Terrible Twos or Early Signs of Psychopathology? Developmental Patterns in Early Identified Preschoolers With Cochlear Implants Compared With Hearing Controls.

OBJECTIVE: Cochlear implants (CIs) have dramatically improved the lives of children who are deaf or hard of hearing; however, little is known about its implications for preventing the development of psychiatric symptoms in this at-risk population. This is the first longitudinal study to examine the early manifestation of emotional and behavioral disorders and associated risk and protective factors in early identified preschoolers with CIs compared with hearing peers. DESIGN: Participants were 74 children with CIs and 190 hearing controls between ages 1 and 5 years (mean age, 3.8 years). Hearing loss was detected using the Newborn Hearing Screening in The Netherlands and Flanders. Parents completed the Early Childhood Inventory-4, a well-validated measure, to evaluate the symptoms of DSM-IV-defined psychiatric disorders, during three consecutive years. Language scores were derived from each child's medical notes. RESULTS: Children with CIs and hearing controls evidenced comparable levels of disruptive behavior and anxiety/depression (which increased with age in both groups). Greater proficiency in language skills was associated with lower levels of psychopathology. Early CI and longer duration of CI use resulted in better language development. In turn, higher early language skills served as a protective factor against the development of disruptive behavior symptoms. CONCLUSIONS: This longitudinal study uniquely shows that improvement in language skills mitigates the development of early signs of psychopathology. Early identification of hearing loss and CIs help children improve their language skills.

Evidence-Based Inclusion Criteria for Cochlear Implantation in Patients With Postlingual Deafness.

OBJECTIVES: This study determined the relationship between preoperative phoneme and word scores and the gain in speech perception after cochlear implantation in a large cohort of patients. The authors aimed to define evidence-based selection criteria for cochlear implantations in adults with postlingual deafness. DESIGN: This retrospective study included 364 adults with postlingual deafness who received a cochlear implant between 2000 and 2013 at the Leiden University Medical Center. The gain in speech perception observed postimplantation was compared with preoperative-aided/binaural speech perception scores, measured at 65 dB SPL in quiet. Patients who showed preoperative phoneme scores on monosyllabic words above 50% were also tested for speech perception in the presence of speech-shaped background noise, at a +5 dB signal to noise ratio. RESULTS: Speech perception in quiet improved after implantation in all except 7 patients. Average scores in quiet continued to improve, up to approximately 1 year after implantation. When participants were divided into five groups, based on preoperative speech perception scores, all groups showed gains in speech perception, except for the group with aided preoperative phoneme scores above 80%. However, all patients who were tested preoperatively with the addition of background noise showed improvements in speech perception in noise after the cochlear implantation. CONCLUSIONS: Although the decision to implant should consider individual ear differences and other factors that might apply to a particular case, based on our data, all patients with preoperative scores of either 80% (phonemes correct) or 60% (words correct) and lower in an optimal-aided situation are potential candidates for a cochlear implant, provided that their preoperative speech perception score decreases below 50% (phonemes correct) or 20% (words correct), when background noise is added at a +5 dB signal to noise ratio.

Missing Data in the Field of Otorhinolaryngology and Head & Neck Surgery: Need for Improvement.

OBJECTIVE: Clinical studies are often facing missing data. Data can be missing for various reasons, for example, patients moved, certain measurements are only administered in high-risk groups, and patients are unable to attend clinic because of their health status. There are various ways to handle these missing data (e.g., complete cases analyses, mean substitution). Each of these techniques potentially influences both the analyses and the results of a study. The first aim of this structured review was to analyze how often researchers in the field of otorhinolaryngology/head & neck surgery report missing data. The second aim was to systematically describe how researchers handle missing data in their analyses. The third aim was to provide a solution on how to deal with missing data by means of the multiple imputation technique. With this review, we aim to contribute to a higher quality of reporting in otorhinolaryngology research. DESIGN: Clinical studies among the 398 most recently published research articles in three major journals in the field of otorhinolaryngology/head & neck surgery were analyzed based on how researchers reported and handled missing data. RESULTS: Of the 316 clinical studies, 85 studies reported some form of missing data. Of those 85, only a small number (12 studies, 3.8%) actively handled the missingness in their data. The majority of researchers exclude incomplete cases, which results in biased outcomes and a drop in statistical power. CONCLUSIONS: Within otorhinolaryngology research, missing data are largely ignored and underreported, and consequently, handled inadequately. This has major impact on the results and conclusions drawn from this research. Based on the outcomes of this review, we provide solutions on how to deal with missing data. To illustrate, we clarify the use of multiple imputation techniques, which recently became widely available in standard statistical programs.

Can You Hear What I Think? Theory of Mind in Young Children With Moderate Hearing Loss.

OBJECTIVES: The first aim of this study was to examine various aspects of Theory of Mind (ToM) development in young children with moderate hearing loss (MHL) compared with hearing peers. The second aim was to examine the relation between language abilities and ToM in both groups. The third aim was to compare the sequence of ToM development between children with MHL and hearing peers. DESIGN: Forty-four children between 3 and 5 years old with MHL (35 to 70 dB HL) who preferred to use spoken language were identified from a nationwide study on hearing loss in young children. These children were compared with 101 hearing peers. Children were observed during several tasks to measure intention understanding, the acknowledgement of the other's desires, and belief understanding. Parents completed two scales of the child development inventory to assess expressive language and language comprehension in all participants. Objective language test scores were available from the medical files of children with MHL. RESULTS: Children with MHL showed comparable levels of intention understanding but lower levels of both desire and belief understanding than hearing peers. Parents reported lower language abilities in children with MHL compared with hearing peers. Yet, the language levels of children with MHL were within the average range compared with test normative samples. A stronger relation between language and ToM was found in the hearing children than in children with MHL. The expected developmental sequence of ToM skills was divergent in approximately one-fourth of children with MHL, when compared with hearing children. CONCLUSION: Children with MHL have more difficulty in their ToM reasoning than hearing peers, despite the fact that their language abilities lie within the average range compared with test normative samples.

Concern for Others: A Study on Empathy in Toddlers with Moderate Hearing Loss.

Empathy, the ability to feel the emotions of others and respond affectively to these emotions, is an important factor in the development of social competence. The purpose of this study was to examine empathy levels in toddlers with moderate hearing loss (MHL) compared to toddlers with no hearing loss (nHL), and to explore the relation between language ability and empathy. We focused on affective empathy and the precursors of cognitive empathy. A total of 23 toddlers with MHL and 21 toddlers with nHL participated in the study. Parent report (ITSEA) and observation measures were used to rate the toddlers' levels of empathy. The results showed that the levels of affective empathy in toddlers with MHL and with nHL were similar on both measures. Toddlers with MHL lagged behind their peers with nHL on some precursors of cognitive empathy (intention understanding and joint attention). Language ability was unrelated to empathy levels in both groups of toddlers. In conclusion, toddlers with MHL seem to be at risk for problems in their empathy development. Although they are aware of the emotions of others, the development of more complex skills needed for an adequate empathic response is delayed in comparison with their hearing peers.

Correction: Low Empathy in Deaf and Hard of Hearing (Pre)Adolescents Compared to Normal Hearing Controls.

[This corrects the article DOI: 10.1371/journal.pone.0124102.].

Quality of life of children with hearing loss in special and mainstream education: A longitudinal study.

OBJECTIVES: To compare the quality of life (QoL) of children with hearing loss (HL) and children with normal hearing (NH) and to examine how the QoL of children with HL changes over time, considering language skills, type of hearing device, degree of HL, and type of education. METHODS AND MATERIALS: This longitudinal study included 62 children with HL and their parents. Developmental outcome data were collected at two time points, when the mean ages of the children were 4 and 11 years. The Pediatric Quality of Life (PedsQL™) questionnaire, which includes assessments of Physical, Emotional, Social, and School functioning, was completed by parents at both time points and by the children with HL at the second time point. Receptive and expressive language skills at 4 years were assessed by the Reynell Developmental Language Scale. Results were compared with a Dutch normative sample. RESULTS: The QoL of children with HL was similar to that of children with NH at both time points on two of the four QoL scales, Emotional and Physical functioning. On the other two scales, Social and School functioning, children with HL who attended special education and children who switched to mainstream education showed lower scores than children with HL who were consistently in mainstream education and lower scores than children with NH. The School QoL of children with HL decreased over time, as did the School QoL of children with NH. Social QoL of children with cochlear implants decreased over time, but this was not the case in children with hearing aids. Language skills and the degree of HL did not clinically improve the QoL over time of preschool children with HL. CONCLUSIONS: The QoL of children with HL in mainstream education and the Physical and Emotional QoL of all children with HL were satisfactory. It is essential to develop specific guidance regarding school activities for children with HL in special education and for children with HL who switch to mainstream education in order to increase their social QoL.

Pediatric Auditory Brainstem Implant Users Compared With Cochlear Implant Users With Additional Disabilities.

OBJECTIVES: To evaluate long-term language development in children with prelingual deafness who received auditory brainstem implants (ABIs) compared with children who received cochlear implants (CIs) at the same hospital. Additional non-auditory disabilities were taken into account. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Ten children with bilateral malformations of the cochlea and/or cochlear nerve who received ABIs, including seven with additional disabilities, and 147 children with CIs as a reference group, including 22 children with additional disabilities. INTERVENTION: ABIs were implanted at 1.3 to 6.2 years of age. Follow-up ranged from 1.1 to 7.7 years. MAIN OUTCOME MEASURES: Receptive and expressive language abilities were assessed using the Infant Toddler Meaningful Auditory Integration Scale (IT-MAIS), the Categories of Auditory Performance (CAP), the Meaningful Use of Speech Scale (MUSS), and the Speech Intelligibility Rate (SIR). RESULTS: Of the 10 children with ABIs, seven had long-term follow-up data. Within 1 year, six of the seven children with ABIs could identify sounds, respond to speech, and use their voice to attract attention. Language skills developed at a slower rate than in children with CIs and reached the same competence level when additional disabilities were absent. These language skills matched, on average, those of children with CIs with additional disabilities. CONCLUSION: For deaf children with bilateral inner ear malformations, ABIs provide satisfactory auditory input. Children with ABIs are able to develop receptive and expressive language skills comparable to those of children with CIs with additional disabilities. Using this knowledge, preoperative parent counselling can be refined.

Low empathy in deaf and hard of hearing (pre)adolescents compared to normal hearing controls.

OBJECTIVE: The purpose of this study was to examine the level of empathy in deaf and hard of hearing (pre)adolescents compared to normal hearing controls and to define the influence of language and various hearing loss characteristics on the development of empathy. METHODS: The study group (mean age 11.9 years) consisted of 122 deaf and hard of hearing children (52 children with cochlear implants and 70 children with conventional hearing aids) and 162 normal hearing children. The two groups were compared using self-reports, a parent-report and observation tasks to rate the children's level of empathy, their attendance to others' emotions, emotion recognition, and supportive behavior. RESULTS: Deaf and hard of hearing children reported lower levels of cognitive empathy and prosocial motivation than normal hearing children, regardless of their type of hearing device. The level of emotion recognition was equal in both groups. During observations, deaf and hard of hearing children showed more attention to the emotion evoking events but less supportive behavior compared to their normal hearing peers. Deaf and hard of hearing children attending mainstream education or using oral language show higher levels of cognitive empathy and prosocial motivation than deaf and hard of hearing children who use sign (supported) language or attend special education. However, they are still outperformed by normal hearing children. CONCLUSIONS: Deaf and hard of hearing children, especially those in special education, show lower levels of empathy than normal hearing children, which can have consequences for initiating and maintaining relationships.

Early identification: Language skills and social functioning in deaf and hard of hearing preschool children.

OBJECTIVE: Permanent childhood hearing impairment often results in speech and language problems that are already apparent in early childhood. Past studies show a clear link between language skills and the child's social-emotional functioning. The aim of this study was to examine the level of language and communication skills after the introduction of early identification services and their relation with social functioning and behavioral problems in deaf and hard of hearing children. STUDY DESIGN: Nationwide cross-sectional observation of a cohort of 85 early identified deaf and hard of hearing preschool children (aged 30-66 months). METHODS: Parents reported on their child's communicative abilities (MacArthur-Bates Communicative Development Inventory III), social functioning and appearance of behavioral problems (Strengths and Difficulties Questionnaire). Receptive and expressive language skills were measured using the Reynell Developmental Language Scale and the Schlichting Expressive Language Test, derived from the child's medical records. RESULTS: Language and communicative abilities of early identified deaf and hard of hearing children are not on a par with hearing peers. Compared to normative scores from hearing children, parents of deaf and hard of hearing children reported lower social functioning and more behavioral problems. Higher communicative abilities were related to better social functioning and less behavioral problems. No relation was found between the degree of hearing loss, age at amplification, uni- or bilateral amplification, mode of communication and social functioning and behavioral problems. CONCLUSION: These results suggest that improving the communicative abilities of deaf and hard of hearing children could improve their social-emotional functioning.

Self-esteem in hearing-impaired children: the influence of communication, education, and audiological characteristics.

OBJECTIVE: Sufficient self-esteem is extremely important for psychosocial functioning. It is hypothesized that hearing-impaired (HI) children have lower levels of self-esteem, because, among other things, they frequently experience lower language and communication skills. Therefore, the aim of this study was to compare HI children's self-esteem across different domains with those of normal hearing (NH) children and to investigate the influence of communication, type of education, and audiological characteristics. METHODS: This large (N = 252) retrospective, multicenter study consisted of two age- and gender-matched groups: 123 HI children and 129 NH controls (mean age  = 11.8 years). Self-reports were used to measure self-esteem across four domains: perceived social acceptance by peers, perceived parental attention, perceived physical appearance, and global self-esteem. RESULTS: HI children experienced lower levels of self-esteem regarding peers and parents than NH controls. Particularly HI children who attended special education for the deaf were at risk, even after correcting for their language development and intelligence. Yet, levels of global self-esteem and self-esteem involving physical appearance in HI children equalled those of NH controls. Furthermore, younger age at implantation and longer duration of having cochlear implants (CIs) were related to higher levels of self-esteem. CONCLUSION: HI children experience lower levels of self-esteem in the social domains. Yet, due to the heterogeneity of the HI population, there is high variability in levels of self-esteem. DISCUSSION: Clinicians must always be aware of the risk and protective factors related to self-esteem in order to help individual patients reach their full potential.

Psychopathology and its risk and protective factors in hearing-impaired children and adolescents: a systematic review.

IMPORTANCE: Pediatric hearing impairment is a chronic handicap that can potentially lead to the development of psychopathology. Yet, for hearing-impaired children and adolescents, the exact occurrence of various forms of psychopathology and its causes are unclear, while this knowledge is essential to enable targeted screenings and interventions. OBJECTIVE: To investigate the level of psychopathological symptoms in hearing-impaired children and adolescents as compared with normally hearing peers. Second, the influence of type of hearing device and possible risk and protective factors on psychopathology were examined. EVIDENCE REVIEW: A systematic literature search was performed covering relevant databases, including PubMed, Embase, and Web of Science. Two independent researchers identified the relevant articles. The final search was performed on May 2, 2013, and resulted in a total of 35 articles. FINDINGS: Literature consistently demonstrated that hearing-impaired children and adolescents were more prone to developing depression, aggression, oppositional defiant disorder, conduct disorder, and psychopathy than their normally hearing peers. Levels of anxiety, somatization, and delinquency were elevated in some, but not all, hearing-impaired participants, for reasons related to sex, age, and type of school. Divergent results were obtained for the level of attention-deficit/hyperactivity disorder and the influence of type of hearing device on psychopathology. Possible risk and protective factors were identified, including age at detection and intervention of hearing loss, additional disabilities, communication skills, intelligence, type of school, and number of siblings. CONCLUSIONS AND RELEVANCE: Literature on psychopathology in hearing-impaired children and adolescents is scarce and sometimes inconsistent. To define a more precise occurrence of psychopathology, more studies are needed. These studies should have a longitudinal design to draw firmer conclusions on causality. Hopefully, this will lead to more knowledge in the future to help and support each hearing-impaired individual.