Andrea D. Warner-Czyz

The children speak: An examination of the quality of life of pediatric cochlear implant users

Objective: To examine the results of health-related quality-of-life questionnaire scores from profoundly deaf children fitted with at least one cochlear implant (CI) and to compare their responses with those of normal-hearing mates of similar age and their parents. Study Design: Cross-sectional study utilizing a generic quality-of-life questionnaire designed to be completed by both parents and children independently of each other. Setting: Questionnaires completed at various summer camps designed for children with CIs in Texas and Colorado. Subjects and Methods: Eighty-eight families from 16 states were divided into two subgroups by age of cochlear implantation: an eight- to 11-year-old group and a 12- to 16-year-old group. The KINDL-R Questionnaire for Measuring Health-Related Quality of Life in Children and Adolescents was distributed, and CI participants completed the questionnaire independently of their participating family member. Results: CI users in both age groups scored similarly to their normal-hearing peers and their parents. Younger CI users scored their family domain lower compared with their normal-hearing peers. Teen CI users scored the school domain lower compared with their parents. Among CI participants, earlier implantation and longer CI use resulted in higher quality-of-life scores. Conclusion: Children with CIs experience quality of life similar to that of normal-hearing peers. Parents are reliable reporters on the status of their childs overall quality of life.

Parent versus child assessment of quality of life in children using cochlear implants

OBJECTIVE Children with hearing loss who use cochlear implants have lower quality of life (QoL) in social situations and lower self-esteem than hearing peers. The childs QoL has been assessed primarily by asking the parent rather than asking the child. This poses a problem because parents have difficulty judging less observable aspects like self-esteem and socio-emotional functioning, the domains most affected by hearing loss. METHODS This case-control study evaluated QoL in 50 preschoolers using a cochlear implant and their parents with the Kiddy KINDL(®), an established QoL measure. Childrens responses were compared to a hearing control group and correlated with demographic variables. We used a questionnaire for parents and a face-to-face interview with children. T-tests were used to compare (a) paired parent-child ratings and (b) children with cochlear implants versus normal hearing. Pearson rank correlations were used to compare QoL with demographic variables. RESULTS Children using cochlear implants rated overall QoL significantly more positively than their parents (M(Difference)=4.22, p=.03). Child rating of QoL did not differ significantly by auditory status (cochlear implant (82.8) vs. hearing (80.8), p=.42). Overall QoL correlated inversely with cochlear implant experience and chronologic age, but did not correlate with implantation age. CONCLUSIONS Preschool children using cochlear implants can assess adequately their own QoL, but parents afford valuable complementary perspective on the childs socio-emotional and physical well-being. Preschool children using cochlear implants rate overall QoL measures similar to hearing peers. A constellation of QoL measures should be collected to yield a better understanding of general QoL as well as specific domains centered on hearing loss.

Improvements in visual attention in deaf infants and toddlers after cochlear implantation

The aims of this study were to examine the development of visual attention in deaf and hearing infants and toddlers, and assess whether improvements in visual attention were observed in the deaf sample after 12 months of cochlear implantation. A novel puppet task, based on a measure of attention developed with normally hearing infants, was administered to 88 deaf and 42 normal-hearing children at three time points: baseline, six and 12 months post-implantation for the deaf sample. At baseline, deaf children demonstrated significantly more inattentive looks during the puppet skits than hearing children, and these looks were of longer duration, confirming the results of prior studies which have documented deficits in visual attention in deaf children. Longitudinal analyses showed significant decreases in the frequency of inattentive looks for both groups, with a significant decrease in the duration of inattentive looks only for the cochlear implant group. The largest decrease in duration of off-task looks occurred at six months post-implantation, indicating that improvements occurred rapidly after restoration of auditory input. These results provided support for the ‘division of labor’ hypothesis which suggests that deaf children with no access or limited access to sound must monitor their environment visually, making it difficult for them to focus and attend to specific tasks. Cochlear implantation appeared to alter the developmental trajectory of visual attention in a positive manner. The clinical implications of visual attention for the development of early language, reading and social skills are discussed.

Health-related quality of life in children and adolescents who use cochlear implants

OBJECTIVE Examination of health-related quality of life (HRQoL) in children and adolescents who wear a cochlear implant (CI) primarily has depended on parent proxy report of the childs HRQoL rather than child self-report and generic domains rather than CI-specific issues. This study simultaneously assessed self-report ratings on a generic HRQoL instrument and a preliminary CI module in pediatric CI users. The impact of demographic factors (chronologic age, age at CI, and CI experience) on HRQoL also was explored. METHODS This cross-sectional study included 138 children grouped by chronologic age: 4-7, 8-11 and 12-16 years. The KINDL(R) questionnaire for measuring HRQoL in children and adolescents (generic) and a preliminary CI module (specific) were completed as a researcher-administered interview (4-7 years) or self-administered questionnaire (8-16 years) at CI summer camp or home. Scores were transformed to a 100-point scale with 100 representing the most positive response. The impact of chronologic age group on HRQoL ratings was evaluated using Analysis of Variance. Spearman rank-order correlations and point-biserial correlations tested associations between demographic factors and HRQoL scores. Principal factor analysis was used to discover the factor structure and internal consistency of the preliminary CI module. RESULTS The youngest group (M=82.8) rated generic HRQoL significantly more positively than older children (8-11 years: M=75.3; 12-16 years: M=70.4). Similar significant results emerged on the overall CI module (4-7 years: M=79.8; 8-11 years: M=77.8; 12-16 years: M=71.3). The youngest group rated CI-specific items on friends and self-image more positively than older groups, but reported greater difficulties hearing teachers at school. The oldest group provided more consistent responses than younger groups on the CI module (Cronbach α=0.72). Generic and CI module scores correlated positively (r=0.19, p=.03) but this association reflects the strong correlation in the oldest group (r=0.49, p=0.0033) and camouflages non-significant results in younger groups. CONCLUSION Chronologic age impacts self-report of HRQoL for pediatric CI users such that younger children rate HRQoL more positively than older children and adolescents on a generic instrument and preliminary CI module. Older children provide more consistent responses on the CI module. Results support the need for further development of a CI-specific self-report HRQoL instrument.

Early Sign Language Exposure and Cochlear Implantation Benefits

This study examines whether early sign language exposure in children with CIs influences speech recognition, speech intelligibility, language, and reading outcomes. BACKGROUND: Most children with hearing loss who receive cochlear implants (CI) learn spoken language, and parents must choose early on whether to use sign language to accompany speech at home. We address whether parents’ use of sign language before and after CI positively influences auditory-only speech recognition, speech intelligibility, spoken language, and reading outcomes. METHODS: Three groups of children with CIs from a nationwide database who differed in the duration of early sign language exposure provided in their homes were compared in their progress through elementary grades. The groups did not differ in demographic, auditory, or linguistic characteristics before implantation. RESULTS: Children without early sign language exposure achieved better speech recognition skills over the first 3 years postimplant and exhibited a statistically significant advantage in spoken language and reading near the end of elementary grades over children exposed to sign language. Over 70% of children without sign language exposure achieved age-appropriate spoken language compared with only 39% of those exposed for 3 or more years. Early speech perception predicted speech intelligibility in middle elementary grades. Children without sign language exposure produced speech that was more intelligible (mean = 70%) than those exposed to sign language (mean = 51%). CONCLUSIONS: This study provides the most compelling support yet available in CI literature for the benefits of spoken language input for promoting verbal development in children implanted by 3 years of age. Contrary to earlier published assertions, there was no advantage to parents’ use of sign language either before or after CI.

Electric charge requirements of pediatric cochlear implant recipients enrolled in the childhood development after cochlear implantation study

Objective: To evaluate mapping characteristics of children with cochlear implants who are enrolled in the Childhood Development After Cochlear Implantation (CDACI) multicenter study. Study Design: Longitudinal evaluation during 24 months of speech processor maps of children with cochlear implants prospectively enrolled in the study. Setting: Six tertiary referral centers. Subjects: One hundred eighty-eight children enrolled in the CDACI study who were 5 years old or younger at the time of enrollment. Of these children, 184 received unilateral implants, and 4 received simultaneous bilateral implants. Intervention: Children attended regular mapping sessions at their implant clinic as part of the study protocol. Maps were examined for each subject at 4 different time intervals: at device activation and 6, 12, and 24 months postactivation. Main Outcome Measures: Mean C/M levels (in charge per phase) were compared for 4 different time intervals, for 3 different devices, for 6 different implant centers, and for children with normal and abnormal cochleae. Results: All 3 types of implant devices demonstrate significant increases in C/M levels between device activation and the 24-month appointment. Significant differences in mean C/M levels were noted between devices. Children with cochlear anomalies demonstrate significantly greater C/M levels than children with normal cochleae. Conclusion: The CDACI study has enabled us to evaluate the mapping characteristics of pediatric patients who use 3 different devices and were implanted at a variety of implant centers. Analysis of such data enables us to better understand the mapping characteristics of children with cochlear implants.

Cochlear Implantation Updates: The Dallas Cochlear Implant Program

This report provides an overview of many research projects conducted by the Dallas Cochlear Implant Program, a joint enterprise between the University of Texas at Dallas, the University of Texas Southwestern Medical Center, and Childrens Medical Center. The studies extend our knowledge of factors influencing communication outcomes in users of cochlear implants. Multiple designs and statistical techniques are used in the studies described including both cross sectional and longitudinal analyses. Sample sizes vary across the studies, and many of the samples represent large populations of children from North America. Multiple statistical techniques are used by the team to analyze outcomes. The team has provided critical information regarding electrode placement, signal processing, and communication outcomes in users of cochlear implants.

Self-esteem in children and adolescents with hearing loss.

Children with hearing loss are at risk for lower self-esteem due to differences from hearing peers relative to communication skills, physical appearance, and social maturity. This study examines the influence of generic factors unrelated to hearing loss (e.g., age, gender, temperament) and specific factors associated with hearing loss (e.g., age at identification, communication skills) on how children with hearing loss wearing cochlear implants or hearing aids appraise self-esteem. Fifty children with hearing loss wearing cochlear implants or hearing aids participated (Mean age: 12.88 years; mean duration of device use: 3.43 years). Participants independently completed online questionnaires to assess communication skills, social engagement, self-esteem, and temperament. Children with hearing loss rated global self-esteem significantly more positively than hearing peers, t = 2.38, p = .02. Self-esteem ratings attained significant positive correlations with affiliation (r = .42, p = .002) and attention (r = .45, p = .001) temperaments and a significant negative association with depressive mood (r = − .60, p < .0001). No significant correlations emerged between self-esteem and demographic factors, communication skills, or social engagement. Because successful communication abilities do not always co-occur with excellent quality of life, clinicians and professionals working with children with hearing loss need to understand components contributing to self-esteem to improve identification, counseling, and external referrals for children in this population.

American parent perspectives on quality of life in pediatric cochlear implant recipients.

Objectives: Cochlear implantation influences not only communication but also psychosocial outcomes in children with severe to profound hearing loss. Focusing on issues specific to cochlear implantation (e.g., self-reliance, social relations, education, effects of implantation, and supporting the child) may provide a more accurate and relative view of functional status of pediatric cochlear implant (CI) recipients. The present study analyzes parental perspectives of CI-specific health-related quality of life (HRQoL) in children with CIs to determine (a) if parents differentially rate their child’s quality of life according to psychosocial domain (e.g., communication, self-reliance, education); (b) if associations exist between quality of life domains specific to cochlear implantation in pediatric implant recipients; and (c) if demographic variables (i.e., chronologic age, age at cochlear implantation, duration of device experience) mediate parent ratings of quality of life in pediatric CI recipients. Design: Parents of 33 children with CIs (mean age, 9.85 years; mean age of CI activation, 2.47 years; mean device experience, 7.47 years) completed a validated condition-specific questionnaire, Children With Cochlear Implants: Parental Perspectives. Results: Parents positively rated most HRQoL domains, although education and effects of implantation received significantly less positive ratings (p < 0.01). Three domains (communication, self-reliance, and well-being) significantly correlated with at least 5 other domains, suggesting that positivity in one domain co-occurs with positivity in other domains. Demographic variables (chronologic age, CI activation age, and duration of CI use) did not correlate significantly with psychosocial outcomes; rather, parents reported positive HRQoL and successful functional use of CI across demographic variables. Conclusions: Parents of children and adolescents with CIs rate overall HRQoL positively across psychosocial domains. Significantly less positive ratings of education and effects of implantation may result from limited access to CI-related accommodations and varying parent expectations, warranting further exploration to maximize psychosocial and performance outcomes in pediatric CI users.

A comparative study of psychosocial development in children who receive cochlear implants

Abstract Objectives This study assessed self-reported quality of life of children with a cochlear implant (CI), comparing results with two published reports from the past decade. Methods Participants included 33 pediatric CI recipients with a mean age of 10.12 years (SD = 3.59), mean implantation age of 1.36 years (SD = 0.46), and mean CI experience of 6.23 years (SD = 1.75). Children in all three studies completed a self-report quality-of-life questionnaire that included seven benefit and six problem items, rated on a 5-point Likert scale. Results Outcomes revealed agreement across studies in overall benefit and problem ratings. Environmental awareness and frustration reduction were the most and least positively rated outcomes, respectively. Items contributing to overall ratings differed across studies. Current CI recipients rated speech production, making new friends, and understanding speech more positively and taking extra care of the device more negatively than previous generations of pediatric CI users. Discussion Overall, benefits outweigh problems of the device, according to children using CI. Differences in issues motivating self-report ratings reflect changes in CI candidacy, technology, and social participation over the past decade. These findings emphasize the need for clinicians to address not only communication needs, but also quality-of-life issues to optimize outcomes in children using CI.