comprises the elementary schools (Grund- RESULTS
schule; grades 1 to 4 without certification). Level I secondary Device Use and Auditory Performance
education is provided at general schools (Hauptschule), middle Of the 174 respondents to the questionnaire, 86.8% regularly
schools (Realschule), comprehensive schools (Gesamtschule), used their CIs for more than 11 hr per day and 2% were nonus-
and academic high schools (Gymnasium; grades 5 to 10), lead- ers (Fig. 1; the questionnaire contained an open-ended ques-
tion about the number of hours they wore their CIs daily). The
ing to a subject-related entrance qualification for technical col-
remaining 11.2% indicated they wore their devices for between
lege/universities of applied science (Fachhochschule). Level II 1 and 10 hr each day. When asked if they need to use their device
secondary education (Gesamtschule, Gymnasium, Fachober- “in the family,” 88% selected “always” from the answer set for
stufe) involves grades 11 to 13 in academic high schools and this question; the figures for “in school” and “in their jobs”
qualifies the student for university. Vocational training can be were 94 and 68%, respectively. The questionnaire revealed that
chosen in mainstream or special schools for those with hearing only 14% of the surveyed individuals could not understand any
impairment or deafness. spoken language. (Thirty-nine percent replied that they could
To examine occupation outcomes, survey data were con- and 47% stated that they could, but only partially.) The survey
also asked participants if they could understand spoken lan-
verted into International Standard Classification of Occupa-
guage without lipreading, with three possible answers: “yes,”
tions-88 skill levels (ISCO), conceived by the International “partially,” and “no.” The respondent had to choose his answer
Labor Office which uses four hierarchical categories (Table 4, between these three possibilities.
International Labor Office 1990). The median CAP for respondents to the questionnaire was
Data from the German General Social Survey (ALLBUS) 5.41 (SD 1.96; Table 2) in contrast to the median CAP for non-
for 2012 were used as a basis for comparing school education, respondents which was 4.43 (SD 2.02). This difference was sta-
occupation, and employment status with those of the general tistically significant (t(786) = 5.48; p < 0.001). The CAP level
population in Germany (GESIS 2012). ALLBUS 2012 is a for the entire group (i.e., respondents and nonrespondents) was
4.63 with a SD of 2.04. Relevant data (numbers of recipients,
biennial survey on attitudes, behaviors, and social structure in
medians, or modes) are given in Table 1. For further evalua-
Germany, designed to obtain a representative cross-sectional tion, data were divided into different subgroups with special
statistical analysis of the population. ALLBUS 2012 data which characteristics (Table 5). Examples are male and female (only
was age matched to the survey respondents (18 to 44 years) German native speakers without additional disabilities); Ger-
were used for comparison. man native speakers and individuals with other first languages

TABLE 3.  ISCED-97 level and options for further education

No. of
Type of School Respondents (%) ISCED Level Options for Further Education
General qualification for university entrance 23 (19.39) 3 College, university
Subject-related entrance qualification 19 (11.52) 3 College, university
Secondary school 65 (39.39) 2 Recognized higher-level occupations requiring formal training
Secondary school 27 (16.36) 2 Vocational training
Not (yet) graduated 13 (7.88) 1

“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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 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX 5

TABLE 4.  ISCO-88 major groups and skill level The auditory performance of bilaterally implanted partici-
pants (CAP: 6.2) was significantly better than that of unilaterally
ISCO-88 Skill
ISCO-88 Major Group Level
implanted individuals (CAP: 4.7; t(144) = 6.865; p < 0.001).
Significant differences in CAP could not be evaluated
1 Legislators, senior officials, and managers —
between perilingually deafened (CAP: 5.6) and prelingually
2 Professionals 4
deafened participants (CAP: 4.9) because the number of perilin-
3 Technicians and associate professionals 3
4 Clerks 2
gual recipients was low (n = 16). Furthermore, the numbers of
5 Service workers and shop and market sales 2 perilingually deafened and postlingually deafened (CAP: 5.5)
workers individuals were too small for statistical analysis.
6 Skill agricultural and fishery workers 2 Participants with postlingual acquired hearing loss using CIs,
7 Craft and related workers 2 however, showed significantly higher CAP scores than participants
8 Plant and machine operators and assemblers 2 with prelingual acquired hearing loss (t(103) = −2.792; p = 0.006).
9 Elementary occupations 1 Participants using CIs who could understand spoken language with-
0 Armed forces — out lipreading obtained better hearing-test results than participants
who could partially understand spoken language (t(120) = 5.312;
ISCO, International Standard Classification of Occupation.
p < 0.001).
One question in the survey addressed participants’ preferred
(without additional disabilities); and participants with and with-
means of communication with their friends and acquaintances. Of
out additional disabilities (only German native speakers). The
the participants, 81% used spoken language, 6 individuals used a
nature of the groups in question is described in the fourth col-
combination of spoken language and 6 individuals used German
umn of Table 5. Individuals for whom the current status was not
sign language. Due to the unequal distribution, statistical tests of the
known were excluded, thus decreasing the quantity of subject
difference were not performed. There were differences in auditory
data. The number of recipients in each subgroup is given in the
performance for participants who underwent their vocational train-
second column; as these numbers are small, statistical calcula- ing in mainstream institutions compared with those who received
tions could not be performed for every subgroup. vocational training in institutions for those with hearing impair-
Outcomes differed for the various subgroups. No significant ment or deafness. Those who attended mainstream establishments
differences in CAP levels were found for survey respondents for tended to demonstrate auditory performance that was categorized
gender (t(412) = 0.893; p = 0.372). Significant differences in CAP higher (e.g., categories 6, 7, and 8) but small participant numbers
levels were found for survey respondents for mother tongues, age precluded statistical analysis of this difference.
at implantation, onset of deafness, and use of spoken language. The questionnaire also asked participants for a self-assess-
German native speakers (participants with additional disabilities ment of their reading and writing skills. Participants who
excluded) showed significantly higher CAP scores than did indi- affirmed the section of the questionnaire where it states “that
viduals with other mother tongues (t(35) = 2.794; p = 0.008). they can read books and newspapers without any problems”
Age at implantation exhibited a significant and strong inverse did not demonstrate auditory performance that was catego-
correlation with CAP level (r = −0.575; p < 0.001). Children rized higher than that of participants who did not tick this box.
implanted below 3 years of age and children implanted at 3 years With regard to writing skills, however, those who affirmed they
or above showed significant differences in auditory performance “can easily record personal experiences in writing” attained
(t(203) = 7.121; p < 0.001). Younger children achieve a CAP significantly higher categories than those who can responded
score of 6.0, with older children obtaining a CAP score of 4.6. “only partially” to this section (t(82) = 5.124; p < 0.001).

Fig. 1. Daily CI use in hours. CI indicates cochlear implant.

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

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 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX 7

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
Fig. 2. School education.
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
mainstream schools.” Most of the participants (95%) stated that the survey, 41% of the participants using CIs and 77% of the
they needed their CIs daily for communication in school, and ALLBUS 2012 respondents were in work, whereas 43% of the
83% of the respondents reported using spoken language as their recipients of these implants surveyed were still in school or
preferred means of communication while in school. vocational training.
Forty-nine percent of the users of CIs and only 29% of the
Occupation ALLBUS 2012 respondents (p < 0.001) have been unemployed
When asked how necessary the CIs were for their on-the-job at least once during their life (Fig. 5).
communication, up to 97% of participants selected the choice
“permanently” with regard to using their CIs at work, 68% DISCUSSION
selected “always,” and 29% selected “sometimes.” This related
to another section of the questionnaire, where 94% of partici- This retrospective study examined auditory performance,
pants using CIs, selected “spoken language” as the preferred educational status, vocational training, and occupational out-
means of communication in the workplace. comes for recipients of CIs who were implanted in childhood, and
Only 6% of the respondents used an frequency modulation compared these with outcomes for peers with normal hearing.
system at work. Special technical support for participants using
CIs was reported in only 19% of workplaces. At the time of the Auditory Performance
survey, 57% of the respondents had finished their education, Auditory performance depended on the use of the device.
with 43% still in school, in vocational training or studying. Our data supported the findings by Beadle et al. (2005), namely
Figure 3 shows the ISCO-88 skill level of the recipients of that young people used their CIs throughout their lifetime, espe-
CIs compared with those of ALLBUS 2012 respondents. At cially during critical life periods such as adolescence. Two per-
the time of the survey, 57% of the respondents had finished cent of those who completed the survey were nonusers (with

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.

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8 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX

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
Fig. 4. Institutions for vocational training. degree of plasticity in central auditory pathways in early child-
hood and the “sensitive period,” an aspect frequently discussed
Beadle et al. reporting a figure of 3%). Most of our participants by different authors (Sharma et al. 2002; Lesinski-Schiedat et
used their device all day, including for social contact. The real- al. 2004; Sharma et al. 2005; Kral & O’Donoghue 2010; Kral &
life auditory situation was that the surveyed participants were Sharma 2012; Illg et al. 2013). This knowledge concerning the
able to understand common phrases without lipreading (CAP: “sensitive periods” involving maturation of the neural auditory
5.41). The recipients of CIs who did not respond to the sur- pathway was unavailable in the early years of pediatric implan-
vey were able to understand speech sounds without lipreading tation, when only deaf children with long experience of hearing
(CAP: 4.43). It may be that the individuals surveyed were more aids received CIs. Therefore, the mean implantation age of our
highly motivated and bring greater understanding to their read- study group was high (Table 1) compared with that in recent
ing and writing. The better placed an individual is in terms of studies.
various factors—such as additional handicap, age at implanta-
tion, time of deafness, implantation mode, use of spoken lan- Education
guage, and use of sign language—the better his or her auditory A further aim of this study was to evaluate education sub-
performance. Adolescents attending mainstream schools dur- sequent to cochlear implantation. In general, there was no
ing vocational training show higher CAP levels (CAP: 6) than difference between participants using CIs and German normal-
their peers in special schools for people who are deaf (CAP: 4). hearing peers in terms of educational qualifications achieved at
In addition, Huber et al. (2015) and Langereis and Vermeulen secondary school (GESIS 2012); there was, however, a differ-
(2015) reported that mainstreamed students had superior audi- ence compared with the German deaf population.
tory performance compared with those in special schools for The GINKO study (Weber & Schlenker-Schulte 2011) sur-
those with hearing impairment. Spencer and Tomblin (2009) veyed about 5000 German adult deaf persons with or without
described the input from the CI as a prerequisite for phonologi- hearing devices concerning their educational qualifications and
cal awareness and phonological processing which is needed to other parameters. Compared with the present CI data, 11.7%
decode words and it is, therefore, an important requirement for more deaf individuals from the GINKO study attended second-
the development of oral language. For participants using sign ary school and 2.4% more obtained a secondary-school certifi-
language, CI input did not favor such good outcomes. Users cate than users of CIs in the present study.

Fig. 5. Proportion of participants using CIs and ALLBUS 2012 respondents unemployed at some point in their lives. CI indicates cochlear implant.

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 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX 9

What was particularly striking was the difference between situation. The data from this present study on occupations reflect
participants using CIs and the normal-hearing group in subject- the educational situation. Without university entrance certifi-
related entrance qualifications for technical college and general cates, it is rare that recipients of CIs receive tertiary education
qualifications for university entrance. The cochlear-implanted and achieve high-level occupations, both in Germany and in
adolescents did not achieve the same educational level as nor- other European countries. More users of CIs than normal-hear-
mal-hearing German peers, 15% of whom achieved a general ing peers worked in level 2 areas; this includes service workers,
qualification for university entrance (GESIS 2012). This con- shop, and market sales workers, skilled agricultural and fishery
firmed hypothesis b, namely: “Adolescents or adults with pedi- workers, craft and related workers, plant and machine operators,
atric cochlear implantation have a poorer level of education than and assemblers or clerks. This supports hypothesis c: Adoles-
their normal-hearing peers.” cents or adults with pediatric cochlear implantation have poorer
However, if the data are compared with outcomes for the occupational prospects than their normal-hearing peers. Ruben
German deaf population, 2.9% more participants using CIs had (2000), too, reported on the general experience that deaf persons
a subject-related entrance qualification for technical college and without implants were largely excluded from tertiary educa-
4.9% more had a general qualification for university entrance tion. This had a knock-on effect in terms of lower-level employ-
(Weber & Schlenker-Schulte 2011). In Austria, the educational ment. Another crucial question was that of which occupations
level of the 52 CI-using students did not differ from that of the were nowadays open to students. To those attending mainstream
hearing population (Huber et al. 2008). However, it should be classes, the full range of options is available, but often only a
noted that most participants had residual hearing at least in the restricted selection is on offer to students in schools for those
second ear, because the duration of hearing-aid use was 10.1 with deafness or hearing impairment. At the turn of the millen-
(2.5) years for adolescents and 11.4 (2.5) years for adults in nium, Bohms (1999) reported that only 46 possible occupations
this study. Furthermore, the maximum age at onset of deafness were available to deaf people in Germany, whereas young people
was 24 years. Some adolescents or adults in this study benefited without disabilities had over 400 options. Our literature search
from their first 2 years with hearing. As with the Austrian popu- revealed a great paucity of studies on this.
lation, the level of school education among German participants Nevertheless, the present data showed that the employment
using CIs was found to correlate with the maternal educational rate of participants using CIs (41%) is much lower than that of
background. This was also found for normal-hearing students the general population (77%), although 65% of recipients of
(Davis-Kean 2005). CIs had concluded their vocational training with a certificate.
These comparisons showed that, right from the start, pediat- In one study (GESIS 2012), the proportion of normal-hearing
ric users of CIs had had better educational possibilities than deaf peers with work-related qualifications was 93.6%. In the pres-
people who lacked these implants. Their educational opportuni- ent study, 9% of users of CIs were unemployed, and during their
ties will increase because of new technologies and the current lifetime they have been affected by unemployment to a sig-
trend toward early implantation. 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,
Occupation whereas Weber and Schlenker-Schulte’s (2011) survey revealed
The third aim was to evaluate the occupational situation of that 68.4% were in work and 12.1% unemployed. Because, in
participants using CIs. The results showed that the majority of this current investigation, 43% of the surveyed participants
users of CIs were able to choose their own occupational path, using CIs were still in school—with 32% of these in vocational
unlike in times before World War II, when the deaf had access training—further studies on employment and unemployment
only to noncommunication-based handicrafts (Bohms 1999). were required to obtain conclusive data allowing comparison
Bohms (1999) assumed that deaf persons were not offered of recipients of CIs with normal-hearing peers. Furthermore,
integral education on a universal basis area-wide until the 20th the unemployment rate among people with hearing impairment
century. Therefore, many children and adolescents with hearing varies between countries. It is, for example, almost four times
impairment had educational deficiencies and could work only in as high as the general unemployment rate in the United King-
low-level occupations. There will certainly be many differences dom (Hear-it AISBL 2015). In Denmark, unemployment levels
between countries in the educational and occupational status of among job seekers who are hearing impaired were twice the
adolescents and adults who are hearing impaired. For example, general rate. Notwithstanding variations from country to coun-
1041 deaf people working in high-level occupations in United try, the general trend is clear: Individuals with hearing impair-
States between 1871 and 1963 (Geisberger 1963) were success- ment face numerous barriers in the labor market. In a survey on
ful because they underwent lengthy vocational training up to the obstacles to employment, 70% of the respondents believed that
age of 27, involving small classes (5 to 8 students) and special they were taken out of consideration for jobs they had applied
methods. for because of their hearing impairment or deafness (Hear-it
Most of the respondents to this study were satisfied with AISBL, undated).
their job and pay, as well as their relationship with their super- The correlation between auditory performance and both age at
visor and colleagues. This substantiates the findings of Fazel implantation and school type would appear to play an important
and Gray (2007), who reported that CIs helped to improve job part in determining career success. A positive linear correlation
satisfaction and career prospects. found between CAP and ISCO-88 skill level confirms hypothesis
Based on the results of this retrospective study, it could also c, namely that the lower the auditory performance level, the lower
be assumed that nowadays good CI performers have the same the chance someone has of attending mainstream schools and
opportunities as their normal-hearing peers, but other early pedi- gaining access to higher-status careers. Early detection of hear-
atric users of CIs were underprivileged in their occupational ing loss and early cochlear implantation were important if deaf

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10 ILLG ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX

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