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Research ArticleOriginal Research

Children With Hearing Loss and Increased Risk of Injury

Joshua R. Mann, Li Zhou, Michael McKee and Suzanne McDermott
The Annals of Family Medicine November 2007, 5 (6) 528-533; DOI: https://doi.org/10.1370/afm.740
Joshua R. Mann
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Li Zhou
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Michael McKee
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Suzanne McDermott
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  • Children with hearing loss/impairment and injury proneness: a one-way equation?
    Eleni Th Petridou
    Published on: 10 November 2008
  • Children/families with hearing loss � more research needed
    Steven Barnett
    Published on: 24 December 2007
  • Reply to Dr. Xiang
    Joshua R. Mann
    Published on: 20 December 2007
  • Safety and Injury Research Among Children With Disabilities
    Huiyun Xiang
    Published on: 15 December 2007
  • Response to Dr. Osterling
    Joshua R Mann
    Published on: 29 November 2007
  • Children with Hearing Loss - do they understand the safety issues?
    Wendy L Osterling
    Published on: 29 November 2007
  • Published on: (10 November 2008)
    Page navigation anchor for Children with hearing loss/impairment and injury proneness: a one-way equation?
    Children with hearing loss/impairment and injury proneness: a one-way equation?
    • Eleni Th Petridou, Athens, Greece
    • Other Contributors:

    In the November-December 2007 issue of Annals of Family Medicine, Mann et al concluded that children with hearing loss may be at increased risk of injury (1). The investigators reach this conclusion by interpreting raw data from the Medicaid insurance system, highlighting in the original paper that the available Medicaid records allow them to comment only on the rates of injury treatment and not the actual rates of inju...

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    In the November-December 2007 issue of Annals of Family Medicine, Mann et al concluded that children with hearing loss may be at increased risk of injury (1). The investigators reach this conclusion by interpreting raw data from the Medicaid insurance system, highlighting in the original paper that the available Medicaid records allow them to comment only on the rates of injury treatment and not the actual rates of injury. This obstacle is hard to bypass given measurement problems in injury, which stem from existing data sources or registries, or retrospective primary data collection and the associated limitations. Even so, their conclusion seems quite robust.

    By browsing through the paper one would think that the authors put their finger on a self-evident issue supported with hard data. Provided that accidental injuries are the unintended consequences of individual behaviour within a hazardous environment, one would easily conclude that individuals with any kind of impairment or disability are prone to accidental injury since they have to make targeted behavioural adaptations according to their disability. Moreover, too often, we design our physical environment for people who are highly motivated to prevent injury but tragically ignore involuntary risks taken by impaired or disabled individuals, particularly children.

    On a careful study of the original paper, this obvious ascertainment does not seem to emerge that obviously. Indeed, if one attempts to further elaborate on the authors' suggestions for injury prevention among children with hearing loss/impairment in order that they are applied in a wider context than merely in the USA, there seem to be three hierarchical axes to approach the issue from a public health perspective: 1. Further research, including quantitative components needs to be done on the circumstances under which the injury occurred, specifically focusing on personal risk factors that predict members of this group at high injury risk and those with the greater potential for injury reduction. 2. Once risk components are identified, collaboration schemes should be envisioned that ensure the collaboration of health/social authorities with educational and safety experts as well as deaf individuals and their families and ultimately the provision to policy makers of updated proposals on the framework of prevention policies and self monitoring procedures needed for the implementation of respective strategic plans. 3. Funding injury prevention initiatives is of crucial importance and may turn out to be the main obstacle in any decision making process aiming to address injury prevention among disabled. The substantial lifelong economic burden of an injury and its sequels could be a stand alone motivation for governmental organizations discouraging the funding of prevention policies. Yet, politicians are particularly keen to rather respond to daily burning demands. Therefore, the “chronic” condition of inadequate governmental commitment to injury prevention and control usually leads interested parties to seek support from private initiatives with insurance companies being the prime candidates. It has been hypothesized that insurance companies could benefit financially from loss reductions, as they are the ones who pay for injury losses. (2) Even if well founded proposals are attractively presented, however, the outcome may be meagre, as the insuring system may compensate higher losses by increasing customer premiums. Patronizing of charity organizations by socially respected figures has been an effective means to generate income for research and applied action programs in traditionally underfunded public health areas, whereas some social corporate responsibility generated initiatives have recently been welcomed.

    Conclusively, Mann et al, have contributed in the injury prevention and control field by putting facts into numbers as concerns the case of deaf children. Only a systematic measurement of the burden that injury imposes on our society helps us fully understand the critical need to cure this pervasive killer and crippler. It is up to local initiatives, thereafter to take the case further into fruition.

    References

    1. Mann JR, Zhou L, McKee M, McDermott S. Children with hearing loss and increased risk of injury. Ann Fam Med. 2007;5::528-33. 2. O¢Neill B. Reducing injury losses: what private insurers can and cannot do. In: Injury prevention and control. Eds: Mohan D.and Tiwari G. Published by Taylor & Francis, 2000

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (24 December 2007)
    Page navigation anchor for Children/families with hearing loss � more research needed
    Children/families with hearing loss � more research needed
    • Steven Barnett, Rochester NY, USA

    There is little research on the health and healthcare of people with birth or childhood onset hearing loss. Adults who became deaf before age 3yrs (called “prelingual”) have poorer health and less frequent clinician visits than non-deaf adults [1]. Qualitative research [2] and expert opinion [3] report some prelingual deaf adults use emergency department services frequently or inappropriately. It is possible that the...

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    There is little research on the health and healthcare of people with birth or childhood onset hearing loss. Adults who became deaf before age 3yrs (called “prelingual”) have poorer health and less frequent clinician visits than non-deaf adults [1]. Qualitative research [2] and expert opinion [3] report some prelingual deaf adults use emergency department services frequently or inappropriately. It is possible that the healthcare behaviors of prelingual deaf adults have roots in their childhood health and healthcare experiences. I am not aware of health research with non-deaf adults who have birth- or childhood-onset unilateral or less severe bilateral hearing loss.

    Mann et al [4] give a glimpse of the health and healthcare behaviors of some families with a child with hearing loss. In their secondary analyses of claims data, they found that a group of Medicaid enrollees with at least two episodes of a hearing loss diagnosis code had more emergency department visits and more treated injuries than a comparison group. I agree with the authors that these findings warrant more research. The authors discuss the limitations of their research in the article. I comment on two of these limitations here (use of billing records and potential confounders) because they can help shape future research. My two research questions are: 1) For children who are deaf or hard of hearing, how do children with a diagnosis code for hearing loss compare with those without the diagnosis code? 2) Are the factors related to clinicians’ decision to use a hearing loss diagnosis code also associated with the likelihood of injury treatment?

    The authors mention the challenges of using billing data to identify children with hearing loss. I suspect that most Medicaid children with hearing loss were not identified in the data. Before exclusions, Mann et al found 4,647 South Carolina Medicaid children with a hearing loss diagnosis code in 2003. South Carolina Medicaid insures 300,000 [5] to 500,000 [6] children, so the prevalence of a hearing loss diagnosis code is at most 1.5%. This is far below the 11% prevalence of any degree of childhood hearing loss cited in the article’s Introduction (the prevalence of hearing loss is probably higher in the Medicaid population, since, as the authors point out, childhood hearing loss is associated with low income). Since most Medicaid children with hearing loss would not have a diagnosis code for hearing loss, it would be helpful to know which children with hearing loss get a hearing loss diagnosis code.

    For respondents to the Medicare Current Beneficiary Survey, hearing loss diagnosis codes are not a good way to identify people with hearing loss: 81% of respondents who reported a hearing loss did not have a claim with a hearing loss diagnosis code, and 63% of respondents with a hearing loss diagnosis code reported no trouble hearing [7, Table 3]. I have not seen similar data for children or Medicaid. With future research we need to study clinicians’ decisions about the hearing loss diagnosis codes before we can reliably use these codes to answer questions about people with hearing loss.

    Knowing about clinicians’ decisions regarding the use of hearing loss diagnosis codes would affect how I interpret the study’s findings. For example, although hearing loss diagnosis codes do not indicate severity of hearing loss, it is possible that clinicians are more likely to use a hearing loss diagnosis code with a child who is deaf or has profound bilateral hearing loss. This would be consistent with the authors’ speculation about the mechanism of risk for injury treatment in children with a hearing loss diagnosis code (limited detection of environmental sounds and sub-optimal communication with parents). However, it is not consistent with most children with hearing trouble: 38% have unilateral hearing trouble and 32% have bilateral hearing trouble but “can hear words spoken or whispered” [8, Table 1]. Knowing if injury risk was highest in children with more severe hearing loss would help me to focus prevention efforts in the community and in clinical practice, without alarming families with a child who may not be at increased risk for injury.

    Clinician decisions to use a hearing loss diagnosis code may be related to factors that also are related to injury risk. For example, clinicians who see more patients with hearing loss may be more likely to use a hearing loss diagnosis code. Hearing loss is more prevalent outside of a Metropolitan Statistical Area (MSA) [8, Table 9], and rural children are at increased risk for injury [9]. If use of a hearing loss diagnosis code is related to rural location, that might explain some of the increase in injury treatment associated with hearing loss diagnosis codes in children. Future research could adjust analyses for the hospital’s or the child’s ZIP code or county to see if some of the difference between the study and comparison group may be related to rural location.

    Another possibility is that clinicians may be more likely to use hearing loss diagnosis codes with patients with severe comorbidities, such as those who require institutional level care. The authors report that the study group is 15 times more likely than the comparison group to qualify for Medicaid because of the need for institutional level care. Hearing loss alone would not require institutional level care, so it seems that the reason for qualifying for Medicaid (income vs. institutional level care) could function as a measure of comorbidity. The authors excluded children with some known comorbidities from their analyses. I am curious how analyses adjusted for institutional level care would change the relative risk for injury treatment and use of emergency department services for children with a hearing loss diagnosis code.

    I agree with the authors and the comments from Drs. Osterling and Xiang that we need further research on the health of children with hearing loss. If that research will continue to use billing data, then we need to study clinician decision-making as it relates to hearing loss diagnosis codes. Consistent with Dr. Xiang’s comments, future research would be most useful for family physicians if it examined health and healthcare in the context of families. For example, perhaps having a child who is deaf or hard of hearing increases stress in the family such that all the children in that family, regardless of hearing status, are at increased risk for injuries or poor health outcomes. Alternatively, perhaps having a child who is deaf or hard of hearing helps to focus a family on health and healthcare such that all children in that family have frequent clinician visits and perhaps better adherence with preventive services such as immunizations. Family level research also should examine parents’ health and healthcare; family caregiver’s health is an emerging public health issue [10]. Working with those research results, clinicians, deaf individuals, their families, public health officials, and other interested parties could design interventions to promote health and prevent illness or injury in families with a member who is deaf or hard of hearing.

    References

    1. Barnett S, Franks P. Health care utilization and adults who are deaf: Relationship with age at onset of deafness" Health Services Research. 2002;37 (1), 103–118.

    2. Steinberg A, Barnett S, Meador H, Wiggins E, Zazove P. (2006). Healthcare system accessibility: Experiences and perceptions of Deaf people. Journal of General Internal Medicine. 2006;21(3):260-266.

    3. Rochester Deaf Health Task Force Report. 2004. Finger Lakes Health Systems Agency, Rochester NY. http://www.flhsa.org/pubs/Deaf%20Health%20Task%20Force%20Report.pdf (Accessed December 2, 2007).

    4. Mann JR, Zhou L, McKee M, McDermott S. Children with hearing loss and increased risk of injury. Ann Fam Med. 2007;5(6):528–533.

    5. South Carolina - Kaiser State Health Facts. http://www.statehealthfacts.org/mfs.jsp?rgn=42&rgn=1 (Accessed December 2, 2007).

    6. 2005 South Carolina Kids Count Report. http://www.sckidscount.org/kc05.asp?COUNTYID=47 (Accessed December 2, 2007).

    7. Identification of Performance Standards for The Deaf and Hard of Hearing: Report on the Analysis of Data Sources for Assessing the Health Status of Deaf and Hard of Hearing People. A Report to The Centers for Medicare & Medicaid Services, prepared by Delmarva Foundation for Medical Care, Inc, Easton, MD and Gallaudet Graduate Research Institute, Gallaudet University, Washington, DC. March 7, 2002.

    8. Ries, Peter W. Prevalence and characteristics of persons with hearing trouble: United States, 1990-91. National Center for Health Statistics. Vital Health Stat 10(188). 1994. http://cdc.gov/nchs/data/series/sr_10/sr10_188.pdf

    9. Safe Kids Worldwide (SKW). Rural Safety. Washington (DC): SKW, 2007. http://www.usa.safekids.org/content_documents/2007_Fact_Sheet_Rural_Safety.doc (accessed December 2, 2007).

    10. Talley RC, Crews JE. Framing the public health of caregiving. Am J Public Health. 2007;97:224–228.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (20 December 2007)
    Page navigation anchor for Reply to Dr. Xiang
    Reply to Dr. Xiang
    • Joshua R. Mann, Columbia, SC, USA
    • Other Contributors:

    We would like to thank Dr. Xiang for his comments, and for summarizing his own work in the are of injury epidemiology in children with disabilities. We agree that an important strength of our study was our ability to control for general propensity to seek treatment, as measured by the number of visits for non-injury reasons.

    We also acknowledge Dr. Xiang's point about not being able to examine the psychosocial c...

    Show More

    We would like to thank Dr. Xiang for his comments, and for summarizing his own work in the are of injury epidemiology in children with disabilities. We agree that an important strength of our study was our ability to control for general propensity to seek treatment, as measured by the number of visits for non-injury reasons.

    We also acknowledge Dr. Xiang's point about not being able to examine the psychosocial context of the children with and without hearing loss, and how non-medical factors may have impacted injury treatment rates. We agree that it is important to look beyond the simple medical "diagnosis" of a disability and to examine family, environmental, and other factors that may be important. Unfortunately, since we utilized Medicaid billing data for this study, we were limited in the kinds of factors we could assess. Additional research on the psychosocial factors underlying injury risk in children with disabilities is indeed needed.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (15 December 2007)
    Page navigation anchor for Safety and Injury Research Among Children With Disabilities
    Safety and Injury Research Among Children With Disabilities
    • Huiyun Xiang, Columbus, OH, U.S.

    I read with great interest the article by Mann et al in the November/December issue of the Annals of Family Medicine reporting the increased injury risk facing children with hearing loss (1). Using South Carolina Medicaid billing data for 2002-2003, the authors compared rates of emergency department or hospital treatment for injury among children with and without a diagnosis of hearing loss and concluded that children w...

    Show More

    I read with great interest the article by Mann et al in the November/December issue of the Annals of Family Medicine reporting the increased injury risk facing children with hearing loss (1). Using South Carolina Medicaid billing data for 2002-2003, the authors compared rates of emergency department or hospital treatment for injury among children with and without a diagnosis of hearing loss and concluded that children with hearing loss face an increased risk of injury when compared to children without hearing loss.

    Previous research on injury among children with disabilities has produced similar results (2-5). My own research team analyzed data from the 2000-2002 National Health Interview Survey and found that children 5- 17 years of age with a vision/hearing disability had a significantly higher rate of medically treated injuries than did healthy children in the same age range (4.2% vs. 2.5%). In addition, the adjusted odds ratio was similar to the adjusted relative rate reported by Mann et al (3). In another study (to be published in an upcoming article), we found the injury prevalence ratio to be 1.78 (95% confidence interval, 0.95-1.75) among children with hearing problems compared to children without disabilities (4). A similar pattern of increased incidence was found in an analysis of Ohio Medicaid billing data for burn injuries among Ohio Medicaid children with disabilities (5). Scientific findings from research efforts by previous researchers and Mann et al indicate that safety issues and injury prevention are an important public health problem facing millions of children with disabilities in the United States.

    I want to praise Mann et al for using rigorous methods to analyze the rather complex Medicaid billing data. In particular, I would like to commend them for testing whether the elevated rates of injury among children with hearing loss could be due to a potential tendency of that population to seek more emergency or hospital treatment. After controlling for non- injury-related emergency department visits and hospitalizations, Mann et al found that children with hearing loss still had higher rates of injury treatment.

    Another potential problem of injury studies that rely on self- reported interview data is reporting differences between groups. Among children with disabilities this means that the injury-reporting behaviors of parents of children with disabilities could be significantly different than those of parents of children without disabilities. To the best of my knowledge, no study has rigorously examined this important issue. More research is needed to understand the impact of medical care seeking behaviors and recall bias on the conclusions of injury research among children with disabilities.

    While I generally agree with earlier comments regarding the significant findings and clinical care implications of this study, I must admit that I am a little disappointed that Mann et al used the old medical approach to disability. From a public health perspective, the old medical approach to disability is not the ideal approach to injury research among children with disabilities. In fact, Mann et al did not even mention the “biopsychosocial” approach to disability, which has framed both the new research agenda at the National Institute on Disability and Rehabilitation Research and the 2005 Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities (6). The new biopsychosocial approach emphasizes the interaction between impairments, activities, and participation in the physical and social environments. The medical approach, on which most studies have been based in the past (including many of my own publications), emphasizes only the individual’s physical, cognitive, or psychiatric impairments and does not take into account how other aspects of the individual’s life may be affected by his/her impairments. Thus, this biopsychosocial approach to disability may provide a better conceptual framework for future injury research and the development of injury interventions among children with disabilities.

    References

    1. Mann JR, Zhou L, McKee M, McDermott S. Children with hearing loss and increased risk of injury. Ann Fam Med. 2007;5(6):528-33.

    2. Ramirez M, Peek-Asa C, Kraus JF. Disability and risk of school related injuries. Inj Prev. 2004; 10(1): 21-26.

    3. Xiang H, Stallones L, Chen G, Hostetler SG, Kelleher K. Nonfatal injuries among U.S. children with disabling conditions. Am J Public Health. 2005;95(11):1970-1975.

    4. Sinclair SA, Xiang H. Injuries among U.S. children with different types of disabilities. Am J Public Health (published ahead of print at http://www.ajph.org).

    5. Chen G, Sinclair SA, Smith GA, Ranbom L, Xiang H. Incidence and patterns of burn injuries among children with disabilities. J Trauma. 2007;62(3):682-686.

    6. U.S. Department of Health and Human Services. The Surgeon General's Call To Action To Improve the Health and Wellness of Persons with Disabilities. Rockville, MD: Office of the Surgeon General, U.S. Department of Health and Human Services; 2005.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (29 November 2007)
    Page navigation anchor for Response to Dr. Osterling
    Response to Dr. Osterling
    • Joshua R Mann, Columbia, SC, USA
    • Other Contributors:

    We would like to thank Dr. Osterling for the insights regarding the relevance of our article for clinical practice. We agree that tailored interventions for preventive education and counseling are an important field for future research. These interventions should address issues related to hearing per se, but also should help provide parents/caregivers with skills for effective hazard communication with children who have...

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    We would like to thank Dr. Osterling for the insights regarding the relevance of our article for clinical practice. We agree that tailored interventions for preventive education and counseling are an important field for future research. These interventions should address issues related to hearing per se, but also should help provide parents/caregivers with skills for effective hazard communication with children who have hearing loss. Of course, it is vital that any intervention developed be evaluated for effectiveness prior to large scale implementation. Meanwhile, it would seem advisable for clinicians to be aware of the apparent increased risk of injury in these children and to discuss this with parents.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (29 November 2007)
    Page navigation anchor for Children with Hearing Loss - do they understand the safety issues?
    Children with Hearing Loss - do they understand the safety issues?
    • Wendy L Osterling, Salt Lake City, Utah

    In the November/December issue of The Annals of Family Medicine, Mann et al reported that children with hearing loss are more likely than other children to end up in an emergency room with injuries. Few studies have looked closely at the injury rate of children with disabilities. Dr. Mann's group focused on deaf and hard-of-hearing children and found that the rate of injury treatment in this population was more than two...

    Show More

    In the November/December issue of The Annals of Family Medicine, Mann et al reported that children with hearing loss are more likely than other children to end up in an emergency room with injuries. Few studies have looked closely at the injury rate of children with disabilities. Dr. Mann's group focused on deaf and hard-of-hearing children and found that the rate of injury treatment in this population was more than two-fold regardless of age, race, and sex. This significant finding could have important consequences in the general health and cost of medical care in these children. This indicates that better communication and education is needed to reach out to children with hearing loss and their specific language needs.

    Active efforts by the World Health Organization, Centers for Disease Control and Prevention, and Early Hearing Detection and Intervention have dramatically improved the screening, identification and early intervention in newborns with hearing loss. The most common etiology of hearing loss in children are nonsyndromic genetic causes. These children can be as active, curious, and playful as normal children with the exception of inability to hear well. A hearing loss can significantly impact language development and communication. Depending on the age of onset of hearing loss and early intervention, the child is at high risk for language delay, both expressive and receptive areas. It requires more effort for the child to learn to speak and read in the absence of auditory reinforcement. The child may not only miss warning signs of danger (threatening sounds of footsteps or car approaching) and warning calls indicating to watch out, but also may not fully comprehend the significance of the warning. One-on-one instruction should be done in their preferred mode of communication (sign language, cued speech, or lipreading) to explain safety issues and possible consequences. Children with language delay may need more repitition and visual demonstration. Studies have shown that deaf children are more easily distracted by peripheral visual field stimuli and background noises and less able to localize sound. However, the deaf child may also be more focused and determined on the task and less aware of surrounding sounds and activity. In addition to one-on-one instruction, deaf children should be encouraged to be more aware of their surroundings.

    The data from Mann's study indicates that we need to further understand of the needs and education of children with hearing loss. There have been many efforts to establish pediatric injury prevention programs and the Medical Home. More focused education in these programs can help parents, teachers, and therapists of children with hearing loss and disabilities in general understand the need for teaching safety issues and applying safety precautions in the home. This study should not hinder these children from playing, but change the approach and educational efforts with deaf and hard of hearing children to ensure their understanding.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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Children With Hearing Loss and Increased Risk of Injury
Joshua R. Mann, Li Zhou, Michael McKee, Suzanne McDermott
The Annals of Family Medicine Nov 2007, 5 (6) 528-533; DOI: 10.1370/afm.740

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Children With Hearing Loss and Increased Risk of Injury
Joshua R. Mann, Li Zhou, Michael McKee, Suzanne McDermott
The Annals of Family Medicine Nov 2007, 5 (6) 528-533; DOI: 10.1370/afm.740
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