- Email: [email protected]
Pediatric cochlear implantation: Role of language, income, and ethnicity
International Journal of Pediatric Otorhinolaryngology 79 (2015) 721–724
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Pediatric cochlear implantation: Role of language, income, and ethnicity Derek Wu a,*, Elena Willis Woodson b,1, Jonathan Masur c, John Bent d,2 a
Albert Einstein College of Medicine Department of Otorhinolaryngology – Head and Neck Surgery, Texas Children’s Hospital/Baylor College of Medicine, 5253 Fannin Street Apt 2202, Houston, TX 77004, USA c Department of Radiology, Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19106, USA d Department of Otorhinolaryngology – Head and Neck Surgery, Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine, 3400 Bainbridge Avenue, Greenberg Medical Arts Pavilion, 3rd Floor, Bronx, NY 10467, USA b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 December 2014 Received in revised form 9 February 2015 Accepted 25 February 2015 Available online 6 March 2015
Objective: To compare post-cochlear implantation (CI) early speech perception (ESP) outcomes between a non-English speaking, ethnic minority study group and an English speaking, ethnic majority control group. Study design/methods: We performed a retrospective case-control study at an academic tertiary care children’s hospital. Records were reviewed of 49 children who underwent CI from February 2005 to September 2011. Children with abnormal cognitive function (n = 12), post-surgical complications (n = 1), or incomplete SP testing (n = 24) were excluded. The remaining 12 cases (mean implant age 4.3y) were reviewed for language, income, ethnicity, and ESP scores. Their scores were compared to a subset of patients (n = 18; mean implant age 2.2y) serving as control from the Childhood Development after Cochlear Implantation (CDaCI) study at 1 year follow up where standard ESP testing was performed. Briefly, CDaCI includes a demographically balanced and multicenter-based pediatric cohort from which publications are beginning to define normative post-CI SP outcomes. Results: Of our 12 children, 7 were Hispanic, 2 Caucasian, 2 multi-ethnicity and 1 Russian. 4 were nonEnglish speaking, 5 spoke English as a second language, and 7 were bilingual. Three received bilateral CI. Mean early speech perception (ESP) scores (reported on a scale of 1–4) collected at 6 and 12 months in the study group were 1.71 and 1.75, respectively; in the control group, 3.83 and 3.92. At both follow up intervals the study group performed significantly worse than the control group (6mo P = 0.048, 12mo P = 0.01). Conclusions: This study suggests that among pediatric CI recipients, those from predominantly nonEnglish speaking, socioeconomically disadvantaged backgrounds develop SP at slower than normal rates. Future interventions should be directed at overcoming these obstacles. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Speech perception Pediatrics Cochlear implant Socioeconomic
1. Introduction Acquisition of spoken language relies on the ability to perceive and process external auditory signals. For children with severe hearing impairment who are unable to benefit from traditional
* Corresponding author. Tel.: +1 949 609 9305. E-mail addresses: [email protected] (D. Wu), [email protected] (E.W. Woodson), [email protected] (J. Masur), jbent@montefiore.org (J. Bent). 1 Tel.: +1 4054205134. 2 Tel.: +1 718 920 7042; fax: +1 718 405 9014. http://dx.doi.org/10.1016/j.ijporl.2015.02.030 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
acoustic hearing aids, cochlear implants (CI) have been shown to improve speech and language outcomes [1]. However, there is wide variation in post-implant speech perception (SP) among pediatric patients. Some contributing factors include age at implantation, preoperative language ability, length of implant use, and mode of communication in rehabilitation [2–5]. Limited data exists, however, on the role of cultural background, socioeconomic status (SES), language, and family income in post-implant SP outcomes. These variables likely have a profound impact on postoperative rehabilitation, implant programming, and overall CI success. In order to optimize CI performance in children, the relationship of these variables to postoperative CI speech perception outcomes should be investigated. In this study, we
D. Wu et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 721–724
722
Table 1 Characteristics of CI patients in the Bronx cohort. Patient
Age at CI
Ethnicity
Bilingual
Primary language
Secondary language
ESP (6mo)
ESP (12mo)
1 2 3 4 5 6 7 8 9 10 11 12
7 6 1, 2 10 2 3 3 3 2 5 5 5, 6
Other Hispanic Other Hispanic Hispanic White Hispanic White Russian Hispanic Other Hispanic
Yes Yes No No no Yes No Yes Yes No No Yes
English Spanish Arabic Spanish English Romanian Spanish Albanian English Spanish Bengali Spanish
Arabic English NA NA NA English NA English Russian NA NA English
NA 1 NA 1 NA NA 1 NA 3 3 1 2
2 1 2 2 1 4 1 1 NA NA NA NA
compare post-CI ESP results of patients from a tertiary children’s hospital in the Bronx, NY, a culturally and linguistically diverse group with below average household incomes, to a standardized national cohort.
2. Methods We performed an institutional review board (IRB) approved, retrospective study at an academic tertiary care children’s hospital. Records were reviewed of 49 children who underwent CI from February 2005 to September 2011. Children with abnormal cognitive function (n = 12), post-surgical complications (n = 1), or incomplete SP testing (n = 24) were excluded. The remaining 12 cases (implantation age 1–10y, mean 4.3y) were reviewed for language, income, ethnicity, and early speech perception (ESP) scores. Their scores were compared to a subset of patients (n = 18) from the Childhood Development after Cochlear Implantation (CDaCI) study using a two sample t test. 2.1. Early Speech Perception Testing (ESP) Early speech perception is a test commonly used by audiologists to objectively measure the outcome and effectiveness of postCI rehabilitation in children who were profoundly deaf. It is generally administered to children over the age of two who are able to choose between two presenting alternatives. Briefly, ESP employs a closed set, usually consisting of a picture plate of twelve items, to assess children’s pattern perception, spondaic word identification, and monosyllabic word identification [6]. Scores are reported on a linear scale of increasing auditory skills from 1 to 4: detection (category 1), pattern perception (category 2), some word identification (category 3), and consistent word identification (category 4).
2.2. Childhood Development after Cochlear Implantation Study (CDaCI) CDaCI is a demographically balanced and multicenter-based pediatric cohort study that forms the basis for systematic evaluation of early CI outcomes in children. Specifically, it compares children with CI with an age-matched, normal hearing cohort across several domains including oral language development, auditory performance, psychosocial and behavioral functioning, and quality of life. It is a standardized, national cohort study from which publications are beginning to define normative post-CI SP outcomes [7]. The control group from the present study is derived from a small subset of the CDaCI patients consisting of eighteen children with comprehensive standard ESP assessment at 1 year follow-up [6].
3. Results In our cohort of twelve children, seven were Hispanic (58%), two Caucasian (17%), two multi-ethnicity (17%) and one Russian (8%). Four were non-English speaking, five spoke English as a second language, and seven were bilingual. Mean age at implantation was 4.3 years. Mean household income was $22, 500 (Tables 1 and 2). Three received bilateral CI. Mean early speech perception (ESP) scores collected at 6 and 12 months are 1.71 and 1.75, respectively (Fig. 1). The characteristics of the 188 children with sensorineural hearing loss who received CI in the CDaCI study have been extensively described by Fink et al. [7] in the original paper on CDaCI study design. Briefly, 71% are White, 9% African American, 5% Asian, 11% Other, and 4% declined to answer. The primary language spoken is English. The mean age at implantation was 2.2 years. 22%
Table 2 Comparison of the average household income, ethnicity and language distribution in the Bronx and the CDaCI cohorts. Mean age at implantation (y)
Average househould income (CDaCI reported as number and % of patients in each stratified bracket)
Ethnicity by % of population
Primary spoken language
Bronx CI population
4.3
$22,500
Hispanic: 50% Black: 25% Other: 10% White: 9% Unknown: 6%
CDaCI population
2.2
$100,000+: 31 (16%) $75–100,000: 26 (14%) $50–74,999: 31 (16%) $30–49,999: 42 (22%) $15–29,999: 22 (12%) <$15,000: 15 (8%)
Hispanic: 20% Non-Hispanic or White: 71% Asian: 9%
Spanish: 41% English: 25% Arabic: 0.8% Romanian: 0.8% Albanian: 0.8% Bengali: 0.8% English
D. Wu et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 721–724
Fig. 1. Comparison of ESP scores in children from Bronx cohort and the CDaCI cohort at 6 and 12 months.
of all reported household income fell between $30,000–49,999 (Table 2). Out of the 42 patients from the CDaCI cohort with comprehensive follow-up at 1 year, standard ESP scores were available from six children at 6 months (mean category score 3.83) and twelve children at 1 year (mean category score 3.92) [6]. At both follow-up intervals, the study group performed significantly worse than the control group with respect to ESP outcomes. (6mo P = 0.048, 12mo P = 0.01) 4. Discussion The wide variability in observed SP performance following CI in pediatric patients can be attributed to the inherent heterogeneous nature of the study population. Patients being evaluated for CI often present at different ages with a broad range of auditory, linguistic, and cognitive abilities. Additionally, these differences at baseline are compounded by a host of internal (within family) and external (within community) influences [8]. Ultimately, the interconnectedness of many of these variables challenges our ability to precisely define, isolate, and evaluate how potential determinants of SP contribute to outcomes in children after CI. That said, however, the pediatric CI patients served in the Bronx, NY represent a unique subset of the country’s population with respect to their overall SES, household income, language use, and ethnic diversity, affording us the opportunity to study the implication of these accentuated differences. Based on the SP results obtained at the 6 and 12 month intervals, children from our predominantly non-English speaking, socioeconomically disadvantaged backgrounds develop SP at a significantly slower rate when compared to a normalized national cohort. This is not surprising as SES is inextricably linked to other causative factors such as parental education and support, use compliance, mode of communication, and type of school and rehabilitation program attended, all of which have significant impact on the overall outcomes of CI [2,3,8–10]. We acknowledge two shortcomings in our study. First, the size of our Bronx cohort with complete ESP data is relatively small (n = 12), which can attenuate the study power. However, it is worthy to note that initially 24 children from the Bronx cohort were excluded due to incomplete ESP data. We hypothesize a causal link between the low rate of follow-up in the Bronx cohort to their overall lower SES where parents experience difficulty keeping appointments due to stress, time, or transportation constraints or understanding the importance of continued rehabilitation. Secondly, English ESP testing was uniformly administered regardless of the children’s primary spoken language. This lack of language-appropriate testing could potentially lead to a more dramatic performance difference when comparing our patients with children in the national cohort who are tested against their
723
primary language, English. That said, however, the fact that there is not the tools, appropriately trained audiologists or sufficient therapy time to provide standardized speech perception testing in the wide range of languages needed in our Bronx population may also play a large part in the observation that our Bronx children do worse than control group. While the difference in age of implantation between our sample and the national cohort (4.3y vs 2.2y) may have confounded our results, we do not believe this factor alone explains the drastic difference in SP scores observed. Ideally, the two groups would be well-matched in regards to age of implantation; however, we hypothesize that the reason of this age discrepancy is again likely due to the overall lower SES in the Bronx cohort, which complicates their early access to care from lack of parental awareness, resources, and ability or time to seek medical care for their children, further highlighting the inextricable link between these outcome determinants. Therefore, it is important to recognize these potential social and cultural barriers in CI outcomes. The development of individualized CI therapy for this ethnic minority population may improve speech perception and overall CI success. Given the observable health disparity in the pediatric CI population in the Bronx, NY, efforts should be directed at increasing parental involvement and expanding CI-related services, two areas that have been shown to affect CI outcomes [8]. From our experience, most parents do want to help their children do better, but they simply lack the time, resources, and the knowledge to do so. Efforts should be directed toward initiating more parent-inclusive rehabilitation programs where parents learn to become efficacious language models for their children at home. Not only would patient–child interaction strengthen, but parents would also gain deeper insights and self educate, thus promoting treatment adherence. On the other hand, steps to improve quality and promote access to CI-related services can begin in areas that make up a child’s daily routine, such as in the public school system and in early intervention (EI) programs. Policies should also be in place to attract more certified professionals in underserved areas such as the Bronx to bolster provider to patient ratio. This can increase availability of appointments and reduce wait times for parents with traditionally rigid employment schedules who work multiple jobs with limited transportation access. Government subsidized reimbursements and loan forgiveness programs are some possible incentives to increase provider number. Most importantly, however, awareness must be heightened regarding the impact of SES on SP outcomes of CI children, both at the patient and the provider level. By exploring non-physiologic causes of differential SP outcomes, our findings encourage future research and community efforts in bridging the gap of post-CI outcomes in children across the SES spectrum. Disclosure The authors of this study have no conflict of interests to report. The study received no grants or external funding. References [1] N.R. Peterson, D.B. Pisoni, R.T. Miyamoto, Cochlear implants and spoken language processing abilities: review and assessment of the literature, Restor. Neurol. Neurosci. 28 (2) (2010) 237–250. [2] A.V. Hodges, M. Dolan Ash, T.J. Balkany, J.J. Schloffman, S.L. Butts, Speech perception results in children with cochlear implants: contributing factors, Otolaryngol. Head Neck Surg. 121 (1) (1999) 31–34. [3] G.M. O’Donoghue, T.P. Nikolopoulos, S.M. Archbold, Determinants of speech perception in children after cochlear implantation, Lancet 356 (9228) (2000) 466–468. [4] M. Teschendorf, S. Janeschik, H. Bagus, S. Lang, D. Arweiler-Harbeck, Speech development after cochlear implantation in children from bilingual homes, Otol. Neurotol. 32 (2) (2011) 229–235.
724
D. Wu et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 721–724
[5] E. Thomas, H. El-Kashlan, T.A. Zwolan, Children with cochlear implants who live in monolingual and bilingual homes, Otol. Neurotol. 29 (2) (2008) 230–234. [6] L.S. Eisenberg, K.C. Johnson, A.S. Martinez, C.G. Cokely, E.A. Tobey, A.L. Quittner, et al., Speech recognition at 1-year follow-up in the childhood development after cochlear implantation study: methods and preliminary findings, Audiol. Neurootol. 11 (4) (2006) 259–268. [7] N.E. Fink, N.Y. Wang, J. Visaya, J.K. Niparko, A. Quittner, L.S. Eisenberg, et al., Childhood Development after Cochlear Implantation (CDaCI) study: design and baseline characteristics, Cochlear Implants Int. 8 (2) (2007) 92–116.
[8] E. Kirkham, C. Sacks, F. Baroody, J. Siddique, M.E. Nevins, A. Woolley, et al., Health disparities in pediatric cochlear implantation: an audiologic perspective, Ear Hear. 30 (5) (2009) 515–525. [9] F. Brkic, L. Piric, N. Salihovic, J. Kabil, Cochlear implantation in children: socioeconomic family characteristics, Med. Arh. 64 (1) (2010) 25–27. [10] B. Polat, B. Bas¸aran, H.C. Kara, A. Atas¸, Y. Su¨og˘lu, The impact of social and demographic features on comprehensive receptive and expressive performance in cochlear implant patients, Kulak Burun Bogaz Ihtis. Derg. 23 (2) (2013) 90–95.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Pediatric cochlear implantation: Role of language, income, and ethnicity Derek Wu a,*, Elena Willis Woodson b,1, Jonathan Masur c, John Bent d,2 a
Albert Einstein College of Medicine Department of Otorhinolaryngology – Head and Neck Surgery, Texas Children’s Hospital/Baylor College of Medicine, 5253 Fannin Street Apt 2202, Houston, TX 77004, USA c Department of Radiology, Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19106, USA d Department of Otorhinolaryngology – Head and Neck Surgery, Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine, 3400 Bainbridge Avenue, Greenberg Medical Arts Pavilion, 3rd Floor, Bronx, NY 10467, USA b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 December 2014 Received in revised form 9 February 2015 Accepted 25 February 2015 Available online 6 March 2015
Objective: To compare post-cochlear implantation (CI) early speech perception (ESP) outcomes between a non-English speaking, ethnic minority study group and an English speaking, ethnic majority control group. Study design/methods: We performed a retrospective case-control study at an academic tertiary care children’s hospital. Records were reviewed of 49 children who underwent CI from February 2005 to September 2011. Children with abnormal cognitive function (n = 12), post-surgical complications (n = 1), or incomplete SP testing (n = 24) were excluded. The remaining 12 cases (mean implant age 4.3y) were reviewed for language, income, ethnicity, and ESP scores. Their scores were compared to a subset of patients (n = 18; mean implant age 2.2y) serving as control from the Childhood Development after Cochlear Implantation (CDaCI) study at 1 year follow up where standard ESP testing was performed. Briefly, CDaCI includes a demographically balanced and multicenter-based pediatric cohort from which publications are beginning to define normative post-CI SP outcomes. Results: Of our 12 children, 7 were Hispanic, 2 Caucasian, 2 multi-ethnicity and 1 Russian. 4 were nonEnglish speaking, 5 spoke English as a second language, and 7 were bilingual. Three received bilateral CI. Mean early speech perception (ESP) scores (reported on a scale of 1–4) collected at 6 and 12 months in the study group were 1.71 and 1.75, respectively; in the control group, 3.83 and 3.92. At both follow up intervals the study group performed significantly worse than the control group (6mo P = 0.048, 12mo P = 0.01). Conclusions: This study suggests that among pediatric CI recipients, those from predominantly nonEnglish speaking, socioeconomically disadvantaged backgrounds develop SP at slower than normal rates. Future interventions should be directed at overcoming these obstacles. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Speech perception Pediatrics Cochlear implant Socioeconomic
1. Introduction Acquisition of spoken language relies on the ability to perceive and process external auditory signals. For children with severe hearing impairment who are unable to benefit from traditional
* Corresponding author. Tel.: +1 949 609 9305. E-mail addresses: [email protected] (D. Wu), [email protected] (E.W. Woodson), [email protected] (J. Masur), jbent@montefiore.org (J. Bent). 1 Tel.: +1 4054205134. 2 Tel.: +1 718 920 7042; fax: +1 718 405 9014. http://dx.doi.org/10.1016/j.ijporl.2015.02.030 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
acoustic hearing aids, cochlear implants (CI) have been shown to improve speech and language outcomes [1]. However, there is wide variation in post-implant speech perception (SP) among pediatric patients. Some contributing factors include age at implantation, preoperative language ability, length of implant use, and mode of communication in rehabilitation [2–5]. Limited data exists, however, on the role of cultural background, socioeconomic status (SES), language, and family income in post-implant SP outcomes. These variables likely have a profound impact on postoperative rehabilitation, implant programming, and overall CI success. In order to optimize CI performance in children, the relationship of these variables to postoperative CI speech perception outcomes should be investigated. In this study, we
D. Wu et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 721–724
722
Table 1 Characteristics of CI patients in the Bronx cohort. Patient
Age at CI
Ethnicity
Bilingual
Primary language
Secondary language
ESP (6mo)
ESP (12mo)
1 2 3 4 5 6 7 8 9 10 11 12
7 6 1, 2 10 2 3 3 3 2 5 5 5, 6
Other Hispanic Other Hispanic Hispanic White Hispanic White Russian Hispanic Other Hispanic
Yes Yes No No no Yes No Yes Yes No No Yes
English Spanish Arabic Spanish English Romanian Spanish Albanian English Spanish Bengali Spanish
Arabic English NA NA NA English NA English Russian NA NA English
NA 1 NA 1 NA NA 1 NA 3 3 1 2
2 1 2 2 1 4 1 1 NA NA NA NA
compare post-CI ESP results of patients from a tertiary children’s hospital in the Bronx, NY, a culturally and linguistically diverse group with below average household incomes, to a standardized national cohort.
2. Methods We performed an institutional review board (IRB) approved, retrospective study at an academic tertiary care children’s hospital. Records were reviewed of 49 children who underwent CI from February 2005 to September 2011. Children with abnormal cognitive function (n = 12), post-surgical complications (n = 1), or incomplete SP testing (n = 24) were excluded. The remaining 12 cases (implantation age 1–10y, mean 4.3y) were reviewed for language, income, ethnicity, and early speech perception (ESP) scores. Their scores were compared to a subset of patients (n = 18) from the Childhood Development after Cochlear Implantation (CDaCI) study using a two sample t test. 2.1. Early Speech Perception Testing (ESP) Early speech perception is a test commonly used by audiologists to objectively measure the outcome and effectiveness of postCI rehabilitation in children who were profoundly deaf. It is generally administered to children over the age of two who are able to choose between two presenting alternatives. Briefly, ESP employs a closed set, usually consisting of a picture plate of twelve items, to assess children’s pattern perception, spondaic word identification, and monosyllabic word identification [6]. Scores are reported on a linear scale of increasing auditory skills from 1 to 4: detection (category 1), pattern perception (category 2), some word identification (category 3), and consistent word identification (category 4).
2.2. Childhood Development after Cochlear Implantation Study (CDaCI) CDaCI is a demographically balanced and multicenter-based pediatric cohort study that forms the basis for systematic evaluation of early CI outcomes in children. Specifically, it compares children with CI with an age-matched, normal hearing cohort across several domains including oral language development, auditory performance, psychosocial and behavioral functioning, and quality of life. It is a standardized, national cohort study from which publications are beginning to define normative post-CI SP outcomes [7]. The control group from the present study is derived from a small subset of the CDaCI patients consisting of eighteen children with comprehensive standard ESP assessment at 1 year follow-up [6].
3. Results In our cohort of twelve children, seven were Hispanic (58%), two Caucasian (17%), two multi-ethnicity (17%) and one Russian (8%). Four were non-English speaking, five spoke English as a second language, and seven were bilingual. Mean age at implantation was 4.3 years. Mean household income was $22, 500 (Tables 1 and 2). Three received bilateral CI. Mean early speech perception (ESP) scores collected at 6 and 12 months are 1.71 and 1.75, respectively (Fig. 1). The characteristics of the 188 children with sensorineural hearing loss who received CI in the CDaCI study have been extensively described by Fink et al. [7] in the original paper on CDaCI study design. Briefly, 71% are White, 9% African American, 5% Asian, 11% Other, and 4% declined to answer. The primary language spoken is English. The mean age at implantation was 2.2 years. 22%
Table 2 Comparison of the average household income, ethnicity and language distribution in the Bronx and the CDaCI cohorts. Mean age at implantation (y)
Average househould income (CDaCI reported as number and % of patients in each stratified bracket)
Ethnicity by % of population
Primary spoken language
Bronx CI population
4.3
$22,500
Hispanic: 50% Black: 25% Other: 10% White: 9% Unknown: 6%
CDaCI population
2.2
$100,000+: 31 (16%) $75–100,000: 26 (14%) $50–74,999: 31 (16%) $30–49,999: 42 (22%) $15–29,999: 22 (12%) <$15,000: 15 (8%)
Hispanic: 20% Non-Hispanic or White: 71% Asian: 9%
Spanish: 41% English: 25% Arabic: 0.8% Romanian: 0.8% Albanian: 0.8% Bengali: 0.8% English
D. Wu et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 721–724
Fig. 1. Comparison of ESP scores in children from Bronx cohort and the CDaCI cohort at 6 and 12 months.
of all reported household income fell between $30,000–49,999 (Table 2). Out of the 42 patients from the CDaCI cohort with comprehensive follow-up at 1 year, standard ESP scores were available from six children at 6 months (mean category score 3.83) and twelve children at 1 year (mean category score 3.92) [6]. At both follow-up intervals, the study group performed significantly worse than the control group with respect to ESP outcomes. (6mo P = 0.048, 12mo P = 0.01) 4. Discussion The wide variability in observed SP performance following CI in pediatric patients can be attributed to the inherent heterogeneous nature of the study population. Patients being evaluated for CI often present at different ages with a broad range of auditory, linguistic, and cognitive abilities. Additionally, these differences at baseline are compounded by a host of internal (within family) and external (within community) influences [8]. Ultimately, the interconnectedness of many of these variables challenges our ability to precisely define, isolate, and evaluate how potential determinants of SP contribute to outcomes in children after CI. That said, however, the pediatric CI patients served in the Bronx, NY represent a unique subset of the country’s population with respect to their overall SES, household income, language use, and ethnic diversity, affording us the opportunity to study the implication of these accentuated differences. Based on the SP results obtained at the 6 and 12 month intervals, children from our predominantly non-English speaking, socioeconomically disadvantaged backgrounds develop SP at a significantly slower rate when compared to a normalized national cohort. This is not surprising as SES is inextricably linked to other causative factors such as parental education and support, use compliance, mode of communication, and type of school and rehabilitation program attended, all of which have significant impact on the overall outcomes of CI [2,3,8–10]. We acknowledge two shortcomings in our study. First, the size of our Bronx cohort with complete ESP data is relatively small (n = 12), which can attenuate the study power. However, it is worthy to note that initially 24 children from the Bronx cohort were excluded due to incomplete ESP data. We hypothesize a causal link between the low rate of follow-up in the Bronx cohort to their overall lower SES where parents experience difficulty keeping appointments due to stress, time, or transportation constraints or understanding the importance of continued rehabilitation. Secondly, English ESP testing was uniformly administered regardless of the children’s primary spoken language. This lack of language-appropriate testing could potentially lead to a more dramatic performance difference when comparing our patients with children in the national cohort who are tested against their
723
primary language, English. That said, however, the fact that there is not the tools, appropriately trained audiologists or sufficient therapy time to provide standardized speech perception testing in the wide range of languages needed in our Bronx population may also play a large part in the observation that our Bronx children do worse than control group. While the difference in age of implantation between our sample and the national cohort (4.3y vs 2.2y) may have confounded our results, we do not believe this factor alone explains the drastic difference in SP scores observed. Ideally, the two groups would be well-matched in regards to age of implantation; however, we hypothesize that the reason of this age discrepancy is again likely due to the overall lower SES in the Bronx cohort, which complicates their early access to care from lack of parental awareness, resources, and ability or time to seek medical care for their children, further highlighting the inextricable link between these outcome determinants. Therefore, it is important to recognize these potential social and cultural barriers in CI outcomes. The development of individualized CI therapy for this ethnic minority population may improve speech perception and overall CI success. Given the observable health disparity in the pediatric CI population in the Bronx, NY, efforts should be directed at increasing parental involvement and expanding CI-related services, two areas that have been shown to affect CI outcomes [8]. From our experience, most parents do want to help their children do better, but they simply lack the time, resources, and the knowledge to do so. Efforts should be directed toward initiating more parent-inclusive rehabilitation programs where parents learn to become efficacious language models for their children at home. Not only would patient–child interaction strengthen, but parents would also gain deeper insights and self educate, thus promoting treatment adherence. On the other hand, steps to improve quality and promote access to CI-related services can begin in areas that make up a child’s daily routine, such as in the public school system and in early intervention (EI) programs. Policies should also be in place to attract more certified professionals in underserved areas such as the Bronx to bolster provider to patient ratio. This can increase availability of appointments and reduce wait times for parents with traditionally rigid employment schedules who work multiple jobs with limited transportation access. Government subsidized reimbursements and loan forgiveness programs are some possible incentives to increase provider number. Most importantly, however, awareness must be heightened regarding the impact of SES on SP outcomes of CI children, both at the patient and the provider level. By exploring non-physiologic causes of differential SP outcomes, our findings encourage future research and community efforts in bridging the gap of post-CI outcomes in children across the SES spectrum. Disclosure The authors of this study have no conflict of interests to report. The study received no grants or external funding. References [1] N.R. Peterson, D.B. Pisoni, R.T. Miyamoto, Cochlear implants and spoken language processing abilities: review and assessment of the literature, Restor. Neurol. Neurosci. 28 (2) (2010) 237–250. [2] A.V. Hodges, M. Dolan Ash, T.J. Balkany, J.J. Schloffman, S.L. Butts, Speech perception results in children with cochlear implants: contributing factors, Otolaryngol. Head Neck Surg. 121 (1) (1999) 31–34. [3] G.M. O’Donoghue, T.P. Nikolopoulos, S.M. Archbold, Determinants of speech perception in children after cochlear implantation, Lancet 356 (9228) (2000) 466–468. [4] M. Teschendorf, S. Janeschik, H. Bagus, S. Lang, D. Arweiler-Harbeck, Speech development after cochlear implantation in children from bilingual homes, Otol. Neurotol. 32 (2) (2011) 229–235.
724
D. Wu et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 721–724
[5] E. Thomas, H. El-Kashlan, T.A. Zwolan, Children with cochlear implants who live in monolingual and bilingual homes, Otol. Neurotol. 29 (2) (2008) 230–234. [6] L.S. Eisenberg, K.C. Johnson, A.S. Martinez, C.G. Cokely, E.A. Tobey, A.L. Quittner, et al., Speech recognition at 1-year follow-up in the childhood development after cochlear implantation study: methods and preliminary findings, Audiol. Neurootol. 11 (4) (2006) 259–268. [7] N.E. Fink, N.Y. Wang, J. Visaya, J.K. Niparko, A. Quittner, L.S. Eisenberg, et al., Childhood Development after Cochlear Implantation (CDaCI) study: design and baseline characteristics, Cochlear Implants Int. 8 (2) (2007) 92–116.
[8] E. Kirkham, C. Sacks, F. Baroody, J. Siddique, M.E. Nevins, A. Woolley, et al., Health disparities in pediatric cochlear implantation: an audiologic perspective, Ear Hear. 30 (5) (2009) 515–525. [9] F. Brkic, L. Piric, N. Salihovic, J. Kabil, Cochlear implantation in children: socioeconomic family characteristics, Med. Arh. 64 (1) (2010) 25–27. [10] B. Polat, B. Bas¸aran, H.C. Kara, A. Atas¸, Y. Su¨og˘lu, The impact of social and demographic features on comprehensive receptive and expressive performance in cochlear implant patients, Kulak Burun Bogaz Ihtis. Derg. 23 (2) (2013) 90–95.