Supporting Children with Hearing Loss

Session Objectives
• Understand the impact of
– the diagnosis of hearing loss on a family system
– hearing loss on psycho-social development of a
child

• Become familiar with a pediatric counseling guideline

and understand how to integrate it into your practice
 Child Developmental Model
Teacher, Speech
Language Pathologist
Audiologist,
Physician

?
Pediatric Counseling Guidelines

Birth through transition to school

 Pediatric Counseling Guidelines

• Impact of diagnosis
• Psycho-Social development
– Erik Erikson’s model of development
– Development of self-concept (15 mos+)
– Development of social skills
 Pediatric Counseling Guidelines

• Diagnosis
• Birth to Three years
• Three to Six years
• Six to Eleven years
• Eleven through Adolescence
 Erikson’s Stages
of Psycho-Social Development

• Trust vs. Mistrust (birth – 18 months)

• Autonomy vs. Shame and Doubt
(18 mos – 2 years)
• Initiative vs. Guilt (3 – 6 years)
 Psycho-Social Development
Self-Concept

An individual’s understanding of who they are

• No self
• Self-awareness
• Factual self-concept
• Egocentric view of self-concept
– Self-confidence and self-esteem emerging
• Comparative
• Peer-pressure
• Individuation
 Psycho-Social Development
Social Skills

• Healthy Attachment
• Basic
• Intermediate
• Advanced
Developmental
Index of Audition
and Listening (DIAL)

• Functional auditory
milestones

Palmer and Mormer (1999)

 Impact of Diagnosis

• Sharing information

• Recognizing emotional reactions

• Promoting healthy attachment

• Positively impacting family systems

 Sharing Information
Medical Model Family Centered Model
 What are the benefits of Family-
Centered Care?
(not specific to hearing impairment)

• Improved teaching skills of parent

• Better behavior from child as a result of
improved parental teaching skills
• Decreased parental stress
• Improved satisfaction of services
 Recognizing Emotional Reactions
Feelings Involved with Grief

• Shock/Denial/ Numbness
• Anger/Fear/Panic
• Sadness/Hopeless
• Guilt/Bargaining
• Healthy
acceptance/adaptation
 Grief
Core pain can’t be taken away.
• Feelings must be acknowledged, expressed in a safe,
caring environment.
• Some emotions have an important purpose in helping
parents adjust to the diagnosis
Potential Pitfall: Because parents may have strong
feelings of inadequacy
• Many parents happy to turn over their child to “the
experts”
• Professionals eager to rescue

Luterman (1999)
 Feelings Involved with Grief

• Shock/Denial/Numbness - protects parents from

deep pain and allows parents to build up energy for
the work ahead of them

• Anger - Parents feel cheated. Anger hides their fear.

Many professionals are very afraid of the anger and
respond defensively. Need to help parents capture
and direct their energy effectively.
 Feelings Involved with Grief

• Sadness/Hopelessness – expressing grief – moving

forward
• Guilt:
– Fathers for not protecting the family
– Mothers because she secretly believes she’s at fault for the
hearing loss
– Comes between the marriage, family becomes unbalanced
(Mother+child, father+work)
– Danger is overprotection of child. Conveys helplessness to
the child.
 The Hearing Healthcare Professional
a.k.a.

“The Healer”
• A vicious cycle begins when parental helplessness and
powerlessness intersects with professionals’ need to help,
save, assume the powerful, “expert” role with families
• Results in parents who are:
Over-controlling Lack self-confidence
Self-serving Don’t feel competence
Passive

• Children internalize this powerlessness, helplessness, and

head down a path of life long poor self-esteem
 Parents with Unresolved Grief Can Be:

• Emotionally overwhelmed
• Stuck in anger
• Frequently suppressing their emotions
• Depressed or passive
• Unrealistic or stuck in denial
• Disorganized, confused
• Actively searching for the cause of the hearing loss

Yoshinaga-Itano (2001)
 What can you do?

• Provide immediate, appropriate support

• Have appropriate counseling skills
• Have expert knowledge and experience with living
with hearing loss
• Actively listening
• No judging the family
• Build parental self-esteem, self-confidence

Yoshinaga-Itano (2001)
 What can you do?

Help families understand

• The etiology, emphasizing that cause was not
parents’ intention
• Their child is not fragile
• Their child can do anything, but, may have to do
some things differently
• That taking good care of themselves and their
marriage = taking good care of their child

Luterman (1999)
 What can you do?

Inform parents that:

– Children with congenital and pre-lingual onset of hearing
loss do not experience grief until sometime between 7 – 9
years of age
– Parents need to keep their grief away from child. Child will
misunderstand and misattribute parents’ grief
– Child has best chance of resolving their initial grief if
parents have positively resolved their initial grief
 Healthy Acceptance/Adaptation
• Acknowledge their preference that their
child not be deaf/hard of hearing
• Accept the permanence of the hearing
loss
• Understand and have entire family take
consistent action to make necessary
changes create accessible/effective
communication environment for
deaf/hard of hearing child
 Healthy Attachment
Between Parents and Children

• Deep enduring connections established

between child and caregiver
• Occurs between birth and age 3
• Learned ability
• Result of ongoing reciprocal interactions
characterized by protection, need fulfillment,
limits, love and trust

Levy (2000)
 Healthy Attachment
Can Lead to Development of:

• Basic trust and reciprocity

• Self-regulation of affect and behavior
• Healthy identity = healthy self-worth + autonomy
• Morality based upon empathy, compassion and conscience
• Resourcefulness and resilience for response to future stress
• Stimulating experiences required for healthy brain
development

Levy, (2000)
 Potential Consequences
of Insecure Attachment:

Self-regulation deficits:
– Impulse control
– Self-soothing
– Initiative
– Perseverance
– Inhibition
– Patience

Levy (2000)
 Potential Consequences
of Insecure Attachment:
Development of problem behaviors:
– Impulsiveness
– Hyperactivity
– Inattention
– Seeking stimulation
– Poor self-image
– No friends
– Oppositional and defiant
– Disruptive
– Manipulative
– Blames others (internalized helplessness)

Levy (2000)
 What can you do?

• Inform parents that:

– Teach parents about the importance of healthy
attachment
– Support them through the feelings associated
with grief
– Help them understand the impact hearing
impairment has on communication – avoid
misunderstanding communication difficulties
 Healthy Family System

• Feels empowered
• High self-esteem (especially for the mother)
• Feeling that burdens are shared
• Achieved healthy acceptance of the diagnosis

Luterman (2001)
Healthy Family System
Unhealthy Family System
 What can you do?

• Inform parents
• Be a sounding board
• Listen
• Coach
• Acknowledge
• Brainstorm
• Support
• Model strategies
• Refer to professionals when needed
 Child
Developmental Model
Teacher

Insert your
Audiologist,
picture here Physician

YOU!!
 Psycho-Social Development
Erikson’s Stages
Trust versus Mistrust
(birth – 18 months)

Babies learn to:

• Trust their world if they are kept well-fed, warm,
dry, and receive regular human touch
• Mistrust their world if they are left hungry, cold,
wet, and unattended
 Psycho-Social Development
Erikson’s Stages
Autonomy versus Shame and Doubt
(18 months – 2 years)

Toddlers want to rule their own actions and bodies

With success develop Autonomy

With failure develop Shame and

Doubt in their own abilities
 Self-Concept
Birth – 14 months

• No sense of self
• Child views themselves as extension of their
parent/caregiver
• Classic test: red nose in the mirror; All
children 12 months and younger do not know
they are seeing themselves in a mirror
 Self-Concept
15 months – 2 years

• Self awareness emerges

• Recognize self in a mirror

• Classic test: red nose in the mirror; Most

children 15 – 24 months will notice the red on
their nose and be curious or embarrassed
 Self-Concept
2 - 3 years

• Self concept emerges

• Child identifies themselves as:
– A “girl” or a “boy”
– A “baby” or “big boy/girl”
– A “brother” or “sister” or only child
– By religious affiliation
– By ability
 What can you do?

• Evaluate and support access to alerting

devices
• Include the child in conversations about
hearing loss - positive
• Support families in developing relationships
with other families with children with hearing
loss and with D/HoH adults and older children
 Psycho-Social Development
Erikson’s Stages
Initiative versus Guilt
(3 – 6 years)
Initiative:
• Increased awareness of self and world outside of home
• Eagerly attempts new tasks and play activities
• Successful attempts at new tasks help children learn and
master many things, which becomes self-reinforcing (proud
of themselves) and self-controlling to gain the approval of
adults
 Psycho-Social Development
Erikson’s Stages
Initiative versus Guilt
(3 – 6 years)

Guilt:
• When attempts result in failure or criticism,
the child feels:
Guilty
Incompetent
Helpless
 Self-Concept
3 - 6 years

• Ego-centric thinking
• “I am the world and the world is just like me!”
• Repetition/Practice Mastery
• Mastery Competence
• Competence Self-confidence
• Self-confidence Self-esteem
 Professional as Coach
Parents teach their child.
Professionals support and
coach parents as they teach their child.

Professional Parent Child

 Development of
Social Skills/Interaction

Provide information to parents on:

• Lack of incidental learning due to hearing loss
• Often deaf/hard of hearing children need specific
training on basic and more advanced social skills
• Use of social skills books
• Discriminating between “Can’t Do” or “Won’t Do”
behavior problems

Gresham (1995)
 Frequent Teaching of Social Skills

• For “Can’t do” behavior problems: Use

Modeling, coaching, practice

• For “Won’t do” behavior problems: Use

behavior charts, positive
reinforcement, effective praise, and
noticing (and describing) good
behavior

Gresham (1995)
 Examples of Basic Social Skills

• Eye contact
• Smiling
• Listening (for friendship)
• Introducing yourself
• Meeting new people
• Joining a group
• Giving compliments
 What can you do?

• Promote effective communication strategies -

for all (including YOU!)
• Evaluate and support access to age-
appropriate activities
• Talk to families about social skill development
• Foster development of initiative
 Eileen Rall, Au.D., CCC-A
(215) 590-7612 or rall@email.chop.edu

Center for Childhood Communication

at
The Children’s Hospital of Philadelphia
34th and Civic Boulevard, Room 112
Philadelphia, PA 19104

Thank you!
Psychosocial Development of Children with Hearing Loss
Hearing loss has a negative impact on communication skills and, therefore, creates
additional challenges. Audiologists can support successful experiences at each of
Erikson’s developmental stages by working with the child and family to:
• Ensure that a child has the opportunity to fully participate in the environment by
providing access to auditory and/or visual environmental cues
• Inform families about developmental milestones
• Provide the tools for the child, family, and educators to develop good
communication skills, including amplification, assistive devices, and instruction on
creating effective listening environments
• Encourage the development of appropriate social skills
• Coach caregivers on creating positive and successful experiences when the child
attempts new skills
• Building Trust
• From birth through approximately 3 years of age, Erikson postulates that children experience two
distinct stages of psychosocial development. In the first stage, children learn whether they can trust
their environment and if their basic needs will be consistently met (Berger, 2003). When caregivers
meet children’s basic needs, children learn to trust them and their environment in general. Children
with hearing loss may be at a disadvantage in this stage of development because of several factors.
For example, their parents may not be able to respond consistently to their needs because they are
experiencing grief over their child’s diagnosis. A child may not have access to the auditory cues that
signal that a parent’s attention may be diverted (e.g., doorbell or ringing telephone) or not be
aware of the auditory stimulation a parent is using to comfort the child or to show affection.

The audiologist can support psychosocial development at this stage by:

• Working with families toward healthy acceptance of and adaptation to their child’s hearing loss so
that the parents are emotionally prepared to meet their child’s needs
• Reminding parents that children with hearing loss may perceive a situation very differently from a
child with normal hearing sensitivity
• Ensuring that the child has access—either visual or auditory—to the parents’ communication with
the child and his/her environment (e.g., consistent use of amplification during waking hours, visual
alerting devices for the home) and teaching parents about the characteristics of good listening
environments, effective communication strategies, and appropriate attention-getting skills
• Developing Autonomy
• Erikson’s second stage is the development of autonomy versus shame and doubt. At this stage, children
from about 1 to 3 years of age are challenged to explore their environment and start to take some control
over it. Children will develop a sense of autonomy if their attempts at manipulating their world are
successful or if they are reassured and encouraged when their attempts fail. Shame and doubt may
develop if their attempts at independence are met with disapproval, if every need is anticipated and
provided, or if they are prevented from exploring their world. Children with hearing loss may be at a
disadvantage for developing independence because they do not have access to developmentally
appropriate tools in their environment such as the telephone, household alarms, door-knockers, or
television. They may be overprotected and not encouraged to try new activities or exert their
independence (Berger, 2003). This overprotection teaches children to be helpless.
Audiologists can support positive experiences by:
• Ensuring a child’s access to age-appropriate stimulation, including television, noise-making or musical toys,
visual alerting devices, and the telephone through use of amplification; assistive listening devices; and
visual alerting devices
• Counseling parents to encourage and support age-appropriate activities
• For example, even at this young age, children can take some control of their hearing aids by putting them
in the dehumidifier at night or participating in daily hearing aids checks (by bringing the hearing aid to the
parent and by using the child’s voice for the listening check).
• Audiologists should gently reinforce that a child with hearing loss is not fragile; parents do not need to
protect their child from experiencing failures, but should instead provide reassurance when their child
makes mistakes.
Promoting Initiative
• Erikson’s challenge for 3 to 6 years of age is the development of a sense of “initiative.”
Children with initiative will begin and successfully complete tasks, accept limitations
without guilt, and develop a sense of pride in their accomplishments (Berger, 2003).
Children at this stage believe they will be successful in anything. With positive
reinforcement and appropriate and consistent limitations, children will succeed in this
stage. If their attempts result in failure or criticism, they can develop a sense of guilt for
seeking independence and shame and doubt in their abilities.
• Again, children with hearing loss are at a disadvantage in this developmental stage if
they lack adequate access to their environment and consistent, effective, and
meaningful communication with their peers, parents, teachers, and family. Access to
their environment needs to be extended to areas outside of the home (e.g., school,
playmate’s home, playground, extracurricular/community activities). Linda Hodgdon
(2000) provides excellent suggestions for increasing the amount of visual information
for a child in home and educational settings that don’t rely on the child’s literacy or the
signing skills of the child or others. Visual redundancy and abundance of information in
the child’s environment—in particular of family plans and expectations of the child—
will increase the child’s ability to confirm communication when he or she has to “fill in
the blanks” when communicating with family members, teachers, or peers.
• Promoting Initiative
• Erikson’s challenge for 3 to 6 years of age is the development of a sense of “initiative.” Children with initiative will begin and
successfully complete tasks, accept limitations without guilt, and develop a sense of pride in their accomplishments (Berger, 2003).
Children at this stage believe they will be successful in anything. With positive reinforcement and appropriate and consistent
limitations, children will succeed in this stage. If their attempts result in failure or criticism, they can develop a sense of guilt for seeking
independence and shame and doubt in their abilities.
• Again, children with hearing loss are at a disadvantage in this developmental stage if they lack adequate access to their environment
and consistent, effective, and meaningful communication with their peers, parents, teachers, and family. Access to their environment
needs to be extended to areas outside of the home (e.g., school, playmate’s home, playground, extracurricular/community activities).
Linda Hodgdon (2000) provides excellent suggestions for increasing the amount of visual information for a child in home and
educational settings that don’t rely on the child’s literacy or the signing skills of the child or others. Visual redundancy and abundance of
information in the child’s environment—in particular of family plans and expectations of the child—will increase the child’s ability to
confirm communication when he or she has to “fill in the blanks” when communicating with family members, teachers, or peers.
• Audiologists play a key role in encouraging the development of initiative. They can:
• Ensure that patients have access to age-appropriate activities such as community groups, extracurricular activities, religious services,
computers, safe outdoor play, and telephones
• Encourage use of effective communication skills in and out of the home environment and the educational setting
• Teach children what does and does not comprise a good listening environment and how to seek out and state their needs for good
communication
• Teach children how to use effective attention-getting, communication strategies, and compliments and thankful expressions with peers
and adults in their lives
• Encourage parents to promote a child’s responsibility for care of his or her equipment, such as changing batteries and taking
responsibility for putting hearing aids on
• Teach the child and family about necessary accommodations for children who choose to be involved in sports, such as those suggested
in Time Out! I Didn’t Hear You (Palmer, Butts, Lindley, & Snyder, 1996).
• During these early years, children typically have very favorable opinions of themselves and their
abilities (Berger, 2003). To support the development of a positive self-concept, the audiologist can
respond affirmatively to a child’s seemingly endless need to demonstrate or “show-off” his or her
abilities. In doing so, the child is in fact repeating his or her performance, which eventually leads to
mastery, which then leads to competence, which eventually results in healthy self-esteem. We can
encourage their families to support these behaviors as well.
• Beginning social skills (e.g., following instructions and basic social introductions) should be
mastered during this period. If a child is demonstrating problem behaviors (e.g., temper tantrums,
biting), the audiologist can help assess whether communication problems (e.g., poor listening
environments, limited auditory access, delayed language) may be contributing factors. Gresham
(1994) suggests that parents be encouraged to differentiate between skills a child is not able to
perform (“can’t do”) versus those they are unwilling to perform (“won’t do”). If a child is unable to
perform them, parents can turn to social skills training guides, such as Teaching Social Skills to
Youth: A Curriculum for Child-Care Providers (Dowd & Tierney, 1995). If the child is unwilling to use
appropriate social skills, the family can be encouraged to employ behavior modification techniques
such as charts, positive reinforcement, effective praise, and noticing (and describing) good
behaviors to elicit the desired social skills (Gresham).
• Erik Erikson described psychosocial development as a series of stages or
developmental challenges. At each of these stages, success or failure is dependent
upon “the interaction between the individual’s characteristics and whatever
support is provided by the social environment” (Berger, 2003, p. 38). With positive
experiences, children work through their challenges and develop skills (e.g.,
autonomy, trust, initiative) to help them positively resolve the developmental
challenges still ahead. If, however, children’s attempts at problem resolution result
in consistent failure, they will not be prepared for future challenges.