Parenting stress in parents of children with cochlear implants: relationships among parent stress, child language, and unilateral versus bilateral implants

Evaluating the Relation Between Mothers' Depression Level and Their Cochlear Implanted Children's Social Performance

Since the child's sensorineural hearing loss and its negative consequences, including weak social skills, is one of the most challenging problems for parents and other family members, the main aim of the present study is to investigate if there is any probable relation between the cochlear implanted children's social performance and their mothers' depression level,in this cross-sectional observational analytic research, we implemented the Beck Depression Inventory version- II to evaluate the level of depression in 29 mothers of cochlear implanted children. Also, we assessed their children's social abilities through the Vineland Adaptive Behavior Scale. Finally, the analysis of variance (ANOVA) was carried out to find any probable relation between the mothers' depression level and their children's social performance. The mean difference was significant at the 0.05 level,results indicated no significant difference in the mean social performance of the children mothers encountered with mild or moderate degrees of depression. However, the mean social performance of the children with severely depressed mothers was significantly less than the others,severe to profound sensorineural hearing loss in children might cause various degrees of depression in mothers. Mothers who suffer from severe depression cannot effectively communicate with their children. Consequently, the child will not improve in social interaction well.

Instruments for evaluating the parental emotional status and ecological support systems among parents who considered cochlear implantation for their children with hearing loss: A scoping review

OBJECTIVES

Parents of children diagnosed with severe-to-profound sensorineural hearing loss may experience a range of emotions owing to a lack of knowledge and experience in dealing with such children. However, most audiology clinics only attend to children with deaf and hard of hearing (DHH) and not their parents. Thus, parents' emotional and support needs are frequently excluded from the intervention sessions, making their own needs invisible. This study aimed to identify academic and clinical instruments used for assessing parental emotional status (PES) and ecological support systems (ESS) in early intervention and determine the factors affecting PES and ESS among parents of DHH children undergoing cochlear implantation.

MATERIALS AND METHODS

This scoping review followed the rigorous methodological framework; searched Medline (via OVID and EMBSCO), Scopus, and Web of Science; and selected studies relevant to validated instruments used to evaluate the PES and ESS among parents of DHH children below 6 years old. Before selecting and reviewing relevant articles, two reviewers independently assessed article titles and abstracts from the data sources. Two reviewers verified half of the first reviewer's extracted data.

RESULTS

Overall, 3060 articles were retrieved from the database search, and 139 were selected for full-text review following title and abstract reviews. Ultimately, this study included 22 articles. Among them, 23 and 12 validated instruments, most of which are generic measures, were used for assessing PES and ESS, respectively. Three condition-specific instruments were identified and designed to be administered following cochlear implantation surgery.

CONCLUSIONS

This study revealed that healthcare professionals who interact with parents of DHH children lack the necessary instruments, particularly for parents of children undergoing cochlear implantation surgery. Therefore, it is necessary to develop condition-specific instruments for parents who consider cochlear implantation for their children.

Factors that influence stress in caregivers of 5-year-old children with hearing loss wearing hearing aids or cochlear implants

OBJECTIVE

Stress levels among caregivers of children with hearing loss could influence caregiver-child interactions and ultimately, children's developmental outcomes. Given the limited understanding of stress levels among caregivers of Australian children with hearing loss, the present study aimed to examine stress in caregivers of 5-year-old children with hearing loss wearing hearing aids or cochlear implants and to identify factors associated with greater stress levels.

METHODS

A total of 99 caregivers of 70 hearing aid users and 29 cochlear implant users participated in the study. Caregivers' stress was measured using the 68-item Pediatric Hearing Impairment Caregiver Experience (PHICE) questionnaire that examines caregivers' context-specific stress levels in relation to caring for a child with hearing loss. Factors contributing to stress were identified in relation to eight domains including communication, education, emotional well-being, equipment, financial, healthcare, social, and support.

RESULTS

Across domains, the three most common predictors of increased stress were the use of cochlear implants over hearing aids, use of sign and oral language (mixed) over oral language as the communication mode at home, and increased behavioural difficulties of the child.

CONCLUSION

Overall, reported stress levels among Australian caregivers were low. Identified factors influencing stress levels can inform service provision improvement.

Preschool Children with Hearing Loss: Social Communication and Parenting Stress

Studies on parenting stress (PS) in parents of children with hearing loss (HL) have found relationships between child behavior, language skills and parenting stress. The role of early social communication skills has not been researched before. The aim of this cross-sectional study was to investigate the relationship between child behavior, social communication and PS. The study was performed in a subgroup of a total population sample from the AChild (Austrian Children with Hearing Impairment-Longitudinal Databank) study. Preschool children (n = 81) with all degrees of HL and average cognitive functioning and their families were included, and the Parenting Stress Index (PSI) was used. Through factor component analysis, compound scores for externalizing/internalizing problem behavior and hyperactivity were analyzed. Although mean PS was not elevated, the proportion of those with elevated scores was higher compared with the norm population. There was a strong correlation between child behavior problems and PS (strongest correlation: externalizing problem behavior r = 0.643; p < 0.001). All three problem behaviors accounted for 49.7% of the variance in PS. An indirect effect of social communication on PS was almost completely mediated by problem behavior (especially hyperactivity). The importance of social communication development with respect to problem behavior and PS is highlighted.

Experiences of parents of children with cochlear implants in South Africa: an exploratory study

PURPOSE

Cochlear implantation is a well-established option for early intervention. Children with hearing impairment and their parents are users of intervention services, with parents being more suited to provide insight into their experiences. The purpose of the current study was to describe the experiences of parents of children with cochlear implants (CIs) in the South African context.

METHODS

A qualitative research design was employed. Non-probability, purposive sampling was used. Seven, online semi-structured interviews were conducted with parents of children with CIs. Data were analysed using inductive thematic analysis.

RESULTS

Participants expressed feelings of certainty and assurance in the CI journey. Participants extended gratitude to the healthcare professionals involved in their children's CI journey. Feelings of doubt and stress were noted when coming to terms with the decision of cochlear implantation and financial stressors were noted as a challenge. Many participants found it challenging transitioning their children into school.

CONCLUSIONS

Parents conveyed having no regrets with their decision of cochlear implantation for their child and were grateful for the support provided by healthcare professionals. However, financial, and educational challenges remain. Findings suggest the need for more financial support for cochlear implantation in South Africa, and for adequate inclusive educational settings.

Associations of childhood hearing loss and adverse childhood experiences in deaf adults

Childhood trauma and adverse childhood experiences have a strong relationship with health disparities across the lifespan. Despite experiencing approximately doubled rates of trauma, Adverse Childhood Experiences (ACEs) are poorly characterized in deaf populations. We sought to characterize deaf-specific demographic factors and their association with multiple experiences of ACEs before the age of 18 years old. An analytical cross-sectional approach was used to ascertain associations of deaf-specific demographic factors and experiences with ACEs. The complete dataset included 520 participants for a total response rate of 56%. After adjusting for confounding effects, less severe hearing loss of 16-55 dB (2+ OR: 5.2, 4+ OR: 4.7), having a cochlear implant (2+ OR: 2.1, 4+ OR: 2.6), and not attending at least one school with signing access (2+ OR: 2.4, 4+ OR: 3.7) were significantly and independently associated with reported experiences of multiple ACEs. We conclude that factors associated with childhood hearing loss and language experiences increase risk of experiencing ACEs. Given the strong relationship between ACEs and poor social outcomes, early intervention clinical practice and health policies should consider interventions to support healthy home environments for deaf children.

Parenting Stress in Mothers of Children with Permanent Hearing Impairment

Permanent childhood hearing impairment (PCHI) represents the most frequent sensory pathology at birth. PCHI has a relevant psychological impact on the life of both the affected children and their families. Thus, the aim of this work is to explore the degree of parental distress felt by mothers of a deaf or hard-of-hearing child, to determine if this stress is associated with variables related to the children’s health (e.g., the severity of hearing loss, presence of other conditions, difficulty with treatment options, difficulty with rehabilitation) or family characteristics such as socio-economic and educational status. The study used the Parenting Stress Index–Short Form (PSI-SF) questionnaire administered to mothers. The results were analyzed in relation to variables such as parents’ education level, number of children, severity of hearing loss, presence of other chronic conditions, presence of cognitive delay, familiarity with hearing loss, time of diagnosis, use of prosthetics, and start in a rehabilitation program. The data indicate a correlation between maternal stress levels and low-educational levels, as well as the presence of congenital infections and cognitive delay. These results highlight the need for a comprehensive physical and psychological approach for hearing-impaired children, as stress factors can affect the adherence to effective rehabilitation.

Health-related quality of life among mothers of children with cochlear implants with and without developmental disabilities

BACKGROUND

Cochlear implants (CIs) are widely used among children with severe to profound hearing loss. Raising a child with a CI presents unique challenges to the family, especially when the child has a developmental disability (CI-DD).

AIMS

This study aimed to elucidate the relations between the functioning of children with CIs, their mothers' coping resources (i.e., social support and family-centered care), and maternal health-related quality of life (HRQoL). Also, it examined whether the presence of a DD in addition to the child's deafness moderated these relations.

METHODS AND PROCEDURES

A sample of 100 mothers of children with CIs (54 in the CI-DD group) completed questionnaires regarding perceived social support, family-centered care, and HRQoL.

OUTCOMES AND RESULTS

Mothers of deaf children with CIs and DD experienced lower levels of family functioning and HRQoL across all dimensions compared to mothers of deaf children with CIs without DD. In addition, social support was positively related to HRQoL only among mothers of children in the CI-DD group, indicating the protective role of social support.

CONCLUSIONS AND IMPLICATIONS

Social support is an important coping resource, and psychosocial support is needed for mothers of children with CIs, especially for mothers whose children also have a DD.

Associations Between Caregiver Stress and Language Outcomes in Infants With Autistic and Non-Autistic Siblings: An Exploratory Study

PURPOSE

Caregivers of autistic children present with high stress levels, which have been associated with poorer child outcomes in several domains, including language development. However, prior to this study, it was unknown whether elevated caregiver stress was associated with language development in infant siblings of autistic children (Sibs-autism), who are at increased likelihood of receiving a future diagnosis of autism and/or language impairment compared to infant siblings of non-autistic children. This study explored the degree to which, as well as the mechanisms by which, caregiver stress was linked with later language outcomes of Sibs-autism and infant siblings of non-autistic children (Sibs-NA).

METHOD

Participants were 50 infants (28 Sibs-autism; 22 Sibs-NA) aged 12-18 months at the first time point in this study (Time 1). Infants were seen again 9 months later, at 21-27 months of age (Time 2). Caregiver stress was measured via a validated self-report measure at Time 1. Caregiver language input, the putative mechanism by which caregiver stress may influence later language outcomes, was collected via two daylong recordings from digital recording (Language ENvironment Analysis) devices worn by the child at this same time point. Child language outcomes were measured via standardized and caregiver report measures at Time 2.

RESULTS

Several models testing hypothesized indirect effects of caregiver stress on later child language outcomes through caregiver language input were statistically significant. Specifically, significant indirect effects suggest that (a) caregivers with increased stress tend to speak less to their infants, and (b) this reduced language input tends to covary with reduced child language outcomes later in life for Sibs-autism and Sibs-NA.

CONCLUSIONS

This study provides new insights into links between caregiver stress, caregiver language input, and language outcomes in Sibs-autism and Sibs-NA. Further work is necessary to understand how to best support caregivers and optimize the language learning environments for infants.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21714368.

Associations Between Paternal Play and Executive Function in Deaf and Hard of Hearing Children

PURPOSE

Responsive and dynamic aspects of father-child play are associated with behavioral and neurocognitive development in children and could represent an important contributor to executive function (EF) skills for children who are deaf and hard of hearing (DHH). This study examined associations between paternal behaviors during play and EF skills of DHH children and children with typical hearing (TH).

METHOD

Father-child dyads in families with DHH children (n = 30) and TH children (n = 29) participated in a 15-min video-recorded free-play session that was coded for parental behaviors using Parent-Child Interaction Rating Scales and Rough and Tumble Play Quality. Families also completed an age-appropriate version of the Behavior Rating Index of Executive Function as a measure of child EF.

RESULTS

DHH children were rated as having significantly more everyday difficulties with working memory than TH children. Fathers of DHH children were rated as more intrusive during play than fathers of TH children; however, there were no other differences between paternal groups on coded dimensions of father child play. Paternal respect for child autonomy was associated with fewer child difficulties with planning and organization skills and paternal play engagement was associated with fewer child EF difficulties. Moderation analyses revealed that paternal sensitivity was associated with more working memory difficulties and paternal respect for child autonomy was associated with fewer working memory difficulties for DHH children only.

CONCLUSIONS

Paternal play could be an important environmental context for DHH outcomes. Fathers supporting independent play might generally support EF. Paternal engagement in play might also benefit EF. Results highlight paternal behavioral attributes that could lead to potential father-embedded intervention models.

Research About Parents of Children with Cochlear Implants: A Scoping Review

Parents of children who are deaf or hard of hearing have long attracted interest from researchers, though, since the 1990s, published research about this population has increasingly gravitated toward issues surrounding pediatric cochlear implantation. This scoping review was undertaken to map the nature, extent, and range of three decades of research about parents of children with cochlear implants, and reports on (1) publication characteristics, (2) sampling characteristics, and (3) study design characteristics within 80 peer-reviewed articles published between 1990 and 2020. The results indicate several gaps and gluts within the field, including a lack of diversity within (and detail about) study samples, a disproportionate focus on evaluating parents' personal characteristics and (presupposed) psycho-emotional problems, and a scarcity of participatory or co-constructed projects. The results may inform future research, ensuring a wider range of perspectives and experiences are recorded and issues of highest priority and relevance to families are investigated.

Stress among Parents of Children with Hearing Loss and How They Deal with It: A Systematic Review

Introduction  Parenting a child with hearing loss may be accompanied by high stress levels and several challenges. Objectives  The present systematic review was performed to compile the existing literature pertaining to parental stress in parents of children with hearing loss and coping strategies. Data synthesis  The databases searched include PubMed/Medline, Scopus, Cochrane Library and Cumulative Index to Nursing, and Allied Health Literature. The systematic review was designed and performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement guidelines. The screening for studies was performed independently by two researchers. Methodological quality appraisal was done using the Mixed methods appraisal tool. Twenty-eight studies were identified and included in the present review, which discussed the stress factors and coping mechanism associated with having child with hearing loss reported by parents. The factors leading to stress were thematically classified into parent/family-related factors, child-related factors, and professionals/service-related factors. The coping strategies were thematically classified into improved support systems and better professional resources. Conclusion  The present systematic review was an attempt at exploring the various stress causing factors among parents of children with hearing loss. The various coping strategies would help in better planning services for these parents and helping to lessen the stress.

Development and Validation of a Parenting Stress Module for Parents of Children Using Cochlear Implants

OBJECTIVES

The purpose of this study was to develop and validate a cochlear implant (CI)-specific parenting stress measure using the FDA Guidance on Patient-Reported Outcomes (2009).

METHODS

The development and psychometric validation of the Parenting Stress-CI module for both the Early Childhood (EC; 0-5 years) and School-Age (SA; 6-12 years) versions are reported in this article. Instrument development consisted of qualitative interviews with parents of children with CIs (EC: N = 19; SA: N = 21), content analysis, item development, and cognitive testing of the instrument. Last, we conducted the psychometric validation (EC: N = 72; SA: N = 64), including analyses of internal consistency, test-retest reliability (∼2 weeks between administrations; N = 24), and convergent validity with the Parenting Stress Index-4 (PSI-4).

RESULTS

The final EC version includes 15 questions, and the SA version includes 8 questions. Both the EC and SA versions had strong reliability (EC α = .88; SA α = .85), with all items significantly correlated with the overall module (r = .43-.80). Both versions also had strong test-retest reliability (r = .99, p < .001). Last, analyses of convergent validity demonstrated significant correlations with the PSI-4 Total Stress scale for both Parenting Stress-CI versions (EC r = .66, p < .00; SA r = .45, p < .001).

CONCLUSIONS

The Parenting Stress-CI modules are reliable and valid condition-specific parenting stress instruments for parents of children with CIs ages 0-12 years, filling a significant gap in the literature. These fully validated instruments can be used to assess parental needs for support and guide the development of targeted, family centered interventions.

A comparison of the quality of life of parents of children using hearing aids and those using cochlear implants

Objective

The goal of this study was to evaluate the quality of life of parents of children who use hearing aids (HA) with those who use cochlear implants (CI) in the Indian context and document any differences found.

Methods

The Kannada version of the AQoL-4D was administered in a modified fashion to 131 parents (87 HA and 44 CI). Sociodemographic details were collected for supplemental information on the intervention strategy used.

Results

A total of 49 parents (29 HA and 20 CI) responded to the questionnaire sent. The mean total scores for both the groups were similar (HA group = 17.9 (SD = 5.5), CI group = 17.2 (SD = 3.4)), as was the score for the first subscale (HA group = 8.6 (SD = 2.9); CI group = 8.5 (SD = 2.6)) of the AQoL-4D. No significant differences were found between the two groups on either scores [Total Score: U (N_HA = 29, N_CI = 20) = 280.5, z = −0.194, p > 0.05; Subscale 1 Score: U (N_HA = 29, N_CI = 20) = 281.5, z = −0.176, p > 0.05]. The degree of hearing loss in the hearing aid group was equivalent to that of the cochlear implant group but this did not appear to influence parental quality of life.

Conclusion

Parents of children with hearing aids and cochlear implants appear to be similar on several psychosocial factors in the realms of functional, social, and psychological well-being. In terms of parental quality of life, hearing aids and cochlear implants appear to be equally effective intervention techniques.

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Effect of Hearing impairment of children on their parents.

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Differences in the quality of life across different amplification strategy used.

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Correlation among quality of life, age of child, age of intervention, duration of hearing loss.

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Emotional consequences in Parents having hearing impaired children.

Relationship between parental stress and attitude towards cochlear implantation outcomes in children in an Indian context

PURPOSE

The study was aimed to investigate the relationship between parental stress and attitude of parents towards the outcomes of cochlear implantation in an Indian scenario.

METHODS

A total of 59 parents of children with cochlear implantation participated in the study. The outcomes of cochlear implant was measured using Parental attitudes of various aspects of cochlear implantation questionnaire and parental stress was measured using parental stress scale. The questionnaires were circulated to participants and data was collected in the form of e-survey.

RESULTS

The present study showed that the parental stress level was similar among mothers and fathers. Further, the parental attitude towards communication abilities of children and education were positively correlated with the duration of cochlear implantation. Finally, a significant positive correlation was found between the parental stress and the parental attitude towards communication abilities of children and social skills.

CONCLUSION

The present study showed a positive relationship between parental stress and parental attitude towards the outcomes of cochlear implantation for aspects of communication abilities and social skills.

Parent-Reported Stress and Child Behavior for 4-Year-Old Children with Unilateral or Mild Bilateral Hearing Loss

Children with unilateral or mild bilateral hearing loss are increasingly identified in early childhood. Relatively little is known about how hearing loss affects their developmental trajectory or whether it contributes to parenting stress for these parents. This study aimed to examine child behavior and parenting stress in parents of children with unilateral/mild bilateral hearing loss compared to children with typical hearing. This prospective study involved 54 children with unilateral/mild bilateral hearing loss identified at a median age of 4.5 months (IQR 2.6, 6.5) and 42 children with typical hearing. At age 48 months, child behavior and parenting stress were measured. Auditory and language results were also analyzed in relation to child behavior and parenting stress. Parents of these children did not report significantly more parenting stress or behavior problems than parents of children with typical hearing. However, both parenting stress and child behavior were related to functional hearing in noise.

Multidimensional Family-Centred Early Intervention in Children with Hearing Loss: A Conceptual Model

At least two per thousand newborns are affected by hearing loss, with up to 40% with an additional disability. Early identification by universal newborn hearing screening and early intervention services are available in many countries around the world, with limited data on their effectiveness and a lack of knowledge about specific intervention-related determinants of child and family outcomes. This concept paper aimed to better understand the mechanisms by which multi-dimensional family-centred early intervention influences child outcomes, through parent behaviour, targeted by intervention by a review of the literature, primarily in the field of childhood hearing loss, supplemented by research findings on physiological and atypical child development. We present a conceptual model of influences of multi-disciplinary family-centred early intervention on family coping/functioning and parent–child interaction, with effects on child psycho-social and cognitive outcomes. Social communication and language skills are postulated as mediators between parent–child interaction and non-verbal child outcomes. Multi-disciplinary networks of professionals trained in family-centred practice and the evaluation of existing services, with respect to best practice guidelines for family-centred early intervention, are recommended. There is a need for longitudinal epidemiological studies, including specific intervention measures, family behaviours and multidimensional child outcomes.

Parenting Stress, Self-Efficacy, and Involvement: Effects on Spoken Language Ability Three Years After Cochlear Implantation

OBJECTIVE

This study evaluated associations among parenting stress, self-efficacy, and involvement in relation to spoken language outcomes in young children 3 years following cochlear implantation.

STUDY DESIGN

Cross-sectional.

SETTING

Six university tertiary medical centers.

PATIENTS

One hundred sixty-four young children with bilateral, severe-to-profound sensorineural hearing loss who had 3 years of experience with a CI; children with substantial cognitive impairments were excluded from the study.

MAIN OUTCOME MEASURESS

Family Stress Scale (FSS), Scale of Parental Involvement and Self-Efficacy (SPISE), Oral and Written Language Scales (OWLS).

RESULTS

Correlations were of moderate strength between FSS scores and SPISE scores (Parental Self-Efficacy, r = -0.45, p < 0.01, Parental Involvement r = -0.32, p < 0.01). As hypothesized, parents reporting higher levels of stress reported lower perceptions of self-efficacy and involvement. In addition, results showed that family stress had a direct, negative effect on spoken language (-4.43 [95% confidence interval: -6.97; -1.89]). After controlling for maternal education and activation age, parental self-efficacy mediated the negative effect between family stress and spoken language (indirect effect = -1.91 [3.45; -0.69]; proportion mediated = 0.43). No mediating effects were found for parental involvement.

CONCLUSIONS

These findings highlight the need for parenting interventions that focus on reducing stressors and increasing parents' perceptions of self-efficacy in families of children using cochlear implants. Integration of mental health screening and tailored parenting interventions in CI clinics may increase parental self-efficacy and involvement, with measurable benefits in the child's use of spoken language.

The Impact of Family Environment on Language Development of Children With Cochlear Implants: A Systematic Review and Meta-Analysis

OBJECTIVES

The authors conducted a systematic review of the literature and meta-analyses to assess the influence of family environment on language development in children with cochlear implants.

DESIGN

The Pubmed, excerpta medica dataBASE (EMBASE), Education Research Information Center, cumulative index to nursing and allied health literature (CINAHL), Healthcare Literature Information Network, PubPsych, and Social SciSearch databases were searched. The search strategy included terms describing family environment, child characteristics, and language development. Studies were included that (a) assessed distal family variables (such as parental income level, parental education, family size, and parental stress) with child language outcomes, and/or more proximal correlates that directly affect the child (such as family engagement and participation in intervention, parenting style, and more specifically, the quantity and quality of parental linguistic input) on child language; (b) included children implanted before the age of 5 years; (c) measured child language before the age of 21 years with standardized instruments; (d) were published between 1995 and February 2018; and (e) were published as peer-reviewed articles. The methodological quality was assessed with an adaptation of a previously validated checklist. Meta-analyses were conducted assuming a random-effects model.

RESULTS

A total of 22 study populations reported in 27 publications were included. Methodological quality was highly variable. Ten studies had a longitudinal design. Three meta-analyses on the correlations between family variables and child language development could be performed. A strong effect of the quality and quantity of parental linguistic input in the first 4½ years postimplantation on the child's language was found, r = 0.564, p ≤ 0.001, 95% confidence interval (CI) = 0.449 to 0.660, accounting for 31.7% of the variance in child language outcomes. Results demonstrated high homogeneity, Q(3) = 1.823, p = 0.61, I = 0. Higher-level facilitative language techniques, such as parental expansions of the child's utterances or the use of open-ended questions, predicted child language skills. Risk of publication bias was not detected. The results on the impact of family involvement/participation in intervention on child language development were more heterogeneous. The meta-analysis included mainly cross-sectional studies and identified low to moderate benefits, r = 0.380, p ≤ 0.052, 95% CI = -0.004 to 0.667, that almost attained significance level. Socioeconomic status, mainly operationalized by parental level of education, showed a positive correlation with child language development in most studies. The meta-analysis confirmed an overall low and nonsignificant average correlation coefficient, r = 0.117, p = 0.262, 95% CI = -0.087 to 0.312. A limitation of the study was the lack of some potentially relevant variables, such as multilingualism or family screen time.

CONCLUSIONS

These data support the hypothesis that parental linguistic input during the first years after cochlear implantation strongly predicts later child language outcomes. Effects of parental involvement in intervention and parental education are comparatively weaker and more heterogeneous. These findings underscore the need for early-intervention programs for children with cochlear implants focusing on providing support to parents for them to increase their children's exposure to high-quality conversation.

Stress in Parents of School-Age Children and Adolescents With Cochlear Implants

Parents of children with cochlear implants (CIs) face unique challenges in caring for their child, potentially fostering parental stress. Most studies of stress in parents of CI users do not examine stress specific to having a deaf and hard-of-hearing (DHH) child. This study compares general and condition-specific stress (via the Family Stress Scale) in 31 parents of CI users (8-16 years) to previously published samples of DHH children, and it examines child- and CI-related factors associated with parental stress. Parents of modern-day CI users reported significantly lower stress than parents of children using older-generation CI technology and similar levels of overall stress to parents of young children preimplantation. However, significant item-level differences emerged (e.g., communication, device management) pre- versus postimplant. Child temperament significantly predicted parental stress after controlling for other variables. Intervention strategies for children with CIs should engage a family systems approach to reduce parental stress and better support the child.

Age Differences in the Mediating Effects of Parenting Stress on the Relationship Between Cyanotic Congenital Heart Disease and Externalizing Problems in Children and Adolescents

BACKGROUND

Cyanotic congenital heart disease (CHD) has detrimental effects on behavioral function in children and adolescents. However, few study authors have examined the underlying mechanisms of these effects.

OBJECTIVE

The aims of this study were to investigate the mediating effects of parenting stress in the association between cyanotic CHD and externalizing problems and to explore whether age moderated these mediating effects.

METHODS

A total of 697 children and adolescents (aged 2-17 years) with CHD (252 with cyanotic CHD and 445 with acyanotic CHD) in Taiwan were enrolled. The Child Behavior Checklist and the Parenting Stress Index were used to assess externalizing problems and parenting stress, respectively. Mediation analysis was performed to determine the mediating effects of parenting stress in the association between cyanotic CHD and externalizing problems. A moderated mediation model was used to investigate the moderating effect of age on the observed mediating effects.

RESULTS

Parenting stress significantly mediated the relationship between cyanotic CHD and externalizing problems (unstandardized coefficient B = 0.98; 95% bootstrap confidence interval, 0.23-1.78). Children's age further moderated the mediating effects, with greater effects in older children. Age also moderated the association between cyanotic CHD and parenting stress, such that the effects were only significant in children older than 5.7 years.

CONCLUSIONS

Our study revealed that age affected the mediating effects of parenting stress in the relationship between cyanotic CHD and externalizing problems. Efforts to reduce externalizing problems in children and adolescents with cyanotic CHD by targeting parenting stress may be more effective when age differences are considered.

Factors Associated With Anxiety Symptoms in Australian Deaf or Hard of Hearing Children

Deaf/deaf or hard of hearing (DHH) children are at an increased risk of developing mental health problems, with growing evidence that they may experience greater anxiety symptoms than hearing peers. The present study investigated whether Australian children with varying degrees of hearing loss experienced increased anxiety symptoms compared to hearing children. Furthermore, we examined whether child anxiety symptoms were associated with known risk factors including psychological symptoms of anxiety and depression in parents, age at detection, early intervention and device fitting, type of hearing device, and peer problems. Participants were 65 parents of children with hearing loss aged between 4 and 11 years old (M = 6.05, SD = 1.60) seeking treatment for hearing loss at a specialized hearing clinic in Australia. Based on parent reports, we found that the children with hearing loss had fewer anxiety symptoms than their hearing peers (using normative data). Psychological distress of parents was the only factor that uniquely associated with child anxiety. Parents of children with hearing loss were found to experience greater emotional distress compared to parents of hearing children. This suggests parents may require additional support to cope with the social and economic strains associated with childhood hearing loss.

The influence of age and language on developmental trajectory of theory of mind in children with cochlear implants

OBJECTIVE

The present study investigates if children with cochlear implants (CI) are associated with delayed development of Theory of Mind (ToM) and the differences in gain of ToM ability with respect to age, language and other aspects of CI.

METHODS

One-hundred-eleven children with participation of their hearing parents, aged between 36 months and 132 months, who had congenital profound bilateral deafness and were unilateral CI users; plus 99 healthy children underwent 'Peabody Picture Vocabulary' and 'Sally-Anne' tests. A total of 77 children with CI (mean age: 76.51 months, 31 girls and 46 boys) and 82 healthy children (mean age: 72.41 months, 47 girls and 35 boys) were included in the analyses. Analytic comparisons were created between the controls and children with CI and between subgroups of CI users by univariate and multivariate analysis. The effects of age of hearing aid use, age of CI surgery, duration of CI use, language scores and the presence of risk factors, early rehabilitation with hearing aid and CI on the ToM development were analyzed.

RESULTS

The Sally-Anne test success rates of 67.1% were significantly higher in controls than that of children with CI (49.4%) (p < 0.05). The mean age difference of the children, who were successful in Sally-Anne test was 5.33 months in favor of healthy controls. The ToM task success rates were 57.1% (24/42) and 40% (14/35) in children with early CI and late CI respectively. The children, who were good at language, were also better in Sally-Anne tests, but the mean Peabody Picture Vocabulary test scores were indifferent in the same age group with respect to the presence of CI use (p > 0.05). However, multivariate analysis presented the higher language scores as the only significant independent variable that has impact on the success in Sally-Anne test (p < 0.05).

CONCLUSION

The results revealed that among all children, who did better in ToM were older in age and better in language skills. Children with CI also performed better in false-belief test depending on their language scores. Early CI surgery, older age, and hence longer CI use can provide a well-developed ToM for children with CI.

Relationship Between Parental Stress and their Attitudes Towards Cochlear Implantation Outcomes in Children Referred to Besat Cochlear Implant Center in Hamadan 2018

PURPOSE

This study aimed to investigate the relationship between parental stress and their attitudes towards post-cochlear implantation outcomes in children referred to Besat cochlear implant center in Hamadan during 2018.

DESIGN AND METHODS

In this descriptive cross-sectional study, 100 parents of children with cochlear implantation were selected from Besat cochlear implant center in Hamadan through census method from April to October 2018. The data were collected using a demographic characteristic questionnaire, parental stress scale developed by Berry and Jones, and Parental Attitudes of Various Aspects of Cochlear Implantation. The data were analyzed using SPSS software (version 16) through correlation coefficient, one-way ANOVA, and t-test. P-value <0.05 was considered statistically significant.

RESULTS

The results of this study indicated that parental stress negatively correlated with their attitudes towards the outcomes of cochlear implantation (r = -0.420), including the aspects of communication (r = -0.462), educational (r = -0.398), and social skills (r = -0.445), as well as services provided by the health care centers (r = -0.277), and the efficiencies of cochlear implantation center (r = -0.118) (P < 0.05).

CONCLUSION

According to the results, parents with more positive attitudes towards the areas of communication, educational, and social skills, as well as services provided by the health care centers, and the efficiencies of cochlear implantation center experienced lower levels of stress.

PRACTICE IMPLICATIONS

Nurses can measure the stress and attitudes towards cochlear implantation outcomes in children to accurately assess the needs of the family in order to improve their nursing process and advance the child's rehabilitation program.

Mothers' emotional experiences related to their child's diagnosis of deafness and cochlear implant surgery: Parenting stress and child's language development

OBJECTIVES

The present study aims to assess the emotional experiences, specifically parenting stress, of mothers of children with cochlear implants (CIs), and their children's language development before surgery and at three and six months after CI activation.

METHODS

Twenty mothers of children with CIs were interviewed before their children's surgery about their experiences in connection with the diagnosis of deafness, the surgery and the activation of the CI. The Parenting Stress Index questionnaire and the MacArthur-Bates-Communication Development Inventory were administered before the surgery and at 3 and 6 months after the CI activation.

RESULTS

Analysis of the qualitative data resulting from the interviews showed that the mothers' emotional experiences before the CI surgery were complex. Mothers reported both positive and negative emotions related to deafness, diagnosis and surgery, benefits of the CI, coping strategies and future expectations. The mothers of children with more advanced lexical production six months after CI activation displayed a high frequency of themes related to positive emotions, thoughts and coping strategies before the surgery. Distress on the part of the mothers, perceptions of difficulties in their child and instances of parent-child dysfunctional interaction were negatively and significantly related to the child's language and communication development.

CONCLUSIONS

The findings support the importance of assessing the mother's emotional experience in relation to diagnosis and CI activation before the surgery. IMPLICATIONS FOR CLINICAL PRACTICE ARE DISCUSSED: specifically, the importance of the support offered to the parents, aimed at enhancing both their awareness of their expectations about their child's rehabilitation process and their self-efficacy in supporting the child's adaptation to the use of the CI.

Associations Between Parenting Stress, Language Comprehension, and Inhibitory Control in Children With Hearing Loss

Purpose Parenting stress has been studied as a potential predictor of developmental outcomes in children with normal hearing and children who are deaf and hard of hearing. However, it is unclear how parenting stress might underlie at-risk spoken language and neurocognitive outcomes in this clinical pediatric population. We investigated parenting stress levels and the shared relations between parenting stress, language comprehension, and inhibitory control skills in children with and without hearing loss (HL) using a cross-sectional design. Method Families of children with HL (n = 39) and with normal hearing (n = 41) were tested. Children completed an age-appropriate version of the Concepts & Following Directions subtest of the Clinical Evaluation of Language Fundamentals and the NIH Toolbox Flanker Test of Attention and Inhibitory control. Caregivers completed the Parenting Stress Index-Short Form 4. Results Parenting stress levels were not significantly different between parents of children with and without HL. A significant negative association was observed between parenting stress and our measure of language comprehension in children with HL. A negative association between parenting stress and inhibitory control skills was also found in families of children with HL, but not hearing children. The parenting stress-inhibitory control relationship was indirectly accounted for by delayed language comprehension skills in children with HL. Conclusion Even at moderate levels of parenting stress similar to parents of children with normal hearing, increases in parenting stress were associated with lower scores on our measures of language comprehension and inhibitory control in children with HL. Thus, parenting stress may underlie some of the variability in at-risk pediatric HL outcomes.

Health-related quality of life in children who use cochlear implants or hearing aids

Objectives

First, this study aimed at evaluating the health-related quality of life (HRQoL) and socio-demographic characteristics of children with cochlear implants (CIs) and hearing aids (HAs) from the 2 provinces of the Canary Islands (Spain) on the Kid-KINDL^R_children_7–13. The second goal was to analyze parental background factors and the perspectives of their children with CIs and HAs on Kid_Kiddo-KINDL^R_Parents_ 7–17. Finally, the third objective was to explore agreement between children's self-reports and their parents' reports concerning HRQoL.

Design

The data consisted of 89 children with CIs and 63 children with HAs and their 89 parents, respectively. The socio-demographic characteristics of children and parental background factors included demographic and audiological variables. Student's t-test, one-way ANOVA, post hoc analysis and 4 concordance correlation coefficients (CCC) were used to address the 3 aims.

Results

Children with CIs exhibited a perception of better HRQoL in comparison with children with HAs. Among other differences, children with CIs and HAs and their parents were significantly distinct in Setting (i.e., provinces of Tenerife and Gran Canaria) (t = 2.921, p < 0.010). Moreover, parents were significantly different in some background factors (i.e., age, socioeconomic status, and learning). While Cohen's Kappa values for most dimensions were too small, the ICC and Student's t-test expressed only concordance in the overall HRQoL and Physical well-being.

Conclusions

Children with CIs and their parents demostrated a perception of better HRQoL than children with HAs and their parents. Overall, children's self-ratings of HRQoL differed from their parents' reports.

Parents' views about factors facilitating their involvement in the oral early intervention services provided for their children with hearing loss in Kuwait

OBJECTIVES

Developed countries (such as the Unites States of America, the United Kingdom, and Australia) provide high-quality services to children with hearing loss and their parents, including universal newborn hearing screening, early fitting of hearing devices and access to high quality early, aural intervention. In contrast, many developing countries lack the resources to provide these services. Research evidence suggests that one way to compensate for delays in identification and rehabilitation for children with hearing loss is to involve the family in the early intervention process. However, evidence is deficient around the facilitation of parental involvement in early intervention for families from developing countries. The aim of this study was to investigate the perception of parents from a developing country who have a child with hearing loss to discover the factors that may influence their involvement in early intervention, identify facilitators/barriers for their involvement, and identify the specific needs of involved parents.

METHOD

A qualitative collective case study methodology was used in the form of semi-structured interviews with twenty-one participants.

RESULTS

Two global themes emerged. Firstly, factors influencing parental involvement. This included five subthemes: better communication as the key to building rapport and providing support; disappointment with the service; physical and human resources make a difference; consideration of life beyond the habilitation sessions; and my child matters the most. The second global theme-parental needs-included four subthemes: building trust; ensuring generalization; improving child outcomes; and managing needs of parents versus services. All the discussed themes are supported by quotations from the interviews.

CONCLUSION

The findings suggest that parents of children with hearing loss in developing countries perceive the services provided for their children to be disjointed and not well coordinated. Based on the parent perceptions a set of guidelines that provide a scaffold for service providers working with children with hearing loss in developing countries is outlined. The guidelines are designed to assist services for children with hearing loss in developing countries improve the delivery of their services and increase family involvement, which in turn; will assist in improving their child and family related outcomes.

Childhood hearing loss: Impact on parents and family life

BACKGROUND

Studies investigating the impact of having a child with hearing loss on the lives of parents and families have shown divergent results. Where some studies have reported that childhood hearing loss is associated with parental mental health problems, such as depression and stress, other studies report no impact on parental mental health and/or wellbeing.

OBJECTIVE

The aim of this study was to examine the association between child-related variables-degree of hearing loss, additional disabilities, sign language abilities, cochlear implants (CI), externalizing and internalizing emotional and behavioral difficulties measured by the Strength and Difficulties Questionnaire (SDQ)-and parent-related variables-parents living together, parents' mental health, spouse activities without children, and parents' experience of the child as being a burden for the family.

METHOD

Data of 257 parents of children with hearing loss from a national survey were included.

RESULTS

Only 18% of the children with hearing loss did not live with both parents, a figure significantly lower than that of the general population. The child variables of degree of hearing loss, having a CI or not, and sign language ability were not significantly associated with any of the parent variables investigated. The child having a disability in addition to hearing loss was found to be significantly associated with the frequency of spouses engaging in activities without children and reports that the child was a burden for the family. Both higher externalizing and internalizing scores on the SDQ were significantly associated with parental mental health problems, frequency of spouse activities without children, and the degree to which the child's difficulties were experienced as a burden for the family.

CONCLUSION

Children's hearing loss, per se, was found not to be significantly related to several key parent and family variables. However, children having additional disabilities and behavioral and emotional difficulties were significant with parent and family variables. This study thus underlines the need for further studies concerning relationships among factors related to childhood hearing loss and various family factors in order to better understand their impact on child development and family life.

Satisfaction with Life among Mothers of Pediatric Cochlear Implant Candidates: The Impact of Implant Operation and Sociodemographic Factors

OBJECTIVES

To evaluate the satisfaction with life among mothers of pediatric cochlear implant candidates regarding implant surgery and sociodemographic factors.

MATERIALS AND METHODS

Mothers of 160 pediatric patients with profound sensorineural hearing loss who underwent unilateral cochlear implant surgery were included. A questionnaire form with items on sociodemographic-familial characteristics and Satisfaction with Life Scale (SWLS) was employed via face-to-face interview method before and 12 months after the implant surgery.

RESULTS

The SWLS scores significantly improved after the implant surgery [from 19.1 (7.0) to 28.9 (4.0), p<0.000]. Being unemployed vs. employed [17.9 (6.9) vs. 24.0 (5.3), p=0.000], having another child with hearing disability [13.5 (5.7) vs. 19.7 (6.9), p=0.001], younger (12-24 months) vs. older (>24 months) age of the child at the time of implant surgery [7.1 (0.4) vs. 19.7 (6.6), p=0.001], absence vs. presence of regular follow-up visits [13.0 (0.0) vs. 19.4 (7.1), p=0.002], and presence vs. absence of change in social life after the diagnosis of disease [17.3 (6.5) vs. 20.9 (7.1), p=0.001] were associated with significantly lower SWLS scores among mothers. SWLS scores were positively correlated with patient's age at the time of implant surgery (r=0.206, p=0.009), whereas negatively correlated with the number of household members (r=-0.406, p=0.000) and number of children (r=-0.310, p=0.000).

CONCLUSION

In conclusion, our findings revealed the association of cochlear implantation with a significant increase in mother's life satisfaction, despite the unemployment, presence of another child with hearing disability, and crowded household. Our findings emphasize on the consideration of family systems with special attention to mother's emotional experiences and occupational competence in the intervention programs.

Assessment of Behavioral Problems in Children With Hearing Loss

OBJECTIVE

To compare the prevalence of disruptive behavior problems between preschool-aged children with hearing loss and normal hearing.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary academic center.

PATIENTS

Caregivers of children (2-5 yr old) with normal hearing (NH) (n = 39), hearing loss using hearing aid(s) (HA) (n = 29), or cochlear implant(s) (CI) (n = 21).

INTERVENTION(S)

Demographic information and a mental health history were obtained. Child behavior and language development were assessed.

MAIN OUTCOME MEASURE(S)

The Young Child-Diagnostic Interview Schedule for Children-IV and the MacArthur-Bates Communication Development Inventory III.

RESULTS

Distributions of race, socioeconomic status, insurance status, and parental home situation (single versus two parent family) were similar across all groups. Parents of children with hearing loss were significantly more likely to report behavior problems (HA = 41%, CI = 38%) than parents of NH children (10%; p = 0.002). Children with hearing loss were significantly more likely to meet diagnostic criteria for oppositional defiant disorder (HA = 48%, CI = 48%) than NH children (23%; p = 0.02). More NH children (8%) than hearing impaired children (0%) had accessed mental health services (p = 0.08). NH children were found to have more advanced language development than hearing-impaired children (p < 0.01), but controlling for Communication Development Inventory III percentiles, the observed behavioral differences remained.

CONCLUSION

Controlling for language development, children with hearing loss have higher prevalence of and impairment from disruptive behaviors than their NH peers. These children are less likely to receive appropriate behavioral interventions. Further research is warranted to investigate the impact of disruptive behaviors on speech and hearing rehabilitation. Methods to improve access to effective behavioral interventions in this population are needed.

School-aged Children with Mild Bilateral and Unilateral Hearing Loss: Parents' Reflections on Services, Experiences, and Outcomes

Following the establishment of newborn hearing screening programs, age of identification and length of time before receiving interventions has been reduced for children, including those with milder degrees of hearing loss who were previously not identified until school age. This population of early-identified children requires new support programs for parents. Although literature is emerging on how parents experience the initial years, there is limited information on support needs during early school years. The objectives were to gain insights into parents' experiences with services during the early period of identification until early school years, as well as their perceptions of the consequences of hearing loss on their child's overall development. A qualitative research design informed by Interpretive Description was employed. Individual semi-structured interviews were conducted with 12 parents of children identified with mild hearing loss. Transcripts were analyzed using a constant comparative method. Four themes emerged from the data: early experiences with services and hearing technology, effects of hearing loss on social functioning, effects of hearing loss on language and academics, and experiences in early school years. From parents' perspectives, more support during the early school years is needed to help ensure academic success.

Learning from the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study: summary of 5-year findings and implications

OBJECTIVE

This article summarises findings of the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study, and discusses implications of the findings for research and clinical practice.

DESIGN

A population-based study on outcomes of children with hearing loss. Evaluations were conducted at five years of age.

STUDY SAMPLE

Participants were 470 children born with hearing loss between 2002 and 2007 in New South Wales, Victoria and Queensland in Australia, and who first received amplification or cochlear implantation by three years of age.

RESULTS

The earlier hearing aids or cochlear implants were fitted, the better the speech, language and functional performance outcomes. Better speech perception was also associated with better language and higher cognitive abilities. Better psychosocial development was associated with better language and functional performance. Higher maternal education level was also associated with better outcomes. Qualitative analyses of parental perspectives revealed the multiple facets of their involvement in intervention.

CONCLUSIONS

The LOCHI study has shown that early fitting of hearing devices is key to achieving better speech, language and functional performance outcomes for children with hearing loss. The findings are discussed in relation to changes in clinical practice and directions for future research.

Parental Expectation from Children with Cochlear Implants in Indian Context: a Questionnaire Based Study

Introduction Parental support is important in the habilitation/rehabilitation of children using cochlear implant devices. Hence, it is important for families to know the realistic expectations regarding outcomes from CIs. Objective The objective of the present study is to know the parents' expectation from children using CIs. Methods For this study, we recruited 23 parents of children using CIs. We administered 15 questions translated in to Hindi related to communication abilities, social skills, academic achievement, change in future life, rehabilitation demand, and stress due to hearing impairment. Results The response of the questions (5-point rating scale) related to communication abilities showed that parents were expecting children using CIs to use the telephone (95%), to be able to detect soft sounds (99%), to listen in crowds (86%), to be able to easily understand others (76%), and to show improvement in communication skills (78%). Similarly, for questions related to social skills showed 90% of the parents expecting that their children with CIs should be able to easily make friends with normal hearing peers, and 80% of the parents were expecting the children to achieve high standards in their reading and writing skills. Questions related to change in future life showed 86% of the parents expecting their children with CIs to act like normal hearing children. Further, 78% parents showed positive response regarding importance of intensive training. However, 70% of the parents reported stress in the family due to the existence of the hearing impaired child. Conclusion Overall, the existing questionnaire-based study showed that parents have high expectations from their children with cochlear implant.

Audio-visual speech perception in noise: Implanted children and young adults versus normal hearing peers

OBJECTIVE

The purpose of the current study was to evaluate auditory, visual and audiovisual speech perception abilities among two groups of cochlear implant (CI) users: prelingual children and long-term young adults, as compared to their normal hearing (NH) peers.

METHODS

Prospective cohort study that included 50 participants, divided into two groups of CI (10 children and 10 adults), and two groups of normal hearing peers (15 participants each). Speech stimuli included monosyllabic meaningful and nonsense words in a signal to noise ratio of 0 dB. Speech stimuli were introduced via auditory, visual and audiovisual modalities.

RESULTS

(1) CI children and adults show lower speech perception accuracy with background noise in audiovisual and auditory modalities, as compared to NH peers, but significantly higher visual speech perception scores. (2) CI children are superior to CI adults in speech perception in noise via auditory modality, but inferior in the visual one. Both CI children and CI adults had similar audiovisual integration.

CONCLUSIONS

The findings of the current study show that in spite of the fact that the CI children were implanted bilaterally, at a very young age, and using advanced technology, they still have difficulties in perceiving speech in adverse listening conditions even when adding the visual modality. This suggests that adding audiovisual training might be beneficial for this group by improving their audiovisual integration in difficult listening situations.

The Role of the World Health Organization's International Classification of Functioning, Health and Disability in Models of Infant Cochlear Implant Management

Newborn hearing screening has led to the early diagnosis of hearing loss in neonates and early device fitting is common, based primarily on electrophysiologic and radiologic information, with some supplementary behavioral measures. Such early fitting of hearing devices, in particular cochlear implants (CIs), has been beneficial to the majority of children implanted under the age of 12 months who meet the cochlear implant candidacy criteria. Comorbidities are common in children with hearing loss, although they may not be evident in neonates and may not emerge until later in infants. Evidence suggests that the child's outcomes are strongly influenced by a range of environmental factors including emotional and social support from the immediate and extended family. Consequently, such factors are important in service planning and service delivery for babies and children receiving CIs. The World Health Organization's International Classification of Functioning, Health and Disability (ICF) can provide a framework to facilitate the holistic management of pediatric cochlear implant recipients. The ICF also can be used to map the progress of recipients over time to highlight emerging issues that require intervention. This article will discuss our preliminary use of the ICF to establish clinical practice; develop advocacy skills among clients and their families; identify eligibility for services such as support in educational settings; enable access to modes of service delivery such as telepractice; provide a conceptual framework for policy and program development for pediatric cochlear implant recipients (i.e., in both disability and health services); and, most importantly, establish a clear pathway for the longitudinal management of the cochlear implant in a child's future. It is anticipated that this model will be applied to other populations receiving cochlear implants through our program.

Parental stress among parents of toddlers with moderate hearing loss

BACKGROUND

The purpose of this study was to examine parental stress in parents of toddlers with moderate hearing loss compared to hearing controls. Furthermore, the associations between parental stress and child- and parent-related factors such as language, social-emotional functioning and social support were examined.

DESIGN

The study sample consisted of 30 toddlers with moderate hearing loss and 30 hearing children (mean age 27.4 months). The two groups were compared using the Nijmegen Parenting Stress Index (NPSI) and parent-reports to rate the amount of social support and the children's social-emotional functioning. Receptive and expressive language tests were administered to the children to examine their language ability.

RESULTS

Parents of toddlers with moderate hearing loss reported comparable levels of parental stress to parents of hearing children. Individual differences in parental stress were related to child- and parent-related factors. Poorer social-emotional functioning and language ability of the child were related to higher stress levels in parents. Parents who experienced less social support reported higher stress levels.

CONCLUSIONS

Parents of toddlers with moderate hearing loss experience no more parental stress than parents of hearing children on average. Given parental stress was found to be related to poorer child functioning, early interventionists should be aware of signs of elevated stress levels in parents.

Level of emotion comprehension in children with mid to long term cochlear implant use: How basic and more complex emotion recognition relates to language and age at implantation

OBJECTIVES

The current study was designed with three main aims: To document the level of emotional comprehension skills, from basic to more complex ones, reached by a wide sample of cochlear implant (CI) deaf children with at least 36 months of device use; To investigate subjective and audiological factors that can affect their emotional development; To identify, if present, a "critical age", in which early intervention might positively affect adequate emotional competence development.

DESIGN

This is an observational cohort study. Children with congenital severe/profound deafness were selected based on: aged by 4-11 years, minimum of 36 months of CI use, Italian as the primary language in the family; normal cognitive level and absence of associated disorders or socio-economic difficulties. Audiological characteristics and language development were assessed throughout standardized tests, to measure speech perception in quiet, lexical comprehension and production. The development of emotions' understanding was assessed using the Test of Emotion Comprehension (TEC) of Pons and Harris, a hierarchical developmental model, where emotion comprehension is organized in 3 Stages (external, mental and reflective). Statistical analysis was accomplished via the Spearman Rank Correlation Coefficient, to study the relationship between the personal and audiological characteristics; a multivariate linear regression analysis was carried out to find which variables were better associated with the standardized TEC values; a chi-squared test with Yate's continuity correction and Mann-Whitney U test were used to account for differences between continuous variables and proportions.

RESULTS

72 children (40 females, 32 males) with a mean age of 8.1 years were included. At TEC score, 57 children showed normal range performances (79.17% of recipients) and 15 fell below average (20.83% of recipients). The 16.63% of older subjects (range of age 8-12 years) didn't master the Stage 3 (reflective), which is normally acquired by 8 years of age and failed 2 or all the 3 items of this component. Subjects implanted within 18 months of age had better emotion comprehension skills. TEC results were also positively correlated with an early diagnosis, a longer implant use, better auditory skills and higher scores on lexical and morphosintactic tests. On the contrary, it was negatively correlated with the presence of siblings and the order of birth. The gender, the side and the severity of deafness, type of implant and strategy were not correlated.

CONCLUSIONS

Early implanted children have more chance to develop adequate emotion comprehension, especially when the complex aspects are included, due to the very strong link between listening and language skills and emotional development. Furthermore, longer CI auditory experience along with early intervention allows an adequate communication development which positively influences the acquisition of such competencies.

Parents' Stress and Coping Related to Children's Use of a Cochlear Implant: A Qualitative Study

The aim was to increase understanding of parents' experiences of having a child with a cochlear implant (CI) and to explore how these related to children's use of CI. Twelve parents of children, full-time users or limited users of CIs, participated in the study. Qualitative content analysis showed that the parents of children who used their CI differed from the parents with limited users in how they handled stressors. Support from health care professionals was seen as insufficient. Parents need to get involved in dynamic processes in which health care resources promote parental coping.

The Impact of Childhood Hearing Loss on the Family: Mothers' and Fathers' Stress and Coping Resources

Parenting children who are deaf or hard of hearing (D/HH) presents unique long-term challenges that can place the parents at a greater risk for elevated levels of parenting stress. Adaptation of families to the various challenges presented by childhood hearing loss is influenced by their personal and social coping resources available for managing these stressors and challenges. The current study examined differences in parenting stress and personal (i.e., acceptance of the child who is D/HH and parents' sense of parenting self-efficacy) and social (i.e., formal and informal social support) coping resources between mothers and fathers of children who are D/HH in the Arab sector in Israel. Further, the study examined the relations between coping resources and parenting stress among these parents. Participants included 30 Israeli Arab mother-father couples (n = 60) having a child who is D/HH aged 3-8 years. Findings revealed no significant differences between mothers and fathers regarding parenting stress, child acceptance, or parental support systems. However, mothers reported significantly higher self-efficacy. In addition, correlation analysis indicated that higher coping resources decreased parenting stress levels. Theoretical and practical implications of parental gender in the context of cultural background are discussed regarding parent intervention programs.

Bilateral versus unilateral cochlear implants in children: a study of spoken language outcomes

Objectives:

Although it has been established that bilateral cochlear implants (CIs) offer additional speech perception and localization benefits to many children with severe to profound hearing loss, whether these improved perceptual abilities facilitate significantly better language development has not yet been clearly established. The aims of this study were to compare language abilities of children having unilateral and bilateral CIs to quantify the rate of any improvement in language attributable to bilateral CIs and to document other predictors of language development in children with CIs.

Design:

The receptive vocabulary and language development of 91 children was assessed when they were aged either 5 or 8 years old by using the Peabody Picture Vocabulary Test (fourth edition), and either the Preschool Language Scales (fourth edition) or the Clinical Evaluation of Language Fundamentals (fourth edition), respectively. Cognitive ability, parent involvement in children’s intervention or education programs, and family reading habits were also evaluated. Language outcomes were examined by using linear regression analyses. The influence of elements of parenting style, child characteristics, and family background as predictors of outcomes were examined.

Results:

Children using bilateral CIs achieved significantly better vocabulary outcomes and significantly higher scores on the Core and Expressive Language subscales of the Clinical Evaluation of Language Fundamentals (fourth edition) than did comparable children with unilateral CIs. Scores on the Preschool Language Scales (fourth edition) did not differ significantly between children with unilateral and bilateral CIs. Bilateral CI use was found to predict significantly faster rates of vocabulary and language development than unilateral CI use; the magnitude of this effect was moderated by child age at activation of the bilateral CI. In terms of parenting style, high levels of parental involvement, low amounts of screen time, and more time spent by adults reading to children facilitated significantly better vocabulary and language outcomes. In terms of child characteristics, higher cognitive ability and female sex were predictive of significantly better language outcomes. When family background factors were examined, having tertiary-educated primary caregivers and a family history of hearing loss were significantly predictive of better outcomes. Birth order was also found to have a significant negative effect on both vocabulary and language outcomes, with each older sibling predicting a 5 to 10% decrease in scores.

Conclusions:

Children with bilateral CIs achieved significantly better vocabulary outcomes, and 8-year-old children with bilateral CIs had significantly better language outcomes than did children with unilateral CIs. These improvements were moderated by children’s ages at both first and second CIs. The outcomes were also significantly predicted by a number of factors related to parenting, child characteristics, and family background. Fifty-one percent of the variance in vocabulary outcomes and between 59 to 69% of the variance in language outcomes was predicted by the regression models.

The study compared language abilities of children with unilateral and bilateral cochlear implants (CIs), quantified the rate of language development attributable to bilateral CIs and documented predictors of language development. Children with bilateral CIs achieved significantly better vocabulary outcomes, and 8-year-old children with bilateral CIs had significantly better language outcomes. Improvements were moderated by children’s ages at both first and second CIs. Outcomes were significantly predicted by a number of factors related to parenting, child characteristics, and family background. Fifty-one percent of the variance in vocabulary outcomes and between 59 to 69% of the variance in language outcomes was predicted by the regression models.

Supplemental Digital Content is available in the text.

What can we expect of normally-developing children implanted at a young age with respect to their auditory, linguistic and cognitive skills?

As a result of neonatal hearing screening and subsequent early cochlear implantation (CI) profoundly deaf children have access to important information to process auditory signals and master spoken language skills at a young age. Nevertheless, auditory, linguistic and cognitive outcome measures still reveal great variability in individual achievements: some children with CI(s) perform within normal limits, while others lag behind. Understanding the causes of this variation would allow clinicians to offer better prognoses to CI candidates and efficient follow-up and rehabilitation. This paper summarizes what we can expect of normally developing children with CI(s) with regard to spoken language, bilateral and binaural auditory perception, speech perception and cognitive skills. Predictive factors of performance and factors influencing variability are presented, as well as some novel data on cognitive functioning and speech perception in quiet and in noise. Subsequently, we discuss technical and non-technical issues which should be considered in the future in order to optimally guide the child with profound hearing difficulties. This article is part of a Special Issue entitled <Lasker Award>.

Executive functioning skills in preschool-age children with cochlear implants

PURPOSE

The purpose of this study was to determine whether deficits in executive functioning (EF) in children with cochlear implants (CIs) emerge as early as the preschool years.

METHOD

Two groups of children ages 3 to 6 years participated in this cross-sectional study: 24 preschoolers who had CIs prior to 36 months of age and 21 preschoolers with normal hearing (NH). All were tested on normed measures of working memory, inhibition-concentration, and organization-integration. Parents completed a normed rating scale of problem behaviors related to EF. Comparisons of EF skills of children with CIs were made to peers with NH and to published nationally representative norms.

RESULTS

Preschoolers with CIs showed significantly poorer performance on inhibition-concentration and working memory compared with peers with NH and with national norms. No group differences were found in visual memory or organization-integration. When data were controlled for language, differences in performance measures of EF remained, whereas differences in parent-reported problems with EF were no longer significant. Hearing history was generally unrelated to EF.

CONCLUSIONS

This is the first study to demonstrate that EF deficits found in older children with CIs begin to emerge as early as preschool years. The ability to detect these deficits early has important implications for early intervention and habilitation after cochlear implantation.

Psychological well-being of parents and family caregivers of children with hearing impairment in south India: influence of behavioural problems in children and social support

Parents of children with hearing impairment are at increased risk of mental health morbidities. We examined the predictive factors associated with caregiver's strain and psychological morbidities in parents and family caregivers of children with hearing impairment. In total, n = 201 parents and family caregivers of children with and without hearing impairment aged 3 to 16 years were recruited. Caregiver's strain and psychological morbidities were measured using the Zarit Burden scale and the World Health Organization's Self-Reporting Questionnaire (SRQ-20). Presence of behavioural problems in children was measured using the Strengths and Difficulties Questionnaire. After adjustment, low educational attainment and domestic violence were found to be associated with caregiving strain, whereas dissatisfaction with social support from family, behavioural problems in children, and domestic violence strongly predicted psychological morbidities. Addressing the mental healthcare needs of parents may help in downsizing the impact of psychological morbidities on the well-being of children with hearing impairment.