ORIGINAL RESEARCH

published: 20 February 2018

doi: 10.3389/fpsyg.2018.00161

Personality Traits of Profoundly

Hearing Impaired Adolescents with
Cochlear Implants – A Comparison
with Normal Hearing Peers
Merle Boerrigter 1,2* , Anneke Vermeulen 1,2 , Henri Marres 1,2 and Margreet Langereis 1,2
1
Department of Otorhinolaryngology, Radboud University Medical Center, Nijmegen, Netherlands, 2 Donders Institute for
Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands

The aim of this study was to compare the personality traits of adolescents with
cochlear implants (CIs) to a reference group (normal-hearing peers). In the past, the
personality development of hearing impaired adolescents was severely compromised.
Improved speech perception with CI significantly increased their perspectives. In
addition, differences between the reference group and CI users were investigated on
personality traits according to level of speech perception skills (high/low) and level of
language comprehension (adequate/poor). A cohort of 59 adolescents was assessed
Edited by: 10 years after CI implantation. Personality traits were measured using the standardized
Nuno Barbosa Rocha, Dutch Personality Questionnaire, which consists of 5 scales: Inadequacy, Social
Instituto Politécnico do Porto,
Inadequacy, Recalcitrance (RE), Perseverance, and Dominance. Speech perception
Portugal
and language comprehension were tested with standardized tests. The distributions of
Reviewed by:
David Tomé, personality scores, in the clinical or non-clinical range, for the CI group were compared
Polytechnic Institute of Oporto, to the reference group using the Chi-Square test for Goodness of Fit. Adolescents
Portugal
Dona M. P. Jayakody, with CI showed normal or favorable distributions on all personality scales except for
Ear Science Institute Australia, the RE scale. There was a significant influence of speech perception and language
Australia
comprehension on this scale. Consequently, adolescents with CI who demonstrated
Brian Edward Engdahl,
University of Minnesota, United States high speech perception and adequate language comprehension scores showed similar
*Correspondence: distribution patterns as the reference group on all personality scales. In conclusion;
Merle Boerrigter personality traits that reflect social relations, self-conscience, and school- and task
merle.boerrigter@radboudumc.nl
orientation in adolescents with CI are similar to those in normal-hearing peers. This
Specialty section: holds, despite variations in speech perception ability and language comprehension
This article was submitted to levels, for the CI group. On the RE scale, the adolescents with CI with low speech
Clinical and Health Psychology,
a section of the journal perception and poor language comprehension scores are more likely to score in the
Frontiers in Psychology clinical deviant range and are at risk.
Received: 22 December 2016
Keywords: cochlear implant, hearing loss, personality, adolescence, speech perception, language
Accepted: 31 January 2018
comprehension
Published: 20 February 2018
Citation:
Boerrigter M, Vermeulen A, Marres H
and Langereis M (2018) Personality
INTRODUCTION
Traits of Profoundly Hearing Impaired
Adolescents with Cochlear Implants –
Profound hearing impairment (HI), from birth or early childhood has a lifelong influence
A Comparison with Normal Hearing on communication, language development, mental health, and social and emotional wellbeing
Peers. Front. Psychol. 9:161. (Cambra, 1996; de Graaf and Bijl, 2002). Limitations in hearing and (secondary) problems in
doi: 10.3389/fpsyg.2018.00161 communication and language development negatively affect the mental health of profoundly HI

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Boerrigter et al. Personality of Adolescents with CI

children with hearing aids (Polat, 2003). The majority (95%) where an individual shows little or no responsibility for his/her
of HI children are born in hearing families with aural actions. The HI can also negatively influence the development of
communication as the main form of communication (Mitchell emotional stability and achievement of emotional independence
and Karchmer, 2004). As a consequence, the social, home, and from parents. Research by van Gent et al. (2012) and Wiefferink
community environments are mainly oriented toward auditory- et al. (2012) showed that children with HI had difficulties
based communication. Even with the most powerful hearing using strategies to regulate their emotions and using appropriate
aids, children with a profound HI have no auditory access to social skills compared to hearing peers. Other research shows
environmental sounds, speech sounds, and spoken language. that adolescents and young adults with HI were less confident
Environmental information that is limited or is misinterpreted, and more anxious and dejected than normal-hearing peers and
results in a world that may seem unpredictable and threatening experienced feelings of insufficiency and vulnerability (Filipo
to a young person. Thus, hearing loss effects the information et al., 1999; van Eldik et al., 2004). This might play a role in
about social relations, such as cause and consequence. The impact developing an insecure, dejected, and despondent personality
of a combined sensory and communicative impairment, such trait. Communication problems in adolescents with HI are
as profound hearing loss, on social-emotional and psychosocial associated with lower levels of self-perceived social acceptance
development therefore, is considerable. and less close friendships (van Gent et al., 2011, 2012).
Social and emotional development includes the development Moreover, the personality traits of adults with HI were considered
of personality traits. A social acceptable development of more dependent, less confident, less communicative, passive,
personality traits and behavior corresponds to expectations of the egocentric, and more aggressive than people without a sensory
social environment. These expectations are called developmental disability (Cambra, 1996; Nasralla et al., 2009; du Feu and
tasks and include developing autonomy, achieving emotional Chovaz, 2014).
independence, developing close relationships with peers, The positive influence of CI on speech perception and
achieving socially responsible behavior, and achieving emotional production, language development, and reading comprehension
stability (Sawyer et al., 2012; Pinquart and Pfeiffer, 2014). During is well established (Svirsky et al., 2004; Vermeulen et al.,
the transition from childhood to adolescence, one’s personality 2007; De Raeve, 2010; Kral and O’Donoghue, 2010; Niparko
develops and personality traits are defined (Denham et al., 2009). et al., 2010). However, on complex linguistic and verbal
Personality stabilizes in adulthood (Roberts and DelVecchio, cognitive tasks children with CI lagged behind their hearing
2000). The transition to adolescence is, due to achieving all peers (Kral and O’Donoghue, 2010; Chilosi et al., 2013; Boons
the developmental tasks, a challenging period for hearing et al., 2013a,b; De Raeve et al., 2015). This means that these
adolescents. It is expected that development of personality children have less access to linguistic social and emotional
traits in adolescents with a profound HI will pose additional information compared to normal hearing peers. So CI users
challenges and places this group at risk for developing disordered have limited possibilities to achieve and understand the auditory
personality traits. refinements of social and emotional language (Calderon and
However, the auditory and communication prospects for most Greenberg, 2003). A study of Wiefferink et al. (2012) showed
profound HI children have improved since the 1990s. Due to the that children with CI lag behind on some aspects of emotion
application of cochlear implants (CIs), which provide auditory regulation and social functioning compared to their normal-
input via electrical stimulation of the cochlea, even profoundly HI hearing peers. The children with CI tended to be less socially
people can access environmental sounds, hear their own speech competent, less able to divert their attention and express negative
and the spoken language of others. Thus, it is to be expected emotions more often and more intensely. Language skills seem
that the application of CI would prevent the development of to be positively correlated with emotion regulation and social
disordered personality traits. functioning. CI children with stronger language skills tend
Research on the effect of hearing loss on the development to have stronger social competence skills and fewer negative
of personality traits is scarce. The attainment of developmental external behaviors than CI children with less-developed language
tasks, such as social responsible behavior and close relationships skills.
with peers, can be complicated by hearing loss (Kluwin et al., In the normal hearing population, the auditory system is
2002). Studies of social emotional development and mental adapted to integrate information from both ears. This is referred
health have been carried out. Hearing status seems to play a to as binaural hearing, which enables sound localization and
role in developing socially responsible behavior. For instance, improves the ability to detect sounds at lower levels in noisy
rather than modeling problem solving, parents are more likely environment (Akeroyd, 2006). For children with unilateral CI
to model avoidance and physical action as methods for solving (UCI), speech perception is hindered by background noise, such
problems or they tend to solve social problems for their HI as in classrooms (Sparreboom et al., 2012; Sarant et al., 2014).
child because of the child’s difficulty communicating. As a result, Therefore, they benefit less from incidental learning situations
a HI child is likely to have fewer opportunities to learn from like overhearing a conversation between peers. Children with
the social situation. The child is unaware how his/her behavior bilateral CI (BICI) perform significantly better than children with
affects others and what alternative behavior could be considered UCI on tests of sound localization and speech perception in noise,
(Vaccari and Marschark, 1997; Calderon and Greenberg, 2003). however not as well as normal-hearing peers (Lovett et al., 2010).
Therefore, the expectations are that HI might play a role in These better auditory skills of children with BICI result in better
developing a postponement and avoidance personality trait, receptive vocabulary and significant higher verbal intelligence

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Boerrigter et al. Personality of Adolescents with CI

than in UCI peers, even comparable to levels obtained by hearing TABLE 1 | Descriptive statistics of the participants (n = 59).
peers (Sarant et al., 2014; Sparreboom et al., 2014; De Raeve et al.,
n %
2015; Jacobs et al., 2016). Children with BICI show less behavioral
problems than severely HI children with hearing aids and have Gender Female 34 57.6
comparable levels of empathy and social competence as normal Male 25 42.4
hearing peers (Ketelaar et al., 2013; Theunissen et al., 2014). Unilateral or bilateral CI Unilateral 50 84.7
However, peer problems were still experienced by adolescents Bilateral 9 15.3
with CI (Huber et al., 2015). Educational setting Mainstream 32 54.2
Based on the considerable improvement in auditory Specialized for HI 27 45.8
prerequisites for development of social skills, a positive Additional developmental and No 46 78.0
effect on personality development is expected. Therefore, in this behavior problems Yes 13 22.0
study, we investigated the personality traits of profoundly HI Mean (SD) Range
adolescents with CI. The hypothesis was that the personality
traits of adolescents with CI with relatively high speech Age at testing 14.32 (2.39) 10.71–20.88
perception scores and/or adequate language comprehension Age at implantation 3.65 (2.06) 0.68–10.08
scores would be comparable to those of the reference group Duration of deafness before 3.13 (2.14) 0.29–9.77
implantation
(normal-hearing peers).

Auditory Speech Perception

MATERIALS AND METHODS
Auditory speech perception abilities were assed using a standard
Dutch open set identification test, containing consonant –
Participants
vowel – consonant words (Bosman and Smoorenburg, 1995).
The data was collected during the clinical evaluation procedure
This test was carried out in a sound-treated booth. Stimuli
that routinely occurs at 10 years post-implantation. All subjects
were presented in the sound field at a presentation intensity of
who were able to perform the standardized protocol were
65 dB SPL. Scores are expressed as a percentage of correctly
examined according to clinical presentation order. Data included
recognized phonemes. A score ≥ 85% reflects a high level of
59 eligible participants. Descriptive statistics of the participants
speech perception for HI children with CI and is comparable to
are listed in Table 1. The study group was a heterogeneous group;
those of children with a moderate hearing loss, bilaterally fitted
age at onset of profound hearing loss and age at implantation
with hearing aids, who obtain an average language level (Hicks
ranged substantially. The vast majority of the children (88%) had
and Tharpe, 2002).
no functional residual hearing prior to cochlear implantation.
A small number of children (12%) had a progressive hearing Language Comprehension
loss and benefited from the use of hearing aids pre-implant. Language comprehension z-scores were derived from two
These children received their implants at a relatively high age. different assessments: the Reading Comprehension Test
The high age at implantation and long duration of hearing (Aarnoutse, 1990) and the Peabody Picture Vocabulary Test-III-
loss were unfavorable compared to the current demographics NL (PPVT) (Dunn and Dunn, 2005). The PPVT became available
of implanted children, but were current at the time these in Dutch in 2013. Receptive vocabulary (word comprehension)
subjects received implants. The results of the participants is known to be an important factor in, and is strongly associated
were compared to the results of the standardized reference with, reading comprehension for hearing children (Aarnoutse
group of The Junior Dutch Personality Questionnaire (Junior and van Leeuwe, 1988; De Jong and Van der Leij, 2002) as
Nederlandse PersoonlijkheidsVragenlijst, NPV-J). This reference well as for HI children (Marschark and Harris, 1996). The
group contains 3194 participants with a mean age of 13.4 years outcomes are expressed in z-scores. A z-score ≥ −1.00 indicates
(SD = 1.6). A total of 48% was male and 52% female. Scores a performance within or above the average range of the
were controlled for gender differences. The test protocol and use reference group and is considered to represent an age adequate
of data for scientific purposes was explained to all participants score.
and described in the written evaluation reports for the patients.
Informed consent was obtained in all participants. No specific Personality Traits
ethical approval was required for this study, in accordance with The Junior Dutch Personality Questionnaire NPV-J (Luteijn
regulations in the local University Medical Center and Dutch et al., 2005) was used to measure personality traits of the
Ethical Standards. participants. The questionnaire is a standardized diagnostic tool
for the detection of clinically deviant personality traits. It is
Assessments divided into five scales: Inadequacy (IN), Perseverance (PE),
An audiologist, speech language pathologist, and a psychologist Social Inadequacy (SI), Recalcitrance (RE), and Dominance
collected measures on auditory speech perception, language (DO). The intercorrelations between scales support the validity of
comprehension, and personality, respectively, using the tools the instrument. Scales represent relatively independent domains.
described in the Section “Auditory Speech Perception.” The order Each scale contains a series of statements such as, ‘I like being
of the three assessments was randomized for each subject. alone.’ The answer options are ‘yes,’ ‘no,’ or ‘I don’t know.’

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Boerrigter et al. Personality of Adolescents with CI

Every answer is attributed 0, 1, or 2 points. Scale scores were (clinical deviant) is 15%, the percentage that performs within the
obtained by summing the scores of all questions belonging to average range is 70%, and the percentage that performs above
a scale. Scale scores were compared with the reference group average (positive deviant) is 15%. The effect size was measured
of the NPV-J. A lower score is favorable for all scales except using Cohen’s w.
PE and DO. For PE, a higher score represents a more favorable First, the distributions of average and deviant scores on each
outcome and for DO, extremes (high or low) are less favorable personality trait of the total CI group were compared to those of
outcomes. The psychologist supported all participants (in sign the reference group. Next, the distributions for the personality
or spoken language) to ensure participants understood the test scores for the CI subgroups (speech perception high/low;
questions. language comprehension adequate/poor) were compared to the
The personality questionnaire is used to identify personality reference group of the NPV-J.
traits in or outside the expected range. Outcomes were classified
in average scores or positive or clinical deviant scores (an
average range is between µ−1σ or µ+1σ). Clinical deviant RESULTS
scores indicate dysfunctional personality traits. A high IN scale
score is associated with an insecure, over-sensitive, dejected, Speech Perception and Language
and despondent personality trait and is stated as a clinical
deviant score. A high score on the PE scale is associated with
Comprehension
high responsibility for schoolwork and a reliable and orderly Significant correlations were found between age at implantation
personality trait and is stated as a positive deviant score. and speech perception; rs = −0.540, p = 0.000, two-tailed, n = 56,
Adolescents with a positive deviant score on this scale are between age at implantation and language comprehension;
described as competitive. They can concentrate relatively long rs = −0.463, p = 0.000, two-tailed, n = 56, and between speech
and good and work neatly. A low score on the PE scale perception and language comprehension; rs = 0.534, p = 0.000,
is associated with being unfocussed, untidy and with a low two-tailed, n = 53 for the total CI group. Figure 1 shows the
responsibility for schoolwork, which is stated as a clinical deviant scatter plot of speech perception and language comprehension.
score. On the SI scale, a high score (clinical deviant) is associated Note only a small number of subjects had adequate language
with a shy and introvert personality in social situations. An comprehension scores in the absence of a high speech perception
increased score on the RE scale is stated as a clinical deviant score.
score and is associated with a postponement and avoidance
trait with little or no responsibility regarding one’s own actions. Personality Scales
People who obtain clinical deviant scores on this scale are The adolescents with CI showed significant different distributions
described to behave selfishly, are distrustful, or reject others of average or deviant scores compared to the hearing reference
and feel indignant. On the DO scale, a high score represents group, on two personality scales: PE and RE. No significant
a dominant personality trait and a lower score a dependent different distributions of scores were found between the reference
personality trait. Both scores are stated as a clinical deviant group and the children with CI on the other personality scales:
score. IN, SI, and DO.
In this Section “Personality Scales,” we present the results for
Statistical Analyses the total CI group, followed by the results according to the speech
First, Spearman’s rho correlation between age at implantation, perception and language comprehension subgroups. First, we
speech perception, and language for the total CI group describe positive deviations from the reference group on the PE
(n = 59) was computed. Next, for speech perception, subjects scale (i.e., in favor of the HI adolescents with CI). Second, we
were categorized in a ‘high speech perception subgroup’ report data with negative (clinical) deviations from the reference
(speech perception score ≥ 85%) (n = 38) or ‘low speech group on the RE scale.
perception subgroup’ (speech perception score < 85%) (n = 18).
For language comprehension, subjects were categorized in Positive Deviations on the Personality Scale
‘adequate language comprehension subgroup’ with a z-score Perseverance
of ≥ −1.00 (n = 17) or ‘poor language comprehension The total CI group showed a significant higher proportion of
subgroup,’ with a z-score of < −1.00 (n = 39). PPVT and positive deviant scores compared to the reference group on the
reading outcome scores were distributed evenly over the personality scale PE, χ2 (2, n = 59) = 14.89, p < 0.05. The
subgroups. effect size was large (w = 0.50). This means that significant more
Statistical analyses were performed using IMB SPSS Statistics adolescents with CI (31%) obtained an above average positive
22. For each test, the level of statistical significance was set at score on this scale compared to the reference group.
5%. The percentage average, positive, or clinical deviant scores According to the speech perception subgroups, the high
of the total group and subgroups were computed. The non- speech perception subgroup had a significantly higher proportion
parametric Chi-Square test for Goodness of Fit was used to of positive deviant scores (26%) compared to the reference
compare the distributions of scores of the adolescents with CI group, χ2 (2, n = 38) = 7.13, p < 0.05, with a medium effect
with the distribution of the reference group of the NPV-J. For (w = 0.43). Also, a significantly higher proportion of positive
the reference group, the percentage that performs below average deviant scores was found for the low speech perception subgroup

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Boerrigter et al. Personality of Adolescents with CI

FIGURE 1 | Scatterplot of percentage speech perception scores and language comprehension for the total CI group. Adequate performance on phoneme
recognition ≥ 85%, on language comprehension z ≥ –1.00.

(39%) compared to the reference group on the personality trait significantly higher proportion of clinical deviant scores (44%)
PE, χ2 (2, n = 18) = 8.46, p < 0.05, with a large effect (w = 0.69). compared to the reference group.
There was no significant difference between the adolescents There was no significant difference in RE scores between de
with CI with adequate language comprehension scores and the reference group and the adolescents with CI and adequate
reference group. The poor language comprehension subgroup language comprehension scores. There was, however, a
showed significantly higher proportion of positive deviant scores significant difference in RE scores between the reference group
compared to the reference group on the personality scale PE, χ2 and adolescents with CI with poor language comprehension
(2, n = 39) = 15.77, p < 0.05. The effect size was large (w = 0.64). scores, χ2 (2, n = 39) = 12.95, p < 0.05. The effect size was large
This means that significantly more adolescents with CI with poor (w = 0.58). The poor language comprehension subgroup showed
language comprehension scores (36%) obtained an above average a significantly higher proportion of clinical deviant scores (33%)
positive score on this scale compared to the reference group. compared to the reference group on this scale.
Figure 2 displays the distributions of the PE scale scores Figure 3 displays the distributions of the RE scale scores for
for the reference group, the total CI group, and the CI the reference group, the total CI group, and the CI subgroups.
subgroups. Percentages of the distribution of scores for the Percentages of the distribution of scores for the reference group
reference group are depicted, as well as the percentages of the CI are depicted, as well as the percentages of the CI (sub)groups.
(sub)groups.

Clinical Deviations on the Personality Scale DISCUSSION

Recalcitrance
The total CI group showed a significantly higher proportion of The aim of the present study was to compare the personality
clinical deviant scores (29%) compared to the reference group traits of adolescents with CI to a reference group (normal-hearing
on the personality scale RE χ2 (2, n = 59) = 12.85, p < 0.05. peers). In addition, this study aimed to investigate differences
The effect size was medium to large (w = 0.47). Compared to between the reference group and CI subjects on personality
the reference group, the proportion of subjects classified with traits according to level of speech perception skills (high/low)
clinical deviant RE scores did not significantly differ for the and level of language comprehension (adequate/poor). This
subgroup with high speech perception scores, whereas there study was motivated by previous research that has shown that
was a difference for the subgroup with low speech perception HI adolescents with hearing aids are at risk of developing
scores χ2 (2, n = 18) = 12.50, p < 0.05. The effect size was problems with social emotional and psychosocial development.
large (w = 0.83). The low speech perception subgroup showed a HI adolescents therefore were vulnerable for developing

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Boerrigter et al. Personality of Adolescents with CI

FIGURE 2 | Distributions of the Perseverance scale scores of the reference group, the total CI group and the subgroups. ∗ p < 0.05. Percentages of the distribution
of scores for the reference group are depicted, as well as the percentages of the CI (sub)groups.

FIGURE 3 | Distributions of the Recalcitrance scale scores of the reference group, the total CI group and the subgroups. ∗ p < 0.05. Percentages of the distribution
of scores for the reference group are depicted, as well as the percentages of the CI (sub)groups.

personality disorders. For instance, Hindley et al. (1994) the five investigated personality traits (IN, SI, DO, and PE).
report in a prevalence study of psychiatric disorders in deaf Only for the RE trait, the total CI group, the subgroup with
children and adolescents a percentage of 50.3%. HI limits low speech perception scores and the subgroup with poor
a child’s access to understanding and developing complex language comprehension scores showed a larger proportion
language skills, which could mediate personality development. of scores below average as compared to the reference group.
With CI (implanted in childhood), prelingually profound Which means that more children with CI especially the CI
HI adolescents have auditory access to speech and, in children with low speech perception scores and poor language
most cases, to levels of spoken language. This subsequently comprehension scores show a postponement and avoidance
gives them the opportunity to develop higher level language personality trait with little or no responsibility regarding one’s
and improved social communication skills which facilitates own actions. As hypothesized, adolescents with HI implanted
social learning, a prerequisite for developing a balanced with a CI who demonstrate high speech perception scores
personality. and adequate language comprehension scores showed similar
The results of the present study show that adolescents distributions to normal hearing peers on all personality
with CI showed normal or favorable distributions on four of traits.

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Boerrigter et al. Personality of Adolescents with CI

Indeed, good speech perception appeared to be a factor our study, we were not able to perform analyses between these
in the development of personality among adolescents. This groups.
finding is in line with the study by Nasralla et al. (2009). A positive finding in our study is that the adolescents with
The subjects who obtained low speech perception results in CI did not differ from the reference group in terms of the
the study by Nasralla et al. (2009), reported difficulties in distributions of average or deviancy scores on the scales IN,
the area of interpersonal contacts, reacting according to the SI, and DO. In support of this interpretation, other studies
affective and auditory situations, and did not reach their reported that children with CI could obtain average social
potential compared to the group with the high speech perception skills and self-esteem in comparison to normal hearing peers.
scores. Children with CI showed comparable auditory levels as children
It is clear that hearing loss itself is not the only risk factor with hearing aids, in addition to lower levels of behavioral
for experiencing social and emotional problems and problems problems than children with a hearing aid. The CI group showed
in personality development. It appears that lack of language equal empathy and social competence as normal hearing peers
contributes to these problems (Stevenson et al., 2010; Gentilli and (Ketelaar et al., 2013; Theunissen et al., 2014). No differences
Holwell, 2011). In our study, adolescents with CI attain normal in self-esteem and number of friends between children with CI
distributions on all personality scales if language comprehension and hearing peers were reported (Percy-Smith et al., 2008). Bat-
skills were at an average or higher level. Stevenson et al. (2010) Chava et al. (2005) found that children with CI demonstrated
endorsed the idea that language is a significant factor in the a rapid development in socialization with hearing peers after
psychosocial development of adolescents. The authors stated implantation.
that hearing loss is related to an increased rate of behavior Similarly, the level of auditory and language skills of or
problems because hearing loss is a risk factor for low language our study group does not hinder them in social interactions,
competence. subjectively. Hence, the adolescents’ answers to the questionnaire
Ketelaar et al. (2015) specifically examined the factor language imply that they experience that they are able to comprehend
and reported that emotional language is related to social social situations and that they feel secure. This is reflected in a
functioning among children with CI and that language skill normal personality trait development of (Social) IN.
levels were related to the frequency of behavioral problems. In This social safety also enables them to comply with situations
hearing children with language disorders, difficulties with social rather than to control them, which is reflected in a normal DO
emotional functioning and behavioral adjustment exist not due to personality trait.
the HI. Language is known to support emotional self-regulation Remarkable results were found on the scale PE. The total
and social-cognitive competence. Several studies indicate that group of adolescents with CI as well as both speech perception
young people with specific language impairment are more likely subgroups and the subgroup with poor language comprehension
to exhibit abnormal levels of emotional and behavioral difficulties scores obtained positive deviant scores more frequently
than hearing peers (Toppelberg and Shapiro, 2000; Im-Bolter compared to the reference group. The subgroup with adequate
and Cohen, 2007; Durkin and Conti-Ramsden, 2010; Yew and language comprehension scores did not show this favorable
O’Kearney, 2013). In our study, 66% of the subjects with a difference on the PE trait. Adolescents with CI with poor
CI had high speech perception scores, but nonetheless, 40% language comprehension scores obtained positive deviant scores
had low language comprehension despite good hearing levels. more frequently compared to the reference group. It might be
These are children in which language or learning disorders the case that these children are rewarded for effort rather than
may be present in addition to the hearing loss (Norbury et al., for good performance. Percy-Smith et al. (2008) reported that
2001). boys with CI were better in managing schoolwork and Wheeler
In our study, adolescents with low speech perception et al. (2007) found that children with CI seek support to achieve
scores, poor language comprehension scores, or both, mainstream goals.
frequently had clinical deviant scores on the RE scale. As
stated in the Section “Introduction,” the unpredictability
of actions based on lack of auditory information or CONCLUSION
misinterpretations in communication might result in suspicion
and lack of trust. Mainly for children with UCI, auditory In conclusion, the findings of this study showed that personality
and language skills remained limited and are expected to traits that reflect social relations, self-conscience, and school-
have caused more dysfunctional RE traits than in the norm and task orientation in adolescents with CI are similar to those
group. in normal-hearing peers. This finding holds despite variations
Research of Geers et al. (2013), shows that well-developed in speech perception ability and language comprehension levels
social skills are more associated with the ability to discriminate for the CI group. On the RE trait, however, adolescents with
the nuances of talker identity and emotion than with the low speech perception and/or poor language comprehension
ability to recognize words and sentences through listening. scores more frequently obtained clinical deviant scores. This is
They found that both abilities were better in BICI children an important factor to consider for both schools and services
than in UCI children. This could be a secondary benefit guiding these young adults. The adolescents in our study
of binaural hearing with BICI (Sparreboom et al., 2014). were implanted at a relatively late age compared to modern
However, due to the small sample size of BICI children in standards. Late age at implantation is associated with poorer

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Boerrigter et al. Personality of Adolescents with CI

speech perception and poorer language comprehension. Early AUTHOR CONTRIBUTIONS

(bilateral) implantation is expected to have a further positive
effect on the development of personality traits of profoundly ML and AV formulated the research question. ML and AV
hearing impaired children predominately as a result of improved coordinated the clinical data collection. MB was involved in data
spoken language. collection. All authors provided contributions in the analysis and
interpretation of the data. MB drafted the manuscript, and AV,
HM, and ML provided critical revisions. All authors approved the
ETHICS STATEMENT final version of the manuscript for submission.

This study was carried out in accordance with the Dutch ethical
standards for University Medical Centres. Written informed FUNDING
consent from all subjects was obtained in accordance with the
Declaration of Helsinki. This study was financially supported by Cochlear Benelux.

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1630–1640. doi: 10.1016/S0140-6736(12)60072-5 conducted in the absence of any commercial or financial relationships that could
Sparreboom, M., Langereis, M. C., Snik, A. F., and Mylanus, E. A. (2014). Long- be construed as a potential conflict of interest.
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Sparreboom, M., Leeuw, A. R., Snik, A. F., and Mylanus, E. A. (2012). Sequential Copyright © 2018 Boerrigter, Vermeulen, Marres and Langereis. This is an open-
bilateral cochlear implantation in children: parents’ perspective and device use. access article distributed under the terms of the Creative Commons Attribution
Int. J. Pediatr. Otorhinolaryngol. 76, 339–344. doi: 10.1016/j.ijporl.2011.12.004 License (CC BY). The use, distribution or reproduction in other forums is permitted,
Stevenson, J., McCann, D., Watkin, P., Worsfold, S., Kennedy, C., and Hearing provided the original author(s) and the copyright owner are credited and that the
Outcomes Study Team (2010). The relationship between language development original publication in this journal is cited, in accordance with accepted academic
and behaviour problems in children with hearing loss. J. Child Psychol. practice. No use, distribution or reproduction is permitted which does not comply
Psychiatry Allied Discip. 51, 77–83. doi: 10.1111/j.1469-7610.2009.02124.x with these terms.

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