title: Level of emotion comprehension in children with mid to long term cochlear implant use: How basic and more complex emotion recognition relates to language and age at implantation.
abstract: OBJECTIVE
  The current study was designed with three main aims: To document the level of emotional comprehension skills, from basic to more complex ones, reached by a wide sample of cochlear implant (CI) deaf children with at least 36 months of device use; To investigate subjective and audiological factors that can affect their emotional development; To identify, if present, a "critical age", in which early intervention might positively affect adequate emotional competence development.
  
  
  METHODS
  This is an observational cohort study. Children with congenital severe/profound deafness were selected based on: aged by 4-11 years, minimum of 36 months of CI use, Italian as the primary language in the family; normal cognitive level and absence of associated disorders or socio-economic difficulties. Audiological characteristics and language development were assessed throughout standardized tests, to measure speech perception in quiet, lexical comprehension and production. The development of emotions' understanding was assessed using the Test of Emotion Comprehension (TEC) of Pons and Harris, a hierarchical developmental model, where emotion comprehension is organized in 3 Stages (external, mental and reflective). Statistical analysis was accomplished via the Spearman Rank Correlation Coefficient, to study the relationship between the personal and audiological characteristics; a multivariate linear regression analysis was carried out to find which variables were better associated with the standardized TEC values; a chi-squared test with Yate's continuity correction and Mann-Whitney U test were used to account for differences between continuous variables and proportions.
  
  
  RESULTS
  72 children (40 females, 32 males) with a mean age of 8.1 years were included. At TEC score, 57 children showed normal range performances (79.17% of recipients) and 15 fell below average (20.83% of recipients). The 16.63% of older subjects (range of age 8-12 years) didn't master the Stage 3 (reflective), which is normally acquired by 8 years of age and failed 2 or all the 3 items of this component. Subjects implanted within 18 months of age had better emotion comprehension skills. TEC results were also positively correlated with an early diagnosis, a longer implant use, better auditory skills and higher scores on lexical and morphosintactic tests. On the contrary, it was negatively correlated with the presence of siblings and the order of birth. The gender, the side and the severity of deafness, type of implant and strategy were not correlated.
  
  
  CONCLUSIONS
  Early implanted children have more chance to develop adequate emotion comprehension, especially when the complex aspects are included, due to the very strong link between listening and language skills and emotional development. Furthermore, longer CI auditory experience along with early intervention allows an adequate communication development which positively influences the acquisition of such competencies.
authors.affiliation: Department of Sense Organs, University Sapienza of Rome, 00161 Rome, Italy. Electronic address: p.mancini@uniroma1.it.
authors.forename: Patrizia
authors.initials: P
authors.lastname: Mancini
authors.affiliation: Department of Sense Organs, University Sapienza of Rome, 00161 Rome, Italy. Electronic address: ilariagiallini@hotmail.com.
authors.forename: Ilaria
authors.initials: I
authors.lastname: Giallini
authors.affiliation: Department of Neurology and Psychiatry, University Sapienza of Rome, 00161 Rome, Italy. Electronic address: luca.prosperini@uniroma1.it.
authors.forename: Luca
authors.initials: L
authors.lastname: Prosperini
authors.affiliation: Department of Sense Organs, University Sapienza of Rome, 00161 Rome, Italy. Electronic address: dincer.hilal@gmail.com.
authors.forename: Hilal Dincer
authors.initials: HD
authors.lastname: D'alessandro
authors.affiliation: Department of Otorhinolaryngology, "Guglielmo da Saliceto" Hospital, 29121 Piacenza, Italy. Electronic address: guerzoni1@libero.it.
authors.forename: Letizia
authors.initials: L
authors.lastname: Guerzoni
authors.affiliation: Department of Otorhinolaryngology, "Guglielmo da Saliceto" Hospital, 29121 Piacenza, Italy. Electronic address: alessandra_murri@libero.it.
authors.forename: Alessandra
authors.initials: A
authors.lastname: Murri
authors.affiliation: Department of Otorhinolaryngology, "Guglielmo da Saliceto" Hospital, 29121 Piacenza, Italy. Electronic address: d.cuda@ausl.pc.it.
authors.forename: Domenico
authors.initials: D
authors.lastname: Cuda
authors.affiliation: Department of Sense Organs, University Sapienza of Rome, 00161 Rome, Italy. Electronic address: giovanni.ruoppolo@uniroma1.it.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Ruoppolo
authors.affiliation: Department of Sense Organs, University Sapienza of Rome, 00161 Rome, Italy. Electronic address: marco.devincentiis@uniroma1.it.
authors.forename: Marco
authors.initials: M
authors.lastname: De Vincentiis
authors.affiliation: Department of Sense Organs, University Sapienza of Rome, 00161 Rome, Italy. Electronic address: maria.nicastri@libero.it.
authors.forename: Maria
authors.initials: M
authors.lastname: Nicastri
mesh_terms: D000367:Age Factors; D001307:Auditory Perception; D002648:Child; D002675:Child, Preschool; D019929:Cochlear Implantation; D003054:Cochlear Implants; D015331:Cohort Studies; D003142:Communication; D032882:Comprehension; D003638:Deafness / Q000534:rehabilitation*; D004644:Emotions; D000066499:Facial Recognition; D005260:Female; D006801:Humans; D007558:Italy; D007804:Language Development; D016014:Linear Models; D008297:Male; D015999:Multivariate Analysis; D012938:Social Perception; D013067:Speech Perception; D018709:Statistics, Nonparametric
keywords: Children; Cochlear implant; Early implantation; Emotion comprehension; Language development