Today’s blog is written by my friend and colleague, Andrea Warner-Cyz. Dr. Andrea Warner-Czyz, Associate Professor at The University of Texas at Dallas, investigates communication and quality of life in children with hearing loss using cochlear implants (CIs). Her research focuses on risk and protective factors that underlie variability in speech, language, and hearing skills, and how these factors affect social interaction in in children and adolescents with hearing loss.
The art of conversation
Our efforts as parents, clinicians, and researchers concentrate on development of speech, language, and hearing skills in children with hearing loss. Our intense focus on how to communicate downplays the importance of how to communicate. That is, some children with hearing loss show a disparity between outcomes achieved in the clinic in a controlled, ideal environment and implementation of those same skills in real-world situations. They may develop the speech recognition, speech production, and language skills that qualify them to “graduate” from clinical services because they reach levels within the normal range. However, they struggle in applying the speech, language, and hearing skills learned in clinic to social interactions, which may negatively affect how children with hearing loss relate to peers.
Several studies report children and adolescents with hearing loss exhibit difficulties making and maintaining friendships. I have queried children and adolescents with hearing loss on how many friends they have, ranging from no friends to lots of friends. They respond similarly to hearing peers, with three-fourths of both groups indicating they have either several or lots of friends. I was thrilled with these results! However, one parent told me her daughter marked she had several friends on our survey, but she really had one to two good friends; the others were acquaintances. Clinicians and other parents echo the feeling that children and adolescents with hearing loss often cannot distinguish between acquaintances and true friendship.
That made me think, and should make all of us think, how children and adolescents with hearing loss interact with peers in both positive and negative ways. Our research group started looking beyond friendship quantity to examine friendship quality – how much a relationship is characterized by companionship, validation and caring, intimate exchange, or conflict. In children and adolescents with typical development, friendship quality increases with age and maturity. We have new data showing adolescents using cochlear implants rate the quality of their relationship with their best friend less positively than adolescents with typical hearing. In fact, adolescents with cochlear implants appraise friendship quality more similarly to younger children with typical hearing – which confirms anecdotal reports from parents that their children with hearing loss prefer to socialize with children one to two years younger. This suggests they can and do have positive relationships with other children, even if they are not the same age.
We also have explored the effect of hearing loss on peer victimization – unwanted aggressive, repeated behavior(s) by another youth or group of youths in which a power imbalance exists (whether perceived or actual). Certain factors increase the chance of getting bullied for all children. For example, children with inadequate social skills have fewer friends, more peer problems, and poorer peer relationships than children with acceptable social competence. Children and adolescents who are weak or different due to health issues or exceptionalities also experience higher victimization rates. In fact, children with special needs report twice the rate of getting bullied than children without exceptionalities. Children with hearing loss have increased risk of getting picked on because (a) wearing auditory technology makes them look different; and (b) having trouble listening and/or having difficulty expressing themselves can make them communicate and socialize differently than hearing peers.
Our recently published study examines this issue in a contemporary group of adolescents with hearing loss to determine if having hearing loss affects the prevalence or type of peer victimization, and which factors (if any) coincide with being bullied in those with hearing loss. Participants included 56 adolescents (12-18 years) with hearing loss using hearing aids, cochlear implants, or both. All adolescents with hearing loss communicated orally and participated in mainstream education. They had a mean age of 14.1 years, mean age at device fitting of 3.3 years, and mean duration of device experience of 10.8 years. We compared reported prevalence and type of peer victimization with previously published data on 4,326 adolescents in the general population (DeVoe and Murphy, 2011).
Adolescents with hearing loss and those in the general population completed a survey assessing the occurrence and type of peer victimization: Teasing (i.e., being made fun of, called names, insulted), having rumors spread about them, threats with harm, physical harm (i.e., pushed, shoved, tripped, spit on), coercion (i.e., being forced to do something they did not want to do), purposeful exclusion from activities, or property destruction. Adolescents with hearing loss also completed a series of online questionnaires about their self-reported ability to communicate, quantity and quality of friendships, and self-assessment of temperament (i.e., affiliation, attention, shyness, frustration) and behavior (i.e., depressive mood).
Adolescents with hearing loss self-reported twice the rate of peer victimization than adolescents in the general popultion (50% vs. 28%). In fact, rates of getting bullied at least one way mirrors rates reported by children with special needs (40-68%). Adolescents with and without hearing loss differed not only on if, but also how they experienced victimization. Adolescents in the general population most frequently reported teasing (19%), rumors (17%), and physical harm (9%). Adolescents with hearing loss reported not only higher frequencies of teasing (26%) and rumors (21%), but also five times the rate of social exclusion than adolescents in the general population (26% vs. 5%). Surprisingly, the bullied and non-bullied groups of adolescents with hearing loss did not differ on measures of communication competence, social competence, temperament or behavior.
How can parents and professionals help?
When I think about peer victimization in children and adolescents with hearing loss, my mind always returns to one teenager I met at a cochlear implant camp years ago. The peers he considered friends would act nice to him one day, then bully him in multiple ways other days. When I asked why he was picked on, he told me he spent the first five years of his life learning how to listen and speak. He did not go to playgroups or learn how to interact with children his own age. His statement has had a profound impact on me. Could parents and professionals focus on other areas to help children with hearing loss succeed, both academically and socially?
We know that parenting style and parental involvement influences peer relationships. Parents can facilitate social skills and inclusion from a young age by involving their children in playgroups, sports teams, and group activities. This may mean they serve as a “concierge” who organizes activities and events, but it ensures their child remains part of a group. Parents also can teach language about emotions by calling attention to how others may feel based on facial expressions, body language, and words, which can influence sensitivity and emotional intelligence during social interactions. Additionally, frequent, open communication between parents and children – even 15 minutes a day – can create a trusting environment that promotes honest, non-judgmental sharing of information. Such interactions may provide a chance for parents to look for signs of bullying such as differences in physical (e.g., changes in sleep or eating patterns) and psychosocial well-being (e.g., withdrawal, anxiety, depression, anger, irritability).
Professionals have a role in addressing peer relationships, too. This starts with thinking beyond basic speech, language, and hearing skills to incorporate the parameters of social communication. Knowing the rules of social interactions (i.e., equal turn-taking between partners, making eye contact, reading facial expressions and body language) can boost social-pragmatic skills. Clinicians can focus on these skills through individual instruction, role-playing, or social skills groups to improve social competence and reduce vulnerability to peer victimization. Professionals also can screen for peer victimization during appointments by asking about friendships and possible experiences with peer victimization. Clinicians should describe situations (e.g., teasing, pushing, being left out) versus using the term “bullying” for an accurate measure of occurrence without coloring results with negative connotation of the term. If a child reports peer victimization, professionals can direct families to online resources such as www.stopbullying.gov and https://successforkidswithhearingloss.com/. Clinicians also can include issues related to peer victimization on the child’s educational plan by (a) designating a “home base” or “safe person” to which a student can go when feeling unsafe; and (b) targeting social-pragmatic (see above) and self-advocacy skills.
Parents and professionals alike can enhance self-advocacy skills in children and adolescents with hearing loss. This could start with ensuring the child has the language, knowledge, and confidence to describe their hearing loss and auditory technology. Skills could blossom into advocating for better communication strategies (i.e., asking for clarification when they cannot understand what a speaker said) and requesting help from a trusted source. With regard to peer victimization, children and adolescents may need explicit instruction to identify and report when victimization occurs and to say “no” to stop the situation.
Because peer relationships assume a more prominent social support role over family relationships in adolescence, emphasizing how to communicate with peers becomes as important as the communication basics themselves. Parents and professionals should think about the art of communication early and often, regularly checking in with children with hearing loss on the status of their peer relationships to help maximize their quality of life.