Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology
journal homepage: www.elsevier.com/locate/ijporl
Mainstream school readiness skills of a group of young cochlear implant
users
Cila Umata,b,∗
, Siti Zamratol-Mai Sarah Mukarib
, Norbaya Nordina
, Tiagarajan A/L Annamalayb
,
Basyariatul Fathi Othmanb
a
Audiology Program, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia
b
Institute of Ear Hearing & Speech, Universiti Kebangsaan Malaysia, Jalan Temerloh, 53200, Kuala Lumpur, Malaysia
A R T I C L E I N F O
Keywords:
Mainstream school readiness
Cochlear implant
Normal hearing
Children
Parents
Teachers
A B S T R A C T
Objectives: The aims of the study were to compare the mainstream school readiness skills of young cochlear
implant (CI) users to that of a group of normal hearing (NH) children and assessed the inter-rater agreement
between parents and teachers on school readiness skills of the CI children.
Methods: A total of 11 parents and 8 teachers of the 6-year old CI children participated and rated the children
using the School Readiness Scale to Year One. Data from 207 6-year old NH children from five states in Malaysia
were also collected using the same scale which has nine domains. Results from the NH children were categorized
into the 25th and 75th percentile scores to be the reference cut-offs for below average (below the 25th percentile),
average (25th to 75th percentile) and above average (above 75th percentile).
Results: The school readiness skills of the CI children were lower than the NH group as rated by teachers
especially in the civic and language and communication domains. Comparisons between parents' and teachers'
ratings for 8 CI children indicated that teachers tended to rate the CI children's school readiness poorer than that
of parents especially in the academic domain. Intra-class correlation analysis revealed poor inter-rater agree-
ment.
Conclusions: The results suggest that our CI children, generally, need an intervention ‘bridging’ program to
improve their school readiness skills. Parents and teachers had different views on the readiness of the CI children
at school entry level.
1. Introduction
Mainstream school readiness refers to how prepared a child is to
enter the Year 1 elementary school. Preparedness here refers to a child
who is developmentally, emotionally and socially ready to enter a new
world of learning that is different from their social environment at
home or pre-school learning. Several studies [3,21] have shown the
importance of development of self-regulation in young children and its
association with better school readiness skills in these children. Parental
involvement and/or family experiences are crucial in preparing
these children for good school readiness skills [2,18,25] and so as the
children's experiences and interaction with their pre-school teachers
[6,17,24]. The present study examined the school readiness of a group
of hearing-impaired children with cochlear implants (CI) to enter the
Year One elementary schools in the Malaysian mainstream education as
compared to a group of normal hearing (NH) six years old children,
from the perspectives of their kindergarten teachers and parents.
It is known that childhood hearing loss presents challenges to
speech and language development of the affected child especially
spoken language. Language deficits in young hearing-impaired children
influenced language-related areas of development such as their mind
and literacy development [9]. These limitations have been shown to
impact social interaction which is an important component in helping
young children learn pre-literacy skills [4]. Mastering the pre-literacy
skills consequently relate to their school readiness and academic performance
[26]. A study which compared the executive functioning of
73 hearing-impaired children with CI (aged 3–5 years old and 7–17
years old) with that of matched age range of 78 children with NH revealed
that children with CIs had two to five times greater risk of being
‘clinically significant deficits’ compared to the NH group [8]. This
finding suggests that children with a CI have greater challenges in terms
of acquiring sufficient level of experiences for development of their
school readiness skills.
Our previous studies have shown that the majority of our CI
https://doi.org/10.1016/j.ijporl.2018.01.031
Received 9 November 2017; Received in revised form 23 January 2018; Accepted 23 January 2018
∗
Corresponding author. Audiology Program, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia.
E-mail address: cila@ukm.edu.my (C. Umat).
International Journal of Pediatric Otorhinolaryngology 107 (2018) 69–74
Available online 31 January 2018
0165-5876/ © 2018 Elsevier B.V. All rights reserved.
T
children were enrolled into the mainstream education [13,15]. However,
they were not performing academically at par with their NH
counterparts [14]. In the study by Mukari et al. [14] who studied 20 CI
children attending the mainstream education, it was found that while
25% of these children achieved ‘above average’ academic performance
(> 75th percentile) in their final year school exams, 56.25% were in
the ‘below average’ range (< 25th percentile) compared to their NH
classroom peers. The findings of our earlier study had motivated us to
investigate how ready our CI children were at the school entry point to
enrol into the mainstream education.
School readiness skills of a young child are multi-dimensional [10].
Therefore, a tool to measure school readiness of Malaysian children was
constructed based on five components of readiness: child readiness;
home or family readiness; school readiness; global readiness and community
readiness [10]. The development of the Web-based Ecological
Assessment System (WEBEASR) involved many stakeholders in a child
development, namely preschool teachers (100 respondents), 100 primary
one teachers, 100 parents and 100 community leaders (school
principals, professionals and government officials). The School Readiness
to Year One scale which is a component of the WEBEASR has high
internal consistency with the overall α value of 0.9773 [11]. The scale
consists of 80 items in nine domains: academic (10 items), socio-emotional
(8 items), gross motor (8 items), fine motor (8 items), self-help skills
(7 items), language & communication (12 items), moral (8 items), aesthetic
& creativity (9 items) and civic (10 items). A total of 26 kindergarten
teachers rated the readiness of 377 kindergarten children using
this scale. It was found that these NH Malaysian children had very high
readiness (more than 4 point on the Likert scale) in six out of nine
domains (gross motor, self-help skills, language and communication, moral,
aesthetic and creativity and civic). That study also found that children
with higher level of school readiness had parents who were more often
involved with the child development and spent more quality time with
the child than those who did not.
The present study investigated the school readiness skills of a group
of young CI users and compared that to a group of NH 6-years old
children using the School Readiness to Year One scale [11]. Since parents
and teachers both play important roles in enriching a child's development
and experience prior to school entry, this study also compared the
agreement between the two groups of raters (parents and kindergarten
teachers) in judging the school readiness of the CI children at the school
entry point.
2. Material and methods
2.1. Ethical approval
This study has been approved by the Universiti Kebangsaan
Malaysia (UKM) Human Ethics Committee with the reference code
UKM PPI/111/8/JEP-2016-557.
2.2. Participants
For the CI group, respondents were parents and teachers of the six
years old CI children in the UKM Cochlear Implant Program. The inclusion
criteria were six years old in 2016, using oral communication
mode, and a consistent CI user. Children who use sign language as their
main communication mode and/or non-users were excluded from the
study. A total of 11 parents and teachers of the CI children who fulfilled
the criteria were invited to participate. Parents or teachers of the CI
children who fulfilled the inclusion criteria but did not give their consent
to participate in the study were also excluded.
For the NH group, respondents were the kindergarten teachers of six
years old children. Apart from having normal hearing, the children
must had normal physical and language development as reported by
teachers. Teachers were recruited among those in the government preschools
(Tabika KEMAS) and teachers of the CI children in private
kindergartens nationwide. Teachers who did not consent to participate
were excluded from the study.
2.3. Instrument
The School Readiness to Year One scale [11] as described above, was
utilized in this study. Each item used a 5-point Likert scale with 1 being
strongly disagree and 5 for strongly agree.
2.4. Procedure
Parents of the identified CI children were contacted through telephone
to get their consent to participate, to confirm their contact addresses
and school contacts, if they agreed to participate. The school
readiness scale was then mailed out to the participants together with
the consent form and the study information sheet. The teachers of the
CI children were also requested to rate the CI children as well as the NH
children in their respective classrooms.
For the NH group, approval letter was first obtained from the
Malaysian Ministry of Woman and Family Development to contact the
government pre-schools (Tabika KEMAS) throughout Malaysia for the
teachers to participate in the study. Upon getting their approval, the
scale was mailed out to the teachers to provide data for each of the
children in their classes.
All respondents were asked to return the completed questionnaires
to the researchers using the stamped envelope provided.
2.5. Data analyses
Data distribution was first assessed to determine its normality. For
the analyses, the scores in each domain were averaged. Descriptive data
were reported using mean values, range and standard deviations (SDs).
The data for the NH children were used to provide the reference cut-offs
for the 25th and 75th percentiles for each domain. In this study, the
children's scores were classified into three groups; 1) above average for
scores greater than the 75th percentile, 2) average, for scores between
the 25th to the 75th percentile, and 3) below average, for scores below
the 25th percentile. The CI data (from teachers only) were then mapped
onto these references which were presented using the boxplots and
tables. The intra-class correlations were conducted to examine the
agreement between the parents and teachers ratings on the school
readiness skills of the CI children in each domain. All analyses were
done using the Statistical Package for the Social Sciences (SPSS) version
23.0.
3. Results
3.1. Participants
A total of 11 parents and eight teachers provided the school readiness
data of the CI children. The eight teachers also provided the data
for the NH children in their classes. Apart from that, 14 teachers from
Tabika KEMAS participated in which four were from the northern state
of Peninsular Malaysia (Kedah), six were from the East Coast
(Kelantan), two were from the south (Melaka) and two were from the
central region of Peninsular Malaysia (Selangor). These teachers contributed
to a total of 207 six years old NH children in Malaysia to be the
reference data of school readiness of Malaysian children. Table 1 shows
the demographic details of the CI and NH children in this study.
About 63.6% of the parents had tertiary education as their highest
level of education and 36.4% completed their high school education. In
terms of their socioeconomic status, 36.4% had more than RM 5000/
month, 27.3% had a monthly household income between RM 3500.00
to RM 4999.00 and 27.3% had an income of less than RM 2500/month.
C. Umat et al. International Journal of Pediatric Otorhinolaryngology 107 (2018) 69–74
70
3.2. School readiness scores
Table 2 shows the means and the standard deviations (SDs) for the
NH children for each domain including the 25th and the 75th percentiles
scores. The values indicated that, generally, most of the NH children
scored highly in all domains of school readiness scale, with six out
of the nine domains had the 25th percentile score of 4 or over. The
other three domains which were language and communication (domain
F), aesthetic and creativity (domain H) and civic (domain I) had the 25th
percentile cut-off scores of 3.67, 3.56 and 3.90, respectively.
Fig. 1 reveals the school readiness data of the CI children (the black
dots) when plotted against the NH performances (in box plots) for each
of the school readiness domains. It is seen from the figure that the
largest data spread is seen for the domain of language and commu-
nication.
Table 3 shows the teachers' ratings of the CI children as compared to
that of the NH peers. As can be seen in Table 3, the CI children performed
remarkably poorer than the NH children especially in the areas
of civic in which 80.0% were rated as below average and language and
communication (62.5% were below average).
3.3. Comparing teachers' and parents' school readiness scores
Eight CI children had their school readiness rated by both their
teachers and parent (Table 4). Note that the total number of responses
in each domain was different as in some domains, participants opted
not to answer. Of importance, from Table 4 however, teachers tended to
rate the CI children's school readiness poorer than that of parents except
in the domains of self-help skill, in which the children received similar
ratings from both raters and civic, where parents gave poorer rating
than teachers'.
Intra-class correlations (ICC) were performed to examine the
agreement between the parents' and teachers' scores on the CI children
school readiness skills. The results revealed poor inter-rater agreement
with ICC values of less than 0.5 for all the domains as shown in Table 4.
4. Discussion
This study examined the mainstream school readiness skills in nine
domains for a group of six-year olds CI children and compared that to a
pool of NH children of matched chronological age as rated by teachers.
It also assessed the agreement between parents' and teachers' ratings on
the readiness skills of the CI children.
Our first main finding was that the NH children were rated by the
teachers with relatively high scores in all domains suggesting their
readiness to enrol into the mainstream education. This finding is consistent
with that reported by Majzub & Rashid [11]. According to the
developmental psychobiological approach as discussed by Blair & Raver
[3], these findings, in which NH children achieved high scores in all
domains suggest that at the age of six, they have developed sufficient
self-regulation abilities that allow them to engage effectively in
learning. According to the above model, when children are able to
manage stimulation and attention from the environment (friends and
teachers), they are considered as ready to start school. The domain with
the lowest score was ‘Aesthetic and Creativity’ with a mean of
4.05 ± 0.64 (out of 5 on the Likert scale). The 25th and 75th percentile
scores for this domain were at 3.56 and 4.56, respectively. Aesthetic and
creativity domain involves dynamic interactions of large-scale brain
systems [1] and that right-brain hemispheric dominance underlying
such complex cognitive processes [5]. Among the items in this domain
are ‘able to create simple origami’, ‘able to utilise natural materials to
produce an object’, and ‘able to draw and make collages’. Creativity relates
a lot to experience especially in parent-child interaction and their home
learning environment [16]. A study have shown that the brain can be
trained to be more creative [22]. According to Parker et al. [16], increment
in parents' understanding for play and thus, their ability to
facilitate their children's learning through play, increases the children's
creativity or curiosity. This leads to positive behaviour in classrooms.
Our findings may suggest that in Malaysians' parenting style, play activities
in parent-child interaction might be lacking that to some extent,
has impacted the children's creative thinking process.
In comparing the CI children school readiness skills to that of their
NH counterparts, teachers rated them as ‘below average’ for many of
the domains. In 3 out of 9 domains, 50% or more of the CI children
were rated as performing at below average. These domains include civic
(80.0%), language and communication (62.5%), and academic (50.0%).
Revisiting the relation between school readiness and self-regulation
using the developmental psychobiological approach, self-regulation is
about ‘adjustment in response to experience’. In CI children, less than
optimum auditory experience may have negatively impacted the integrated
developmental processes at the biological and behavioural
levels underlying self-regulation and consequently, school readiness
skills of these children. Our results in part support the earlier study
reported by Pratt et al. [18]. They examined how multiple family risk
factors experienced during the first three years of life predicted children's
school readiness. Using cumulative risk model, their findings
revealed that a greater number of risks across infancy, toddlerhood and
early preschool years significantly predicted poorer school readiness
outcomes in the kindergarten years. In this case, hearing loss is considered
as a risk factor. Congenital hearing impairment affects many
aspects of the child's live. Kronenberger et al. [8] reported that a large
majority of CI children were at greater risk of clinically significant
Table 1
Demographic profiles of the CI and NH children.
Children's Profiles Cochlear implant (CI) Normal hearing
(NH)
Number of participants 11 207
GENDER
Males 7 116
Females 4 91
RACES
Malays 5 182
Chinese 5 24
Indians 1 1
SCHOOLS
Kindergartens (6 years old) 11 207
TYPES OF SCHOOLS
Government 3 158
Private 8 49
AGE (Months)
Mean age of implantation 29.91 ± 10.73 N/A
Range of age of implantation 14–43 N/A
Mean duration of CI experience
(months)
46.45 ± 10.64 N/A
Range of duration of CI experience
(months)
30–59 N/A
Table 2
The school readiness scores for the NH children as rated by their teachers.
Domains Mean SD 25th percentile 75th percentile
A. Academic 4.53 0.57 4.08 5.00
B. Socio-emotional 4.39 0.60 4.00 5.00
C. Gross motor 4.27 0.60 4.00 4.88
D. Fine motor 4.53 0.52 4.13 5.00
E. Self-help 4.53 0.49 4.14 5.00
F. Language and
communication
4.19 0.68 3.67 4.83
G. Moral 4.45 0.56 4.00 5.00
H. Aesthetic and creativity 4.05 0.64 3.56 4.56
I. Civic 4.11 0.49 3.90 4.40
C. Umat et al. International Journal of Pediatric Otorhinolaryngology 107 (2018) 69–74
71
deficits across multiple domains of executive functioning as compared
to the NH children. In that study, the relative risks for pre-schoolers and
school aged CI children were greatest in the following areas: comprehension
and conceptual learning, factual memory, attention, sequential
processing, working memory and novel problem-solving. In a more
recent publication by Hall et al. [7] it was concluded that language
deprivation and not auditory deprivation due to hearing impairment
that may impair executive function. The CI children in this study were
implanted at relatively late age (mean age of implantation at
29.9 ± 10.7 months) with the mean duration of implant experience at
45.5 ± 10.6 months, which was less than four years of hearing experience.
Thus, it is not surprising that the CI children were rated by
their teachers to have poorer school readiness skills as compared to
their NH peers in many of the domains.
The third main finding was that parents' and teachers' ratings of the
school readiness skills of the CI children were different. In response to
this finding, we revisited the developmental psychobiological approach
[3] as the unifying framework for the study of school readiness. According
to this model, the environment and interpersonal interactions
Fig. 1. The school readiness scores of the CI children in each of the
domain against the NH children as rated by their teachers.1
1
Horizontal lines in the box plot indicate 50th percentile cut-off
points.
Table 3
Teachers' ratings of the CI children as compared to that of the NH children.
Domains Below average
(%)
Average (%) Above average
(%)
A. Academic 50.0 37.5 12.5
B. Socio-emotional 37.5 62.5 0.0
C. Gross motor 14.3 85.7 0.0
D. Fine motor 33.3 66.7 0.0
E. Self-help 20.0 80.0 0.0
F. Language and
communication
62.5 37.5 0.0
G. Moral 37.5 62.5 0.0
H. Aesthetic and creativity 37.5 50.0 12.5
I. Civic 80.0 20.0 0.0
The bolds indicate the top two domains where the CI children were performing at below
average (as rated by teachers).
Table 4
Parents' (P) and teachers' (T) ratings for 8 out of 11 CI children.
Domains Respondents Number of responses (n) Below average (%) Average (%) Above average (%) Intra-class correlation (ICC)
A. Academic Teachers (T) 8 25.0 50.0 25.0 0.3
Parents (P) 8 25.0 12.5 62.5
B. Socio-emotional T 7 14.3 85.7 0.0 −2.7
P 7 42.9 57.1 0.0
C. Gross motor T 7 14.3 71.4 14.3 −0.4
P 7 14.3 85.7 0.0
D. Fine motor T 5 20.0 60.0 20.0 −0.8
P 5 0.0 80.0 20.0
E. Self-help T 5 20.0 60.0 20.0 12.625
P 5 20.0 40.0 40.0
F. Language and communication T 7 14.3 42.8 42.9 −0.1
P 7 14.3 71.4 14.3
G. Moral T 8 25.0 50.0 25.0 −0.3
P 8 37.5 50.0 12.5
H. Aesthetic and creativity T 8 25.0 50.0 25.0 −10.7
P 8 12.5 75.0 12.5
I. Civic T 4 0.0 75.0 25.0 −3.6
P 4 0.0 75.0 25.0
The bold indicates the top domain which shows the largest inconsistency between parents' and teachers' ratings.
C. Umat et al. International Journal of Pediatric Otorhinolaryngology 107 (2018) 69–74
72
are embedded biologically to shape the development of a child's brain
and behaviour. In this context, parents are the one who provide that
‘world experiences’ to a child before they enter pre-school. This is
further emphasized by a longitudinal study on maternal mind-mindedness
that aimed to study the mechanism on how family environment,
specifically maternal mind-mindedness, relate to a child's school
readiness [2]. In that study, it was found that maternal mind-mindedness
in infancy impacted on the child's language at age two, consequently
support effortful control at ages three and four, and finally
promote school readiness of the child in kindergarten. Effortful control
is defined as the ability to suppress a dominant response in favour of a more
context appropriate response [20]. Parents therefore, judged their
hearing-impaired children's school readiness skills based on their experiences
and interactions with their children since birth. While teachers
on the other hand, must have based their judgments from their
interactions with these children at schools and compared their developmental
skills to that of their NH peers within a relatively shorter
period of time. Teacher-child interaction and class activities have been
shown to significantly associated with school readiness skills of a child
[6,24]. The mismatch between the expectations of the school environment
as seen by teachers and the expectations of the environment or
world experiences that prepare a child for school entry as seen by
parents was evidenced in this study.
The implications from this relatively small study suggest for the
need of an intervention or intermediate ‘bridging’ program to improve
school readiness skills of the CI children. Several studies have shown
that intervention could help to address this issue [12,19,21]. Schmitt
et al. [21] for example, conducted an 8-week self-regulation intervention
study on 276 children in 14 Head Start classrooms in the United
States. Results indicate that children in the intervention group achieved
stronger levels of self-regulation and academic achievement over the
preschool year as compared to the control group. In cases of hearingimpaired
children, it is also important to improve the language environment
so as to support the children's spoken language development
[23]. Language deficits and differences in hearing-impaired children,
particularly in the development of grammar [9] have detrimental effects
in language-related areas of development which underlie various
school readiness skills as evidenced in this study.
In the Malaysian Education system, all seven-year old children must
commence their primary school education as age is used as a criterion
to consider that the child is developmentally ready for school. Our results
suggest that the CI children, being deprived auditorily due to
hearing impairment which consequently has widespread effects on their
brain development, should be placed in the intervention program before
commencing their mainstream education. This warrants for executive
action in terms of policy change.
However, that the present study was conducted on a relatively small
sample of CI children, and the CI children in this group were implanted
relatively late. It is possible that early implantation, resulting in better
speech and language development would lead to better school readiness
score. Further study is undergoing to collect more evidence on the
school readiness skills of the six years old CI children in Malaysia.
5. Conclusions
It is concluded from this study that CI children were lacking behind
their NH peers in terms of their school readiness skills at the school
entry point. Parents and teachers agreement on their school readiness
skills were poor. It is suggested that an intervention or bridging program
to improve the school readiness skills of the CI children before
enrolling into the mainstream education should be implemented.
Conflicts of interest
The authors declare that there is no conflict of interest involved in
this study.
Acknowledgments
Funding
This work was supported by the Universiti Kebangsaan Malaysia
[grant numbers GUP-2016-078 and DPP-2015-126].
Conference presentation
This study was presented as an oral presentation at the 11th Asia
Pacific Symposium on Cochlear Implants and Related Sciences (APSCI
2017) held on the 19th – 22nd September 2017 at Famagusta, Turkish
Republic of Northern Cyprus.
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