Representativeness in Studies of Early Cochlear Implantation
We read with interest the review by Belzner and Seal (2009) on demographics in research samples of children with cochlear implants (CIs). We applaud the authors’ effort in evaluating and promoting the awareness of representativeness of research study samples in this pediatric population as reported in the peer-reviewed literature. In Belzner and Seal’s review, one of the longitudinal outcomes reports that was examined was Quittner et al. (2007), which reported on a subset (n=88) of CI recipients from the Childhood Development after Cochlear Implantation (CDaCI) Study (N=188). While the subsample of CDaCI participants demonstrated some racial diversity, the chi-square value led to the conclusion that the subsample was not representative of the national pediatric deaf population. It is surprising, however, that the authors referred to the Fink et al. (2007) publication, which provided a detailed description of the CDaCI Study’s design and participants as well as non-participants, but they did not choose to examine the representativeness of the full CDaCI cohort.
In designing and conducting the CDaCI Study, tremendous efforts were put in place to ensure the diversity and representativeness of the children enrolled in the CDaCI Study. These efforts included enlisting multiple implant centers from diverse geographic locations across the nation and carefully documenting and comparing the participants to those who were eligible but declined participation. In response to Drs. Belzner and Seal’s comments regarding the representativeness of the CDaCI Study sample, and thus the generalizability of the CDaCI Study results to young children with sensorineural hearing loss fitted with CIs, we provide the race/ethnicity distribution for the CI cohort of the CDaCI Study (Table 1). As can be seen, the percentages for the race/ethnicity categories of the CDaCI Study are similar to, and in fact, the demographic distribution of children with CIs in the CDaCI Study does not significantly differ from, the 2000 U.S. Census data, as was reported in Drs. Belzner and Seal’s review.
Representativeness of Children With Cochlear Implantation in the CDaCI Cohort.
We agree with Drs. Belzner and Seal that generalization of outcomes has to be done very carefully. Though the CDaCI Study was also shown by the authors to not be representative of the larger deaf population in terms of disabilities and socioeconomic status, our study design and comprehensive data collection regarding these and other important confounds have enabled us to track critical outcomes and correlates of successful CI use while controlling for these confounds with multivariable-adjustment in data analyses (Fink et al., 2007; Markman et al., 2011; Niparko et al., 2010). We believe this approach is critical in assessing real world comparative effectiveness and share Drs. Belzner and Seal’s appreciation for the representativeness of the study population.
Available from: Alexandra L Quittner
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ABSTRACT: To examine the impact of cochlear implant (CI) intervention on health-related quality of life (HRQOL) assessed by both self- and parent-reported measures.
In this national study of children implanted between ages 6 months and 5 years, HRQOL of 129 children 6-year post-CI was compared to 62 internal study (NH1) and 185 external (NH2) samples of hearing children frequency-matched to the CI group on sociodemographic variables. HRQOL ratings of children and their parents in each group, measured using the Child Health and Illness Profile-Child Edition, were compared, and their associations with the Family Stress Scale were investigated.
CI children reported overall and domain-specific HRQOL that was comparable to both NH1 and NH2 peers. CI parents reported worse child scores than NH1 parents in Achievement, Resilience, and Global score (p's < 0.01) but similar or better scores than socioeconomically comparable NH2 parents. Higher family stress was negatively associated with all parent-reported HRQOL outcomes (p's < 0.01). Parent-child correlations in HRQOL global scores trended higher in CI recipients (r = 0.50) than NH1 (r = 0.42) and NH2 (r = 0.35) controls.
CI recipients report HRQOL comparable to NH peers. These results, from both child and parent perspective, lend support to the effectiveness of CI intervention in mitigating the impact of early childhood deafness. Family stress was associated with worse HRQOL, underscoring a potential therapeutic target. Parent-child agreement in HRQOL scores was higher for CI families than NH families, which may reflect higher caregiver insight and involvement related to the CI intervention.
Available from: Alexandra L Quittner
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ABSTRACT: This study compared levels of social competence and language development in 74 young children with hearing loss and 38 hearing peers, age: 2.5-5.3 years. This study was the first to examine the relationship between oral language and social competence using a dynamic systems framework in children with and without hearing loss. We hypothesized that, due to deficits in oral language, children who were deaf would display lower levels of social competence than their hearing peers. Furthermore, language age would predict social competence scores. Social competence was measured using a general and deaf-specific measure. Results showed that children with hearing loss performed significantly worse than hearing peers on the general measure, but better than the norms on the deaf-specific measure. Controlling for maternal education and income, regression analyses indicated that hearing status and language age predicted social competence in both groups. Among children with hearing loss, correlations were also found between age at diagnosis, age at amplification, and two of the general social competence measures. Results supported our hypothesis that deficits in language would have cascading negative effects on the development of social competence in young, deaf children. Development of early intervention programs that target both language and social skills are needed for this population.
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