The Psychosocial and Lingual Effects of Mild to Profound Hearing Loss on School-Aged Children
Abstract
This paper explores the various effects of sensorineural hearing loss (SNHL) on the social functioning of school aged children. All information is derived from well-respected and peer-reviewed journals. The introduction will include a neurobiological explanation of SNHL along with a snapshot of current research. Language and its relation to social function will be explored. Current sources suggest that the inability to distinguish close frequencies may contribute to the delayed language development of SNHL children (Halliday & Bishop, 2005; Meinzen-Derr et al., 2014). The impact of language expression and perception on joining and functioning in a social group is then noted, followed by the exploration of external social factors, such as discrimination and prejudice. Kouwenberg, Rieffe, Theunissen, and Rooij’s study on peer victimization, in conjunction with other research papers, is used to explain the difficulties a child suffering from SNHL may encounter during the social integration process. The psychological well-being of a hearing impaired child will then be analyzed as an outcome of the internal and external consequences of SNHL. The mentioned three categories will be integrated to provide an accurate understanding of SNHL’s effects on the psychosocial aspects of the growing child.
The Psychosocial Effects of Mild to Severe Hearing Loss on School-Aged Children
Introduction
Aristotle once said “man is by nature a social animal.” The key role of communication in forming civilization has created in man a need to socialize. When isolated from communication with civilization, humans undergo severe psychological trauma, as demonstrated by Baek’s 2014 analysis of social isolation. For children with congenial sensorineural hearing loss (SNHL), mild forms of aforementioned psychological disturbance may be present as a result of the implications of the disability (Skribc, Milankov, Veselinovic, and Todorovic, 2012). In this research paper, the language development, external factors, and psychological troubles of a school-aged child with mild, moderate, severe, or profound SNHL will be assessed.
According to the Centers for Disease Control and Prevention, 1.4 out of every 1,000 babies are born with hearing loss. As one of the most prevalent developmental disabilities during infancy, SNHL is also one that greatly impacts a child’s social and psychological health. Many drawbacks of SNHL is now offset by the implantation of cochlear implants (CI) and hearing aids (HA). However, hearing technology is a recent development; the cochlear implant was not widely used in children until the 1990’s. The novelty of the field explains why CI’s and HA’s possess processing ability far below that of the biological auditory system. As a result, those implanted with CI’s or using HA’s often show noticeable differences in social capability when compared to hearing children.
Language is a key development for the proliferation of social ability (Bat-Chava, Martin, and Kosciw, 2005). For those with SNHL, language development is often delayed, yielding a verbal intelligence that is unfit for a child’s age. As a result, discrimination from the child’s peers may occur. The child’s slow lingual development also partially explains the difficulty of the SNHL child’s integration into a social group (Bat-Chava, Martin, and Kosciw, 2005). These social groups may also be discriminative towards the physical symptoms of the disability (visible hearing aids and cochlear implants) and thus reject the integration of children with SNHL. As a result of the delayed development of language and the unwillingness of some social groups to accommodate the subjects in question, children with SNHL are more withdrawn from society and thus more susceptible to psychiatric disorders than normal hearing children.
Neurobiology of Sensorineural Hearing Loss
Before further elaboration on the consequences of SNHL, the nature of hearing loss must be understood. The concept of hearing is best described as the translation of sound waves into electrical impulses. This process starts at the visible ear, where sound waves are collected. Sound then enters the auditory canal and vibrates the eardrum. The ossicles, the three bones of the middle ear, convey the vibrations and magnify them by twentyfold. The last bone of the ossicles, the stapes, conducts the vibrations into the liquid environment of the cochlea. Movement of the liquid in the cochlea stimulates the hair cells of the Organ of Corti, which transduces this movement into electrical signals used in the nervous system.
The visible ear, auditory canal, and the ossicles compose of the outer and middle ear. Damage or malfunction of these parts is known as conductive deafness. Surgery or hearing aids are often used to offset such disability.
Sensorineural hearing loss, the topic of this research paper, involves damage to the inner ear. The hair cells in the Organ of Corti develop improperly and thus cannot transduce sound waves into electrical signals. Sometimes, it is the auditory nerve that is affected. The aforementioned cochlear implant bypasses the cochlear system by creating the electrical signals while the hearing aid amplifies certain frequencies to improve hearing.
Language Development
In hearing communities, verbal and written language is used as an extremely important medium for communication. If fluent language is not achieved, communication breaks down and restricts a child’s ability to socialize. This crucial aspect of communication and socialization begins development in the womb (Hindley, 1997). Mampe, Friederici, Christophe, and Wermke’s study shows that a baby’s cry, a rather primitive form of communication, is shaped by their mother’s native language (2009). This form of environmental language learning is used throughout one’s life. If the fetus and the later infant is not exposed to sound, the lingual development of the child will be greatly affected. Children with severe to profound SNHL face a similar problem, while those with milder forms of hearing loss are affected to a lesser extent. As a result of their decreased ability to pick up sounds from the environment, children with SNHL often show a delay in language development (Schirmer, 1985). In this section, language development will be broken down chronologically, starting with the reception of frequencies, to the later development of receptive and expressive language.
Distinguishing Frequencies
Frequencies of sound is the most basic building block of language; any dialect or language is strung together by a unique sequence of frequencies. In children with SNHL, closer frequencies of audible sound are not distinguished with ease, if the frequencies are able to be distinguished at all. Studies conducted on adults with acquired SNHL demonstrated a decreased ability to discriminate between two frequencies (Freyman & Nelson, 1987). Impaired audibility may account for such impaired discrimination, but other theories for this phenomenon has been suggested (Freyman & Nelson, 1991).
Many researchers have since wondered if the impaired frequency discrimination in adults can be generalized to children. To combat this problem, Halliday and Bishop conducted a set of experiments that tested frequency discrimination in children with milder forms of SNHL (2005). In this study, 22 children with mild to moderate hearing loss and 22 normal hearing children of similar age were used as subjects. The just-noticeable difference of frequency discrimination were calculated; one set of tests were done at a center frequency of 1 kilohertz, and another set at 6 kilohertz. The mean difference thresholds at the two central frequencies showed a significant difference between the SNHL group and the normal hearing group. As hypothesized, the SNHL group were less adept at discriminating frequencies at both central frequencies of 1 kHz and 6 kHz.
Implications: There have been hypotheses set forward that attribute the delayed language development of children with SNHL directly to the child’s decreased ability to distinguish between frequencies. Halliday and Bishop also tested this hypothesis by administering standardized tests of language ability to all participants (2005). This test data is then compared to the difference thresholds determined by Halliday and Bishop’s frequency tests. Initial observation revealed a correlation among a child’s frequency difference threshold, literacy, and non-word repetition in the overall data. However, when only the SNHL group was examined, no significant correlations were discovered. There exists a lack of research in this area; the effects of decreased frequency discrimination can only be stated with confidence when more promising evidence is presented.
Phonological and Grammatical Development
The next critical step in constructing language lies in the reception and memory of phonemes, morphemes, and words. The rules of the language, how sounds are strewn together, also needs to be learnt before successful communication can occur among peers. Note that child mother communication will not be discussed, as mother child dialogue starts and can operate in absence of fluent language.
Phonological Development: To research the phonological development of children with SNHL, a study was conducted on 14 Cantonese-speaking children with either cochlear implants or hearing aids (Law & So, 2006). The children were observed as they named pictures and retold stories, their phonological abilities were explained by their use of phonemes and phonological processes. All except one child had incomplete phonological inventories, even though all participants were at the age of expected complete phonetic development. There is insufficient research in this subject to confidently generalize the Hong Kong study by Law and So (2009) to the English-speaking population. However, a study conducted on English speaking children concluded that “children with CIs have the potential to develop age-appropriate early literacy skills by preschool age but are likely to lag behind their NH [normal hearing] peers in phonological awareness” (Ambrose, Fey, & Eisenberg, 2012).
Development of Syntax and Semantics: Only two viable resources could be found concerning the development of syntax and semantics in a child with SNHL. In a study conducted by Barbara Schrimer in 1985, 20 children with severe to profound hearing loss were tested for their ability in semantics, syntax, and use. When the data was analyzed, the syntax and semantics development was seen as normal, but delayed. In another study conducted by Boons et al., half the participants with SNHL achieved age appropriate levels of grammar and semantic ability (2013). If a link is found between audibility and semantics/syntax development in further research, then children with milder forms of SNHL may be very mildly impacted, if at all, by their handicap in this regard.
Implications: In short, development of phonetic, semantic, and syntactic knowledge is best described as delayed. Being building blocks of complex language, delay in these domains can thus lead to improper development or receptive and expressive language. In the next section, the development of complex communication is reviewed and compared between children with SNHL and normally hearing children.
Development of Complex Receptive and Expressive Language
The reception of frequencies allows for the development of basic units of language, which in turn can prosper into a comprehensive understanding of communication. Difficulties and malfunctions in the previous two domains can thus affect the development of receptive and expressive communication.
In a study conducted by Meinzen-Derr et al. in 2014, a majority deaf or hard of hearing children fell short “of achieving age-appropriate language levels.” Children of three to six years of age with mild to profound SNHL were assessed using the Preschool Language Scales-Fifth Assessment (for language), Leiter International Performance Scale-Revised (for cognition), Vineland Adaptive Behavior Scales – Second Edition (communication and social function), and the Pediatric Evaluation of Disability Inventory (also measured communication and social function). The processing of language and nonverbal IQ was found to have a correlation to the communication and social function of the child. Regardless of severity of hearing loss, the children with SNHL was found to have a lower communication and social function scores (and thus lower language and nonverbal IQ scores) than the hearing children. However, this study was conducted on children from one single institution, a condition which may have affected the results of the study.
Similarly, a study conducted by Lloyd, Lieven, and Arnold in 2005 demonstrated a delay in the expressive and receptive communication skills in a portion of the SNHL group. The listening and speaking skills of group of children with severe to profound hearing loss, all of whom have either cochlear implants or hearing aids, were compared to those of a younger group of children with normal hearing. The children were tested in giving and receiving both clear and unclear instructions. A child’s score is then derived from the percentage of accurate instructions, successful responses, and clarification requests. No significant difference was found between the expressive capabilities of the normal hearing group and the SNHL group. This indicates a clear developmental delay, as the normal hearing group was of a younger age. The younger participants were actually found to have a better receptive communication capability than that of the SNHL group, indicating a severe lag in that domain.
The complex receptive and expressive language development in SNHL children was found, by Meinzen-Derr et al.’s and Lloyd et al.’s studies, to be delayed. Numerous other studies, such as that of Stevenson, McCann, Watkin, Worsfold, and Kennedy (2010), demonstrates the same developmental lag seen in children with SNHL.
Implications: Researchers have established a link between language comprehension and social ability (Meinzen-Derr, 2014). A delay in both expressive and receptive language will cause many social issues that begin almost right after installation into a mainstreamed school. Decreased lingual function can lead to prejudice from peers and a breakdown of communication. These problems in an educational society can lead to discrimination, sometimes at its most extreme form: bullying (Hindley, 1997). The next sections will combine poor language development with other internal and external factors and discuss the implications as a result of such shortcomings.
Social Function
A child’s social development is heavily influenced by the child’s language development (Meizen-Derr, 2014). Proper grasp of lingual properties will enable a child to pick up social cues and lessons from his or her environment (Kouwenberg, Rieffe, Theunissen & Rooij, 2012). For many children with SNHL, the ability to learn from the environment is impaired. Thus, less indirect social learning occurs. A child’s impaired language may also spark prejudice and eventually discrimination against the individual. Studies have shown that it is much harder for children with SNHL to become integrated in a school setting (Bat-Chava et al., 2005). Also, reports of bulling and unfair behavior is more prevalent among students with SNHL than those with normal hearing capabilities. Questions of self-identity also arise from the self-consciousness of one’s hearing disability (Rich, Levinger, Werner, & Adelman, 2013). The combination of internal and external factors has the potential to create serious implications for the child’s psychosocial well-being. There is a definite lack of research in this area, especially concerning the self-identity aspect of hearing loss.
Internal Factors that Effect Social Function
During development, children with SNHL will encounter many questions of self-identity concerning their hearing loss. A child may either accept his physical disability or choose to adopt a hearing identity. The effects of this choice are currently unknown, as only one study was found to briefly describe the internal struggles of a hearing impaired child.
In a self-report study conducted by Rich, Levinger, Werner, and Adelman in 2013, hearing impaired adolescents of 14-18 years old were given a questionnaire that inquired about their integration and societal experience. Responses on the self-identity question contained both instances of acceptance and rejection of the disability. Eight subjects accepted their hearing loss and stressed their well-being as a result of hearing aid and cochlear implants. The other six participants had rejected their physical handicap and thought of themselves as hearing people. In fact, many children regarded hearing loss and its related society as inferior, thus refusing to be attributed to such inferiority. This acceptation/rejection decision is most likely influenced by personality, as well as external forces such as parental and peer judgment.
Note that the mentioned study was conducted on individuals out of the present study’s age group. Younger hearing impaired children may or may not have gone through such questioning of self, but development in that sector is not unknown to begin early. It is crucial for the parents of a child to express unconditional positive regard and place the child in the most appropriate environment for the resolution of the aforementioned stage.
There is also a study that exhibits a mild degree of learned helplessness in children with SNHL. Lloyd et al.’s 2005 study found that children with SNHL were less likely to ask for clarification, even though they were not as linguistically developed as the normally hearing participants. The researchers hypothesized that the embarrassment as a result of the frequent breakdowns in communications experienced by children with SNHL will instill a sense of learned helplessness. Thus, hearing impaired children are less likely to ask for clarification.
Study on the internal struggles of a child with SNHL during development is relatively scarce. Current research suggests the questioning of self-identity. The growing child can either choose to accept the physical disability or to reject it and try to assume a hearing status in society (Rich et al., 2013). Another study also highlights the manifestation of learned helplessness in some hearing impaired children (Lloyd et al., 2005). However, if the precautions are taken to establish a loving environment for the child, proper resolution of these troubles can occur and minimize any damage to the psychosocial well-being of the hearing impaired child.
External Factors that Effect Social Function
Compared to the study of internal self-resolution, there is a lot more research conducted on the external resistance to the socialization and integration of children with SNHL. There is a trend of increased difficulty in all social aspects of the child. Reports of increased bullying, fewer opportunities for socialization, and difficulty in making friends is prevalent among those with hearing impairment (Kouwenberg et al., 2012).
The attitudes of children towards deaf individuals was assessed in a Dutch study conducted by de Laat, Freriksen, & Vervloed (2013). Questionnaires were given to over 400 participants of 13 to 26 years old. The participants’ attitudes towards the deaf were compared with that towards the blind, paralyzed, and intellectually disabled. Generally, the participants regarded the blind and the deaf more positively than the paralyzed and intellectually disabled. However, this finding does not show whether the deaf are considered on the same social level as those with normal hearing; numerous other studies have indicated a sense of inferiority in the hard of hearing as a direct motivator of increased prejudice and bullying.
To gather information on the discrimination and prejudice towards hard of hearing children, Kouwenberg et al. conducted a self-report study on 188 children in the Netherlands and Belgium (2012). Although there was no mean difference in victimization across the hearing impaired and the normal hearing group, further analysis revealed a significant difference between the two groups. The hearing impaired group reported having few opportunities for socialization (such as parties) and received more mean comments and was ignored more when the responses were compared to those of the hearing group. The severity of the hearing loss and the type of technology used (Cochlear implants vs. hearing aids) was found to have no impact on the severity of social pushback. However, enrollment in special programs for the hearing impaired did seem to worsen the discrimination and prejudice towards the hard of hearing child.
Another study conducted by Weiner, Day, and Galvan in 2013 demonstrated a similar phenomenon. Over 800 hearing impaired children from various U.S. schools filled out the Olweus Bullying Questionnaire, which is composed of multiple choice questions that aim to paint an accurate picture of a child’s experiences of bullying. Weiner et al. concluded that hearing impaired children were bullied two to three times more than regular hearing children. In addition, the researchers also found that school staff were less likely to stop bullying behavior if it involved a child with a hearing impairment.
No study could be found that suggested the equal treatment of hearing and hearing impaired children. The evidence points to the contrary; children with SNHL were treated far worse than normal hearing children. Self-reports from numerous participants indicate a higher prevalence of bullying and other discriminatory behavior (Weiner et al., 2013; Kouwenberg et al., 2012; Hindley, 1997).
Implications
The psychosocial capabilities of a child with SNHL will typically be formed by the conjunctive work of normal psychosocial development and the child’s responses to the internal and external struggles highlighted above. If improper resolution of the mentioned factors are achieved, then the psychosocial wellbeing of the child may suffer. Surprisingly, many studies reveal that the social skills of children with SNHL do not differ significantly from that of normally hearing children (Ketelaar, Rieffe, Wiefferink, & Frijns, 2013). This indicates that an elevated level of social pushback does not necessarily result in decreased social competence.
In 2013, a study conducted by Giacomo et al. measured the cognition, adaptive competence, social function, and emotional intelligence in 20 children with profound SNHL. The Leiter International Performance Scale-Revised (tests non-verbal intelligence), Vineland Adaptive Behavior Scale (VABS, tests personal and social skills), and Strengths and Difficulties Questionnaire (SDQ, parental report on behavior and relationships of the children) were administered to the 20 participants. No significant difference was found between the results from the Leiter International Performance Scale-Revised and the VABS of the normal hearing and hard of hearing group. The SDQ contains 25 questions that measure emotional symptoms, conduct issues, hyperactivity-inattention, social behavior, and peer conflicts. The results from the SDQ tests revealed significant differences across two domains, which will be discussed in a later section.
In a similar study conducted by Ketelaar et al. (2013), the social ability and empathetic potential of children with severe to profound hearing loss was compared to those of normally hearing children. This study was performed on a relatively young population of a mean age of 39 months. Ketelaar et al. gathered the social and empathetic competence of the 150 sampled children by administering questionnaires to the parents of the children. The results were similar to that of the Giacomo et al. study (2013): no difference in social competence was discovered. In fact, no link was found between language skills and social or empathetic potential. Instead, a child’s empathic behaviors were a better predictor of their social competence.
In a naturalistic observational study conducted in 2011, Deluzio and Girolametto observed a 20 minute group interaction between two groups of children. Each child was observed and the initiations, responses, and length of interactions were recorded and analyzed. Again, similar results were achieved. Although the children suffering from severe/profound SNHL had delayed language and social development, no difference was found between the socialization skills between the hearing group and the hard of hearing group. However, Deluzio and Girolametto concluded that the children with SNHL was ignored more often: fewer initiations were made towards the mentioned group, and the initiations commenced by the SNHL group was ignored more often than those of the hearing group.
There is an abundance of evidence that suggests that the social competence of children with SNHL is not compromised despite the slow development of language and social abilities (Ketelaar et al, 2013; Deluzio & Girolametto, 2011; Giacomo, 2013). The current research also suggests that the increased social pushback, driven by discrimination and prejudice, has no profound effect on the social abilities of hearing impaired children. The lack of communication and socialization that is observed in older (adolescent) children is not the result of impaired social function, but rather the effects of societal friction.
Psychiatric Aspects of SNHL
The prevalence and manifestation of psychiatric problems in a child with SNHL are the ultimate malefactor to the psychosocial wellbeing of the child. Although the social competence of a child was not disrupted by the delayed language and social function, long term peer victimization can increase a child’s risk for contracting various psychological problems (Kouwenberg et al., 2012). Also, language was found to have an indirect link to the prevalence of behavioral problems (Barker et al., 2009). The manifestation of psychological troubles has the potential, if not observed and corrected promptly, to proliferate into a life-altering condition. Note that this section will not discuss the prevalence of congenial disorders, such as autism, that is attributed to SNHL.
Link between Language and Behavioral Issues
In 2009, Barker et al. conducted various studies in order to construct a model that predicted behavioral problems in children with SNHL. 116 severely/profoundly deaf children, along with 69 children of normal hearing, were subject to parental reports, taped observations, and a wide range of cognitive and lingual measures. The Barker et al. team successfully demonstrated that behavioral problems were more prevalent in hearing impaired children than the normally hearing children. The researchers were also able to construct a model that related language, attention, and behavior. Through their research, a link between language, attention, and behavioral disorders was discovered. Language development can affect the prevalence of behavioral anomalies both directly and indirectly. Delayed language development was attributed to lower capability for sustained attention, which was correlated to increasing behavioral issues. This finding suggests that the prevalence of psychological anomalies in children with SNHL can be decreased by improving the children’s language development process.
Prevalence of Psychological Disorders
All studies retrieved for reference point to the heightened probability for the manifestation of psychological illness in children with SNHL. Aggression, psychopathy, ADHD, defiance, and conduct disorders are among the most prevalent behavioral disorders seen in sampled children (Theunissen et al., 2013). Little evidence can be found that points to the contrary; in fact, no available study suggested the equal prevalence of mental disorders in children with SNHL and normally hearing children.
Kronenberger, Beer, Castellanos, Pisoni, and Miyamoto conducted a cross sectional study on a sample of 73 children in 2014. Two groups, one of 3 to 5 years old and another of 7 to 17 years old, of mixed hearing impaired (severe/profound SNHL) and normally hearing children were tested on executive functioning (the ability to comprehend, attend, and strategize). The executive function of a child was scored by the Learning, Executive, and Attention Functioning Scale (LEAF), which is highly reliable and valid. The Behavior Rating Inventory of Executive Function (BREIF) was also used as a parental report of the child’s executive function. The results showed more difficulties with comprehension, learning, working memory, and problem solving in the hearing impaired children (as measured by the LEAF). The BRIEF results revealed a decreased ability for children with SNHL to control emotions and demonstrated a decrease in working memory function. Kronenberger et al. also concluded that children with SNHL were 2 to 5 times more likely to possess a significant lag in executive function than normally hearing children. As a result of the language-attention-behavior link discovered by Barker et al. in 2009, one can hypothesize that the deficits in attention measured by the LEAF has the potential to cause behavior issues in children with SNHL.
The Strengths and Difficulties Questionnaire (SDQ) aims to describe a child’s emotional status, misbehavior, inattention, social behavior, and relationship problems through a set of 25 attributes. The SDQ was used in numerous studies that attempted to describe the behavioral problems seen in children with SNHL. A previously mentioned study conducted by Giacomo et al. in 2013 employed the SDQ in their testing. The SDQ rating was divided into stress, behavior, hyperactivity, and prosocial behavior subscales. No significant difference between the hearing impaired and normal hearing groups were found in the hyperactivity and stress subscales. However, a difference was found in emotional and peer problems, indicating more emotional troubles and breakdown of communication in the hearing impaired group.
A similar study used parent, teacher and student versions of the SDQ (Anmyr, Larsson, Olsson, & Freijd, 2012). Much like the findings of Giacomo et al., an increased emotional symptoms score was attributed to the hearing impaired group. The researchers of the parent-teacher-student SDQ study also discovered that around a quarter of the hearing impaired participants rated themselves in a way that suggested mental illness.
Such self-suggestion of mental illness is not without justification, a study conducted by Theunissen et al. (2013) concluded that the hearing impaired were subjected to a higher prevalence of a wide range of psychological disorders. 261 children from various institutions, schools, and backgrounds were recruited as samples in the study. The Self Report Instrument for Reactive and Proactive Aggression, the Delinquency Questionnaire, Psychopathy Screening Device, and Child Symptom Inventories-Version 4 were used to assess the aggressive behavior, delinquency, psychopathy, and emotional/behavioral disorders, respectively. The results show that children with SNHL possessed “higher levels of proactive aggression, symptoms of psychopathy, ADHD, ODD, and CD” (Theunissen et al., 2013).
Behavior issues, as demonstrated by a variety of studies, are more prevalent in children with SNHL. However, certain environmental factors can increase or decrease the prevalence of behavioral problems in the subjects in question.
Factors that Increase/Decrease Prevalence
The language-attention-behavior model illustrated in a previous section can be manipulated to decrease the prevalence of behavioral malfunction. By supplementing the development of language, attention can be improved and thus fewer behavioral issues will be present. The opposite can be done; by providing an inappropriate environment for the child, he or she will be more prone to psychological disorder.
The Theuniseen et al. (2013) study mentioned previously also commented on such issue. Attendance to a deaf-only school heightened the risk of other behavioral problems, such as aggression and delinquency. The demographics of the Theuniseen et al. study was compared to the results. The comparison revealed that older age, lower economic status, lower intelligence and language development were attributed to more prevalent and severe behavioral issues.
The topic of decreasing the prevalence of psychological disorders among hearing impaired children requires a paper much longer than the current literature review. Recent research has consistently established a strong link between environment and language development (Schirmer, 1985). Thus, many researchers have been pushing for the improvement of schools and other learning environments to aid language development in children with SNHL.
Conclusions
Literature reviews and research projects aimed to describe language development, social function, and psychological distress in children with SNHL are rather narrow in nature. Very few studies have aimed to combine the previously mentioned categories. The current paper does just that by establishing a link between language, social function, and psychological manifestation. Current research suggests the reciprocal influence of the language-socialization-disorder triangle. Children with SNHL are generally impaired in their language development, leading to decreased social interaction (note that social capabilitywas shown not to be affected) and thus increased prevalence of psychological disorder (Topol, Girard, St Pierre, Tucker, & Vohr, 2011; Barker et al., 2009).
Children and adults with SNHL were determined to be less capable of distinguishing frequency (Halliday & Bishop, 2005). No link between frequency determination and language development has been researched thoroughly, but the impairment may have effect on language development. A study conducted in Hong Kong indicated the delayed phonological development of hearing impaired children (Law & So, 2006). Another basic building block of language, syntax, was discovered to be impaired in development as well (Schirmer, 1985). These delays in basic language development leads to the impairment of complex receptive and expressive language (Lloyd et al., 2005).
These impediments in language development, as well as the physical symptoms of the handicap, can lead to decreased social function. Deluzio and Girolametto discovered that children with SNHL were ignored more often, even when they initiated conversations at the same rate as normal hearing children. Kouwenberg et al. (2012) discovered similar results: children were ignored more often, received more mean comments, and were given fewer opportunities for socialization. Internal struggles are also present in a hearing impaired child’s development. Rich et al. described the process of either accepting or rejecting hearing impaired identity in children with SNHL (2013). Although there is an increase in the social pushback and internal conflict in children with SNHL (resulting in decreased social interaction), their social capability may not be necessarily be impacted (Ketelaar, Rieffe, Wiefferink, & Frijns, 2013). This indicates that a non-prejudiced environment can highly benefit the psychosocial well-being of hearing impaired children.
Current research has discovered a heightened prevalence of psychological disorder among children with SNHL. Theunissen et al.’s study revealed more aggression, ADHD, psychopathy, and defiance in children with SNHL. Other studies, such as that of Anmyr et al. in 2012, report similar findings. Barker et al. discovered a link between language, attention, and behavioral problems in 2009, indicating that better language development can indirectly decrease the prevalence of behavioral problems.
Through the referenced research, it can be concluded that a hearing impaired child’s delayed language development heavily impacts the child’s later social interaction and psychosocial well-being. However, it should be noted that parents should not set lower expectations as a result of the disability. Kouwenberg et al. (2012) discovered that higher parental expectations in children with SNHL results in lower victimization and thus a healthier psychosocial mindset. The lingual and social development of children with SNHL is best characterized as delayed; these delays increase the prevalence of behavioral disorder. However, by providing a loving yet challenging environment, the social and lingual capability of a child with SNHL can be increased and prevalence of psychological disorder decreased.
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Abstract
This paper explores the various effects of sensorineural hearing loss (SNHL) on the social functioning of school aged children. All information is derived from well-respected and peer-reviewed journals. The introduction will include a neurobiological explanation of SNHL along with a snapshot of current research. Language and its relation to social function will be explored. Current sources suggest that the inability to distinguish close frequencies may contribute to the delayed language development of SNHL children (Halliday & Bishop, 2005; Meinzen-Derr et al., 2014). The impact of language expression and perception on joining and functioning in a social group is then noted, followed by the exploration of external social factors, such as discrimination and prejudice. Kouwenberg, Rieffe, Theunissen, and Rooij’s study on peer victimization, in conjunction with other research papers, is used to explain the difficulties a child suffering from SNHL may encounter during the social integration process. The psychological well-being of a hearing impaired child will then be analyzed as an outcome of the internal and external consequences of SNHL. The mentioned three categories will be integrated to provide an accurate understanding of SNHL’s effects on the psychosocial aspects of the growing child.
The Psychosocial Effects of Mild to Severe Hearing Loss on School-Aged Children
Introduction
Aristotle once said “man is by nature a social animal.” The key role of communication in forming civilization has created in man a need to socialize. When isolated from communication with civilization, humans undergo severe psychological trauma, as demonstrated by Baek’s 2014 analysis of social isolation. For children with congenial sensorineural hearing loss (SNHL), mild forms of aforementioned psychological disturbance may be present as a result of the implications of the disability (Skribc, Milankov, Veselinovic, and Todorovic, 2012). In this research paper, the language development, external factors, and psychological troubles of a school-aged child with mild, moderate, severe, or profound SNHL will be assessed.
According to the Centers for Disease Control and Prevention, 1.4 out of every 1,000 babies are born with hearing loss. As one of the most prevalent developmental disabilities during infancy, SNHL is also one that greatly impacts a child’s social and psychological health. Many drawbacks of SNHL is now offset by the implantation of cochlear implants (CI) and hearing aids (HA). However, hearing technology is a recent development; the cochlear implant was not widely used in children until the 1990’s. The novelty of the field explains why CI’s and HA’s possess processing ability far below that of the biological auditory system. As a result, those implanted with CI’s or using HA’s often show noticeable differences in social capability when compared to hearing children.
Language is a key development for the proliferation of social ability (Bat-Chava, Martin, and Kosciw, 2005). For those with SNHL, language development is often delayed, yielding a verbal intelligence that is unfit for a child’s age. As a result, discrimination from the child’s peers may occur. The child’s slow lingual development also partially explains the difficulty of the SNHL child’s integration into a social group (Bat-Chava, Martin, and Kosciw, 2005). These social groups may also be discriminative towards the physical symptoms of the disability (visible hearing aids and cochlear implants) and thus reject the integration of children with SNHL. As a result of the delayed development of language and the unwillingness of some social groups to accommodate the subjects in question, children with SNHL are more withdrawn from society and thus more susceptible to psychiatric disorders than normal hearing children.
Neurobiology of Sensorineural Hearing Loss
Before further elaboration on the consequences of SNHL, the nature of hearing loss must be understood. The concept of hearing is best described as the translation of sound waves into electrical impulses. This process starts at the visible ear, where sound waves are collected. Sound then enters the auditory canal and vibrates the eardrum. The ossicles, the three bones of the middle ear, convey the vibrations and magnify them by twentyfold. The last bone of the ossicles, the stapes, conducts the vibrations into the liquid environment of the cochlea. Movement of the liquid in the cochlea stimulates the hair cells of the Organ of Corti, which transduces this movement into electrical signals used in the nervous system.
The visible ear, auditory canal, and the ossicles compose of the outer and middle ear. Damage or malfunction of these parts is known as conductive deafness. Surgery or hearing aids are often used to offset such disability.
Sensorineural hearing loss, the topic of this research paper, involves damage to the inner ear. The hair cells in the Organ of Corti develop improperly and thus cannot transduce sound waves into electrical signals. Sometimes, it is the auditory nerve that is affected. The aforementioned cochlear implant bypasses the cochlear system by creating the electrical signals while the hearing aid amplifies certain frequencies to improve hearing.
Language Development
In hearing communities, verbal and written language is used as an extremely important medium for communication. If fluent language is not achieved, communication breaks down and restricts a child’s ability to socialize. This crucial aspect of communication and socialization begins development in the womb (Hindley, 1997). Mampe, Friederici, Christophe, and Wermke’s study shows that a baby’s cry, a rather primitive form of communication, is shaped by their mother’s native language (2009). This form of environmental language learning is used throughout one’s life. If the fetus and the later infant is not exposed to sound, the lingual development of the child will be greatly affected. Children with severe to profound SNHL face a similar problem, while those with milder forms of hearing loss are affected to a lesser extent. As a result of their decreased ability to pick up sounds from the environment, children with SNHL often show a delay in language development (Schirmer, 1985). In this section, language development will be broken down chronologically, starting with the reception of frequencies, to the later development of receptive and expressive language.
Distinguishing Frequencies
Frequencies of sound is the most basic building block of language; any dialect or language is strung together by a unique sequence of frequencies. In children with SNHL, closer frequencies of audible sound are not distinguished with ease, if the frequencies are able to be distinguished at all. Studies conducted on adults with acquired SNHL demonstrated a decreased ability to discriminate between two frequencies (Freyman & Nelson, 1987). Impaired audibility may account for such impaired discrimination, but other theories for this phenomenon has been suggested (Freyman & Nelson, 1991).
Many researchers have since wondered if the impaired frequency discrimination in adults can be generalized to children. To combat this problem, Halliday and Bishop conducted a set of experiments that tested frequency discrimination in children with milder forms of SNHL (2005). In this study, 22 children with mild to moderate hearing loss and 22 normal hearing children of similar age were used as subjects. The just-noticeable difference of frequency discrimination were calculated; one set of tests were done at a center frequency of 1 kilohertz, and another set at 6 kilohertz. The mean difference thresholds at the two central frequencies showed a significant difference between the SNHL group and the normal hearing group. As hypothesized, the SNHL group were less adept at discriminating frequencies at both central frequencies of 1 kHz and 6 kHz.
Implications: There have been hypotheses set forward that attribute the delayed language development of children with SNHL directly to the child’s decreased ability to distinguish between frequencies. Halliday and Bishop also tested this hypothesis by administering standardized tests of language ability to all participants (2005). This test data is then compared to the difference thresholds determined by Halliday and Bishop’s frequency tests. Initial observation revealed a correlation among a child’s frequency difference threshold, literacy, and non-word repetition in the overall data. However, when only the SNHL group was examined, no significant correlations were discovered. There exists a lack of research in this area; the effects of decreased frequency discrimination can only be stated with confidence when more promising evidence is presented.
Phonological and Grammatical Development
The next critical step in constructing language lies in the reception and memory of phonemes, morphemes, and words. The rules of the language, how sounds are strewn together, also needs to be learnt before successful communication can occur among peers. Note that child mother communication will not be discussed, as mother child dialogue starts and can operate in absence of fluent language.
Phonological Development: To research the phonological development of children with SNHL, a study was conducted on 14 Cantonese-speaking children with either cochlear implants or hearing aids (Law & So, 2006). The children were observed as they named pictures and retold stories, their phonological abilities were explained by their use of phonemes and phonological processes. All except one child had incomplete phonological inventories, even though all participants were at the age of expected complete phonetic development. There is insufficient research in this subject to confidently generalize the Hong Kong study by Law and So (2009) to the English-speaking population. However, a study conducted on English speaking children concluded that “children with CIs have the potential to develop age-appropriate early literacy skills by preschool age but are likely to lag behind their NH [normal hearing] peers in phonological awareness” (Ambrose, Fey, & Eisenberg, 2012).
Development of Syntax and Semantics: Only two viable resources could be found concerning the development of syntax and semantics in a child with SNHL. In a study conducted by Barbara Schrimer in 1985, 20 children with severe to profound hearing loss were tested for their ability in semantics, syntax, and use. When the data was analyzed, the syntax and semantics development was seen as normal, but delayed. In another study conducted by Boons et al., half the participants with SNHL achieved age appropriate levels of grammar and semantic ability (2013). If a link is found between audibility and semantics/syntax development in further research, then children with milder forms of SNHL may be very mildly impacted, if at all, by their handicap in this regard.
Implications: In short, development of phonetic, semantic, and syntactic knowledge is best described as delayed. Being building blocks of complex language, delay in these domains can thus lead to improper development or receptive and expressive language. In the next section, the development of complex communication is reviewed and compared between children with SNHL and normally hearing children.
Development of Complex Receptive and Expressive Language
The reception of frequencies allows for the development of basic units of language, which in turn can prosper into a comprehensive understanding of communication. Difficulties and malfunctions in the previous two domains can thus affect the development of receptive and expressive communication.
In a study conducted by Meinzen-Derr et al. in 2014, a majority deaf or hard of hearing children fell short “of achieving age-appropriate language levels.” Children of three to six years of age with mild to profound SNHL were assessed using the Preschool Language Scales-Fifth Assessment (for language), Leiter International Performance Scale-Revised (for cognition), Vineland Adaptive Behavior Scales – Second Edition (communication and social function), and the Pediatric Evaluation of Disability Inventory (also measured communication and social function). The processing of language and nonverbal IQ was found to have a correlation to the communication and social function of the child. Regardless of severity of hearing loss, the children with SNHL was found to have a lower communication and social function scores (and thus lower language and nonverbal IQ scores) than the hearing children. However, this study was conducted on children from one single institution, a condition which may have affected the results of the study.
Similarly, a study conducted by Lloyd, Lieven, and Arnold in 2005 demonstrated a delay in the expressive and receptive communication skills in a portion of the SNHL group. The listening and speaking skills of group of children with severe to profound hearing loss, all of whom have either cochlear implants or hearing aids, were compared to those of a younger group of children with normal hearing. The children were tested in giving and receiving both clear and unclear instructions. A child’s score is then derived from the percentage of accurate instructions, successful responses, and clarification requests. No significant difference was found between the expressive capabilities of the normal hearing group and the SNHL group. This indicates a clear developmental delay, as the normal hearing group was of a younger age. The younger participants were actually found to have a better receptive communication capability than that of the SNHL group, indicating a severe lag in that domain.
The complex receptive and expressive language development in SNHL children was found, by Meinzen-Derr et al.’s and Lloyd et al.’s studies, to be delayed. Numerous other studies, such as that of Stevenson, McCann, Watkin, Worsfold, and Kennedy (2010), demonstrates the same developmental lag seen in children with SNHL.
Implications: Researchers have established a link between language comprehension and social ability (Meinzen-Derr, 2014). A delay in both expressive and receptive language will cause many social issues that begin almost right after installation into a mainstreamed school. Decreased lingual function can lead to prejudice from peers and a breakdown of communication. These problems in an educational society can lead to discrimination, sometimes at its most extreme form: bullying (Hindley, 1997). The next sections will combine poor language development with other internal and external factors and discuss the implications as a result of such shortcomings.
Social Function
A child’s social development is heavily influenced by the child’s language development (Meizen-Derr, 2014). Proper grasp of lingual properties will enable a child to pick up social cues and lessons from his or her environment (Kouwenberg, Rieffe, Theunissen & Rooij, 2012). For many children with SNHL, the ability to learn from the environment is impaired. Thus, less indirect social learning occurs. A child’s impaired language may also spark prejudice and eventually discrimination against the individual. Studies have shown that it is much harder for children with SNHL to become integrated in a school setting (Bat-Chava et al., 2005). Also, reports of bulling and unfair behavior is more prevalent among students with SNHL than those with normal hearing capabilities. Questions of self-identity also arise from the self-consciousness of one’s hearing disability (Rich, Levinger, Werner, & Adelman, 2013). The combination of internal and external factors has the potential to create serious implications for the child’s psychosocial well-being. There is a definite lack of research in this area, especially concerning the self-identity aspect of hearing loss.
Internal Factors that Effect Social Function
During development, children with SNHL will encounter many questions of self-identity concerning their hearing loss. A child may either accept his physical disability or choose to adopt a hearing identity. The effects of this choice are currently unknown, as only one study was found to briefly describe the internal struggles of a hearing impaired child.
In a self-report study conducted by Rich, Levinger, Werner, and Adelman in 2013, hearing impaired adolescents of 14-18 years old were given a questionnaire that inquired about their integration and societal experience. Responses on the self-identity question contained both instances of acceptance and rejection of the disability. Eight subjects accepted their hearing loss and stressed their well-being as a result of hearing aid and cochlear implants. The other six participants had rejected their physical handicap and thought of themselves as hearing people. In fact, many children regarded hearing loss and its related society as inferior, thus refusing to be attributed to such inferiority. This acceptation/rejection decision is most likely influenced by personality, as well as external forces such as parental and peer judgment.
Note that the mentioned study was conducted on individuals out of the present study’s age group. Younger hearing impaired children may or may not have gone through such questioning of self, but development in that sector is not unknown to begin early. It is crucial for the parents of a child to express unconditional positive regard and place the child in the most appropriate environment for the resolution of the aforementioned stage.
There is also a study that exhibits a mild degree of learned helplessness in children with SNHL. Lloyd et al.’s 2005 study found that children with SNHL were less likely to ask for clarification, even though they were not as linguistically developed as the normally hearing participants. The researchers hypothesized that the embarrassment as a result of the frequent breakdowns in communications experienced by children with SNHL will instill a sense of learned helplessness. Thus, hearing impaired children are less likely to ask for clarification.
Study on the internal struggles of a child with SNHL during development is relatively scarce. Current research suggests the questioning of self-identity. The growing child can either choose to accept the physical disability or to reject it and try to assume a hearing status in society (Rich et al., 2013). Another study also highlights the manifestation of learned helplessness in some hearing impaired children (Lloyd et al., 2005). However, if the precautions are taken to establish a loving environment for the child, proper resolution of these troubles can occur and minimize any damage to the psychosocial well-being of the hearing impaired child.
External Factors that Effect Social Function
Compared to the study of internal self-resolution, there is a lot more research conducted on the external resistance to the socialization and integration of children with SNHL. There is a trend of increased difficulty in all social aspects of the child. Reports of increased bullying, fewer opportunities for socialization, and difficulty in making friends is prevalent among those with hearing impairment (Kouwenberg et al., 2012).
The attitudes of children towards deaf individuals was assessed in a Dutch study conducted by de Laat, Freriksen, & Vervloed (2013). Questionnaires were given to over 400 participants of 13 to 26 years old. The participants’ attitudes towards the deaf were compared with that towards the blind, paralyzed, and intellectually disabled. Generally, the participants regarded the blind and the deaf more positively than the paralyzed and intellectually disabled. However, this finding does not show whether the deaf are considered on the same social level as those with normal hearing; numerous other studies have indicated a sense of inferiority in the hard of hearing as a direct motivator of increased prejudice and bullying.
To gather information on the discrimination and prejudice towards hard of hearing children, Kouwenberg et al. conducted a self-report study on 188 children in the Netherlands and Belgium (2012). Although there was no mean difference in victimization across the hearing impaired and the normal hearing group, further analysis revealed a significant difference between the two groups. The hearing impaired group reported having few opportunities for socialization (such as parties) and received more mean comments and was ignored more when the responses were compared to those of the hearing group. The severity of the hearing loss and the type of technology used (Cochlear implants vs. hearing aids) was found to have no impact on the severity of social pushback. However, enrollment in special programs for the hearing impaired did seem to worsen the discrimination and prejudice towards the hard of hearing child.
Another study conducted by Weiner, Day, and Galvan in 2013 demonstrated a similar phenomenon. Over 800 hearing impaired children from various U.S. schools filled out the Olweus Bullying Questionnaire, which is composed of multiple choice questions that aim to paint an accurate picture of a child’s experiences of bullying. Weiner et al. concluded that hearing impaired children were bullied two to three times more than regular hearing children. In addition, the researchers also found that school staff were less likely to stop bullying behavior if it involved a child with a hearing impairment.
No study could be found that suggested the equal treatment of hearing and hearing impaired children. The evidence points to the contrary; children with SNHL were treated far worse than normal hearing children. Self-reports from numerous participants indicate a higher prevalence of bullying and other discriminatory behavior (Weiner et al., 2013; Kouwenberg et al., 2012; Hindley, 1997).
Implications
The psychosocial capabilities of a child with SNHL will typically be formed by the conjunctive work of normal psychosocial development and the child’s responses to the internal and external struggles highlighted above. If improper resolution of the mentioned factors are achieved, then the psychosocial wellbeing of the child may suffer. Surprisingly, many studies reveal that the social skills of children with SNHL do not differ significantly from that of normally hearing children (Ketelaar, Rieffe, Wiefferink, & Frijns, 2013). This indicates that an elevated level of social pushback does not necessarily result in decreased social competence.
In 2013, a study conducted by Giacomo et al. measured the cognition, adaptive competence, social function, and emotional intelligence in 20 children with profound SNHL. The Leiter International Performance Scale-Revised (tests non-verbal intelligence), Vineland Adaptive Behavior Scale (VABS, tests personal and social skills), and Strengths and Difficulties Questionnaire (SDQ, parental report on behavior and relationships of the children) were administered to the 20 participants. No significant difference was found between the results from the Leiter International Performance Scale-Revised and the VABS of the normal hearing and hard of hearing group. The SDQ contains 25 questions that measure emotional symptoms, conduct issues, hyperactivity-inattention, social behavior, and peer conflicts. The results from the SDQ tests revealed significant differences across two domains, which will be discussed in a later section.
In a similar study conducted by Ketelaar et al. (2013), the social ability and empathetic potential of children with severe to profound hearing loss was compared to those of normally hearing children. This study was performed on a relatively young population of a mean age of 39 months. Ketelaar et al. gathered the social and empathetic competence of the 150 sampled children by administering questionnaires to the parents of the children. The results were similar to that of the Giacomo et al. study (2013): no difference in social competence was discovered. In fact, no link was found between language skills and social or empathetic potential. Instead, a child’s empathic behaviors were a better predictor of their social competence.
In a naturalistic observational study conducted in 2011, Deluzio and Girolametto observed a 20 minute group interaction between two groups of children. Each child was observed and the initiations, responses, and length of interactions were recorded and analyzed. Again, similar results were achieved. Although the children suffering from severe/profound SNHL had delayed language and social development, no difference was found between the socialization skills between the hearing group and the hard of hearing group. However, Deluzio and Girolametto concluded that the children with SNHL was ignored more often: fewer initiations were made towards the mentioned group, and the initiations commenced by the SNHL group was ignored more often than those of the hearing group.
There is an abundance of evidence that suggests that the social competence of children with SNHL is not compromised despite the slow development of language and social abilities (Ketelaar et al, 2013; Deluzio & Girolametto, 2011; Giacomo, 2013). The current research also suggests that the increased social pushback, driven by discrimination and prejudice, has no profound effect on the social abilities of hearing impaired children. The lack of communication and socialization that is observed in older (adolescent) children is not the result of impaired social function, but rather the effects of societal friction.
Psychiatric Aspects of SNHL
The prevalence and manifestation of psychiatric problems in a child with SNHL are the ultimate malefactor to the psychosocial wellbeing of the child. Although the social competence of a child was not disrupted by the delayed language and social function, long term peer victimization can increase a child’s risk for contracting various psychological problems (Kouwenberg et al., 2012). Also, language was found to have an indirect link to the prevalence of behavioral problems (Barker et al., 2009). The manifestation of psychological troubles has the potential, if not observed and corrected promptly, to proliferate into a life-altering condition. Note that this section will not discuss the prevalence of congenial disorders, such as autism, that is attributed to SNHL.
Link between Language and Behavioral Issues
In 2009, Barker et al. conducted various studies in order to construct a model that predicted behavioral problems in children with SNHL. 116 severely/profoundly deaf children, along with 69 children of normal hearing, were subject to parental reports, taped observations, and a wide range of cognitive and lingual measures. The Barker et al. team successfully demonstrated that behavioral problems were more prevalent in hearing impaired children than the normally hearing children. The researchers were also able to construct a model that related language, attention, and behavior. Through their research, a link between language, attention, and behavioral disorders was discovered. Language development can affect the prevalence of behavioral anomalies both directly and indirectly. Delayed language development was attributed to lower capability for sustained attention, which was correlated to increasing behavioral issues. This finding suggests that the prevalence of psychological anomalies in children with SNHL can be decreased by improving the children’s language development process.
Prevalence of Psychological Disorders
All studies retrieved for reference point to the heightened probability for the manifestation of psychological illness in children with SNHL. Aggression, psychopathy, ADHD, defiance, and conduct disorders are among the most prevalent behavioral disorders seen in sampled children (Theunissen et al., 2013). Little evidence can be found that points to the contrary; in fact, no available study suggested the equal prevalence of mental disorders in children with SNHL and normally hearing children.
Kronenberger, Beer, Castellanos, Pisoni, and Miyamoto conducted a cross sectional study on a sample of 73 children in 2014. Two groups, one of 3 to 5 years old and another of 7 to 17 years old, of mixed hearing impaired (severe/profound SNHL) and normally hearing children were tested on executive functioning (the ability to comprehend, attend, and strategize). The executive function of a child was scored by the Learning, Executive, and Attention Functioning Scale (LEAF), which is highly reliable and valid. The Behavior Rating Inventory of Executive Function (BREIF) was also used as a parental report of the child’s executive function. The results showed more difficulties with comprehension, learning, working memory, and problem solving in the hearing impaired children (as measured by the LEAF). The BRIEF results revealed a decreased ability for children with SNHL to control emotions and demonstrated a decrease in working memory function. Kronenberger et al. also concluded that children with SNHL were 2 to 5 times more likely to possess a significant lag in executive function than normally hearing children. As a result of the language-attention-behavior link discovered by Barker et al. in 2009, one can hypothesize that the deficits in attention measured by the LEAF has the potential to cause behavior issues in children with SNHL.
The Strengths and Difficulties Questionnaire (SDQ) aims to describe a child’s emotional status, misbehavior, inattention, social behavior, and relationship problems through a set of 25 attributes. The SDQ was used in numerous studies that attempted to describe the behavioral problems seen in children with SNHL. A previously mentioned study conducted by Giacomo et al. in 2013 employed the SDQ in their testing. The SDQ rating was divided into stress, behavior, hyperactivity, and prosocial behavior subscales. No significant difference between the hearing impaired and normal hearing groups were found in the hyperactivity and stress subscales. However, a difference was found in emotional and peer problems, indicating more emotional troubles and breakdown of communication in the hearing impaired group.
A similar study used parent, teacher and student versions of the SDQ (Anmyr, Larsson, Olsson, & Freijd, 2012). Much like the findings of Giacomo et al., an increased emotional symptoms score was attributed to the hearing impaired group. The researchers of the parent-teacher-student SDQ study also discovered that around a quarter of the hearing impaired participants rated themselves in a way that suggested mental illness.
Such self-suggestion of mental illness is not without justification, a study conducted by Theunissen et al. (2013) concluded that the hearing impaired were subjected to a higher prevalence of a wide range of psychological disorders. 261 children from various institutions, schools, and backgrounds were recruited as samples in the study. The Self Report Instrument for Reactive and Proactive Aggression, the Delinquency Questionnaire, Psychopathy Screening Device, and Child Symptom Inventories-Version 4 were used to assess the aggressive behavior, delinquency, psychopathy, and emotional/behavioral disorders, respectively. The results show that children with SNHL possessed “higher levels of proactive aggression, symptoms of psychopathy, ADHD, ODD, and CD” (Theunissen et al., 2013).
Behavior issues, as demonstrated by a variety of studies, are more prevalent in children with SNHL. However, certain environmental factors can increase or decrease the prevalence of behavioral problems in the subjects in question.
Factors that Increase/Decrease Prevalence
The language-attention-behavior model illustrated in a previous section can be manipulated to decrease the prevalence of behavioral malfunction. By supplementing the development of language, attention can be improved and thus fewer behavioral issues will be present. The opposite can be done; by providing an inappropriate environment for the child, he or she will be more prone to psychological disorder.
The Theuniseen et al. (2013) study mentioned previously also commented on such issue. Attendance to a deaf-only school heightened the risk of other behavioral problems, such as aggression and delinquency. The demographics of the Theuniseen et al. study was compared to the results. The comparison revealed that older age, lower economic status, lower intelligence and language development were attributed to more prevalent and severe behavioral issues.
The topic of decreasing the prevalence of psychological disorders among hearing impaired children requires a paper much longer than the current literature review. Recent research has consistently established a strong link between environment and language development (Schirmer, 1985). Thus, many researchers have been pushing for the improvement of schools and other learning environments to aid language development in children with SNHL.
Conclusions
Literature reviews and research projects aimed to describe language development, social function, and psychological distress in children with SNHL are rather narrow in nature. Very few studies have aimed to combine the previously mentioned categories. The current paper does just that by establishing a link between language, social function, and psychological manifestation. Current research suggests the reciprocal influence of the language-socialization-disorder triangle. Children with SNHL are generally impaired in their language development, leading to decreased social interaction (note that social capabilitywas shown not to be affected) and thus increased prevalence of psychological disorder (Topol, Girard, St Pierre, Tucker, & Vohr, 2011; Barker et al., 2009).
Children and adults with SNHL were determined to be less capable of distinguishing frequency (Halliday & Bishop, 2005). No link between frequency determination and language development has been researched thoroughly, but the impairment may have effect on language development. A study conducted in Hong Kong indicated the delayed phonological development of hearing impaired children (Law & So, 2006). Another basic building block of language, syntax, was discovered to be impaired in development as well (Schirmer, 1985). These delays in basic language development leads to the impairment of complex receptive and expressive language (Lloyd et al., 2005).
These impediments in language development, as well as the physical symptoms of the handicap, can lead to decreased social function. Deluzio and Girolametto discovered that children with SNHL were ignored more often, even when they initiated conversations at the same rate as normal hearing children. Kouwenberg et al. (2012) discovered similar results: children were ignored more often, received more mean comments, and were given fewer opportunities for socialization. Internal struggles are also present in a hearing impaired child’s development. Rich et al. described the process of either accepting or rejecting hearing impaired identity in children with SNHL (2013). Although there is an increase in the social pushback and internal conflict in children with SNHL (resulting in decreased social interaction), their social capability may not be necessarily be impacted (Ketelaar, Rieffe, Wiefferink, & Frijns, 2013). This indicates that a non-prejudiced environment can highly benefit the psychosocial well-being of hearing impaired children.
Current research has discovered a heightened prevalence of psychological disorder among children with SNHL. Theunissen et al.’s study revealed more aggression, ADHD, psychopathy, and defiance in children with SNHL. Other studies, such as that of Anmyr et al. in 2012, report similar findings. Barker et al. discovered a link between language, attention, and behavioral problems in 2009, indicating that better language development can indirectly decrease the prevalence of behavioral problems.
Through the referenced research, it can be concluded that a hearing impaired child’s delayed language development heavily impacts the child’s later social interaction and psychosocial well-being. However, it should be noted that parents should not set lower expectations as a result of the disability. Kouwenberg et al. (2012) discovered that higher parental expectations in children with SNHL results in lower victimization and thus a healthier psychosocial mindset. The lingual and social development of children with SNHL is best characterized as delayed; these delays increase the prevalence of behavioral disorder. However, by providing a loving yet challenging environment, the social and lingual capability of a child with SNHL can be increased and prevalence of psychological disorder decreased.
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