FAPCI Questionnaire for Russian-Speaking Children After Cochlear Implantation

According to the World Health Organization (WHO), more than 1.5 billion people live with hearing loss. Of these, 430 million have moderate or severe hearing loss [1]. Without treatment, various health problems and socioeconomic changes can occur, including reductions in cognition, social interaction, employment status, and annual income [2]. Cochlear implantation has become a routine surgical procedure worldwide for treating profound hearing loss in individuals who do not benefit from well-fitted hearing aids [3]. Cochlear implantation was first approved for bilateral postlingually deaf adults in the 1980s [3, 4]. The indications for cochlear implants (CIs) have significantly expanded to include patients with less severe hearing loss, children, patients with single-sided deafness [4], and patients following intracochlear schwannoma resection [5].

The first cochlear implantations in children in Kyrgyzstan were performed by foreign colleagues from Russia, Ukraine, and Germany approximately ten years ago. As no CI program was available in Kyrgyzstan until recently, some parents sent their children abroad for surgery [6]. Until 2020, Kyrgyzstan operated under a quota system, with CI surgeries conducted in Turkey.

Since 2018, several initiatives and local programs have been launched to provide hearing-impaired children in Kyrgyzstan with access to CI [6].

With an estimated 140,000 to 160,000 newborns per year in Kyrgyzstan, there is a projected need for at least 50 to 150 CIs for deaf children annually [6]. Besides a nationwide newborn hearing screening program, a CI program for children has been initiated locally.

The question arose regarding how to assess speech development following CI surgery in Kyrgyzstan, as no validated measuring instruments are currently available. Various measures exist to evaluate speech perception and language skills in children, including visual-habitual procedures in the presence of speech competitors or proxy assessments [7]. The most frequently used parent-proxy instruments are the Little Ears Auditory Questionnaire [8] and the Infant-Toddler Meaningful Auditory Integration Scale [9]. Both instruments are designed to monitor the early auditory behavior of infants and toddlers aged less than 24 months.

The Functioning after Pediatric Cochlear Implantation (FAPCI) instrument was developed in 2007 [10] and assesses the communicative abilities of children older than 24 months. The FAPCI tool is a psychometrically validated scale designed to evaluate the communicative performance of children aged 2 to 5 years, considering the conceptual framework of the WHO’s International Classification of Functioning [11]. The FAPCI instrument comprises 23 items/questions, each with a five-level response scale, yielding total scores ranging from 23 to 115 [10, 12, 13]. The instrument captures children’s everyday expressive and receptive communicative behaviors as reported by parents or primary caregivers. It has been validated and demonstrates good reliability. Originally provided in American English, the FAPCI has been translated and adapted into German [14, 15], Korean [16], Portuguese [17], Hindi [18], and Kyrgyz [6]. Kyrgyz and Russian are the official national languages in Kyrgyzstan, with several minority languages also spoken, including Uzbek, Tajik, and Uyghur. This two-center study aims to adapt the English version of the FAPCI into Russian to measure the development of verbal communicative performance in Russian-speaking children with CI in Kyrgyzstan.

Ethical considerations

The Ethics Committee of the General Medical Council of Mecklenburg-West Pomerania (A 2025-0079) approved the study design. The conduct of this study strictly adhered to the revised version of the Helsinki Declaration. The Russian version of the ethics application was made available to the Kyrgyz colleagues.

Procedure

Two professional translators from Kyrgyzstan proficient in both languages performed the translation of the questionnaire from English into Russian, including linguistic and cultural adaptation, back-translation, and comparative linguistic analysis. Following the guidelines for the cross-cultural adaptation of self-reporting measures [19], a few cultural adaptations were required. However, the original essence of the questions was preserved as much as possible, similar to the Kyrgyz version [6]. Table 1 outlines all the required adaptations and changes. The Russian version maintains a consistent child-friendly style, with simple forms, short phrases, and a conversational structure (Table 2). The adaptation of the original English FAPCI questionnaire into Russian was carried out with careful attention to cultural and linguistic features, ensuring both validity and clarity for Russian-speaking parents. In some cases, questions were reformulated with simpler and more natural constructions, and proper names as well as children’s songs were culturally adapted. Speech errors characteristic of children at the initial stages of language development were intentionally preserved in the examples to enhance realism and clarity. Where necessary, additional words were introduced to improve comprehension, while redundant expressions were eliminated per Russian grammar. This approach enabled the preservation of the precise meaning and intent of the original questions while making them accessible and natural in Russian.

Participants

Normal Hearing Cohort: The 23-item FAPCI-RU instrument was distributed at the National Center of Maternity and Childhood Care in Bishkek, Kyrgyzstan, in cooperation with the Department of Otorhinolaryngology, Head and Neck Surgery at the KMG Klinikum in Güstrow, Germany (Table 2). Participants were healthy children of Russian-speaking hospital employees and individuals accompanying children receiving treatment in the hospital.

Table 1:

Table 2:

All parents and children older than six, if appropriate, were informed about the study’s aims and provided their written consent. Parents were asked to complete the survey. The mean age of the NH group was 60.4 months ± 24.3 months, with an age range of 13–102 months.

The 23-item FAPCI-RU instrument was also distributed at the National Center of Maternity and Childhood Care in Bishkek, Kyrgyzstan, exclusively to Russian-speaking parents of prelingual bilateral deaf children implanted between 2020 and 2024. The mean age of the CI group was 64.8 months ± 26.7 months, with an age range of 24–126 months (Table 3). To ascertain test-retest reliability, the questionnaire was distributed to the 17 parents of CI children a second time within two to three weeks. Exclusion criteria included malformations of the inner ear and cognitive disorders.

The children’s hearing age (duration of CI use) was calculated from the initial fitting of the speech processor, ranging from nine to 60 months. The initial fitting of the speech processor was performed four weeks after CI surgery. Therefore, the date of the initial fitting was used as the basis for calculating hearing age. The proportion of children receiving bilateral CIs was 6% (N = 2).

Standardized audiologic rehabilitation for implanted children was performed every three months during the first year and every five to six months in the second year. From the third year onward, adjustments to the speech processor are carried out annually at the clinic. Since there is no state program for the rehabilitation of children with CIs, speech therapy rehabilitation has been conducted at private centers, educational institutions, and private audiologists’ practices in the children’s places of residence, usually financed by the parents, Qatari projects, and the Rotary Club Kühlungsborn-Bad Doberan (Germany) [6].

FAPCI questionnaire data were entered into an electronic database in Güstrow, Germany, and verified by double-data entry. FAPCI scores ranged from 23 to 115, with higher scores indicating better communicative performance. FAPCI scores were calculated by summing the scores of all items and assigning a score of 0 to items with no response. Missing data on several items were found in one survey, and one child with residual hearing in the contralateral ear resulted in only 35 surveys being used for evaluation. Exploratory analyses were conducted using graphical displays and frequency distributions to identify potential outliers for further data validation.

SPSS Version 30.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analyses. Data were evaluated using descriptive statistical methods and comparative tests. Numerical tests were expressed as mean ± standard deviation, and categorical variables as percentages. Statistical tests (Kolmogorov test and Shapiro- Wilk test) indicated a non-normal distribution for all parameters (all p-values < 0.05). Nonparametric tests were performed for group comparisons whenever appropriate. Spearman statistics were used for correlational analyses. A p-value of < 0.05 was accepted as statistically significant in all analyses. To verify the internal consistency of the 23 items of the FAPCI-RU instrument, Cronbach’s alpha was calculated. There are different reports about the acceptable values of alpha, ranging from 0.70 to 0.95 [20], with a recommended maximum alpha value of 0.90 [21]. Curve fitting was performed using polynomial terms in linear regression.

FAPCI-RU score results were collected from a cross-sectional cohort of 35 CI children and from 28 parents of children with NH. (Table 3). The results of two children had to be excluded. Questions 1 to 9 were not answered in one questionnaire, and the other child did not have bilateral deafness; the opposite ear had residual hearing, which could still be treated with a hearing aid. Cronbach’s alpha for internal consistency was 0.96 for the CI group and 0.93 for the NH group. As deleting individual questions did not change internal consistency, all questions were retained (Table 2). Pearson’s correlation test revealed a significant positive correlation between test and retest scores of the children in the CI group (r17 = 0.94, p < 0.001). Analyses indicated a positive correlation in the NH group between FAPCI-RU scores and age (r28= 0.691, p < 0.001).

Figure 1 displays the group medians and distributions. Comparison analyses revealed significantly better FAPCI-RU scores in children with normal hearing (96.8 ± 13.5) than in children with CI (64.6 ± 22.6) (p < 0.001).

Analyses revealed a positive correlation in the CI group between FAPCI-RU scores and age (r35= 0.398, p = 0.018) as well as the duration of CI use (hearing age) (r35= 0.630, p < 0.001). There was no correlation between FAPCI-RU scores, and age at implantation was not significant (r35= 0.04, p = 0.98).

Cross-sectional FAPCI-RU scores from 28 NH children show that the scores consistently increase with age (Figure 2). Communicative performance in healthy children, as measured by FAPCI-RU, rapidly increases until three years, after which a stable plateau is reached.

Figure 3 portrays the results of the survey depending on age in children with CI. According to the original publication, the data on the age at implantation were considered. The FAPCI-RU score tends to increase in both groups with increasing age. Considering the regression lines of Figure 3, children who received implants early showed a faster increase in FAPCI-RU scores than those who received implants later. However, there are significant individual variations.

Considering the hearing age (duration of CI use), the regression lines indicate that children who received implants early and wore them for a shorter period achieved lower FAPCI-RU scores than those who received implants later (Figure 4). However, as the hearing age increased, the values rose more quickly than in children who received implants later.

To establish a CI program in Kyrgyzstan, standardized postoperative care should be implemented, including audiological and speech therapy rehabilitation, besides neonatal hearing screening, standardized preoperative diagnostics, and the training of CI surgeons as recommended [6]. In a previous study, we implemented a Kyrgyz version of the FAPCI instrument for Kyrgyzspeaking children with CI in Kyrgyzstan between the ages of 2 and 6 [6]. As some children grow up speaking Russian as their native language in Kyrgyzstan, the implementation of a Russian version of the FAPCI instrument was recommended. This study aimed to adapt the established English-language FAPCI questionnaire and create a Russian version. A comparison of the demographic data of the children included in the study indicated a similar age distribution and comparable duration of CI use, but a slightly higher proportion of female CI users in the current study (FAPCI-RU) compared to the Kyrgyz study (FAPCI-Kyrg). Regardless, the Russian version of the FAPCI questionnaire exhibits psychometric characteristics similar to the Kyrgyz version.

The results of the reliability analysis, with Cronbach’s alpha of 0.96, correspond to those of the original English version by Lin et al., who reported it as 0.86 [12]. As deleting individual questions did not change internal consistency, all questions were retained. The FAPCI versions now available in other languages achieve similarly high internal consistency scores (German between 0.795 and 0.987 [15], Hindi 0.90 [18], Brazilian 0.948 [17], and Kyrgyz 0.96) [6]. The validity analysis suggests that the FAPCI score increases with the children’s age. However, this is a cross-sectional study and not a longitudinal one. The regression curves shown in Grugel et al. [15] approximate the regression lines of actual temporal hearing-speech development. It would be useful to have the FAPCI questionnaire completed to assess the communication skills of healthy children aged 2–6 to map the actual progression. The few children in this study who received early implants were also younger than those who received late implants. Therefore, some children had understandably lower scores. Older children can compensate cognitively [6]. With increasing duration of CI use (hearing age), the FAPCI score improved more rapidly in children who received early implants than in those who received them late. However, the quantity and quality of speech therapy post-CI surgery, besides the duration of use, are key factors not adequately reflected in this study.

After 6 years and 6 months, a so-called ceiling effect sets in, meaning that, the greater the age, the more children achieve the possible maximum score of 115 [15]. Therefore, the use of the FAPCI questionnaire for assessing the language development of older children appears less useful. However, our data also indicate that a few older children with NH did not achieve the maximum score of 115. Therefore, it is important to include 7- to 9-year-old children in a follow-up study.

The comparison of FAPCI scores of children with NH and CI children demonstrated deficits in communication among children with CI. Several factors determine speech development with CI. Besides biological factors (e.g., intact auditory nerve, normal brain development), underlying pathologies, the presence of other disabilities, correct electrode insertion and proper adjustment of the speech processor, the timing of implantation in cases of congenital deafness, and audiological and speech therapy rehabilitation after CI surgery are decisive factors in the success of CI surgery [22].

The timing of CI surgery has a stronger influence on the speech development of the child than the duration of implant use [23]. Children implanted between 16 and 24 months reached a preschool language scale comparable to hearing age-mates by 4.5 years. Children implanted after 24 months did not keep pace with hearing peers. To minimize the time of deafness and the lack of sensory input to the brain, CI surgery should be performed before the age of 2 [24-27].

In this study, only about one-third of the bilaterally prelingually deaf children examined (N = 12) received implants before the age of 2. Sixty-six percent of the children received their implants between the ages of 3 and 4. The present study’s CI group was quite heterogeneous concerning the age of CI surgery, pathology, and hearing rehabilitation. All implanted children were born deaf in both ears. Genetic testing was not performed, and previous infections that could have contributed to deafness were not reported. Despite the varied rehabilitation programs, the children received in their hometowns, the results of the study show a significant improvement in the communication skills of the implanted children in Kyrgyzstan. This improvement is also attributed to the high level of commitment shown by the parents, who take every opportunity to provide their children with hearing therapy. However, in Kyrgyzstan, rehabilitation facilities need to be established in the medium and long term inside and outside the clinics that perform the implantations (family-centered intervention) [28].

On the one hand, the study results demonstrate the applicability of the questionnaire developed to assess the communication skills of Russian-speaking healthy children and children with CI aged 2 to 6. On the other hand, the study highlights the need for early CI in prelingually deaf children. Based on the limited data of the study, the results confirm that the earlier the implantation, the faster the improvement in the communication skills of CI children.

The limitation of the study is the limited data on children with NH and those with CI implants. Therefore, the aim is to conduct a follow-up study to better validate the results statistically. According to the original study [4], the study design was to include only Russian-speaking children to prevent data distortion due to multilingual influence. The inclusion of bilingual children cannot be ruled out with certainty. It would also be interesting to explore the extent to which the communication skills of bilingual or multilingual Kyrgyz children can be assessed using the FAPCI-RU questionnaire.

The Russian version of the FAPCI questionnaire exhibits psychometric characteristics similar to the English and Kyrgyz versions. Its use is recommended for Russian-speaking children to assess early childhood communication skills following cochlear implantation. For children in Kyrgyzstan who do not speak Kyrgyz or Russian, it is particularly important to create a separate version.

The study was funded by the Lehnhardt Foundation.

The authors declare that there is no conflict of interest.

The authors thank Anastasia Odaeva, V.I. Vernadsky Crimean Federal University, Faculty of Foreign Philology, for translating English into Russian, including linguistic and cultural adaptation, back-translation, comparative linguistic analysis, and comments.

We also thank Dr. Phil. Yvonne Seebens for her insightful comments on earlier versions of the manuscript.

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