This study evaluated the phonological skills and reading abilities of CI children. The majority of participants scored below the average normal scores. Both PA and reading skills were strongly correlated to each other, as well as moderately correlated to language development, but not associated with the chosen side of implantation. The age of implantation was correlated to reading development only for older participants.

PAT and ARST results

Since the study involved CI children of different age groups with variable PA and reading profiles, all sub-tests of the PAT and the ARST were tested in all participants, whenever applicable. We used validated tests originally designed to assess normally hearing children, and not simplified versions, to capture the full range of skills, including advanced ones.

Findings are echoing similar results from previous studies where CI children significantly underperformed their normally hearing peers at PA [18, 25, 26] and reading tasks [2, 7, 9, 10]. Better reading performance in normally hearing students was usually attributed to stronger alignment of auditory and visual inputs, more phonological skills, greater speech and language capabilities, wider representation of words, richer vocabulary, and better verbal comprehension [2, 12, 14, 25]. These skills are expected to be less developed in CI children due to the period of auditory deprivation. As shown in the results, for instance, participants have not yet developed age-appropriate language, and accordingly, learning to read changes to an exercise of learning language itself [27]. Furthermore, despite its benefits, their integration into regular schools might have hampered the individualized support that suits their learning pace, and hindered their reading acquisition accordingly.

Conversely, other studies reported higher general levels of reading and/or PA skills in CI children, attaining levels equivalent to hearing peers of their age [13, 16], a finding that was frequently attributed to their enhanced language skills following CIs.

The high standard deviations of participants’ scores in the current study reflect the considerable intra-group variability in performance, as some participants were reading at or above their chronological age’s expected level. This observation is also in accordance with other studies [7, 14, 28].

Relation between PA and reading

PA is the metalinguistic ability to reflect on and/or consciously manipulate the sound structure of language [29] and is usually assessed via tasks that require segmenting, blending, isolating, deleting, or substituting phonological units. It is frequently regarded as a pre-literacy skill [30]. However, the underlying cause of reading deficits in CI children is sometimes debatable, particularly when it comes to the link between PA and reading attainment. While some [31, 32] argued that phonological skills are crucial to good reading outcomes in deaf children, others [33] believed they are less important. Cupples et al. [34] believe that the inconsistent findings reported across studies are probably due to a failure to control other variables that can influence children’s PA and/or reading outcomes.

Despite the fact that phonological representations develop differently in hearing and deaf children who use spoken language, poor phonological development has been found to correlate with poor reading skills in both typically hearing children [29] and the deaf population, including CI users [16, 34, 35]. Such findings are in line with the results of this study.

When Geers and Hayes [3] investigated the role of PA in reading acquisition, they found that high school students with CIs scored better on reading measures than on PA ones. Yet, participants of the current study, who were all elementary students, scored comparably in both PA and reading tasks. It would be interesting to follow up these patients to see how their performance in both tests has differed over the years.

Association of PA and reading with the age of CI

While many studies [6, 12] claim that early implantation is linked to better prognosis in speech and language skills and, subsequently, reading outcomes, some studies [34, 36, 37] report that it has not always guaranteed better outcomes.

Due to the wide age range in the current study, age is predictably an intervening factor. To minimize its effect, we stratified the study group into two: “at or above” and “below” the age of 9 years, which is the median chronological age. The age of receiving CIs was not correlated to PA scores in both age groups, yet it was positively correlated to reading for the older group. The positive correlation between age at implantation and reading competency in the current study might infer that the older deaf patients are implanted, the better reading performance they would develop, but this must be interpreted cautiously. The lack of a negative correlation may be related to the fact that participants received their CIs at an average chronological age of 4 years (or even older for the group of patients ≥ 9 years), which is not young enough to demonstrate the benefits of early implantation because the first 2 years of life are crucial for the auditory input needed for language development. Another explanation may be related to the interference of other confounding variables that influence the reading performance of CI children, e.g., CI technology and device adjustment, efficiency of the rehabilitation program, educational placement, family support, and pre-implant language abilities [19] (e.g., for an older child to receive a CI that is covered by health insurance in Egypt, more advanced language requirements are needed. As shown in Table 1, on average, the group of patients at or above the age of 9 years uttered their first sentence before they received their CI). Thus, the age of implantation should be viewed as just one of several factors influencing prognosis [36]. Moreover, Geers et al. [10] suggested that the effect of age of surgery may be attenuated over time and become non-predictive of outcomes in older CI children.

Association of PA and reading with language abilities

Oral language is fundamental to reading for deaf children. This study showed that the more advanced their language skills were, the higher CI children scored in PA and reading tests. This is in line with Harris et al. [35], who also found a very strong correlation between the language of deaf children (both hearing aid and CI users) and their reading scores. They proposed that good language size is a mediating factor in the relationship between children’s PA and reading skills in both normally hearing and deaf children. Wass et al. [38] also indicated that receptive vocabulary is the most significant predictor of reading comprehension in CI children.

It is necessary to note, though, that no data was available about participants’ language profiles at the time of receiving CI or at any time before the study started. Nonetheless, the age at which they uttered their first words and sentences can provide insight into their language development. Information about the changes in the progression of language, PA, or reading skills over time, how they were compared to normally developing peers, or how they were linked to one another, was not known. Thus, a longitudinal study would be informative to explore how language, PA, and reading skills evolve and are related to one another over the years, and whether the gap between chronological age and reading skills in children with CI widens or reduces with age.

Choosing the ear to be implanted

Yalcinkaya [39] recommended that the left ear be chosen for implantation, as the left hemisphere can undertake the liabilities of the right hemisphere and not vice versa. The author noticed that, in prolonged follow-up, children whose right ears were implanted showed marked improvement in speech perception and language, but they were delayed in advanced reading skills. In the current study, implanting the right or left cochlea showed comparable results in PA and reading tests. Nevertheless, a true comparison of the left versus right ear would necessitate recruiting participants with bilateral implantations or at least controlling other confounding factors that might interfere with outcomes.

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