Social Determinants of Health and Language and Academic Outcomes in Pediatric Cochlear Implantation: A Systematic Review and Meta-Analysis

Lauren Mueller; Dean Adkins; Allison Kao; Marie-Ange Munyemana; Dorina Kallogjeri; Judith E Lieu

doi:10.1001/jamaoto.2024.3564

. 2024 Nov 14;151(1):29–38. doi: 10.1001/jamaoto.2024.3564

Social Determinants of Health and Language and Academic Outcomes in Pediatric Cochlear Implantation

A Systematic Review and Meta-Analysis

Lauren Mueller ^1,², Dean Adkins ¹, Allison Kao ³, Marie-Ange Munyemana ¹, Dorina Kallogjeri ^1,⁴, Judith E Lieu ^1,^✉

¹Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, School of Medicine, St Louis, Missouri

²School of Medicine, Tulane University, New Orleans, Louisiana

³Medical Scientist Training Program, Washington University in St Louis, School of Medicine, St Louis, Missouri

⁴Statistics Editor, JAMA Otolaryngology–Head & Neck Surgery

Accepted for Publication: August 23, 2024.

Published Online: November 14, 2024. doi:10.1001/jamaoto.2024.3564

^✉

Corresponding Author: Judith E. Lieu, MD, MSPH, Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, 660 S. Euclid Ave., Mailstop MSC #8115-029-08, St Louis, Missouri 63110.

Author Contributions: Dr Mueller had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Mueller, Munyemana, Lieu.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Mueller, Lieu.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Mueller, Kallogjeri.

Administrative, technical, or material support: Adkins, Lieu.

Supervision: Lieu.

Conflict of Interest Disclosures: Dr Adkins reported grants from Washington University School of Medicine and research support from the National Institute on Deafness and Other Communication Disorders (NIDCD) within the National Institutes of Health (NIH) during the conduct of the study. Dr Kallogjeri reported personal fees from JAMA Otolaryngology–Head & Neck Surgery outside the submitted work. No other disclosures were reported.

Funding/Support: The research reported in this publication was supported by the National Institute of Deafness and Other Communication Disorders (NIDCD) within the National Institutes of Health (NIH) through the Development of Clinician/Researchers in Academic ENT training grant, award numbers R25DC020706.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr Kallogjeri is Statistics Editor of JAMA Otolaryngology–Head & Neck Surgery but was not involved in any of the decisions regarding review of the manuscript or its acceptance. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Data Sharing Statement: See Supplement 2.

^✉

Corresponding author.

PMCID: PMC11565371 PMID: 39541141

Key Points

Question

How are social determinants of health associated with language development and academic achievement in recipients of pediatric cochlear implants?

Findings

In this systematic review and meta-analysis of 5714 children with cochlear implants, parental involvement, education level, and low socioeconomic status were moderately to strongly associated with language outcomes. To provide quantitative anchoring, age of cochlear implant was weakly to moderately associated with language outcomes.

Meaning

The study results suggest that social determinants of health are associated with childhood language development and academic achievement, and in addition to efforts to expedite cochlear implant placement in eligible children, optimal outcomes may be achieved with interventions centered on the child’s home, primary medical care, and school environment.

Abstract

Importance

Cochlear implants can restore sound and enable speech and language development for children with severe to profound sensorineural hearing loss. Long-term outcomes of pediatric cochlear implant recipients are variable. Although the association between social determinants of health (SDH) and pediatric cochlear implant outcomes has been explored, the strength of this association has not been quantitatively synthesized in the literature.

Objective

To determine the association of SDH with language and academic outcomes in pediatric cochlear implant recipients.

Data Sources

In August 2023, the following databases were searched: Embase.com, Ovid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, Cumulated Index to Nursing and Allied Health Literature Plus, APA PsycINFO, and ClinicalTrials.gov. Following duplicate exclusion of 8687 results, 5326 records were finalized.

Study Selection

Abstract screening, full-text review, and risk of bias assessment was performed by 1 to 2 reviewers. Articles were included if an effect size for an SDH variable that was associated with measures of language, communication, reading, academics, and quality of life was reported.

Main Outcomes and Measures

A random-effects meta-analysis was performed, with standardized regression coefficients measuring the relative direction and magnitude of a variable association with the outcome of interest.

Results

Of 5326 articles, 40 articles that included a total of 3809 children were included in the systematic review; 20 articles that included a total of 1905 children were included in the meta-analysis. Parental involvement, education level, and low socioeconomic status were moderately to strongly associated with language outcomes (β = 0.30; 95% CI, 0.13-0.48; β = 0.45; 95% CI, 0.29-0.62; β = −0.47; 95% CI, −0.83 to −0.10, respectively). Known determinants of language outcomes, such as the age of cochlear implantation and duration of cochlear implant use, demonstrated moderate to no associations with language outcomes (β = −0.30; 95% CI, −0.43 to −0.17; β = 0.19; 95% CI, −0.26 to 0.63, respectively).

Conclusions and Relevance

The results of this systematic review and meta-analysis suggest that SDH are associated with childhood language development and academic achievement. In addition to efforts to expedite cochlear implant placement in eligible children, optimal outcomes may be achieved with interventions centered on the child’s home, primary medical care, and school environment.

This systematic review and meta-analysis examines the association of social determinants of health with language and academic outcomes in pediatric cochlear implant recipients.

Introduction

Severe to profound hearing loss affects 1 in 2000 births.¹ For children with a diagnosis of severe to profound sensorineural hearing loss (HL), cochlear implants are used to restore sound, with the rate of cochlear implant increasing from 7648 to 9344 per 100 000 person-years from 2015 to 2019.² Cochlear implantation at an early age has been associated with language and academic outcomes comparable with children with healthy hearing.^3,4,5

Long-term outcomes vary within groups of pediatric cochlear implant recipients; differences in receptive language abilities in children with HL varies most on entrance to elementary school.⁶ Access to cochlear implants may be associated with insurance coverage or a financial ability to afford health care.⁷ Geographic location may be associated with cochlear implant use when a patient lives a considerable distance from an otolaryngologist, audiologist, and speech therapist, which limits access to cochlear implant activation, mechanical repairs, and auditory therapy.⁸ Variations in pediatric cochlear implant outcomes may stem from household and environmental factors, also known as social determinants of health (SDH).

As defined by the US Centers for Disease Control and Prevention, SDH are the conditions in which people are born, grow, work, live, and age that shape the conditions of daily life, such as race and ethnicity, insurance status, socioeconomic status (SES), and education level.⁹ The interest of the World Health Organization in understanding the associations of SDH with health outcomes has increased the reporting of SDH in the literature.⁹ A previous systematic review qualitatively summarized the sociodemographic disparities in pediatric cochlear implant language outcomes, demonstrating that SES and parental education can be associated with short-term language outcomes.¹⁰ However, to our knowledge, no meta-analysis has quantitatively evaluated the strength of the association of SDH with pediatric cochlear implant outcomes. Understanding the contribution of SDH to language and academic outcomes may result in targeted interventions to increase parent resources, child learning accommodations, and household educational support. This study systematically reviewed and meta-analyzed the associations of SDH with language development and academic achievement in pediatric cochlear implant recipients in combination with other factors known to be associated with outcomes.

Methods

Literature Search

A medical librarian searched using a combination of keywords and controlled vocabulary in Embase.com, Ovid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, Cumulated Index to Nursing and Allied Health Literature Plus, APA PsycINFO, and ClinicalTrials.gov. The search was completed on August 2, 2023, and 8687 results were found. Of these, 3323 duplicate records were deleted, resulting in 5326 unique citations in the project library. Search strategies for each database can be found in the eAppendix in Supplement 1.

The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) reporting guidelines were followed to report results. One reviewer (L.M.) screened all titles and abstracts for relevance. Two reviewers completed full-text reviews. Studies were included if the article reported an effect size for an SDH variable that was associated with outcomes of pediatric cochlear implantation. SDH data extracted included SES, race and ethnicity, location (rural or urban), immigration status, parental education, parental involvement, social and educational support, bilingualism, insurance status, and access to health care (further defined in eTable 1 in Supplement 1). Additional variables known to be associated with outcomes were extracted, namely age at cochlear implantation and duration of cochlear implant use. Outcomes included measures of speech, language, reading, academics, and quality of life. Non–English language articles, editorials, reviews, opinion pieces, combined hearing aid data, animal studies, and case reports of fewer than 5 individuals were excluded.

Risk-of-Bias Assessment

The risk of bias was assessed using the Newcastle-Ottawa Scale, which rates study risk as low (scores of 7 or higher), medium (scores between 4 and 6), or high (scores of 3 or less) based on the presence of selection, outcome, and overall risk of bias.¹¹ Two reviewers performed a risk-of-bias assessment, and any differing assessments were resolved with discussion.

Meta-Analysis

The reported effect size of this meta-analysis was the standardized regression coefficient, which allowed for the inclusion of variable outcomes. This effect size measured the relative direction and magnitude of the association of a factor with the outcome of interest.¹² In a simple regression, the standardized regression coefficient equals the correlation coefficient.^13,14 For studies reporting only Pearson correlations and standard errors, they were converted to standardized regression coefficients.^13,14 Effect sizes are interpreted as weak (0.00-0.20), moderate (0.21-0.50), and strong (>0.50) and may be bidirectionally interpreted.¹⁵ A random-effects analysis was performed for all analyses, and heterogeneity was evaluated with τ², H², and I² statistics. A sensitivity analysis was performed using a leave-one-out method to identify whether studies contributed to high heterogeneity. Meta-regression was performed to evaluate the confounding association of age at cochlear implant or duration of cochlear implant use and SDH factors with outcomes. Analyses were conducted using SPSS, version 29 (IBM).

Results

Following exclusion of duplicates, 5326 articles were identified. After a review of titles and abstracts, 244 articles underwent full-text review. During the review process, 3 additional articles were discovered during the review of citations and included in the final review. Ultimately, 40 articles were included in the systematic review, comprising 3809 children (Figure 1). Language outcomes were measured in 32 studies that included a total of 3375 children. Eight studies, including a total of 986 children, measured academic outcomes. The meta-analysis included 20 studies of 1905 children that measured the associations of SDH with language and academic outcomes.

Risk-of-bias assessments (eTables 2 and 3 in Supplement 1) showed that the risk of bias was high for 3, medium for 18, and low for 19 studies. Multiple assessment tools were used to quantify outcomes in children with cochlear implants. Outcomes included speech perception, receptive and expressive language skills, total language abilities, reading skills, academic ability, and quality of life. Most studies measured multiple outcomes (Table^{7,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52}).

Table. Outcome Measures of Speech Perception, Language, Reading, and Academic Abilities in Pediatric Cochlear Implant Recipients.

Source	Mean (SD), y		Outcome, outcome measure	Dependent SDH variable of interest measured
Source	Age of implant	Cochlear implant use duration	Outcome, outcome measure	Dependent SDH variable of interest measured
Measures of language abilities in pediatric cochlear implant recipients
Hodges et al,¹⁶ 1999	6 (Range, 2-14)	2.1 (Range, 0.25-5)	Speech perception, PBK open set word score^a	SES rank (scale, 1-5), multilingualism, school setting
O’Donoghue et al,¹⁷ 2000	4.3 (15)	NA	Speech perception, CDT	SES rank
Geers et al,¹⁸ 2002	3.5 (0.75)	5.5 (0.75)	Speech perception, spoken language, and total language, multiple battery test^a	Parental education level, school setting, parent participation
Geers et al,¹⁹ 2003	3.3 (0.83)	5.5 (0.75)	Speech perception, multiple battery test^a; spoken language, IPSyn^a; total language, IPSyn total score^a	SES, school setting
Wie et al,²⁰ 2007	4.2 (2.4)	3.2 (1.8)	Speech perception, PBK^a; speech recognition, ESP^a	School setting, parental education
Niparko et al,²¹ 2010	2.9 (1.7)	1.1 (1.0)	Speech comprehension, RLDS^a; spoken language, RLDS^a	Low SES (family income <$50 000), parental involvement
Boons et al,²² 2012	2.2 (1.1)	2 (0)	Speech comprehension, RLDS^a; expressive language, SELT^a	Multilingualism, parental involvement
Ceh et al,²³ 2013	1.3 (0.3)	4.6 (1.4)	Speech comprehension, RLDS^a and OWLS^a	Parent involvement
Geers et al,²⁴ 2011	3.3 (0.5)	5.5 (0.8)	Total language, multiple battery test^a	Younger age at cochlear impant, SES
Yim,²⁵ 2012	NA	NA	Receptive vocabulary, PPVT in English and Spanish^a; auditory comprehension, PLS^a; speech production, GFTA-3^a; expressive speech, EOWPVT^a	Amount of Spanish spoken at home
Harris et al,²⁶ 2013	3.8 (1.7)	8.0 (3.7)	Word recognition, PBK^a; sentence recognition, HINT-C^a; receptive vocabulary, PPVT^a; receptive and expressive vocabulary, CELF^a	Parental education (scale, 1-9)
Ruffin et al,²⁷ 2013	3.0 (1.7)	12.2 (3.6)	Receptive vocabulary, PPVT^a; sentence recognition, HINT-C^a; receptive and expressive vocabulary, CELF^a	SES (family salary on scale of 1-10, 1 = <$5500; 10 = >$95 000)
Chen et al,²⁸ 2014	2.7 (1.0)	1.6 (0.7)	Sentence recognition in quiet, PSI	Parental education (years of education)
Sarant et al,²⁹ 2014	NA	NA	Receptive vocabulary, PPVT^a	Parental education (attainment of tertiary education), parental involvement (Moeller family rating scale)
Barnard et al,³⁰ 2015	1.1 (0.9)	NA	Speech recognition, PBK^a	Parental education (attainment of postsecondary education), SES (greater or less than median income level), parental involvement (maternal sensitivity to communication needs), racial or ethnic minority group status (White or member of racial or ethnic minority group)
Chen et al,³¹ 2015	NA	NA	Speech perception, ESP^a; receptive language, CDI^a	Parental education (years)
Hamid et al,³² 2015	NA	NA	Auditory performance, EARS^a; total language performance, EARS^a	Parental involvement (0-2) during testing, geographic distance
Sharma et al,³³ 2017	2.7 (Range, 0.7-4)	12 (0)	Auditory performance, CAP^a; sound recognition, MAIS; speech production, SIR^a	SES (<$7500/y, $7500-15 000/y, >$15 000/y), parent education (high school, bachelor’s degree, master’s degree), and geographic distance
Tolan et al,⁷ 2017	5.3 (4.8)	NA	Auditory performance, Ling 6-sound test	Insurance status (private or public/none).
Bavin et al,³⁴ 2018	0.8 (Range, 0.5-1.8)	NA	Vocabulary, CDI^a	Parent education (scale, 1-4)
Long et al,³⁵ 2018	1.9 (1.1)	.25 (0)	LittlEARS auditory questionnaire	Maternal education (scale, 1 to 3)
Lu et al,³⁶ 2018	3.4 (1.4)	7 (0)	Receptive language, CDI^a; speech perception, ESP^a; sound recognition, MAIS; expressive language, CDI^a	SES (income/mo)
Panda et al,³⁷ 2019	NA	4.4 (2.5)	Auditory performance, CAP^a	SES (income/mo), parental involvement, geographic distance (>10 km), parental education
Alenzi et al,³⁸ 2020	NA	NA	Auditory performance, CAP^a; speech production, SIR^a	SES (income/mo), parental education
Fan et al,³⁹ 2020	1.3	2 (0)	Auditory performance, CAP^a; speech production, SIR^a	Parental education (university level), parental involvement
Noroozi et al,⁴⁰ 2020	NA	NA	Auditory performance, CAP^a	Maternal education (scale, 1-4)
Wie et al,⁴¹ 2020	0.9 (0.3)	NA	Receptive vocabulary, PPVT^a; receptive grammar, TROG-2^a; expressive grammar, ITPA^a	Maternal education (scale, 1-6)
Cejas et al,⁴² 2021	2.4 (1.2)	3 (0)	Listening comprehension and oral expression, OWLS^a	Parental involvement (scale of parental involvement and self-efficacy, maternal education [scale, 1-3])
Eskridge et al,⁴³ 2021	1.7 (0.6)	NA	Receptive language, OWLS, PLS, and CELF-4^a; expressive language, OWLS, PLS, CELF-4^a	Insurance status (public or private insurance)
Liao et al,⁴⁴ 2023	1.2 (Range, 0.6-4.4)	NA	Receptive language, CELF-4^a	Insurance status (public or private insurance), racial or ethnic minority status (White or member of a racial or ethnic minority group)
Measures of reading abilities in pediatric cochlear implant recipients
Geers et al,⁴⁵ 2003	3.5 (0.8)	5.5 (0.8)	Reading, PIAT and WRMT^a	SES, parental involvement, school setting
Connor et al,⁴⁶ 2004	6.8 (3.1)	4.2 (2.2)	Reading comprehension, WRMT^a	SES using insurance status as proxy (private or public insurance status), race (White or member of racial or ethnic minority group)
Sarant et al,⁴⁷ 2015	NA	NA	Reading, WIAT-III^a	Parental involvement (Moeller family rating scale)
Guerzoni et al,⁴⁸ 2020	1.8 (0.9)	NA	Reading, Prove di lettura MT^a	Parental education (y)
Measures of academic abilities in pediatric cochlear implant recipients
Hyde et al,⁴⁹ 2011	3.3 (3.2)	6.2 (3.8)	Academic achievement, Zaidman-Zait and Most questionnaire^a	Education setting
Theunissen et al,⁵⁰ 2014	3.8 (2.9)	8.1 (2.8)	Attention deficit/hyperactivity disorder, child symptom inventories^a	SES
Sarant et al,⁴⁷ 2015	NA	NA	Mathematics, WIAT-III^a	Parental involvement (Moeller family rating scale)
Sarant et al,⁵¹ 2018	NA	NA	Hyperactivity, Strengths, and Difficulties Questionnaire^a	Parental education (tertiary education or none), parental involvement
Diaz et al,⁵² 2019	3.7 (1.3)	10 (0)	Grade failure, parent questionnaire	Parental education (secondary education or none)

Open in a new tab

Abbreviations: CAP, categories of auditory perception; CDI, communicative development inventory; CDT, connected discourse tracking; CELF, clinical evaluation of language fundamentals; EARS, evaluation of auditory responses to speech; EOWPVT, expressive 1-word picture vocabulary test; ESP, Early Speech Perception; GFTA, Goldman Fristoe test of articulation; HINT–C , hearing in noise test for children; IPSyn, Index of Productive Syntax; ITPA, Illinois Test of Psycholinguistic Abilities; MAIS, meaningful auditory integration scale; NA, not applicable; OWLS, Oral Written Language Scales; PBK, phonetically balanced word lists–Kindergarten; PIAT, Peabody individual achievement test; PLS, Preschool Language Scale; PPVT, Peabody picture vocabulary test; PSI, Pediatric Speech Intelligibility Test; RLDS, Reynell Developmental Language Scale; SDH, social determinants of health; SELT, Schlichting expressive language test; SES, socioeconomic status; SIR, speech intelligibility rating; TROG-2, test for reception of grammar; WIAT-III, Wechsler individual achievement test; WRMT, Woodcock reading mastery test.

^{^a}

Indicates standardized and validated measures.

Language Outcomes

Parental Education

Eight studies reported the association of parental education with standardized language scores and were included in the meta-analysis.^{20,28,31,33,34,38,41,53} The pooled standardized regression coefficient of the 6 studies with expressive language scores demonstrated a moderate to strong association with parental education (β = 0.45; 95% CI, 0.29-0.62; I² = 0; Figure 2). The pooled standardized regression coefficient for the 5 studies with standard speech perception scores demonstrated a moderate association with parental education (β = 0.27; 95% CI, 0.16-0.37; I² = 0.10; eFigure 1 in Supplement 1).

Figure 2. — Lines indicate confidence intervals of effect sizes and whiskers, estimated overall confidence intervals. CDI indicates communicative development inventory; CDT, connected discourse tracking; ERVT, expressive vocabulary test; ITPA, Illinois Test of Psycholinguistic Abilities; SIR, speech intelligibility rating.

A narrative review found that higher parental education was associated with receptive and expressive language abilities during the first 3 years after implantation.^26,37,39,47 Children of parents with high education levels had higher mean receptive language scores than those with low education levels.^35,40 Four additional studies reported a small to insignificant association between parental education and language outcomes.^18,19,30,42 In addition, pediatric cochlear implant recipients with highly educated parents were more likely to have fewer than 1 grade failure, as opposed to more than 1.⁵² High parental education was a strong negative predictor of children’s hyperactivity scores.⁵¹ One study found no statistically significant association of parental education with reading scores.⁴⁸ Overall, parental education demonstrated a moderate to strong association with language and academic outcomes.

Socioeconomic Status

Seven studies reporting the association of SES with standardized language scores were meta-analyzed.^{16,21,27,33,36,37,38} The pooled standardized regression coefficient demonstrated a moderate association between low SES and expressive language, speech perception, and receptive language (β = −0.47; 95% CI, −0.83 to −0.10; I² = 0; Figure 3; β = −0.31; 95% CI, −0.48 to −0.15; I² = 0.50; eFigure 2 in Supplement 1; β = −0.37; 95% CI, −0.56 to −0.18; I² = 0; eFigure 3 in Supplement 1, respectively).

Figure 3. — Lines indicate confidence intervals of effect sizes and whiskers, estimated overall confidence intervals. PCDI indicates communicative development inventory; RDLS, Reynell developmental language scale; SIR, speech intelligibility rating.

In narrative review, higher SES had a moderate association with language and speech perception scores.^27,33 Six additional studies reported no statistically significant association between SES and total language outcomes.^{17,19,24,30,45,54} However, high SES was a weak positive predictor of reading scores.¹⁸ Low SES had a small correlation with attention-deficit hyperactivity disorder severity.⁵⁰ Overall, SES demonstrated a weak to moderate association with language and reading outcomes.

Age at Cochlear Implantation

Fifteen studies reporting the association of age of cochlear implantation with standardized language outcomes were included in meta-analysis.^{16,20,21,25,27,31,33,36,37,38,41,43,46,47,53} Among the included studies, the mean age of implantation ranged from 11 months to 6 years. Most studies (12 [75%]) reported a mean cochlear implantation age of older than 2 years. The pooled standardized regression coefficient for age at cochlear implantation demonstrated moderate association with standardized expressive language scores (β = −0.30; 95% CI, −0.43 to −0.17; I² = 0.45; Figure 4). One study was removed from this meta-analysis due to high heterogeneity, reducing the I² from 0.61 to 0.45, but with no association with the effect size.³⁸

Figure 4. — Lines indicate confidence intervals of effect sizes and whiskers, estimated overall confidence intervals. CDT indicates connected discourse tracking; ERVT, expressive vocabulary test; GFTA, Goldman Fristoe test of articulation; OWLS, oral written language scales; PCDI, communicative development inventory; RDLS, Reynell developmental language scale; SIR, speech intelligibility rating; Woodcock, Woodcock reading mastery test.

The pooled standardized regression coefficient for age at cochlear implantation on speech perception, receptive language, and total language scores demonstrated a weak or no association (β = −0.14; 95% CI, −0.23 to −0.04; I² = 0.34; eFigure 4a in Supplement 1; β = −0.12; 95% CI, −0.45 to 0.22; I² = 0.85; eFigure 5a in Supplement 1; β = −0.03; 95% CI, −0.23 to 0.16; I² = 0; eFigure 7a in Supplement 1, respectively). When restricted to low risk of bias and inception cohort studies, the pooled standardized regression coefficient for age at cochlear implantation and standardized receptive language scores showed no significant association (β = −0.36; 95% CI, −0.96 to 0.25; I² = 0.94; eFigure 5c in Supplement 1). When a meta-regression was performed to evaluate age at cochlear implantation and outcomes simultaneously, age of cochlear implantation was not associated with standardized speech perception, receptive, expressive, and total language scores (eFigures 4b, 5b, 6, and 7b in Supplement 1). Four additional studies with weak to no associations between age at cochlear implant and total language outcomes were identified on narrative review.^19,24,39,54 Overall, age of cochlear implantation demonstrated a weak to no association with language outcomes. However, most studies reported a mean cochlear implantation age of older than 2 years.

Duration of Cochlear Implant Use

Eight studies were meta-analyzed for the association of cochlear implant use duration with standardized language outcomes.^{16,20,25,27,28,32,37,43} The mean duration of cochlear implant use ranged from 1.13 years to 12.2 years. The pooled standardized regression coefficient of duration of cochlear implant use on standardized speech perception, receptive language, and expressive language scores demonstrated no statistically significant association and overall high heterogeneity (β = 0.27; 95% CI, −0.17 to 0.70; I² = 0.97; eFigure 8 in Supplement 1; β = 0.19; 95% CI, −0.26 to 0.63; I² = 0.83; eFigure 9 in Supplement 1; and β = 0.02; 95% CI, −0.11 to 0.15; I² = 0; eFigure 10 in Supplement 1).

Parental Involvement

Two studies were included in the meta-analysis of the association of parental involvement with standardized language scores.^42,47 The pooled standardized regression coefficient demonstrated a moderate association between parental involvement and total language abilities (β = 0.30; 95% CI, 0.13-0.48; I² = 0.24; eFigure 11 in Supplement 1). A narrative review found that cochlear implant recipients with higher parental involvement scored higher on receptive language measures, and those whose parents read to them daily showed less language delay.^21,23,29 Poor parental motivation and involvement were associated with worse auditory and speech performance.^22,30,37 Four additional studies reported no significant association between parental involvement and total language outcomes.^18,19,39,42

School Setting

The pooled standardized regression coefficient of mainstream school setting on standardized receptive language scores demonstrated a moderate association (β = 0.37; 95% CI, 0.18-0.56; I² = 0; eFigure 12 in Supplement 1).^16,20 A narrative review found that placement in mainstream school settings had a weak association with spoken and total language skills.⁵⁴ Two additional studies reported no significant association between school setting and total language outcomes.^18,19 Overall, placement in mainstream educational settings demonstrated a weak to moderate association with language outcomes.

Insurance Status

There were insufficient data based on insurance status for meta-analysis. Cochlear implant recipients with public insurance, compared with those with private insurance, were significantly delayed in attaining auditory proficiency as determined by Ling-6 sounds.⁷ Private insurance status, which was intended to be used as a proxy for SES, was moderately associated with receptive language scores.⁴³ Public insurance status had a substantial negative association with receptive language outcomes.⁴⁴

Race and Ethnicity

Children of racial and ethnic minority groups were found to be at higher risk than White children for developing poor speech recognition.³⁰ Being a member of a racial or ethnic minority group was negatively associated with receptive language outcomes but was not significantly associated with reading outcomes.^44,46

Multilingualism

After 3 years of cochlear implant use, oral multilingualism was negatively associated with speech comprehension and expression.²² The amount of Spanish spoken at home had a small to medium strength of association with poorer English language outcomes.²⁵ However, another study reported no significant association between multilingualism and speech perception abilities.¹⁶

Geography

Geographic distance from a speech-language therapy center was found to have a weak association with auditory and language abilities.³² Two studies reported no significant association between geographic distance and total language outcomes.^33,37

Academic Outcomes

Three studies reported the association of age of cochlear implantation with academic outcomes and were meta-analyzed (eFigure 13 in Supplement 1).^46,47,48 The pooled standardized regression coefficient of age at cochlear implantation on standardized reading scores demonstrated a strong association between the age of cochlear implantation and academic reading abilities (β = −0.53; 95% CI, −0.81 to −0.26; I² = 0.46).

Higher parental involvement scores, as measured by the Moeller family rating scale, were strongly correlated with higher reading scores and moderately correlated with higher mathematics scores of children.⁴⁷ Two studies reported no statistically significant association between parental involvement and reading outcomes.^18,51

Placement in mainstream education settings was moderately associated with standardized reading scores and overall academic achievement.^45,49 Public insurance status, which was intended to be used as a proxy for SES, was a weak negative predictor of reading comprehension scores.⁴⁶ Being a member of a racial or ethnic minority group was not significantly associated with reading outcomes.^44,46

Discussion

This systematic review and meta-analysis summarized and quantitatively synthesized the literature reporting the associations of SDH with language and academic outcomes in children who have received cochlear implants. The meta-analysis identified moderate to strong associations of parent education, parent involvement, and SES with language outcomes. Age of cochlear implantation demonstrated weak or no associations with language outcomes, but studies reporting on duration of cochlear implant use did not show statistically significant associations.

Early age of cochlear implantation is widely accepted as being associated with language outcomes in children with congenital and prelingual bilateral severe to profound HL.^55,56 However, the benefit may be diminished when the age of cochlear implantation and duration of cochlear implant use are evaluated in the context of SDH.⁴⁴ Insurance status (eg, Medicaid/public or employer-based/private), which is often a proxy for SES, can pose a barrier to cochlear implantation.⁵⁷ While insurance eligibility criteria are expanding, inequities in access according to insurance status continue to exist.⁵⁸ A recent study demonstrated that access to health care necessities and the ability to pay medical bills is associated with language outcomes of children with HL, potentially caused by lower prioritization of hearing health care in a household struggling to supply basic necessities.⁵⁹ Household SES affects child language outcomes by being associated with other household characteristics and family environments, including parental involvement and parental education.^60,61 When analyzing recordings of children’s daily interactions, lower household income and lower parental education levels were associated with fewer child-spoken words, caregiver-child interactions, and exposure to spoken language.^62,63 This language gap in children of lower education and income levels, known as the 30 million–word gap, has been shown to be associated with poor academic performance and educational attainment later in childhood.^64,65 The results of this study underscored a nuanced perspective: SDH, such as low parental education, low parental involvement, or low SES, may act as barriers to the benefit of age of cochlear implant and duration of cochlear implant use.

The success of pediatric cochlear implantation may be determined by the child’s home, primary care, and school environment. Historically, school-based interventions, such as individualized educational plans and assistive listening devices, accommodated school-aged children with HL. However, a nationally representative cross-sectional survey demonstrated that children with HL had worse school engagement than those without, including decreased participation in sports and an increased likelihood of unfinished school work.⁶⁶ To bridge the language development and academic achievement gap for children of lower SES, early intervention in the home environment is likely necessary.

Pediatric medical homes are another opportunity for intervention to increase parent involvement and education for all children. Recognizing the pivotal role parents play in a child’s listening and language development, speech-language therapy incorporates intentional and action-focused parental involvement in developing the auditory and language skills of a child with HL.^67,68 Various initiatives have aimed to enhance parental knowledge and involvement. Parental knowledge assessment at the 1-week newborn visit was associated with the likelihood of parental response to language cues and social involvement with the child.⁶⁹ Educational material provided in the newborn hearing screening setting demonstrated a short-term increase in parental hearing and language development–related knowledge.⁷⁰ Literacy programs providing newborns and infants with books may enrich language environment and promote child-parent interactions.^71,72 The importance of early intervention in addressing child social inequities becomes as crucial as early amplification in enhancing language and academic outcomes in children with severe to profound HL.⁷³ Teaching parents how to extend the speech and language training from school to home and purposefully engaging them as partners of early intervention may help children with HL as well as children with typical hearing.

Limitations

This study had several limitations. Most studies reported a mean cochlear implantation at older than 2 years, so future studies with younger age at cochlear implantation may show stronger associations with language and academic outcomes. Publication bias may have resulted in excluding negative data from the study. The relative lack of reporting statistically insignificant data impeded data extraction from several studies. Some of the included studies performed a bivariate analysis and reported effect sizes that were not adjusted for potential confounding factors. The outcomes reported in this study were measured by multiple different assessments at varying points in the child’s cochlear implant experience. This limitation was addressed by including only standardized and validated outcome measures and reporting demographic information of each study’s population. SDH were defined by their social context; excluding non–English-language publications may have prevented some studies from being included. However, there was low overall heterogeneity among the studies that evaluated the association of SDH with the outcomes. Combining data from more countries and cultures may increase a future systematic review’s generalizability and insight into potential interventions.

Conclusions

The results of this systematic review and meta-analysis suggest that SDH are associated with language development and academic achievement. In addition to efforts to expedite cochlear implant placement in eligible children, optimal outcomes may be achieved with interventions centered on the child’s home, primary medical care, and school environment.

Supplement 1.

eAppendix.

eFigure 1. Effect of Parental Education on Standardized Speech Perception Scores

eFigure 2. Effect of Low Socioeconomic Status (SES) on Standardized Speech Perception Scores

eFigure 3. Effect of Low Socioeconomic Status (SES) on Standardized Receptive Language Scores

eFigure 4. Effect of Age at Cochlear Implant (CI) Implantation on Standardized Speech Perception Scores

eFigure 5. Effect of Age at Cochlear Implant (CI) Implantation on Standardized Receptive Language Scores

eFigure 6. Effect of Age at cochlear implant (CI) Implantation on Standardized Expressive Language Scores According to Mean Age of CI Implantation.

eFigure 7. Effect of Age at Cochlear Implant (CI) on Standardized Total Language Scores

eFigure 8. Effect of Duration of cochlear implant (CI) Use on Standardized Speech Perception Scores

eFigure 9. Effect of Duration of cochlear implant (CI) Use on Standardized Receptive Language Scores

eFigure 10. Effect of Duration of cochlear implant (CI) Use on Standardized Expressive Language Scores

eFigure 11. Effect of Parental Involvement on Total Language Scores

eFigure 12. Effect of Placement in Mainstream School Settings on Standardized Receptive Language Score

eFigure 13. Effect of Age at cochlear implant (CI) Implantation and Standardized Reading Scores.

eTable 1. Definition of Social Determinants of Health (SDH) Variable

eTable 2. Risk of Bias Assessment

eTable 3. Newcastle-Ottawa Risk of Bias Assessment

jamaotolaryngolheadnecksurg-e243564-s001.pdf^{(1.1MB, pdf)}

Supplement 2.

Data sharing statement

jamaotolaryngolheadnecksurg-e243564-s002.pdf^{(15.8KB, pdf)}

References

1.Billings KR, Kenna MA. Causes of pediatric sensorineural hearing loss: yesterday and today. Arch Otolaryngol Head Neck Surg. 1999;125(5):517-521. doi: 10.1001/archotol.125.5.517 [DOI] [PubMed] [Google Scholar]
2.Nassiri AM, Marinelli JP, Lohse CM, Carlson ML. Age and incidence of cochlear implantation in the pediatric population with congenital bilateral profound hearing loss. Otol Neurotol. 2023;44(7):e492-e496. doi: 10.1097/MAO.0000000000003932 [DOI] [PubMed] [Google Scholar]
3.Cejas I, Barker DH, Petruzzello E, Sarangoulis CM, Quittner AL. Cochlear implantation and educational and quality-of-life outcomes in adolescence. JAMA Otolaryngol Head Neck Surg. 2023;149(8):708-715. doi: 10.1001/jamaoto.2023.1327 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Tomblin JB, Barker BA, Spencer LJ, Zhang X, Gantz BJ. The effect of age at cochlear implant initial stimulation on expressive language growth in infants and toddlers. J Speech Lang Hear Res. 2005;48(4):853-867. doi: 10.1044/1092-4388(2005/059) [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Dunn CC, Walker EA, Oleson J, et al. Longitudinal speech perception and language performance in pediatric cochlear implant users: the effect of age at implantation. Ear Hear. 2014;35(2):148-160. doi: 10.1097/AUD.0b013e3182a4a8f0 [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Busch T, Brinchmann EI, Braeken J, Wie OB. Receptive vocabulary of children with bilateral cochlear implants from 3 to 16 years of age. Ear Hear. 2022;43(6):1866-1880. doi: 10.1097/AUD.0000000000001220 [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Tolan M, Serpas A, McElroy K, et al. Delays in sound recognition and imitation in underinsured children receiving cochlear implantation. JAMA Otolaryngol Head Neck Surg. 2017;143(1):60-64. doi: 10.1001/jamaoto.2016.2730 [DOI] [PubMed] [Google Scholar]
8.Noblitt B, Alfonso KP, Adkins M, Bush ML. Barriers to rehabilitation care in pediatric cochlear implant recipients. Otol Neurotol. 2018;39(5):e307-e313. doi: 10.1097/MAO.0000000000001777 [DOI] [PMC free article] [PubMed] [Google Scholar]
9.World Health Organization . Closing the gap in a generation: health equity through action on the social determinants of health: final report of the commission on social determinants of health. Accessed July 6, 2024. https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1
10.Omar M, Qatanani AM, Douglas NO, et al. Sociodemographic disparities in pediatric cochlear implantation outcomes: a systematic review. Am J Otolaryngol. 2022;43(5):103608. doi: 10.1016/j.amjoto.2022.103608 [DOI] [PubMed] [Google Scholar]
11.Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Accessed October 21, 2023. https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
12.Lleras C. Path analysis. In: Kempf-Leonard K, ed. Encyclopedia of Social Measurement. Elsevier; 2005:25-30. doi: 10.1016/B0-12-369398-5/00483-7 [DOI] [Google Scholar]
13.Cohen J. Statistical Power Analysis for the Behavioral Sciences. Academic press; 2013. doi: 10.4324/9780203771587 [DOI] [Google Scholar]
14.Grissom RJ, Kim JJ. Effect Sizes for Research: Univariate and Multivariate Applications. Routledge; 2012. doi: 10.4324/9780203803233 [DOI] [Google Scholar]
15.Fey CF, Hu T, Delios A. The measurement and communication of effect sizes in management research. Manage Organ Rev. 2023;19(1):176-197. doi: 10.1017/mor.2022.2 [DOI] [Google Scholar]
16.Hodges AV, Dolan Ash M, Balkany TJ, Schloffman JJ, Butts SL. Speech perception results in children with cochlear implants: contributing factors. Otolaryngol Head Neck Surg. 1999;121(1):31-34. doi: 10.1016/S0194-5998(99)70119-1 [DOI] [PubMed] [Google Scholar]
17.O’Donoghue GM, Nikolopoulos TP, Archbold SM. Determinants of speech perception in children after cochlear implantation. Lancet. 2000;356(9228):466-468. doi: 10.1016/S0140-6736(00)02555-1 [DOI] [PubMed] [Google Scholar]
18.Geers AE. Factors affecting the development of speech, language, and literacy in children with early cochlear implantation. Lang Speech Hear Serv Sch. 2002;33(3):172-183. doi: 10.1044/0161-1461(2002/015) [DOI] [PubMed] [Google Scholar]
19.Geers A, Brenner C, Davidson L. Factors associated with development of speech perception skills in children implanted by age five. Ear Hear. 2003;24(1)(suppl):24S-35S. doi: 10.1097/01.AUD.0000051687.99218.0F [DOI] [PubMed] [Google Scholar]
20.Wie OB, Falkenberg ES, Tvete O, Tomblin B. Children with a cochlear implant: characteristics and determinants of speech recognition, speech-recognition growth rate, and speech production. Int J Audiol. 2007;46(5):232-243. doi: 10.1080/14992020601182891 [DOI] [PubMed] [Google Scholar]
21.Niparko JK, Tobey EA, Thal DJ, et al. ; CDaCI Investigative Team . Spoken language development in children following cochlear implantation. JAMA. 2010;303(15):1498-1506. doi: 10.1001/jama.2010.451 [DOI] [PMC free article] [PubMed] [Google Scholar]
22.Boons T, Brokx JP, Dhooge I, et al. Predictors of spoken language development following pediatric cochlear implantation. Ear Hear. 2012;33(5):617-639. doi: 10.1097/AUD.0b013e3182503e47 [DOI] [PubMed] [Google Scholar]
23.Ceh KM, Bervinchak DM, Francis HW. Early literacy gains in children with cochlear implants. Otol Neurotol. 2013;34(3):416-421. doi: 10.1097/MAO.0b013e31827b4b81 [DOI] [PubMed] [Google Scholar]
24.Geers AE, Brenner C, Tobey EA. Article 1: Long-Term outcomes of cochlear implantation in early childhood: Sample characteristics and data collection methods. Ear Hear. 2011;32(1)(suppl):2S-12S. doi: 10.1097/AUD.0b013e3182014c53 [DOI] [PMC free article] [PubMed] [Google Scholar]
25.Yim D. Spanish and English language performance in bilingual children with cochlear implants. Otol Neurotol. 2012;33(1):20-25. doi: 10.1097/MAO.0b013e31823c9375 [DOI] [PubMed] [Google Scholar]
26.Harris MS, Kronenberger WG, Gao S, Hoen HM, Miyamoto RT, Pisoni DB. Verbal short-term memory development and spoken language outcomes in deaf children with cochlear implants. Ear Hear. 2013;34(2):179-192. doi: 10.1097/AUD.0b013e318269ce50 [DOI] [PMC free article] [PubMed] [Google Scholar]
27.Ruffin CV, Kronenberger WG, Colson BG, Henning SC, Pisoni DB. Long-term speech and language outcomes in prelingually deaf children, adolescents and young adults who received cochlear implants in childhood. Audiol Neurootol. 2013;18(5):289-296. doi: 10.1159/000353405 [DOI] [PMC free article] [PubMed] [Google Scholar]
28.Chen Y, Wong LL, Chen F, Xi X. Tone and sentence perception in young Mandarin-speaking children with cochlear implants. Int J Pediatr Otorhinolaryngol. 2014;78(11):1923-1930. doi: 10.1016/j.ijporl.2014.08.025 [DOI] [PubMed] [Google Scholar]
29.Sarant J, Harris D, Bennet L, Bant S. Bilateral versus unilateral cochlear implants in children: a study of spoken language outcomes. Ear Hear. 2014;35(4):396-409. doi: 10.1097/AUD.0000000000000022 [DOI] [PMC free article] [PubMed] [Google Scholar]
30.Barnard JM, Fisher LM, Johnson KC, et al. ; CDaCI Investigative Team . A prospective longitudinal study of U.S. children unable to achieve open-set speech recognition 5 years after cochlear implantation. Otol Neurotol. 2015;36(6):985-992. doi: 10.1097/MAO.0000000000000723 [DOI] [PMC free article] [PubMed] [Google Scholar]
31.Chen Y, Wong LLN, Zhu S, Xi X. A structural equation modeling approach to examining factors influencing outcomes with cochlear implant in Mandarin-speaking children. PLoS One. 2015;10(9):e0136576. doi: 10.1371/journal.pone.0136576 [DOI] [PMC free article] [PubMed] [Google Scholar]
32.Hamid AA, Elshazly M, Eldessouky T, Ghaffar HA, Radwan A, Monem AA. Predictors of language and auditory skills in Egyptian children with a cochlear implant. Egypt J Otolaryngol. 2015;31(3):170-175. doi: 10.4103/1012-5574.161605 [DOI] [Google Scholar]
33.Sharma S, Bhatia K, Singh S, Lahiri AK, Aggarwal A. Impact of socioeconomic factors on paediatric cochlear implant outcomes. Int J Pediatr Otorhinolaryngol. 2017;102:90-97. doi: 10.1016/j.ijporl.2017.09.010 [DOI] [PubMed] [Google Scholar]
34.Bavin EL, Sarant J, Leigh G, Prendergast L, Busby P, Peterson C. Children with cochlear implants in infancy: predictors of early vocabulary. Int J Lang Commun Disord. 2018;53(4):788-798. doi: 10.1111/1460-6984.12383 [DOI] [PubMed] [Google Scholar]
35.Long Y, Liu H, Li Y, et al. Early auditory skills development in Mandarin speaking children after bilateral cochlear implantation. Int J Pediatr Otorhinolaryngol. 2018;114:153-158. doi: 10.1016/j.ijporl.2018.08.039 [DOI] [PubMed] [Google Scholar]
36.Lu X, Qin Z. Auditory and language development in Mandarin-speaking children after cochlear implantation. Int J Pediatr Otorhinolaryngol. 2018;107:183-189. doi: 10.1016/j.ijporl.2018.02.006 [DOI] [PubMed] [Google Scholar]
37.Panda S, Sikka K, Singh V, et al. Comprehensive analysis of factors leading to poor performance in prelingual cochlear implant recipients. Otol Neurotol. 2019;40(6):754-760. doi: 10.1097/MAO.0000000000002237 [DOI] [PubMed] [Google Scholar]
38.Alenzi SH, Halawani RT, Alshalan AM, Habis SA, Alsanosi AA. Influence of family environment on the outcomes of cochlear implantation in pediatric recipients. Saudi Med J. 2020;41(5):485-490. doi: 10.15537/smj.2020.5.25070 [DOI] [PMC free article] [PubMed] [Google Scholar]
39.Fan X, Sui R, Qi X, et al. Analysis of the developmental trajectory and influencing factors of auditory and speech functions after cochlear implantation in Mandarin Chinese speaking children. Acta Otolaryngol. 2020;140(6):501-508. doi: 10.1080/00016489.2020.1736622 [DOI] [PubMed] [Google Scholar]
40.Noroozi M, Nikakhlagh S, Angali KA, Bagheripour H, Saki N. Relationship between age at cochlear implantation and auditory speech perception development skills in children. Clin Epidemiol Glob Health. 2020;8(4):1356-1359. doi: 10.1016/j.cegh.2020.05.011 [DOI] [Google Scholar]
41.Wie OB, Torkildsen JVK, Schauber S, Busch T, Litovsky R. Long-term language development in children with early simultaneous bilateral cochlear implants. Ear Hear. 2020;41(5):1294-1305. doi: 10.1097/AUD.0000000000000851 [DOI] [PMC free article] [PubMed] [Google Scholar]
42.Cejas I, Mitchell CM, Barker DH, Sarangoulis C, Eisenberg LS, Quittner AL. Parenting stress, self-efficacy, and involvement: effects on spoken language ability three years after cochlear implantation. Otol Neurotol. 2021;42(10S):S11-S18. doi: 10.1097/MAO.0000000000003374 [DOI] [PMC free article] [PubMed] [Google Scholar]
43.Eskridge HR, Park LR, Brown KD. The impact of unilateral, simultaneous, or sequential cochlear implantation on pediatric language outcomes. Cochlear Implants Int. 2021;22(4):187-194. doi: 10.1080/14670100.2020.1871267 [DOI] [PubMed] [Google Scholar]
44.Liao EN, Yaramala N, Coulthurst S, et al. Impact of sociodemographic disparities on language outcomes after cochlear implantation in a diverse pediatric cohort. Otolaryngol Head Neck Surg. 2023;168(5):1185-1196. doi: 10.1002/ohn.178 [DOI] [PubMed] [Google Scholar]
45.Geers AE. Predictors of reading skill development in children with early cochlear implantation. Ear Hear. 2003;24(1)(suppl):59S-68S. doi: 10.1097/01.AUD.0000051690.43989.5D [DOI] [PubMed] [Google Scholar]
46.Connor CM, Zwolan TA. Examining multiple sources of influence on the reading comprehension skills of children who use cochlear implants. J Speech Lang Hear Res. 2004;47(3):509-526. doi: 10.1044/1092-4388(2004/040) [DOI] [PubMed] [Google Scholar]
47.Sarant JZ, Harris DC, Bennet LA. Academic outcomes for school-aged children with severe-profound hearing loss and early unilateral and bilateral cochlear implants. J Speech Lang Hear Res. 2015;58(3):1017-1032. doi: 10.1044/2015_JSLHR-H-14-0075 [DOI] [PubMed] [Google Scholar]
48.Guerzoni L, Mancini P, Nicastri M, Fabrizi E, Giallini I, Cuda D. Does early cochlear implantation promote better reading comprehension skills? Int J Pediatr Otorhinolaryngol. 2020;133:109976. doi: 10.1016/j.ijporl.2020.109976 [DOI] [PubMed] [Google Scholar]
49.Hyde M, Punch R, Grimbeek P. Factors predicting functional outcomes of cochlear implants in children. Cochlear Implants Int. 2011;12(2):94-104. doi: 10.1179/146701010X12677899497317 [DOI] [PubMed] [Google Scholar]
50.Theunissen SCPM, Rieffe C, Kouwenberg M, et al. Behavioral problems in school-aged hearing-impaired children: the influence of sociodemographic, linguistic, and medical factors. Eur Child Adolesc Psychiatry. 2014;23(4):187-196. doi: 10.1007/s00787-013-0444-4 [DOI] [PubMed] [Google Scholar]
51.Sarant JZ, Harris DC, Galvin KL, Bennet LA, Canagasabey M, Busby PA. Social development in children with early cochlear implants: normative comparisons and predictive factors, including bilateral implantation. Ear Hear. 2018;39(4):770-782. doi: 10.1097/AUD.0000000000000533 [DOI] [PubMed] [Google Scholar]
52.Diaz L, Labrell F, Le Normand MT, Guinchat V, Dellatolas G. School achievement of deaf children ten years after cochlear implantation. Neuropsychiatr Enfance Adolesc. 2019;67(1):50-57. doi: 10.1016/j.neurenf.2018.07.006 [DOI] [Google Scholar]
53.Szagun G, Stumper B. Age or experience? the influence of age at implantation and social and linguistic environment on language development in children with cochlear implants. J Speech Lang Hear Res. 2012;55(6):1640-1654. doi: 10.1044/1092-4388(2012/11-0119) [DOI] [PubMed] [Google Scholar]
54.Geers AE, Nicholas JG, Sedey AL. Language skills of children with early cochlear implantation. Ear Hear. 2003;24(1)(suppl):46S-58S. doi: 10.1097/01.AUD.0000051689.57380.1B [DOI] [PubMed] [Google Scholar]
55.Leigh JR, Dettman SJ, Dowell RC. Evidence-based guidelines for recommending cochlear implantation for young children: Audiological criteria and optimizing age at implantation. Int J Audiol. 2016;55(suppl 2):S9-S18. doi: 10.3109/14992027.2016.1157268 [DOI] [PubMed] [Google Scholar]
56.Warner-Czyz AD, Roland JT Jr, Thomas D, Uhler K, Zombek L. American Cochlear Implant Alliance Task Force guidelines for determining cochlear implant candidacy in children. Ear Hear. 2022;43(2):268-282. doi: 10.1097/AUD.0000000000001087 [DOI] [PMC free article] [PubMed] [Google Scholar]
57.Zhang L, Links AR, Boss EF, White A, Walsh J. Identification of potential barriers to timely access to pediatric hearing aids. JAMA Otolaryngol Head Neck Surg. 2020;146(1):13-19. doi: 10.1001/jamaoto.2019.2877 [DOI] [PMC free article] [PubMed] [Google Scholar]
58.Liu X, Rosa-Lugo LI, Cosby JL, Pritchett CV. Racial and insurance inequalities in access to early pediatric cochlear implantation. Otolaryngol Head Neck Surg. 2021;164(3):667-674. doi: 10.1177/0194599820953381 [DOI] [PubMed] [Google Scholar]
59.Townsend J, Conrad C, Williams S, Wiley S, Meinzen-Derr J. The association between family resources and language among young children who are deaf and hard of hearing. J Dev Behav Pediatr. 2023;44(9):e625-e632. doi: 10.1097/DBP.0000000000001225 [DOI] [PMC free article] [PubMed] [Google Scholar]
60.Dubow EF, Boxer P, Huesmann LR. Long-term effects of parents’ education on children’s educational and occupational success: mediation by family interactions, child aggression, and teenage aspirations. Merrill Palmer Q (Wayne State Univ Press). 2009;55(3):224-249. doi: 10.1353/mpq.0.0030 [DOI] [PMC free article] [PubMed] [Google Scholar]
61.Holt RF, Beer J, Kronenberger WG, Pisoni DB, Lalonde K. Contribution of family environment to pediatric cochlear implant users’ speech and language outcomes: some preliminary findings. J Speech Lang Hear Res. 2012;55(3):848-864. doi: 10.1044/1092-4388(2011/11-0143) [DOI] [PMC free article] [PubMed] [Google Scholar]
62.Gilkerson J, Richards JA, Warren SF, et al. Mapping the early language environment using all-day recordings and automated analysis. Am J Speech Lang Pathol. 2017;26(2):248-265. doi: 10.1044/2016_AJSLP-15-0169 [DOI] [PMC free article] [PubMed] [Google Scholar]
63.Hart B, Risley TR. Meaningful Differences in the Everyday Experience of Young American Children. Paul H Brookes Publishing; 1995. [Google Scholar]
64.Durham R, Hammer C, Tomblin J, Catts H. Kindergarten oral language skill: a key variable in the intergenerational transmission of socioeconomic status. Research in Social Stratification and Mobility. 2007;25:294-305. doi: 10.1016/j.rssm.2007.03.001 [DOI] [Google Scholar]
65.Weisleder A, Fernald A. Talking to children matters: early language experience strengthens processing and builds vocabulary. Psychol Sci. 2013;24(11):2143-2152. doi: 10.1177/0956797613488145 [DOI] [PMC free article] [PubMed] [Google Scholar]
66.Khalsa IK, Chan DK. Hearing impairment and school engagement outcomes in US children. JAMA Otolaryngol Head Neck Surg. 2023;149(12):1091-1100. doi: 10.1001/jamaoto.2023.2897 [DOI] [PMC free article] [PubMed] [Google Scholar]
67.Zaidman-Zait A, Young RA. Parental involvement in the habilitation process following children’s cochlear implantation: an action theory perspective. J Deaf Stud Deaf Educ. 2008;13(2):193-214. doi: 10.1093/deafed/enm051 [DOI] [PubMed] [Google Scholar]
68.Costa EA, Day L, Caverly C, Mellon N, Ouellette M, Wilson Ottley S. Parent-child interaction therapy as a behavior and spoken language intervention for young children with hearing loss. Lang Speech Hear Serv Sch. 2019;50(1):34-52. doi: 10.1044/2018_LSHSS-18-0054 [DOI] [PubMed] [Google Scholar]
69.Leung CYY, Suskind DL. What parents know matters: parental knowledge at birth predicts caregiving behaviors at 9 months. J Pediatr. 2020;221:72-80. doi: 10.1016/j.jpeds.2019.12.021 [DOI] [PubMed] [Google Scholar]
70.Sowa LE, Thomas JMN, Hundertmark AC, Baroody FM, Suskind DL. Leveraging the universal newborn hearing screen to impact parental knowledge of childhood speech development in low socioeconomic populations: a randomized clinical trial. Int J Pediatr Otorhinolaryngol. 2021;146:110763. doi: 10.1016/j.ijporl.2021.110763 [DOI] [PubMed] [Google Scholar]
71.Guevara JP, Erkoboni D, Gerdes M, et al. Effects of early literacy promotion on child language development and home reading environment: a randomized controlled trial. J Pediatr X. 2020;2:100020. doi: 10.1016/j.ympdx.2020.100020 [DOI] [PMC free article] [PubMed] [Google Scholar]
72.Mendelsohn AL, Mogilner LN, Dreyer BP, et al. The impact of a clinic-based literacy intervention on language development in inner-city preschool children. Pediatrics. 2001;107(1):130-134. doi: 10.1542/peds.107.1.130 [DOI] [PubMed] [Google Scholar]
73.Dreyer BP. Closing the gap: interventions to ameliorate inequities in early brain development and school performance in poor children. J Pediatr. 2020;221:8-10. doi: 10.1016/j.jpeds.2020.02.004 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials