Psychosocial Development in a Danish Population of
Children With Cochlear Implants and Deaf and Hard-ofHearing Children
1.
1.
Jesper Dammeyer
+ Author Affiliations
1.University of Copenhagen
Correspondence should be sent to Jesper Dammeyer, Højlandsvangen 43, 2700 Brønshøj, Denmark (email: Jesper.dammeyer@psy.ku.dk).
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Received May 8, 2008.
Revision received March 9, 2009.
Accepted August 12, 2009.
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Abstract
Research has shown a prevalence of psychosocial difficulties ranging from about 20% to 50% among children
with hearing loss. This study evaluates the prevalence of psychosocial difficulties in a Danish population in
relation to different explanatory variables. Five scales and questionnaires measuring sign language, spoken
language, hearing abilities, and psychosocial difficulties were given to 334 children with hearing loss. Results
show that the prevalence of psychosocial difficulties was 3.7 times greater compared with a group of hearing
children. In the group of children with additional disabilities, the prevalence was 3 times greater compared
with children without additional disabilities. If sign language and/or oral language abilities are good, the
children do not have a substantially higher level of psychosocial difficulties than do hearing children. This
study documents the importance of communication—no matter the modality or degree of hearing loss—for the
psychosocial well-being of hearing-impaired children.
Psychosocial difficulties involve both psychological and social aspects of a child's life. There are several basic
behavioral and emotional elements that characterize a child without psychosocial difficulties. These include
among other things feeling good about oneself, feeling comfortable around other people, controlling tension
and anxiety, and being able to meet goals. Psychosocial refers to the interrelation of behavioral and social
factors. The concept is associated to general well-being and quality of life (Martikainen, Bartley, & Lahelma,
2002).
Hearing impairment among children affects psychosocial development, but there is no consensus about the rate
of prevalence. Table 1 lists studies conducted within the past 15 years. Studies concerning children younger
than 19 years of age were selected. The different studies find prevalence rates of psychosocial difficulties
ranging from no more than normal to 77% among children with hearing loss. The majority of studies find a
prevalence ranging from about 20% to 50%. There is also no overall consensus about factors affecting
psychosocial difficulties among children with hearing loss. Keilmann, Limberger, and Mann (2007) find low
level of psychosocial difficulties among children attending mainstream schools compared with special schools,
and other studies (Hindley, Hill, McGuigan, & Kitson, 1994) find the level of psychosocial difficulties lower at
deaf schools compared with hearing-impaired units. A higher prevalence of psychosocial difficulties among
boys was found in some research (Polat, 2003; Sinkkonen, 1994) but not in others (van Eldik, Treffers,
Veerman, & Verhulst, 2004). Polat (2003) did find an association between degree of hearing loss and
psychosocial difficulties (deaf vs. hard of hearing), butSinkkonen (1994) and Hintermair (2007) did not.
Finally, van Eldik et al. (2004) found a higher prevalence of psychosocial difficulties among deaf children 12–
18 years of age than among children 4–11 years of age, butPolat found that older children were better adjusted
related to psychosocial well-being than younger children. Some other factors have been discussed: Several
studies (van Eldik et al., 2004; van Gent, Goedhart, Hindley, & Treffers, 2007; Hindley et al.,
1994; Hintermair, 2007; Polat, 2003; Sinkkonen, 1994) found additional disabilities (physiological and/or
psychiatric disorders) associated with a higher prevalence of psychosocial difficulties. As in studies concerning
hearing children, parental resources and stress (Hintermair, 2006), socioeconomic status, and ethnicity, among
other things, had also been discussed in relation to psychosocial well-being of hearing-impaired children
(Stacey, Fortnum, Barton, & Summerfield, 2006).
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Table 1
Studies evaluating psychosocial difficulties among deaf and hard-of-hearing children
In the past decade, discussions have also focused on psychosocial well-being of deaf/hard-of-hearing children
with cochlear implants (CI) as compared with deaf/hard-of-hearing children without CI (Bat-Chava, Martin, &
Kosciw, 2005; Boyd, Knutson, & Dahlstrom, 2000; Huber, 2005;Khan, Edwards, & Langdon, 2005; Nicholas
& Geers, 2003). As seen inTable 2, where studies conducted within the past 8 years concerning children
younger than 19 years of age were selected, it appears that the overall psychosocial well-being of deaf/hard-ofhearing children with CI lies somewhere between that of deaf/hard-of-hearing children without CI and hearing
children, but results and conclusions vary considerably. The same factors as mentioned previously have been
discussed (Stacey et al., 2006), but few studies have been conducted and they often meet limitations regarding
the number of participants, use of relevant control groups (deaf signing children and hearing children), and the
number of relevant explanatory variables. Auditory speech performance has of course been of special interest
in some studies. Huber found that health-related quality of life correlate with auditory speech performance,
butNicholas and Geers did not find this association.
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Table 2
Studies evaluating psychosocial difficulties among deaf/hard-of-hearing children with cochlear implants (CI)
Controversies between a medical/audiological versus a cultural/ecological perspective on deafness (Blume,
1999; Hindley et al., 1994; Polat, 2003) are part of the discussions about the psychological development of
deaf/hard-of-hearing children with and without CI. In Denmark (and in Scandinavia, in general), there has, for
several years, been a high standard of service and education for deaf children and their families, focusing on a
bicultural (deaf and hearing) and bilingual (signed and oral) perspective (Heiling, 1995). A bicultural and
bilingual perspective has been found to be positive for deaf children's psychosocial and cognitive development
because it gives the children a greater ability for natural communication from early in life and an ability to
develop a self-image and self-esteem as a deaf person (Heiling, 1995; Hindley, 2000; Preisler, 1999). Studies
do find that sign language abilities correlate with psychosocial well-being (Polat, 2003; Sinkkonen, 1994).
Adequate communication seems to be important for deaf children's development. Parental hearing status has
also been discussed as an important issue within this perspective (Mayberry, 2003). Polat found that deaf
children of deaf parents did have a better psychosocial adjustment than deaf children of hearing parents.
Overall, discussions are ongoing as to whether or not it is deafness per se, or some environmental factors that
influence psychosocial well-being among children with hearing loss (Polat, 2003). It is still unclear if CI and a
high level of auditory performance and speech intelligibility are a better protection against psychosocial
difficulties than are deaf culture and good sign language abilities. The aim of this study was to evaluate the
prevalence of psychosocial difficulties in a large group of deaf/hard-of-hearing children with and without CI in
Denmark and to evaluate a number of explanatory factors.
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Method
Sample
Three hundred thirty-four children from six different schools all over Denmark were included: 114, 82, and 34
children from the three Danish schools for the deaf, and 12, 44, and 48 children from three different “center
schools” having “hearing classes” parallel to hearing children. Seven schools were invited to participate, but
one center school declined due to time constraints. All are public schools for deaf and hard-of-hearing children
in Denmark. All use sign language, oral Danish, or some kind of a combination (total communication) adjusted
to the child. With a prevalence ratio of moderate to profound hearing loss at 1.1:1000 (van Naarden, Decouflé,
& Caldwell, 1999), the 334 children comprised about 50% of all children in Denmark with moderate to
profound hearing loss. Some of the children with moderate hearing loss and children with CI were enrolled in
mainstream schools and were not included in this sample.
The 334 children included in this study were all children at the six schools, except for 9 of the children (3%).
In two cases, the parents did not permit participation, and in seven other cases, the parents did not respond or
the teacher did not send back the questionnaires.
All 334 children were between 6 and 19 years old (M = 12.8, SD = 2.8), of which 183 were boys (55.2%) and
151 were girls (45.2%). The children were divided into three separate groups: deaf, hard of hearing, and
children with CI. One hundred nineteen were deaf (36.4%), 116 were hard of hearing (35.5%), and 92 had CI
(28.1%). Seven cases gave no information concerning this. An unaided average hearing level of approximately
80 dB was used to divide between deaf and hard-of-hearing children. Mean age of the deaf children was 14.1
years (SD = 2.3), the hard of hearing children 12.9 years (SD = 2.9), and the cochlear-implanted children 11.0
years (SD = 2.4). Mean age of cochlear implantation was 6.1 (SD = 3.2), and average number of years
following implantation (age of hearing) was 4.8 (SD = 3.4).
Measure
The study contained four single-item scales and one questionnaire: a speech intelligibility scale, an auditory
performance scale, a sign language production scale, a sign language understanding scale, and a psychosocial
well-being questionnaire. All scales and the questionnaire were completed by the teachers at the schools.
Speech and hearing.
Categories of Auditory Performance (CAP; Archbold, Lutman, & Marshall, 1995) and Speech Intelligibility
Rating (SIR; Allen, Nikolopoulos, Dyar, & O'Donoghue, 2001) were applied for assessment of the level of
auditory performance and speech intelligibility. CAP and SIR are frequently used in research. CAP is a singleitem scale with a range of 0–7. Level 0 is “no awareness of environmental sounds” and Level 7 “uses a
telephone with a known speaker.” SIR is also a single-item scale with a range of 1–5. Level 1 is “connected
speech is unintelligible …” and 5 “connected speech is intelligible to all listeners ….” Interrater reliability was
evaluated for the CAP and SIR. Two different teachers completed the CAP and SIR independently for 47
children, and ordinal (quadratic) kappa reached .785 for CAP and .848 for SIR. The sum of CAP and SIR, the
“oral score”, was calculated for each child.
Sign language.
Two single-item ratings of sign language production scale (SPS) and sign language understanding scale (SUS)
were included in the study. Due to the impossibility of finding any short screenings of Danish sign language
for research, the SPS and SUS were designed for this project. SPS is a single-item scale with a range of 1–5.
Level 1 is “the child does not produce signs” and Level 5 “the child has a fluent and almost conventional
correct sign language.” SUS is a single-item scale with a range of 0–7. Level 0 is “does not comprehend or
attend to signs” and Level 7 “is able to take part in longstanding and complex conversation in sign language.”
The range of the SUS and SPS corresponds to that of the CAP and SIR scales. Interrater reliability was
evaluated. Two different teachers completed the SUS and SPS independently for 74 children, and ordinal
(quadratic) kappa reached .944 for SUS and .921 for SPS. Validity was evaluated for the SUS by comparing
ratings of 12 children with the score of the Danish translation (Seiler & Larsen, 2005) of the Assessing British
Sign Language Development: Receptive Skills Test (Herman, Holmes, & Woll, 1999). Correlation between the
SUS and the sign language receptive skill test reached statistical significance (Spearman rank correlation
coefficient = .905, p < .000). No corresponding test was available for sign language production. The sum of
SPS and SUS scores, the “sign language score”, was calculated for each child.
Psychosocial difficulties.
The Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) was included. SDQ is a short and easy
behavioral screening questionnaire that asks about children's and teenagers’ psychosocial well-being. SDQ has
been translated into Danish (Obel, Dalsgaard, Stax, & Bilenberg, 2003). The version for teachers and parents
was used. The SDQ contains items like “has at least one good friend,” “often loses temper,” and “often lies or
cheats,” and the teacher or the parent is able to answer: “not true,” “somewhat true,” or “certainly true.” The
SDQ goes from 4 to 16 years. Children older than 16 (n = 22) were excluded from the analysis. The SDQ gives
an overall score from 0 to 40, where 0 indicates no problems and 40 indicates a significant number of
problems. In a hearing Swedish population of 900 children, Smedje, Broman, Hetta, and von Knorring
(1999) decided on a cut-off score of 14 (90th percentile) on the SDQ for both boys and girls. The cut-off score
of 14 will be used in this study. SDQ was also rated independently by two teachers of 20 children to evaluate
interrater reliability. Kappa value for rating the child normal (≤14) or not normal (>14) was 0.783. Hintermair
(2007) used the SDQ completed by mothers and fathers in a study of deaf/hard-of-hearing children and found
by evaluating the factor structure that SDQ was a reliable and valid questionnaire to use in samples of
deaf/hard-of-hearing children. Also,Cornes (2007) evaluated the psychometric properties of the SDQ and
found it a reliable and valid questionnaire to use among deaf and hard-of-hearing children.
Information on different variables was obtained by the teachers: gender,age, and cause of hearing loss
(etiology). Etiology was excluded from the analysis because of incomplete information. Ethnicity was recoded
to Danish or not Danish (78% [n = 261] were Danish). Family status was coded to residing with both parents
or not, education level of parents to the sum of parents’ education in years, and parental hearing loss into
having at least one parent with hearing loss or not (9.3% [n = 31] of the children did have at least one parent
with hearing loss). Finally, information on additional disabilities (mental retardation, autism, visual
impairment, physical impairment, etc.) was obtained. Seventy-eight children (23.7%) had additional
disabilities and it was a heterogeneous group: 14 had severe visual impairment, 9 had severe physical
impairment, 31 were mentally retarded, 13 had an autism spectrum disorder, 14 had severe neurological
disorders associated to attention, and 9 had “other” kinds of diagnosed severe developmental disabilities. Ten
children had more than one additional disability. Additional disabilities were coded into no additional
disabilities or one or more moderate to severe physical and/or visual impairment and/or diagnosed severe
developmental disorders (autism, mental retardation, etc.).
In seven cases, the given information was incomplete about at least one variable. Two different teachers
independently gave information about the explanatory variables for 20 children. Kappa values reached
between .69 and 1.00, which was acceptable (Shrout, 1998).
Procedure
The teachers at the schools completed all screenings and data gathering about each child. All participating
teachers knew the children and their families fairly well, and were well educated about the development and
education of hearing-impaired children. Data were collected from May 2006 to May 2007. The questionnaires
were mailed to the school secretary, who distributed and collected them. The teachers were informed about the
study both in a letter and at a meeting at the schools. All parents were informed by mail and asked to allow
their child to participate.
The relationships between SDQ score and explanatory variables including all relevant interaction terms were
analyzed using logistic regression. The SDQ score was dichotomized into normal (≤14) and not normal (>14).
The logistic regression model was found using forward selection (conditional). Odds ratios and descriptive
statistics (percent and number of children above cut-off score on the SDQ) were used to illustrate some of the
results. The statistical procedures were made in SPSS 15.0.
The following explanatory variables were included in the analysis: age, gender, school type (school for the
deaf or center school), ethnicity, family status, education level of parents, parental hearing loss, additional
disabilities, child's hearing status (deaf, hard of hearing, or CI), and finally, as described, oral score (sum score
of CAP and SIR) and sign language score (sum score of SPS and SUS).
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Results
Smedje et al. (1999) decided on a cut-off score of 14 (90th percentile) on the SDQ for both boys and girls in a
hearing Swedish population. In the sample presented here, 37% (n = 115) reached a score of more than 14 on
the SDQ. There were 3.7 times as many psychosocial difficulties as compared with the Swedish population of
hearing children.
In Table 3, the logistic regression model of variables affecting the SDQ score is presented.
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Table 3
Variables affecting the Strengths and Difficulties Questionnaire (SDQ) score
Additional disabilities did have a significant relationship to psychosocial difficulties (p < .001). Odds ratio was
3.2, indicating that children with additional disabilities did have psychosocial difficulties three times more
often compared with children without additional disabilities.
Low sign language and oral abilities were significantly related to psychosocial difficulties (p = .015 and .009,
respectively). Odds ratio for scoring one point higher on SPS or SUS was 0.85, indicating a decreased risk of
15% for having psychosocial difficulties. For one higher point scored on CAP or SIR, odds ratio was 0.92,
indicating a decreased risk of 8%. The impact of sign language and oral abilities can be illustrated: If scores on
both SPS and SUS were at maximum (7 and 5, respectively), then only 16.7% (n = 17) reached a score above
14 on the SDQ. If the scores on the CAP and SIR were at their highest (7 and 5, respectively), then only 14.6%
(n = 6) reached a score above 14 on the SDQ. In the logistic regression model, interactions terms between
additional disabilities and sign language abilities, additional disabilities and oral abilities, gender and sign
language abilities, and gender and oral abilities were not significantly associated to SDQ score. The
relationship between language abilities (signed or oral) and SDQ score was not influenced by gender or
additional disabilities.
An approximate significant higher risk for psychosocial difficulties was found among boys compared with
girls (p = .06). An odds ratio of 0.48 did indicate that boys face psychosocial difficulties two times more often
than girls.
Child's age, parents’ education, child's hearing status (deaf, hard of hearing, or CI), ethnicity (Danish or not),
type of school (deaf or center school), family status, and whether or not the children did have at least one
parent with hearing impairment were all not significantly related to SDQ score.
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Discussion
Some studies focus on the significance of communication as an important issue in the psychological
development of children with hearing loss (Bond, 2000; Hindley, 2000, 2005; Meadow, 1968/2005). This
study supports this view—no matter the modality. If sign language ability or oral Danish was good (defined by
maximum score on SPS and SUS or CAP plus SIR), there was an approximately normal prevalence of
psychosocial difficulties among children with hearing loss. The overall prevalence of 3.7 times as many
children with psychosocial difficulties is in accordance with other studies conducted in different countries (van
Eldik et al., 2004; van Gent et al., 2007; Hindley et al., 1994; Hintermair, 2007; Sinkkonen, 1994).
In this study, psychosocial well-being was not related to hearing loss among parents. This is in contradiction to
the study by Polat (2003), which found better psychosocial well-being among deaf children of deaf parents
than among deaf children of hearing parents. Parental hearing loss seems not to make any difference
concerning psychosocial difficulties in the group of hearing-impaired children. In this study, it was the
language ability, and not if the child was living in a bicultural and bilingual family, that seems to be important.
There were a large number of children with additional disabilities who have psychosocial difficulties. The
much higher prevalence rate within the group of children having additional disabilities, as opposed to children
whose hearing loss was the only disability, is in accordance with other studies (van Eldik et al., 2004; van Gent
et al., 2007; Hindley et al., 1994;Hintermair, 2007; Polat, 2003; Sinkkonen, 1994). One major explanation is
that some pre- and postnatal viral infections (rubella, cytomegalovirus, meningitis) and some of the syndromal
causes of deafness (CHARGE and Goldenhar, among others) both directly and indirectly increase the risk for
mental health problems (Bond, 2000; Hindley, 2005). It is well known that children with multiple disabilities,
also without hearing loss, are at a higher risk for psychosocial difficulties (Bond, 2000; Rutter, Graham, &
Yule, 1970). In this study, additional disabilities affected both signed and oral language abilities. Hearing
impairment and additional disabilities (cognitive, physical, or visual) in combination increase those difficulties
hearing-impaired children face in developing useful signed or oral communication. Communication becomes a
very important area of concern for these children.
Compared with a population of hearing children, there were a lot of children in this study with mental
retardation and autism. This is in accordance with other findings (Bond, 2000; Hindley, 2005).
A higher prevalence of psychosocial difficulties among boys was also found in some existing research (Polat,
2003; Sinkkonen, 1994) but not in others (van Eldik et al., 2004). Polat argues that deaf girls’ superiority in
verbal ability can make the difference. The general delay in language development among boys as compared
with girls leads to, in the case of hearing impairment, an increased risk for psychosocial difficulties. But this
study cannot confirm Polat's view: The relationship between language abilities (signed or oral) and SDQ score
was not influenced by gender.
There were no difference in psychosocial well-being between children with CI and deaf and hard-of-hearing
children. This finding was in accordance with some studies (Khan et al., 2005), but in contrast to others, which
found that deaf/hard-of-hearing children with CI enjoy greater psychosocial well-being than do deaf children
(Bat-Chava et al., 2005). None of these studies controlled for the influence of additional disabilities or sign
language abilities, which this study accentuates as important. Comparing deaf/hard-of-hearing children and
children with CI and additional disabilities can be an issue of concern. In some cases, additional disabilities
have been a contraindication for cochlear implantation (Bertram, 2004), which reduces the number of children
with CI and additional disabilities.
Limitations of the Study
The cochlear-implanted children in this study are not representative of all children with CI in Denmark. A
percentage of the deaf/hard-of-hearing children with CI attend mainstream schools and were not included in
this study. The psychosocial well-being of deaf/hard-of-hearing children with CI in mainstream schools may
differ from that which was found in the results of this study. In light of these results, it may be reasonably
assumed that the difference would depend on the communication abilities of the children and the possibility of
communication support in the school setting.
Other variables distinguishing this population of deaf/hard-of-hearing children with CI from other populations
are as follows: age of implant surgery, which is high in this group of children (M = 6.1 years, SD = 3.2), and
age of hearing (years of CI use), which is low (M = 4.8 years, SD = 3.4). Early cochlear implantation, before 5
years of age, will result in an average improved oral communication (Stacey et al., 2006). This study cannot be
generalized to cochlear-implanted children in general.
Psychosocial difficulties were evaluated in this study using short screenings completed by the child's
teacher. Boyd et al. (2000) found that questionnaires in which parents report on the psychosocial well-being of
their cochlear-implanted children are not preferable because they rate social functioning too high. Stacey et al.
(2006) also found that parents of children with hearing loss reported more favorable judgments than did their
teachers or simply avoided reporting very poor outcomes. Contrary to parents’ reports, teachers’ knowledge of
the children can be limited, especially regarding information about the family.
Some of the differences in results and conclusions among studies about cochlear-implanted children seem to
depend on the methods employed. Questionnaires answered by parents show fairly normal psychosocial wellbeing (Chmiel, Sutton, & Jenkins, 2000; Huber, 2005), but ratings from a videotaped peer task (Boyd et al.,
2000) as well as from observations in natural settings (Preisler, Ahlström, & Tvingstedt, 1997) uncovered
problems related to communication in social interaction with other children. Further research, especially
longitudinal studies and studies using structured and nonstructured video observations in natural settings
(Preisler, Tvingstedt, & Ahlström, 2005; Preisler et al., 1997), must be done in order to elaborate upon the
relationship between hearing impairment, communication, and psychosocial difficulties for deaf, hard-ofhearing, and cochlear-implanted people of all ages.
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Conclusions
The level of sign language performance among the children in general was high. There were 3.7 times as many
children presenting psychosocial problems as compared with a group of hearing children. Communication, oral
or signed, is an important issue of concern in relation to children with hearing loss and psychosocial
difficulties. This seems to be true for all groups of children, no matter the degree of hearing loss, whether they
are deaf, hard of hearing, or cochlear implanted. If communication is good (defined by maximum score on SPS
and SUS), the risk of psychosocial difficulties decreases substantially.
The degree of psychosocial difficulties is higher among children with additional disabilities and among boys.
This study does not include children attending mainstream schools, which creates limitations for the
possibilities of generalization.
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Acknowledgments
No conflicts of interest were reported.
This study is part of a project conducted at the University of Copenhagen in cooperation with Fredericiaskolen
and Aalborgskolen, Denmark. The author thanks the teachers at the schools for the deaf and “center” schools
for taking part in the data collection.
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© The Author 2009. Published by Oxford University Press. All rights reserved. For Permissions, please email:
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Correlates of Psychosocial Adjustment in
Deaf Adolescents With and Without
Cochlear Implants: A Preliminary
Investigation
1.
1.
1.
1.
1.
1.
1.
1.
Irene W. Leigh
1.Gallaudet University
2.New York University School of Medicine
3.Gallaudet University
Correspondence should be sent to Irene W. Leigh, Department of Psychology, Gallaudet University, 800 Florida Avenue NE,
Washington, DC 20002 (e-mail: irene.leigh@gallaudet.edu).
Deborah Maxwell-McCaw
1.Gallaudet University
2.New York University School of Medicine
3.Gallaudet University
Correspondence should be sent to Irene W. Leigh, Department of Psychology, Gallaudet University, 800 Florida Avenue NE,
Washington, DC 20002 (e-mail: irene.leigh@gallaudet.edu).
Yael Bat-Chava
1.Gallaudet University
2.New York University School of Medicine
3.Gallaudet University
Correspondence should be sent to Irene W. Leigh, Department of Psychology, Gallaudet University, 800 Florida Avenue NE,
Washington, DC 20002 (e-mail: irene.leigh@gallaudet.edu).
John B. Christiansen
+ Author Affiliations
1.Gallaudet University
2.New York University School of Medicine
3.Gallaudet University
Correspondence should be sent to Irene W. Leigh, Department of Psychology, Gallaudet University, 800 Florida Avenue NE,
Washington, DC 20002 (e-mail: irene.leigh@gallaudet.edu).

Received January 22, 2008.

Revision received August 28, 2008.

Accepted September 5, 2008.
Next Section
Abstract
The number of children who have received cochlear implants (CIs) has increased dramatically in the past two
decades. In view of potential concerns about their psychosocial adjustment, our aim was to assess the effect of
implants on the adolescents’ psychosocial functioning among a group of 57 deaf adolescents with and without
CIs, using published and validated measures completed by the adolescents themselves, their parents, and
teachers. Adolescents with CI tended to be more hearing acculturated, whereas those without CI tended to be
more Deaf acculturated. Despite some differences in background characteristics between the two groups, there
were no differences between them on the psychosocial variables assessed in this study, regardless of the
reporting sources. Rather than having a direct effect on the psychosocial outcomes assessed in this study, it is
through the mediating effect of acculturation and school setting that CI status exerts an influence over many of
this study's outcomes. Recommendations for future research are made in light of our findings.
Adolescence is characterized by rapid physiological,
psychological, and social development (e.g., Harter, 2003; Kroger,
1996; Noller, Feeney, & Peterson, 2001). Deaf adolescents undergoing
these changes also typically confront the challenges of being
deaf in a sound-dominated environment not always attuned to
their auditory and visual needs, particularly in the school
setting. Some authors believe that the academic and
psychosocial adjustment of adolescents with cochlear implants
(CIs) could be adversely affected because of efforts to
“normalize” their status and deny their visual needs (e.g., Ladd,
2003; Lane, Hoffmeister, & Bahan, 1996; Preisler, 2007). Other authors
argue that the CI can serve as a vehicle for positive academic
achievement and psychosocial adjustment because of greater
access to spoken language (Fagan, Pisoni, Horn, & Dillon,
2007; Geers, 2006; Spencer & Marschark, 2003; Wheeler, Archbold,
Gregory, & Skipp, 2007).
The importance of exploring academic and psychosocial
adjustment in adolescents with CI is underscored by the
dramatic increase in the number of children who have received
CI over the past 15 years. According to the three major CI
companies, more than 50,000 children worldwide have received
a CI to date.1 Currently, approximately 12.6% of students in
data reported to the Annual Survey of Deaf and Hard of Hearing
Children and Youth for the 2006–2007 academic year are
reported to have CI (Gallaudet Research Institute, 2006). This is
likely an underestimation, considering these data represent
approximately 60% of all schools and programs enrolling deaf
and hard-of-hearing students. In addition, the most recent
information available from the Annual Survey shows that among
both cochlear-implanted and nonimplanted children in the
United States, 26.5% are in “special schools or centers”
(primarily residential or day schools for deaf children).
Therefore, most deaf students presently attend fully or partially
mainstreamed educational settings.
Although increasing numbers of deaf children have the
potential to hear and use spoken communication after being
implanted, they typically require intensive communication
therapy in order to maximize their expressive and receptive
spoken communication (e.g., Christiansen & Leigh, 2005; Nicholas &
Geers, 2006). There is a small but growing number of studies
investigating the linguistic and academic achievement of these
children which demonstrate that students with CI generally
perform better academically than those without CI (for reviews,
see Fagan, et al., 2007; Geers, 2006; Marschark, Rhoten, & Fabich, 2007).
Whether this superior academic achievement persists over time
is not yet established.
A growing body of literature also demonstrates the effects of
CIs on auditory perception, speech, and oral language
development (e.g., Geers, 2004; Waltzman, 2006). These benefits
are moderated by several variables, including age of
implantation, duration of implant use, and mode of
communication. If implantation results in improved auditory
perception and more advanced speech and oral language skills
in deaf children and adolescents, this may result in better
psychosocial adjustment, especially in the areas of academic
achievement and peer relationships.
Previous SectionNext Section
Psychosocial Adjustment Variables
Social Integration of Deaf Adolescents
A review of research studies of deaf students in mainstream settings indicates that interactions with hearing
students can be positive when deaf adolescents are emotionally secure and participate frequently in social
activities (Leigh & Stinson, 1991; Stinson, Chase, & Kluwin, 1990;Stinson & Kluwin, 2003). However, deaf
students’ peer interactions in the mainstream are not always positive, primarily because of difficulties in
communication access or lack of awareness regarding hearing loss among hearing peers (Antia & Stinson,
1999; Bat-Chava & Deignan, 2001; Eriks-Brophy, et al, 2007; Stinson & Kluwin, 2003). Deaf mainstreamed
students often report feelings of loneliness, few close friendships, and lack of contact with deaf peers (Foster,
1988; Leigh & Stinson, 1991; Stinson & Lang, 1994; Stinson & Whitmire, 1992; Stinson, Whitmire, &
Kluwin, 1996). Within public schools, although deaf adolescents typically experience more comfort and
emotional security in relationships with deaf peers than with hearing peers (Stinson, et al., 1990; Stinson &
Whitmire, 1992), some do report comfort with hearing peers, depending on social and communication
competence (Bat-Chava & Deignan, 2001; Musselman, Mootilal, & MacKay, 1996; Stinson & Antia, 1999).
Parents of deaf children with CIs generally expect that the CI will facilitate communication and psychosocial
adjustment within the family, school, and neighborhood settings. Several studies have used parent perceptions
to explore the psychosocial effects of pediatric cochlear implantation (Bat-Chava & Deignan, 2001; BatChava, Martin, & Kosciw, 2005; Chmiel, Sutton, & Jenkins, 2000; Christiansen & Leigh, 2005; Kluwin &
Stewart, 2000; Nicholas & Geers, 2003). In general, these studies indicate that parents see evidence of
improved quality of life, greater self-esteem, confidence, and outgoing behavior in their implanted children in
comparison to the preimplant stage. Difficulties in social relationships with hearing peers remain, however,
because of residual lags in oral communication skills, limited access to communication within group situations,
and the attitudes of hearing peers. Parents whose children were either adolescents at implantation or who were
implanted against their wishes reported more problems (Christiansen & Leigh, 2005). In summary, recent
studies based on parent perceptions indicate that for deaf students, CIs can help children function better
socially, but they do not guarantee age-appropriate socialization experiences with hearing peers.
One observational study involving a small sample of children and adolescents with CIs noted that their
interaction with hearing peers tended to be unsuccessful (Boyd, Knutson, & Dahlstrom, 2000). Acceptance by
hearing peers is more likely when deaf children exhibit good spoken communication skills, whether they have
implants or not (Bat-Chava & Deignan, 2001, Leigh & Stinson, 1991; Stinson & Kluwin, 2003). Results of
qualitative interviews conducted with deaf children with CIs demonstrate ongoing communication limitations
(Preisler, Tvingstedt, & Ahlstrom, 2005). From information obtained through interviews of young people with
CIs, Wheeler, Archbold, Gregory, and Skipp (2007)suggest how intelligible speech may facilitate comfort in
situations where sign language is not used. Considering that deaf children are typically placed in mainstream
settings, parents, educators, and psychologists continue to be concerned about the social adjustment of deaf
children and adolescents, both with and without implants. However, implanted children and adolescents are
expected to have better communication skills and more positive psychosocial adjustment compared to their
unimplanted peers. It is the goal of this study to assess whether this expectation is warranted.
Behavioral Characteristics of Deaf Adolescents
A review of the literature indicates that the prevalence of negative behaviors in deaf students varies from 4.8%
to 50.3% depending on the sample studied and type of behavior (Schirmer, 2001). Greenberg and Kusche
(1989) note that deaf children exhibit greater impulsivity and inadequate emotional regulation compared to
hearing children. They believe that this is primarily because of limited exposure to language and social
experiences. More recently, Khan, Edwards, and Langdon (2005)found no difference between age-matched
groups of hearing children, children with CI, and children with hearing aids on the Child Behavior Checklist.
However, sustained attention as measured by the Attention Sustained subscale of the Leiter International
Performance Scale-Revised was lower for children with hearing aids in comparison to hearing children and
those with implants. Given that direct communication plays an even more important role in the life of
adolescents compared to younger children (Preisler et al., 2005), there is a need to compare the behavior of
deaf adolescents with and without implants.
Self-perceptions and Identity of Deaf Adolescents
The self-perceptions of deaf mainstreamed students appear to be generally positive even when they are not
accepted by hearing peers (for a review, see Stinson & Kluwin, 2003). Nicholas and Geers (2003) used a
picture assessment of self-image in a sample of 181 8- to 9-year-old children who had been implanted four or
more years. Results indicated that self-perceptions were positive in most aspects of daily life, thus
counteracting earlier concerns about psychosocial problems in implanted children. Whether positive selfperceptions among deaf students continues into adolescence is yet unknown. It is also important to assess how
social identity relates to self-perceptions and psychological well-being in adolescents, given that social identity
reflects a conscious affiliation with a shared social group, thereby providing stability and continuity in selfperceptions (Erikson, 1968, 1980).
According to Corker (1996), deaf identity is not necessarily a core identity for deaf children who grow up
within hearing families. Instead, incorporating a deaf identity into one's self-image is a developmental task that
is influenced by family and school variables. For example, growing up in a family that emphasizes one's
deafness as different from hearing family members or peers can strengthen the salience of a deaf identity,
whereas growing up in an environment that minimizes such differences may diminish the emphasis on
deafness as a core part of one's social identity. In a meta-analytic review of the literature examining factors that
influenced self-esteem in deaf adolescents and adults, Bat-Chava (1993)found five studies that assessed the
relationship between cultural deaf identity and self-esteem. Having a stronger deaf identity contributed
positively to self-esteem in deaf adolescents and adults.
Christiansen and Leigh (2005) were among the earlier explorers of the relationship between CI usage and deaf
identity development, having conducted a small interview study of implanted older adolescents and young
adults, some of whom had stopped using the CI. Almost all those interviewed desired ongoing contact with the
deaf community in addition to socializing with hearing peers. Wheeler, Archbold, Gregory, and Skipp
(2007) later administered a semi-structured questionnaire to 29 young adolescents aged 13–16 with CI in
mainstreamed and specialized educational settings. They found that most participants were flexible in terms of
communication mode and endorsed a perception of deaf identity that was neither culturally Deaf nor strongly
hearing. There was no clear relationship between the educational setting students attended and their identity
status. Whether this flexibility continues into later years remains to be seen, as the participants were in the
younger phase of adolescence.
Borrowing from racial identity development theories (e.g., Helms, 1990),Glickman (1996) proposed that deaf
people evolve through four stages of identity development, from first internalizing the need to be like hearing
people (hearing identity), to confusion about where one belongs (marginality), to an immersion stage
(characterized by denigrating hearing values), and ultimately to a bicultural identity (integrating both hearing
and deaf ways of being). Glickman acknowledges that the process is not necessarily linear. In a study of eight
adolescents with CI and 37 adolescents without CI that used Glickman's (1996) Deaf Identity Development
Scale, mean item scores indicated that hearing identity was more frequently endorsed by participants with a CI
compared to participants without a CI (Wald & Knutsen, 2000). The groups were more similar than different in
the bicultural, immersion, and marginal categories, with the bicultural identity receiving the strongest
endorsement.
Maxwell and Zea (1998) proposed that many deaf people negotiate their involvement in both deaf and hearing
cultures. Borrowing from acculturation research (e.g., Birman, 1994; Landrine & Klonoff, 1994; Zea et al.,
2003), Maxwell and Zea investigated how the various domains of acculturation (e.g., psychological
identification, cultural/linguistic competence, cultural behaviors/involvement) are expressed among deaf
individuals. In a subsequent study involving over 3,000 deaf and hard-of-hearing adults, Maxwell-McCaw
(2001) found that those who were deaf acculturated or bicultural had a more positive sense of overall well-
being than those who were hearing acculturated, suggesting that some degree of affiliation with the Deaf
community facilitated psychological well-being. Marginalized individuals had the lowest levels of
psychological well-being. These findings were supported by a follow-up study in Germany, with bicultural
respondents being most advantaged psychosocially (Hintermair, 2008). Neither Maxwell-McCaw nor
Hintermair specifically examined whether cochlear implantation had a mediating effect on these results. The
current study attempts to build on previous research and examine the effect of cochlear implantation on the
relationship between group identity and psychosocial well-being.
Previous SectionNext Section
Purpose of the Study
The purpose of this investigation was threefold. First, we wanted to expand the knowledge base on the
psychosocial effects of CI by focusing on a group that has received little attention in the literature: deaf
adolescents. To do so, we compared the experience of adolescents with implants to those without implants.
Second, we wanted to go beyond the previous research focus on parents’ perspectives. Specifically, we
collected self-report data from adolescents themselves, as well as data from parents and teachers with the goal
of using multiple sources of data to assess the effect of implants on the psychosocial functioning of deaf
children. Finally, because there has been relatively little research on this topic, our goal was to explore the
associations among multiple variables in a small sample to inform future research. Because of the dearth of
research on the psychosocial adjustment of deaf adolescents with CI (Marschark, 2007; Wheeler, et al., 2007),
we have cast a wide net in an effort to narrow down the factors that are likely to be important indicators of
academic and social functioning.
Previous SectionNext Section
Method
Participants
Fifty-seven deaf high school students, ranging in age from 13 to 18 (M = 15.79, standard deviation [SD] =
1.35), participated in this study. Twenty-eight (49%) were CI users, and 29 (51%) had never used an implant.
Sixty percent of the participants were female (N = 34). Of the 55 adolescents who reported race/ethnicity, the
vast majority was white (n = 46, 84%). Of the parents who reported their own level of education, the majority
was highly educated: 24 (45%) had either 2- or 4-year college education and 22 (42%) had a postgraduate
degree.
For CI users, the average age of implantation was 7 years (M = 7.33, SD = 3.61) and the average length of use
was 8 years (M = 8.37, SD = 3.34). There were no significant differences between implant users and nonusers
in terms of age, ethnicity, gender, age at diagnosis of hearing loss, and parental level of education. Participants
also did not differ in reading ability (7.3 grade equivalent for the CI users and 6.5 for the nonCI users). One
parent (4%) of a participant with a CI was hard of hearing; the remaining 27 sets of parents were hearing. In
the nonimplant group, 9 out of 29 (31%) participants had deaf parents. The two groups differed significantly in
educational placements: 26 (93%) of implant users attended mainstream settings (either full or partial), and 15
(52%) of nonusers attended mainstream settings, χ2 (N = 57; degrees of freedom [df] = 1) = 11.94, p = .001. In
addition, despite attempts to recruit adolescents with comparable levels of hearing loss (before the implant),
the two groups differed on this variable. Of the adolescents with CI whose parents reported this information,
25 (96%) had a profound hearing loss and 1 (4%) had a severe hearing loss. Of those without implants, 16
(67%) had a profound hearing loss, 7 (29%) had a severe hearing loss, and 1 (4%) had a moderate hearing loss,
χ2 (N = 50; df = 2) = 7.41, p = .025. The two groups also differed in preferred mode of communication. The
majority of implant users (77%) preferred to use oral communication exclusively, whereas only 15% of nonusers preferred oral communication. Nonusers reported preference for American Sign Language (ASL) only
(26%), Total Communication/Signing Exact English (26%), and code-switching (26%), χ2 (N = 53; df = 5) =
21.53, p = .001.
Instruments
Adolescents.
Acculturation was assessed using a 30-item version of the Deaf Acculturation Scale (DAS; Maxwell-McCaw,
2001). This version consists of two acculturation scales, one measuring acculturation to Deaf culture and the
other measuring acculturation to Hearing culture. Each scale measures acculturation across five dimensions:
(1) psychological identification (e.g., “I feel that I am part of the Deaf community”), (2) cultural involvement
(e.g., “How much do you enjoy socializing with hearing people?”), (3) cultural preferences (e.g., “I would
prefer my best friend(s) to be deaf”), (4) cultural knowledge (e.g., “How well do you know important events in
American/World history?”), and (5) language competence (e.g., “How well do you sign using American Sign
Language (ASL)?”. Items are scored on a 5-point Likert scale from 1 (e.g., “strongly disagree” or “not at all”)
to 5 (e.g., “strongly agree” or “excellent/like a native”). Subscale scores were averaged, culminating in one
score for Deaf acculturation (DASd) and one for hearing acculturation (DASh). Cronbach alphas for the DASd
subscales ranged from .83 to .96 and for the DASh subscales ranged from .68 to .87.
Self-esteem was assessed using the Self-Perception Profile for Adolescents (Harter, 1988). Respondents
identify which of two statements apply to them (e.g., “Some teenagers find it hard to make friends” or “Other
teenagers find it's pretty easy”) and then rate the statement as “Really true for me” or “Sort of true for me.”
There are nine scales of five items each, culminating in 45 items, scored on a scale from 1 to 4, with higher
scores representing more positive self-perception. We report on three subscales that address self-perception in
academic and social functioning as well as global self-perception because these reflect the factors most
relevant to the purpose of this study. Cronbach's alphas ranged from .67 (global self-esteem) to .77 (scholastic
competence and close friendships).
Satisfaction with Life was assessed using the brief Satisfaction with Life Scale (Diener, Emmons, Larsen, &
Griffin, 1985). This scale consists of five items measuring global life satisfaction, such as “I am satisfied with
my life.” Items are scored on a 7-point scale from 1 (strongly disagree) to 7 (strongly agree). Cronbach's alpha
was .80.
Loneliness was assessed using the four-item version of the Revised UCLA Loneliness Scale (Russell, Peplau,
& Ferguson, 1978; Russell, Peplau, & Cutrona, 1980), a summed rating scale consisting of two positively
worded and two negatively worded items (e.g., “No one really knows me well”). Responses are given on a 4point scale from 1 (“never”) to 4 (“often”). In this study, Cronbach's alpha was .59. At least one other study
found a modest internal reliability (.63) for this scale (Hays & DiMatteo, 1985).
Student demographic form was used to collect demographic information as well as deafness-related variables
(e.g., age at which hearing loss was detected, educational setting), and psychological variables not otherwise
measured (e.g., teacher support as perceived by the student, satisfaction with communication at school, with
family members, and with peers).
Adolescents with implants were also asked about their perceived acceptance by deaf and hearing peers (from 1
“always” to 4 “almost never”) and their patterns of socializing with deaf and hearing peers (from 1 “all the
time” to 4 “very little/never”). Acceptance and socializing were very highly correlated (rhearing = .59, p =
.001; rdeaf = .41, p = .039) and were combined into acceptance/socialization by calculating the mean of the two
items. Items measuring perceived acceptance and socialization were inadvertently left off the questionnaires
for nonusers.
Reading comprehension was assessed by the Reading Comprehension Subtest of the Peabody Individual
Achievement Test-Revised (Markwardt, 1998). For each two-page item, the student reads a sentence silently
and on the next page selects one of four pictures that best illustrates the sentence.
Parents.
Adolescents’ psychosocial functioning was assessed with the Achenbach System of Empirically Based
Assessment (ASEBA; formerly called the Child Behavior Checklist, CBCL), Parent Form (Achenbach &
Rescorla, 2001). Parents report on their child's (ages 6–18) problem behavior and adaptive functioning
(competence), identifying the extent to which “in the past 6 months” each item is “not true,” “somewhat or
sometimes true,” or “very true or often true.” The ASEBA has previously been used effectively with children
and adolescents who are deaf and hard of hearing (e.g.,Wallander, Varni, Babani, Banis, & Wilcoz, 1988). In
this study, we used five subscales from the problem behavior section and two competence subscales, selected
for their relevance to academic functioning (e.g., attention problems) or social functioning (e.g., rule-breaking
behavior, social competence). Cronbach's alphas for the problem-behavior scales ranged from .76 (rulebreaking behaviors) to .86 (Attention problems). Alphas for the competence scales were .56 (social
competence) and .58 (school competence).
Parent demographic form
Parents were asked some of the same questions as the adolescents in order to both corroborate the information
provided by the student as well as to assess major areas of differences between child and parent. Parents were
also asked for demographic information that their adolescents may not have known, such as degree of hearing
loss, etiology, and age at diagnosis. Other items assessed parents’ education and occupation, ethnic/racial
information, and household composition.
Teachers.
Teacher perceptions
Adolescents’ psychosocial functioning was assessed by the adolescents’ teachers using the ASEBA (formerly
called the CBCL), Teacher Form (Achenbach & Rescorla, 2001). This measure covers functioning in two
areas, academic achievement and social functioning. Scales are identical to those on the Parent Form. We used
the same five subscales from the problem behavior section as used on the Parent form. Cronbach's alphas
ranged from .61 (rule-breaking behaviors) to .91 (Attention problems).
Procedure
Participants were recruited through organizations serving deaf individuals and their families, online discussion
groups for parents of deaf children and word of mouth. Interested parents and adolescents contacted one of the
researchers to set up interviews. Two of the researchers traveled throughout the United States for data
collection. Informed consent was obtained from parents and adolescents at the beginning of the scheduled
appointment. Researchers communicated with the adolescents in their preferred mode of communication
(spoken English, signed English, or ASL). Measures were presented in the same order. The typical length of
time required for administration of all adolescent measures was about an hour. The ASEBA Teacher Form was
mailed or given to teachers selected by the adolescents.
In addition, two schools for the deaf2 sent information about the study and parent consent forms to parents of
high school students. Following receipt of completed consent forms mailed by the parents, adolescents were
contacted on site to give their own consent to participate in the study, fill out measures, and provide teacher
names for the Teacher Form, which was then delivered to the teachers to be filled out and mailed to the
researchers. The parents of these adolescents were mailed the parent forms to be filled out and mailed back.
All parents returned their forms. Participating adolescents were paid $10 and their parents were paid $5.
Previous SectionNext Section
Results
Comparing Adolescents’ and Parents’ Responses
Responses to demographic and deaf-related variables that were reported by both adolescents and their parents
are presented in Table 1, along with descriptive data (means and SDs for continuous variables or number of
responses for categorical variables), the level of agreement between the two sources, and the specific source's
information ultimately selected for use in the study. Agreement was calculated either as a percent agreement
(when data were categorical) or as a correlation coefficient (when data were continuous). For most variables,
concordance rates were high. In cases where the information pertained to an adolescent's subjective experience
(e.g., acceptance by peers, perceived teacher report), the adolescent's report was selected for subsequent
analyses. When the information was factual, the source selected was the one who seemed more reliable (e.g.,
fewer missing data).
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Table 1
Concordance between adolescents' and parents' reports
Differences Between Adolescents With and Without CI
Despite our efforts to recruit adolescents with similar characteristics into the two groups, there were significant
differences between the groups in type of schools attended and degree of hearing loss (see Methods). To adjust
for these differences, we compared the two groups on all outcome variables using a series of one-way analysis
of variance with school setting and degree of hearing loss as covariates. Although school setting is not a
continuous variable, it was coded to represent an ordinal variable from most integrated with hearing students
(i.e., full mainstream = 1) to least integrated (i.e., deaf school = 3). Table 2 presents the results of these tests on
all outcome variables. After adjusting for the two covariates, the two groups differed from each other
significantly on one variable: adolescents with CI scored significantly higher on hearing acculturation relative
to those without CI. Approximately 40% of both groups scored as bicultural [χ2 (3, N = 54) = 9.58, p < .05].
Therefore, our results indicate that in this sample, aside from the hearing–Deaf acculturation difference,
adolescents with and without implants were quite similar on the variables assessed in this study.

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Table 2
Analysis of covariance comparing students with and without CIs
The covariate of school setting seems to play a larger role in psychosocial adjustment than CI status.
Compared to those adolescents attending deaf schools, adolescents attending mainstream educational settings
had significantly lower scores in deaf acculturation, higher hearing acculturation, and marginally higher levels
of scholastic self-esteem, friendship self-esteem, and global self-esteem. They also had significantly higher
parent-reported social competence (see Table 2).
The associations between the covariate “Level of hearing loss” and the outcomes were assessed using
an F statistic in an analysis of covariance model. Degree of hearing loss was significantly associated with
hearing acculturation and with attention problems reported by both parents and teachers and had a weaker (and
nonsignificant) association with acculturation to Deaf culture and parent-reported rule breaking behavior
(see Table 2).
Associations between deaf-related variables and psychosocial functioning.
Table 3 presents the bivariate correlations of deaf-related variables with psychosocial functioning, reported for
the full sample by child, parent, and teacher. An overall view reveals that some deaf-related constructs are
related to both child- and parent-reported psychosocial functioning. Teacher-reported functioning is related to
a lesser extent to deaf-related variables and often simply reflects parent-reported functioning. The following
presentation of the analyses is based on psychosocial functioning outcome variables, both those reported by
adolescents themselves and those included in the ASEBA syndrome profile of problems and competence
sections reported by parents and teachers.

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
Table 3
Bivariate correlations for the full sample
Psychosocial indicators reported by adolescents.
Deaf acculturation and hearing acculturation
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As seen in Table 3, deaf acculturation and hearing acculturation were associated with several of the measured
variables and always in the direction opposite of each other. Notably, satisfaction with home communication
was positively related to hearing acculturation. Conversely, number of deaf friends was positively associated
with deaf acculturation and negatively associated with hearing acculturation. Grade was also related to
acculturation such that adolescents in higher grades had higher deaf acculturation scores and lower hearing
acculturation scores than those in lower grades.
Self-perceptions
Several self-esteem subscales were associated with the antecedent variables. As indicated in Table 3, selfreported scholastic competence was negatively associated with age when hearing loss was detected, such that
those whose hearing loss was detected earlier had higher scholastic self-esteem. Students who were more
satisfied with home communication had higher levels of scholastic self-esteem and social competence selfesteem.
Satisfaction with life
Table 3 demonstrates that satisfaction with life was positively related to satisfaction with home
communication.
Psychosocial indicators reported by parents/teachers.
Negative functioning
Attention problems (reported by both parents and teachers) were positively associated with age at which
hearing loss was detected (later age was related to greater problems), rule-breaking was positively associated
with age at detection of hearing loss according to both parent and teacher report, and parent-reported
aggression was positively related to age at which hearing loss was detected (Table 3).
Positive functioning
As Table 3 shows, parent-rated social competence was positively related to satisfaction with home
communication, whereas satisfaction with communication at school was not associated with any of the
indicators of psychosocial functioning. Parent-rated scholastic competence was negatively associated with age
at which hearing loss was detected, age, and grade.
Partial correlations adjusting for implant status.
To assess the possible role of CI use on the relationship among the variables, partial correlations or analysis of
covariance were calculated among all variables, adjusting for CI status. These associations were generally the
same as the bivariate associations reported earlier, indicating that beyond its direct relation with outcomes, CI
status did not have a moderating effect on the relations among variables.
Associations Between Deaf-Related Variables and Psychosocial Functioning for Adolescents
With CIs
In addition to the correlations computed for the full sample, several correlations were computed for the
subsample of adolescents with implants, correlating the same psychosocial functioning variables described
above with those variables assessed only for this subsample: level of teacher support and
socialization/acceptance by hearing peers and deaf peers. Table 4 presents these bivariate correlations.


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Table 4
Bivariate correlations for adolescents with CI
Acculturation and self-perceptions.
Similarly to the full sample, deaf acculturation and hearing acculturation were associated with several of the
measured variables and were always in the direction opposite of each other. Deaf acculturation was positively
related to socialization with and acceptance by deaf peers and negatively related to socialization with and
acceptance by hearing peers. Conversely, hearing acculturation was positively related to socialization with and
acceptance by hearing peers and negatively related to socialization with and acceptance by deaf peers.
Scholastic self-esteem was negatively related to socialization with and acceptance by deaf peers. Satisfaction
with life was negatively associated with perceived teacher support. Finally, loneliness was positively
associated with socialization with and acceptance by hearing peers.
Psychosocial indicators reported by parents and teachers.
None of the parent-reported variables on negative functioning was associated with any of the social variables
assessed for adolescents with implants. Teacher-reported withdrawn behavior was negatively associated with
perceived teacher support and with socialization with/acceptance by hearing peers. Parent-reported scholastic
competence was positively related to socialization with and acceptance by hearing peers (see Table 4), taking
into account the modest reliability of the social and scholastic competence scales on the ASEBA.
Previous SectionNext Section
Discussion
From a psychosocial perspective, deaf adolescents with a CI and those without the device in our sample are far
more similar to each other than might have been anticipated, given the expectations that the CI might make a
significant difference in adolescents’ social development, even while adjusting for educational settings and
degree of hearing loss. Although there are many more similarities than differences between the two groups, our
research reveals the presence of some interesting differences and associations. One purpose of this study was
to examine the associations among multiple variables investigated in this study in order to inform future
research. These differences and future research suggestions are discussed below.
Acculturation
The one notable difference between the two groups is that those with CI are more likely to be acculturated to
hearing society than those who do not use the device, whereas non-CI adolescents are more Deaf acculturated
than those with CI. It is no surprise that the CI group generally is more hearing acculturated, given that many
parents and educators are encouraged to maximize auditory training post-implantation. It is also possible that
this group, even considering their greater degree of hearing loss prior to implantation, had higher hearing
orientation due to hearing aid use and auditory training prior to implantation. In addition, more of the
adolescents without CI were in specialized deaf settings where, despite their relatively lower levels of hearing
loss, auditory training perhaps was less emphasized and deaf identities were more likely to be reinforced. All
these factors could contribute to the difference in the findings on hearing–Deaf acculturation. However, it is
important to emphasize that implant users can be primarily acculturated either to deaf or hearing worlds, or to
both (as indicated by the similar number of participants with bicultural identities in both groups), though this
CI sample was predominately hearing acculturated. Rather than having a direct effect on the psychosocial
outcomes assessed in this study, it seems that CI status exerts an influence over many of this study's outcomes
through the mediating effect of acculturation and school setting. Although it appears that hearing acculturation
is associated with CI use, this does not necessarily mean that the CI is key. Other mediating variables, such as
spoken language competency, also need to be examined. Because this study did not compare differences
between hearing-aid users and CI users, future studies that specifically address this variable may shed more
light on this issue.
Despite the differences in acculturation, the two groups nonetheless do not significantly differ in the other
psychosocial outcomes. This suggests that the differing acculturative experiences between these two groups—
alignment with either the majority hearing society or with Deaf culture—do not have a differential effect on
the psychosocial outcomes of self-esteem, satisfaction with life and loneliness when reported by adolescents
themselves, as well as psychosocial characteristics reported by parents and teachers.
Scholastic Self-esteem, Socialization, and Satisfaction With Life
The negative relationship between scholastic self-esteem and socialization with and acceptance by deaf peers
for CI users might be due to subtle parent and school messages that focus on the value of hearing peer
socialization and mainstream education rather than deaf peer socialization or specialized deaf settings. The
negative association between satisfaction with life and perceived teacher support could be interpreted to mean
that those CI users who were satisfied with life required less teacher support than those with lower satisfaction
scores.
Loneliness Among Deaf Adolescents
In our study, levels of loneliness were similar for both groups, considering that the CI users were mostly in
mainstream settings and adolescents without CI were in mostly specialized settings. Although the reliability of
the Loneliness Scale was modest in this study, our findings appear to be consistent with the existing
literature. Most (2007) found similar levels of loneliness among young deaf adolescents in inclusion settings
and those in specialized classes within a mainstream setting. This finding supports our own findings regarding
the similarity of loneliness levels for students in mainstream and specialized schools. In addition, Most
(2007) reports a negative correlation between speech intelligibility and loneliness only for the inclusion
sample. She suggests that students in the specialized setting may have felt set apart from the mainstream,
whereas students in the inclusion setting may have been subject to ongoing communication difficulties and
feelings of rejection.
Overall, Most's participants had higher levels of loneliness than a normative hearing sample. However, in a
study of the effects of CI experience on loneliness in middle and late childhood, Schorr (2006)found that
loneliness levels among her participants were similar to levels noted in hearing peers. In our sample, loneliness
levels did not significantly differ from those in the normative sample reported for the Revised UCLA
Loneliness Scale (D. Russell, personal communication, December 9, 2007). In alignment with Schorr's
(2006) findings, our findings imply that deaf adolescents are not more lonely compared to hearing peers. The
positive relationship between loneliness and socialization with and acceptance by hearing peers found for CI
users in this study might be explained by the possibility that socialization with hearing peers averts loneliness
mainly in one-on-one interactions but not in group situations where loneliness might easily arise. It would be
helpful to further examine the factors that might be related to loneliness for adolescents with CI, such as
receptive speech comprehension, functional communication skills (particularly in noisy situations), types of
social skills, and the availability of deaf peers in mainstream settings. Future studies should use the full
Revised UCLA Loneliness Scale and assess its reliability with deaf adolescent populations.
Peer Acceptance
Researchers have noted that parents do not consistently evaluate social situations the same way their children
do (e.g., Gregory, Bishop, & Sheldon, 1995). The low correlation between parent and adolescent CI user
ratings of acceptance by deaf peers (−.13) suggests the possibility that adolescents may view their acceptance
by deaf peers differently than parents do. The moderate correlation for acceptance by hearing peers (.45) could
possibly be due to a greater focus by parents on acceptance by hearing peers, which might also influence the
desire of adolescents to view themselves as being accepted by hearing peers. These correlations reinforce the
importance of asking children as well as parents about their perceptions of peer relationships and loneliness.
The Effect of School Setting on Psychosocial Outcomes
Students attending mainstream settings report higher self-esteem within the domains measured in this study,
including scholastic self-esteem. It is impossible to conclude from these data whether adolescents with higher
perceived scholastic self-esteem tend to go to mainstream schools or if attending mainstream schools
contributes to such positive self-perception.
Our results also indicate that adolescents educated in mainstream settings are more likely to be hearing
acculturated compared to those attending deaf schools. Additionally, similar percentages of adolescents with
and without CI endorsed a bicultural identity. This appears to support the idea that even in view of the stronger
orientation toward hearing acculturation on the part of CI users, it is possible for CI users to have bicultural
orientation. Considering the Maxwell-McCaw (2001) and Hintermair (2008) findings of an association
between bicultural identity and well-being, the implication is that of a psychosocially healthy process.
The Effects of Age and Grade on Psychosocial Outcomes
Students in higher grades are more Deaf acculturated, and students in lower grades are more hearing
acculturated. It is possible that students in higher grades increasingly experience communication difficulties
with hearing peers and in the classroom and, as a result, desire a stronger connection with deaf peers or
academic environments with critical masses of deaf students. Alternatively, this result could lend support for
Glickman's (1993) supposition that as deaf individuals explore their identity more fully, they move toward the
immersion stage in order to explore their interest in and comfort within the deaf community. Given that this
sample is composed entirely of adolescents and that, according to Erikson (1968, 1980), adolescence is
focused on explorations of identity, our finding that adolescents in different grades have different levels of
hearing and Deaf acculturation is not surprising. Longitudinal studies following adolescents’ identity
development through several grades as well as the influence of deaf peer presence in mainstream settings may
clarify the extent to which development and exposure to deaf peers influence acculturation choices over time.
The Effect of Hearing Loss levels on Psychosocial Outcomes
Early detection of hearing loss was related to feelings of academic and social competency. Another interesting
finding is the association of hearing loss levels with attention problems and rule-breaking behavior. Based on
parent and teacher reports, lower levels of hearing loss were associated with greater disruptive behavior. It is
possible that when children have greater hearing loss, family members’ expectations about their ability to
communicate are more realistic than when their hearing loss is less severe. Unrealistic expectations about the
child's ability to communicate, in turn, cause family members to report more disruption (Harvey, 2003; Laszlo,
1994; Pipp-Siegel, Sedey, & Yoshinaga-Itano, 2002). When cues are misunderstood, frustration may increase.
It is further possible that those with a more severe hearing loss may have received intervention sooner and
more extensively than those with less severe hearing loss (Kochkin, Luxford, Northern, Mason, & Tharpe,
2007).
The Effect of Home Communication on Psychosocial Outcomes
Based on an analysis of the psychosocial functioning of the entire sample of adolescents with and without CI,
the importance of communication at home is demonstrated by findings that satisfaction with home
communication was positively related with hearing acculturation, scholastic self-esteem, social competence
self-esteem, and satisfaction with life. Considering that early detection of hearing loss was also related to
feelings of academic and social competency, this implies that when parents are hearing, earlier intervention
leads to greater ease of communication at home, which in turn leads to greater comfort in social and academic
environments. Based on a data set of 213 parents in Germany, Hintermair (2006) noted that when the child is
communicatively competent, the child's socioemotional development is facilitated and parents experience less
stress.
Previous SectionNext Section
Conclusion
The purpose of this preliminary study was to assess differences between adolescents with and without implants
in several areas of psychosocial functioning according to reports by adolescents themselves, their parents and
teachers in order to inform future research. In addition, deafness-related antecedents of psychosocial
functioning were examined for all adolescents, both those with and without implants. This study is unique in
that it examines adolescents with CI, a group not previously studied, and includes data from multiple sources:
adolescent themselves, parents, and teachers. Our most notable finding is that deaf adolescents’ functioning—
as measured in this study—is not directly affected by implant status. CI status exerts an indirect influence on
several of the psychosocial outcomes in our study through its effect on acculturation and school setting.
Because our small, nonrandom and self-selected sample may have introduced some biases, our findings should
be replicated with larger and more representative samples, including samples of children implanted at younger
ages than was typically the case in this study. Other types of data, such as objective observations of children
and adolescents with implants in naturalistic settings may shed more light on the possible difference relative to
those without CI. In addition, a longitudinal design to ascertain cause and effect might be appropriate for
answering questions such as the following: Are students who are hearing acculturated choosing to attend
mainstream schools, or does attendance in mainstream schools contribute to hearing acculturation? Our
observations of the minor differences between parent and teacher reports lead us to suggest that future research
could consider omitting teacher reports, which are more difficult to collect. Future research may want to
consider measuring other psychosocial as well as academic constructs, which may yield greater differences
between adolescent CI users and those who do not have a CI.
Overall, it is apparent from this study that the CI is an assistive tool and not a factor that significantly impacts
psychosocial functioning as measured in this study, contrary to what was believed a decade ago. It appears
that, considering the entire sample of participants in this study, how parents and the educational system meet
the psychosocial needs of these deaf adolescents is of more importance than whether or not the adolescent has
a CI.
Previous SectionNext Section
Funding
Priority Grant from the Gallaudet Research Institute.
Previous SectionNext Section
Acknowledgments
The authors wish to thank graduate students Tracy Durham, Brittney Farneth, Caroline Kobek-Pezzarossi,
Angelia Lawson, Cara Miller, and Daniel Nead, as well as Sue Hotto of the Gallaudet Research Institute and
Daniel Russell, PhD, of Iowa State University for their assistance with different portions of this study.
No conflicts of interest were reported.
Previous SectionNext Section
Footnotes
↵ 1 See www.bionicear.com; www.cochlear.com; www.medel.com.


↵ 2 Additional schools declined to participate as staff time to extract parent addresses and mail flyers
were not available.

© The Author 2008. Published by Oxford University Press. All rights reserved. For Permissions, please email:
journals.permissions@oxfordjournals.org
Previous Section
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Parents' Views on Changes in Their
Child's Communication and Linguistic
and Socioemotional Development After
Cochlear Implantation
1.
2.
1.
Kerttu Huttunen* and
Taina Välimaa
+ Author Affiliations
1.University of Oulu
*
Correspondence should be sent to Kerttu Huttunen, Institute of Clinical Medicine, Department of Otorhinolaryngology, P.O.
Box 5000, FI-90014 Oulun yliopisto, Finland (e-mail:kerttu.huttunen@oulu.fi).

Received February 23, 2010.

Revision received May 28, 2010.

Accepted May 29, 2010.
Next Section
Abstract
Our aim was to obtain versatile information on the communication and socioemotional development of
implanted children in their everyday environment. We studied 18 children implanted unilaterally at the mean
age of 3 years 4 months. All had normal nonverbal intelligence, but 8 (44%) had concomitant problems. Their
parents filled out semistructured questionnaires at 6 months and then annually 1–5 years after activation.
Parents reported a change from use of signs to speech, and changes in the children's vocal behavior and spoken
language development. They also reported that children had calmed down and showed an increased sense of
self-confidence and safety with an expanded social life. The greatest changes started to take place 1 year after
implantation. Five years after implantation, two thirds of children were judged to be as independent as their
age peers. We conclude that changes in communication pave the way to benefits in psychosocial development
after implantation.
The cascade of benefits hypothesized to follow cochlear
implantation over time has been discussed by Summerfield and
Marshall (1999). These benefits include enhanced auditory skills,
use of an oral communication mode, and acquisition of useful
levels of spoken language. Spoken language abilities enhance
integration into mainstream primary education, better school
achievement, social versatility, broader options for further
education, better employment, and finally, improved social
independence and better quality of life in adulthood. These
areas comprise a wealth of aspects that are important to
address in addition to the formal measures used at clinics in
the assessment of outcomes of implantation (see Thoutenhoofd et
al., 2005), and parents have been reported to expect changes in
these areas as major outcomes of implantation (Archbold, Lutman,
Gregory, O'Neill, & Nikolopoulos, 2002;Kelsay & Tyler,
1996; Nikolopoulos, Lloyd, Archbold, & O'Donoghue, 2001;Richter et al.,
2000; Sach & Whynes, 2005).
Previous SectionNext Section
Parental Expectations and Their Fulfillment After Implantation
Most research on the outcomes of pediatric cochlear implantation has focused on speech perception, speech
and language development, and communication assessed by formal clinical methods. Only a fraction of all
studies exploring the process and effects of cochlear implantation have focused on parental expectations
regarding the outcome of implantation (Archbold, Sach, O'Neill, Lutman, & Gregory 2008; Dromi & Ingber,
1999;Ingber & Dromi, 2009; Nikolopoulos et al., 2001; Sach & Whynes, 2005;Weisel, Most, & Michael,
2006; Zaidman-Zait & Most, 2005), or, for example, parental concerns or stress (Archbold, Lutman et al.,
2002;Spahn, Burger, Löschmann, & Richter, 2004; Weisel et al., 2006; Zaidman-Zait, 2008). In these studies,
the greatest parental concerns have dealt with making the decision to implant and its long-term effects on the
child, the safety of the implant operation, the technical reliability of the device, speech and language
development, the appropriate educational setting and further education, and the child’s social integration.
Parental stress has also been found to be associated with concomitant problems and the lower communicative
competence of children with impaired hearing (Hintermair, 2006), indicating that children's problems also
affect the quality of life of their parents. Research based on parental views provides ecologically valid and
usually generalizable information on implant outcomes. Views and experiences of other families are useful for
the parents to know both during the implant decision-making process and also later on if readjustment of
expectations is necessary. To detect critical incidents in the life of children and their families and to provide
effective practices in the form of appropriate and timely support, professionals in hospitals and schools need
information on parental views on their child's communication and socioemotional development.
Satisfaction with the effects of implantation depends on the nature and level of expectations that parents have.
However, although parental expectations are often very realistic at the time of implantation, they often change
over time as children acquire more listening experience with the cochlear implant (Nikolopoulos et al.,
2001; Sach & Whynes, 2005; Spahn, Richter, Burger, Löhle, & Wirsching, 2003; Weisel et al., 2006). Weisel
et al. (2006), for example, reported that parental expectations were highest during the period of implant
candidacy and the first years after implantation. Parents often wisely adapt their expectations on the basis of
their child's development. Good results give reason to expect even better outcomes in the future, and obstacles
in the child's development may give reason to lower expectations. Expectations also change in a more general
manner than within single families. As experience has accumulated, with ever younger children being
implanted and implant devices and methods used in implant surgery evolving, expectations have steadily risen
since the 1990s (see, e.g., Cunningham, 1990; Kelsay & Tyler, 1996; Kurki, 1999).
Changing expectations pose challenges to outcome measurement; measures need to be flexible enough to tap
changes in parental expectations and their fulfillment. Instead of using a prospective, longitudinal design,
many studies on the outcomes of pediatric implantation have been carried out by using a cross-sectional
design, and variation in the duration of the children's implant use has often been very large. Additionally, many
studies, although having a prospective repeated-measures design, have concentrated on relatively short-term
outcomes of implantation in the areas of speech perception, communication, and speech and language
development. Wider perspectives obtained by longitudinal follow-ups of parental views on the effects of
implantation on their child, the family, the child's socioemotional development, and quality of life can support
new families both during their decision-making process, in early habilitation after activation of the implant,
and several years after their child’s implantation. To set realistic expectations, and for counseling purposes, it
is also important to know which changes usually take place at different times after implantation.
Change in Communication and Development of Spoken Language After Implantation
Some studies have explored parents’ satisfaction with their child’s habilitation, the outcomes of implantation
(Archbold, Lutman et al., 2002;Archbold, Sach, O'Neill, Lutman, & Gregory, 2006; Huttunen et al.,
2009;Nikolopoulos et al., 2001; Sach & Whynes, 2005), and quality of life after implantation (Archbold et al.,
2002; Huber, 2005; Huttunen, Sorri, & Välimaa, 2003; Huttunen et al.; Nikolopoulos et al.; Sach &
Whynes;Warner-Czyz, Loy, Roland, Tong, & Tobey, 2009). On the basis of parents’ views, researchers have
reported improvement in the child’s speech perception abilities, improved communication, and encouraging
development in speech and language (Archbold et al. 2008; Damen, Krabbe, Archbold, & Mylanus, 2007;
Watson, Hardie, Archbold & Wheeler, 2008). However, depending on the sample of children, up to 20% of
parents have expressed their, at least partial, disappointment with implant outcomes (Archbold et al., 2008).
Change toward an oral communication mode is often expected by the parents, and such change is an indicator
of their children’s auditory and spoken language development. During recent years, some reports have
explored changes of communication mode by means of either retrospective analysis or cross-sectional parental
reports. For example,Watson, Archbold, and Nikolopoulos (2006) showed that of the 176 children they
studied, 83% of those implanted at less than 3 years of age, almost two thirds of those implanted at 3–5 years
of age, and somewhat less than one half of those implanted at an age of 5 years and older were using oral
communication no later than 5 years after implantation. Thus, their communication mode 5 years after
implantation was significantly related to their age at implantation. A change of communication mode most
often occurred 1–3 years after implantation, but sometimes it took place even as late as after 3–5 years of
implant use. Watson and her colleagues also showed that the communication mode of some children later
changed back to using signed communication. This was related to poor results in spoken language
development or underlying language difficulty, for example. Watson, Hardie, Archbold, and Wheeler
(2008)reported that in 113 of 142 families, the children had changed to oral communication, 20 children
showed no change, and 6 children used more signs than speech 5 years after implantation. The reasons for
these changes were either the parents’ decision to use the communication mode that was most effective or most
beneficial for the child’s future, or simply a decision to use the communication mode that the child preferred
(either oral or signed). More recently, Wheeler, Archbold, Hardie, and Watson (2009) showed that different
communication approaches were utilized at various stages in the child’s development after implantation.
Initially, the most effective communication mode was use of signs, but later on a gradual shift toward oral
communication took place as the child’s spoken language abilities developed.
From study to study, certain background and outcome factors appear to be associated with acquisition of an
oral communication mode. Younger age at implantation, for example, clearly provides the child with greater
opportunity to develop speech perception and spoken language (Baumgartner et al., 2002; Connor, Hieber,
Arts, & Zwolan, 2000; Nicholas & Geers, 2007; O’Donoghue, Nikolopoulos, & Archbold, 2000; Svirsky,
Teoh, & Neuburger, 2004; Watson et al., 2006). Of outcome factors, spoken language development and speech
intelligibility seem to be associated with use of an oral communication mode (Huttunen et al., 2009; Tobey,
Rekart, Buckley, & Geers, 2004; Watson et al., 2008; Wheeler et al., 2009), and existence of concomitant
problems seems to be associated with use of a signed communication mode (Huttunen et al.;Wiley, Jahnke,
Meinzen-Derr, & Choo, 2005; Watson et al.; Wheeler et al.).
Changes of the main communication mode can be considered to be reflected even in the educational settings of
implanted children. Archbold, Nikolopoulos, O'Donoghue, and Lutman (1998), Archbold, Nikolopoulos,
Lutman and O'Donoghue (2002), Geers and Brenner (2003) and Geers, Tobey, Moog, and Brenner (2008),
among others, have reported a growing tendency to provide oral education to implanted children in educational
settings. Children with sufficient auditory capacity and speech as their main communication mode seem to
attend school in a mainstream setting, and it may be hypothesized that the communication mode used in the
educational setting, in turn, develops the child’s language and communication further. However, in order to
detect any trends related to implanted children in mainstream settings and to be able to provide these children
the support they need for good school achievement, these aspects need to be explored more with prospective
studies.
Socioemotional Outcomes of Implantation
Fluent communication skills are also one prerequisite for good socioemotional development. A child’s hearing
problems are not only a clear risk factor for spoken language development, they also cause difficulties in early
social experiences and interaction mediated by language, especially when a child with impaired hearing is born
to parents with normal hearing. Roughly 96% of parents who have a child with impaired hearing have normal
hearing themselves (Mitchell & Karchmer, 2004). A vast majority of people in the child’s environment also
have normal hearing ability and use spoken language as their communication mode. It is therefore
understandable that many children with a hearing impairment have been observed to mature slowly in their
ability to understand feelings and thoughts of other people (Edmondson, 2006;Peterson & Slaughter, 2006), in
their social behavior, in their self-regulation skills, and in their self-esteem (see reviews by Ita & Friedman,
1999; Moeller, 2007; Moeller & Schick, 2005). For example, Dutch children with impaired hearing (N = 238)
have been reported to have approximately twice as many emotional/behavioral problems as their peers with
normal hearing (van Eldik et al., 2004). Recently, Dammayer (2010) studied 334 Danish children with a
hearing impairment and found that the prevalence of psychosocial difficulties among them was almost four
times greater than in children with normal hearing. Children with concomitant problems had three times as
many socioemotional problems as those without concomitant problems. Poor sign language and spoken
language abilities were associated with psychosocial difficulties. Dammayer concluded that good
communication abilities, whether in speech or sign language, are essential for the psychosocial well-being of
children with impaired hearing. There is a strong interplay between communication and socioemotional
development also later in life. Most (2007), for example, showed that in a mainstream setting, good speech
intelligibility promotes positive social and emotional feelings in teenage. Teenagers that were in individual
inclusion and had better speech intelligibility rated themselves as feeling less lonely. They also had more
coherence compared with teenagers with poorer speech intelligibility.
Some reports on the effects of implantation on children’s socioemotional development are also available.
Positive changes in general functioning, self-reliance, and well-being; better social relationships with hearing
siblings, other family members, and friends; and improved independence have been found in several studies
(Archbold et al., 2008; Bat-Chava & Deignan, 2001; Damen et al., 2007; Huttunen et al., 2009; Incesulu,
Vural, & Erkam, 2003; Wiley et al., 2005). For example, in their study of 181 children with a cochlear
implant, Nicholas and Geers (2003) reported that the children had good self-competence in daily life at the age
of 8–9 years after 4–6 years of listening experience with the implant. Most of the children studied had a good
self-image and, according to their parents, they were also happy and communicatively and socially well
adjusted. In that study, information was gathered from the children with a low-verbal self-report instrument
and with a parental questionnaire. According to British parents, children with an implant have been found to be
more independent, happy, and satisfied after starting to use the implant (Beadle, Shores, & Wood, 2000). Their
sense of safety, self-esteem, and relationships within the family have also been rated very favorably. As the
greatest area of change after implantation, increased self-confidence of the children has been reported by 77%
of British parents (N = 30;Archbold, Lutman et al., 2002). In a cross-sectional study, Finnish parents also
reported beneficial effects of implantation in the areas of general functioning, self-reliance, well-being, and
social relations (Huttunen et al.). Sahli and Belgin (2006) found no difference in self-esteem between 12- and
19-year-old adolescents with an implant and peers with normal hearing. However, in some studies, despite the
benefits of implantation, some children with an implant perceived their psychosocial life less favorably than
their peers with normal hearing (Huber, 2005), and children have been reported to need support in their social
relationships and social acceptance (Boyd, Knutson, & Dahlstrom, 2000). Again, as also pointed out
by Moeller (2007), there is a constant need for prospective studies on the psychosocial development of
children whose intervention is started early.
It may be concluded that the effects of implantation are multifaceted in nature. To find average developmental
paths, variance in development, and possible reasons for such variance, there is a clear need for prospective
research that explores the outcomes of implantation in everyday life simultaneously in several domains. This is
needed because auditory and spoken language development and changes in the communication and
socioemotional development of these children clearly affect one another and the whole family.
The present prospective qualitative study was set up to explore parental views in ecologically valid settings: at
home and in day-care and school environments. In a follow-up study, we employed a questionnaire that
included both closed-ended and open-ended questions to explore parental perspectives up to 5 years after their
child’s implantation. We sought information on the main communication mode of the child and the people
surrounding him; ease of and changes in communication, speech, and language development; parental
experiences and satisfaction with the outcomes of implantation; and change in the child’s socioemotional
development. We operationalized socioemotional development by asking the parents about the child’s
behavioral changes, peer relations, and independence.
On the basis of the parental questionnaires, four main research questions were set:
1.
How and when does the communication of the children and the people in their environment
change after implantation?
2.
How do the children progress in their speech and language development and how satisfied are the
parents with this progress?
3.
How and when does the children’s socioemotional development change after implantation?
4.
Is the existence of the child’s concomitant problems or the achievement of functional hearing
ability related to implant outcomes in the areas of communication and socioemotional development?
Previous SectionNext Section
Method
Children and Their Families
The informants for this study were 17 families with altogether 18 children (11 girls and 7 boys), who were
implanted unilaterally at the Oulu University Hospital implant center in Finland. A monolingual Finnishspeaking family environment was used as the inclusion criterion for the implanted children. Seven of the
children (39%) were born as the first child in their family. At the end of the follow-up, that is, 5 years after
activation of the implant, the children had, on average, two siblings (range 0–7). Four children in this sample
had one or more siblings with a hearing impairment. In socioeconomic terms, most of the families would be
described as middle class on the basis of the education and working career of the parents. The parents of the
children gave their written informed consent to the study after the study protocol had been approved by the
Ethical Boards of the University of Oulu and the Northern Ostrobothnia Hospital District.
All the children had a bilateral, prelingual, profound hearing impairment that had been diagnosed, on average,
at the age of 1 year 2 months (Table 1). Despite careful examinations, the etiology of the hearing impairment
had remained unknown in 11 (61%) of the children. One child had a hereditary, syndromic hearing impairment
accompanied by a mild visual defect, two children had inner ear malformations, and four had a nonsyndromic
hearing impairment due to a mutation in the GJB2 gene that encodes the connexin 26 protein.


View this table:
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Table 1
Demographic information and details of the hearing and auditory performance of the children with cochlear
implants
According to medical records, the nonverbal intelligence of all the children was found to be within the normal
range. Depending on the decisions made by the psychologists child by child, the Leiter International
Performance scale, Leiter-R, Wechsler Intelligence Scale for Children, third edition, Wechsler Preschool and
Primary Scale of Intelligence—Revised, Test of Visual-Motor Integration, Terman–Merrill–Lehtovaara scales
and/or Terman–Merrill–Hellström tests had been used to test nonverbal intelligence. Eight of the children
(44%) had notations of one to three concomitant problems in their medical records, most often a
developmental language disorder or slight problems with neurological development (e.g., slow development of
gross or fine motor functions, balance problems, developmental verbal dyspraxia). Formal diagnoses were not
necessarily made, but because of these problems, for example, physiotherapy, occupational therapy, or special
education was provided for the children. Of the eight children with concomitant problems, four were girls and
four were boys. Because the whole group of children we studied comprised 11 girls and seven boys, a greater
proportion of the boys had concomitant problems compared with the girls. Because of this uneven distribution,
the results are not presented by gender of the child in the Results section.
Preoperatively, the parents of nine children reported the use of one or two hearing aids (9 hr a day, on
average, SD 3, range 3–13 hr), but none of the 18 children could recognize any speech even with amplification.
After implantation, 10 children used a MED-EL Combi 40+ implant, first with a CIS-PRO and often later on
with a Tempo+ speech processor, and 8 children used either a Nucleus CI24M or CI24R CS implant with a
SPrint (and often later on with an ESPrit 3G) speech processor. The implants were activated at the average age
of 3 years 4 months (median 2 years 9 months; Table 1). Fourteen of 18 (78%) children were implanted before
the age of 4 years. This means that at the beginning of the 5-year follow-up reported here, the age of the
children was, on average, 3 years, and at the end, 8 years. Two children were reimplanted because of a device
failure that occurred at the hearing age of 3 or 4 years. Hearing age means the time elapsed from activation of
an implant, that is, the time a person with a hearing impairment has had the possibility to hear with an implant.
According to the parents, all the children used their implants regularly; from the time point of 6 months to 5
years after activation, the mean duration of daily use of the implant was 12 hr (SD 2, range 5–15).
The children’s devices were programmed so that from the hearing age of 6 months to 5 years, the mean PTA0.5–
4 kHz (pure tone average over the frequencies of 0.5–4 kHz; EU Working Group on Genetics of Hearing
Impairment, 1996) was 31 dB HL, on average (SD 10 dB). The children’s speech recognition was regularly
assessed during their visits to the hospital. Various children’s and adults’ speech recognition test lists (e.g.,
speech recognition test lists for Finnish 3- to 4-year-old and 5- to 6-year-old children and Isolated bi-syllable
words of Jauhiainen, 1974) together with test procedures appropriate for their age and phase of auditory
development were used. This means that either the recorded test lists were presented with loudspeakers in an
auditory open set format where the child responded either by signs or by using speech, or the child was
provided with four alternative responses in visual form and was asked to select the word presented by pointing
to a picture. The speech recognition test results of the children who were followed up were obtained annually
from 11 to 17 children (mean 15) of 18. The mean speech recognition score of the children was 63% (median
80%) after 1 year of implant use, 72% (median 74%) after 2 years, 75% (median 72%) after 3 years, 82%
(median 83%) after 4 years, and 77% (median 86%) after 5 years of implant use (Table 1). The variance in the
measures of central tendency of the scores, especially the means, was affected not only by the auditory
development but also by the number of children tested at each follow-up point. The speech recognition results
with the new implant of the two children who were reimplanted after 3–4 years after the first implantation
were comparable with those achieved with the first implant. Judged by the parents 5 years after implantation,
the mean Categories of Auditory Performance (CAP) score (Archbold, Lutman, & Marshall, 1995;Archbold,
Lutman, & Nikolopoulos, 1998) of the children was 6.4 (median 7, SD 1.1, range 4–7 on a scale of 0–7). The
CAP score is a practical one-digit index that describes the highest level of functional hearing in everyday life.
Information on speech therapy services was collected from the children’s medical records. During the year
immediately preceding implantation, 12 children (67%) had been examined by a speech therapist or attended
speech therapy (mean 15 sessions, SD 20, range 3–66). After activation of the implant, almost all the children
received speech and language therapy, most often twice a week on a regular basis. One to five years after
activation, the mean number of speech therapy sessions received annually ranged from 51 to 65. Due to a
shortage of services provided in their place of domicile, two children received speech therapy for only a few
months after implantation. However, after 5 years had elapsed from activation, the number of speech therapy
sessions received started to drop more generally. Some children were judged to no longer need speech therapy
or there was a local shortage or total lack of speech therapy resources.
Procedure
Information on these 18 children and their families was prospectively collected with questionnaires sent to the
children’s parents altogether seven times: preoperatively and at 6 months and 1, 2, 3, 4, and 5 years after
activation of the implant. At the time point of 6 months after activation, the questionnaires were sent to 14
families (for one child the follow-up started 1 year after activation and for three families the questionnaires
were not sent due to technical reasons in mailing). Demographic information was collected from the children’s
medical records.
For the purposes of this study, a locally devised semistructured questionnaire based on literature and clinical
experience with children with hearing impairments was created to monitor the effects of implantation. In the
late 1990s, during the launching of the cochlear implant program at the Oulu University Hospital, no published
or widely used questionnaires were available for exploring parental views on pediatric cochlear implantation.
In the questionnaire used in this study, open-ended and closed-ended questions were included to explore,
among other things, the main communication mode used by the child and the people in the immediate
environment, reception of sounds and speech, vocalization, speech production and linguistic development,
behavioral changes, peer relations, and independence.
Data Analysis
For the open-ended questions, data-based inductive content analysis was applied (see Carley,
1990; Krippendorff, 1980). The parents’ responses were coded into a manageable number of categories at the
level of phrases and sentences. Coding was first performed independently by the two researchers. Differing
views and interpretations that emerged in a small fraction of the data were then resolved by discussions. The
results are presented as the percentage of all the responses for each theme that was found with the content
analysis.
Previous SectionNext Section
Results
From the preoperative phase to 5 years after activation of the implant, the parents filled out and returned
altogether 112 questionnaires, from 14 to 18 at each time point, resulting in a mean response rate of 95%. The
range of the response rate at different time points was 83%–100%. Because of occasional nonresponse to some
questions, some questionnaires not being sent, and one child being recruited into the study 1 year after
implantation, at different time points the data collected covers from 78% to 100% of the altogether 18 children
studied. The questionnaires were filled out most often by the mothers alone (55%), in 33% of the cases by both
parents together, and in 13% of the cases by the fathers.
Changes in Communication
Main communication mode.
All but two of the children used only signs (signed Finnish or Finnish Sign Language) and all but three parents
used speech and signs during the preoperative phase (Figure 1). The main communication mode of most of the
children and their parents started to change during the first 2 years after implantation. Parents and children
shifted to using speech instead of signing or using speech and signs usually approximately at the same pace.
The same was true for the brothers and sisters of the children (Figure 2), whereas in most cases the
communication mode of friends seemed to be speech at the different data collection points.
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Figure 1
Main communication mode of the children (above) and their parents (below).
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Figure 2
Main communication mode of brothers and sisters (above) and friends (below) of the children with implants.
When we looked at the changes of communication mode in terms of the children’s demographic factors and
auditory development, the results revealed that 5 years after activation, 89% of the children with no
concomitant problems (N = 12) used speech and 11% used speech and signs. Of the eight children with one or
more concomitant problems (problems with motor development or a developmental language disorder), four
(50%) used speech, three (38%) used speech and signs, and one (13%) used sign language. The CAP score
obtained at the hearing age of 5 years was also indicative of the main communication mode of the children:
77% of the children scoring 7 (“Can use the telephone with a familiar talker,” the highest possible CAP score)
used speech as their main communication mode, whereas only 33% of the children who had a CAP score lower
than that used speech as their communication mode. At this stage, 13 of the 18 children were in school
(Finnish children with a profound hearing impairment start school at 6 or 7 years of age), seven of them were
in a mainstream setting, and six were in a special education setting. All the mainstreamed children used speech
as their main communication mode, two of the six children attending a special school used sign language, and
four used speech. At different time points, 6–15 children were in day care outside their home. The day-care
personnel of almost all the children (whose parents had replied to this question concerning the main
communication mode) used speech and signs as their communication mode right before and during the first
year after the child’s implantation (Figure 3). Speech was used more often than speech and signs from around
3 years after implantation onward. Most teachers of school-aged children used speech during the follow-up of
the present study, although also speech and signs or sign language were used with some children who attended
special schools.
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Figure 3
Main communication mode of day care (above) and school personnel (below) of the children with implants.
In order to further explore the various aspects associated with the main communication mode, we also
investigated the amount of instruction in signs that the families received before and after implantation. To
reduce recall bias, we defined the target period to be the previous 6 months before receiving the questionnaire.
The amount of instruction in signs that the families received was associated both with the change of
communication mode and partly also with difficulties in getting services as indicated by the parents. Looking
at the parental responses at all the data points, a mean of 40% (range 0–71) of the families reported having
received instruction in signs during the preceding 6-month period. In 40% of the cases, the instruction received
was in Finnish Sign Language and in 60% of the cases in signed Finnish. Instruction was given at home in a
majority of the cases (73%). The mean number of sessions of sign instruction received within each half-year
period was seven (median 0, SD12, range 0–50). The amount of instruction in signs dropped after 1 year had
elapsed from the child’s implantation: At the 2-year data point, the median number of sessions was down to 0
(Figure 4). The parents were also asked about their opinion on instruction in signs. At the different time points,
learning Finnish Sign Language had been easy for 50% of the parents, and similarly, difficult for half of the
parents. When it was perceived as difficult, the parents especially mentioned that syntax (word order) was
challenging to learn. Additionally, the parents found it difficult to learn the signs and the use of facial
expressions and to remember the signs learned. But, a mean of 79% of the parents learning signed Finnish
found it easy at the different time points and only 21% found it difficult. Signed Finnish was perceived as
easier, for example, because it could be used simultaneously with speech.
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Figure 4
Number of lessons in signs/sign language instruction received by the families during the period of 6 months
preceding each data collection point. Nrefers to the number of families to whom the questionnaires were sent at
each time point.
Perceived ease of communication.
To further explore the parental views on changes in communication, ease of communication was surveyed with
a closed-ended question with six alternative responses (“communication has clearly gotten more difficult,”
“communication has gotten somewhat difficult,” “no change,” “communication has gotten somewhat easier,”
“communication has clearly gotten easier,” and “communication has gotten very much easier”). On the basis of
research literature, we expected more positive than negative changes to take place in communication after
implantation. We wanted to explore more closely how strong these positive changes would be. That is why
there were three positive responses and only two negative responses. Before implantation, the parents of only
two families (14%) perceived communication at home with their child to be easy, nine parents (64%) found it
rather easy, and three (21%) perceived it to be difficult. Compared with that information, it was somewhat
surprising that the parents reported such clear improvement after implantation. None of the parents reported
that communication had gotten more difficult or that no change had been seen. Instead, at the different time
points, a mean of 61% of the respondents reported that communication had gotten very much easier, 28%
reported that it had gotten clearly easier, and 11%, somewhat easier (Figure 5). Most of the parents had noticed
that communication had gotten somewhat easier when 6 months had elapsed from activation of the implant.
After that time point, the parents almost exclusively reported clear or very clear improvement in
communication.
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Figure 5
Positive changes in the ease of communication at home after implantation as a function of time.
The parents were also asked about their opinion on their child’s communication at day care. Compared with
the time preceding implantation, a change in perceived ease of communication in day care took place
approximately 1 year after activation of the implant. Alternative responses, communication has gotten more
difficult, no change, and communication has gotten easier, were given to the parents in this question. At the
hearing age of 6 months, for three of the seven children attending day care and who had been in day care
already preoperatively (43%), no change was noted in the perceived ease of communication, and for four
(57%), communication had become easier. At the hearing age of 1 year, the parents of 11 of 12 children (92%)
felt communication had become easier in day care, but with one child (8%) no change was seen. Later on, the
parents of all 6–10 children attending day care outside their home perceived communication to have gotten
easier in day care. According to the parents, communication with their child had gotten easier at the same pace
in both day care and at home.
Qualitative changes in communication.
In addition to closed-ended questions on changes in communication (see above), the parents were also asked
about qualitative changes in communication with an open-ended question. The parents gave altogether 163
descriptions (mean of 27 descriptions per time point, range 21–34) of how communication with their child had
changed at home after implantation. Content analysis of the parents’ responses revealed five major themes
(Table 2). Enhanced use of an auditory modality was the most frequently mentioned change at all time points.
The parents reported that it was easier to make contact with their child using voice and speech, for example, by
calling the child by name. They no longer had to rely on only touching or visual means to get the child’s
attention. They further reported that everyday life had become easier because the child could be contacted from
a distance. Use of an auditory modality was gradually replacing the use of a visual modality (signing), or the
parents mentioned that communication was starting to be supported by speech reading (based on acquisition of
spoken language). Compared with references to increased use of audition and the decreased role of a visual
modality, mentions of spoken language development were astonishingly rare; they comprised only 15% of all
the parents’ responses to this question.
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Table 2
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Reported changes in communication grouped into five major themes together with the percentages they
represented of all the parents’ responses. The gender and HA of the child are mentioned in parenthesis after the
examples of parental responses
In order to analyze which changes in communication emerged at which time point after implantation, the major
themes derived from the content analysis were examined as a function of time. Some variance in the share of
observations representing different themes was noticed (Figure 6). However, there were actually no distinct
changes in parental views on changes in communication by time point because enhanced use of audition and a
change in the use of a visual modality can be considered to represent different sides of the same process.
Interestingly, observations on spoken language development started to emerge already 6 months after
implantation, and mentions of expanded social life started to emerge at the data point 2 years after
implantation.
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Figure 6
Changes in communication at home as a function of time.
Auditory and Speech and Language Development and Parental Satisfaction With It
To gather information for our second research question, the parents were asked about development of the
auditory and spoken language skills of the children with an implant. According to the parents, the children
started to recognize environmental sounds at the average hearing age of 2 months (SD 1.7 months), perceive
rhythm of music at the average hearing age of 3 months (SD 3), recognize his or her own name (SD 3.5) and
other words at 4 months (SD 4.1), and recognize sentences at the hearing age of 12 months (SD 9.4).
Furthermore, the parents also reported an increase in the children’s vocalization 2 months (SD 2.0) after
activation, on average; onomatopoetics emerged at 5 months (SD 3.9), on average; one- to two-syllable words
emerged at 6 months (SD 5.0), on average; words of three or more syllables came at 10 months (SD 6.9); and
two-word sentences appeared at 12 months (SD 9.4), three-word sentences at 14 months (SD 11.0), and
inflection of words at 17 months after activation (SD 10.6). Variation in the parents’ reports was larger in the
responses to questions on speech production than on speech perception.
Five years after implantation, the parents were asked with open-ended questions whether they were satisfied
with their child’s auditory and spoken language development and whether their child’s development met their
original expectations in these domains. With the help of content analysis, the parents’ responses were classified
into three classes. Eight of the parents (44%) answered that their expectations were exceeded, seven (39%) felt
their expectations were met, and three (17%) reported that their expectations were met only partly or not at all.
When the parents were extremely satisfied with the implant outcomes, they especially emphasized the rapid
progress of their child, the good quality of their child’s speech, and their child’s ability to cope socially with
other people by using spoken language. The parents of three children expressed their disappointment in the
slowness of spoken language development, either in the early phases of habilitation or during the whole period
of the first 5 years after implantation. All these three children had at least one concomitant problem in addition
to their profound hearing impairment. Additionally, one of these children with concomitant problems used
speech and signs as her main communication mode 5 years after implantation, and according to her CAP score
(which was 6), she understood conversation with a familiar talker without speech reading. In our study, age at
implantation was not associated with parental satisfaction with spoken language development.
Socioemotional Development
In our third research question, we were interested in the children’s socioemotional development
operationalized as changes in the child’s behavior, peer relations, and independence.
Changes in the children's behavior.
Using an open-ended question, the parents were asked if their child’s behavior had changed in some way after
the implantation. Four examples were given in parentheses in order to clarify this question for the parents;
whether “the child had calmed down” or “gotten more fidgety,” whether “the child had gotten more selfconfident” or “less self-confident.” At each time point, the parents gave a mean of 28 descriptions (range 23–
31) in response to this question. Content analysis revealed six major themes (Table 3). The parents most often
mentioned an increase in their child’s self-confidence and sense of safety. This theme comprised altogether
34% of all the descriptions given by the parents in response to this question at the different time points. The
other themes were expanded social life (27%), the child’s calming down (14%), change in vocal behavior
(6%), and negative change in behavior (4%). No change or the view that the changes in the child’s behavior
were probably due to maturation (increased age) was reported in 15% of the responses.
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Table 3
Changes in the child’s behavior after implantation grouped into six major themes together with the percentage
these themes represented of all the responses
When the changes were analyzed separately at different data points, the child’s increased self-confidence was
the most prevalent theme mentioned in the parental responses (Figure 7). Five years after implantation, there
was a clear tendency of the parents to report increased self-confidence, especially in children with at least one
concomitant problem compared with children without concomitant problems. In the parents’ responses,
increased self-confidence was mentioned in 6 of 8 (75%) children with concomitant problems and in 4 of 10
children (40%) without concomitant problems. The main communication mode or functional hearing ability in
everyday life (CAP score) was not related to parental reports of their child’s self-confidence in any particular
way at the 5-year data point.
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Figure 7
Changes in the child’s behavior as a function of time.
Children’s peer relations.
To obtain further information on the socioemotional development of the children in our study, the parents were
also asked about the number of friends visiting their child weekly and the number of friends their child visited
weekly. Annually, from 0 to 6 children (mean 2, SD 1.7) per week visited the implanted child, whereas the
child with an implant visited, on average, 1.5 friends (SD 1.3, range 0–6) per week. The number of friends
visiting the child per week remained rather constant over time, whereas the number of friends the implanted
child visited weekly increased relatively evenly year by year and approached a mean of two friends by the time
5 years had elapsed from implantation. It is important to note, however, that both the age of the child with an
implant and the place of residence of the family affected these figures. Children living in sparsely populated
areas naturally did not have equal opportunities to see other children compared with children living in villages
or cities. Additionally, if a child attended a special school far away from home from Monday to Friday, the
possibilities of making friends with the neighborhood children during the weekends were few. This was
particularly true for one child in our study. Furthermore, sign language used by this child did not make it easy
to make contacts with neighborhood children. The children’s functional hearing ability in everyday life was
also reflected in their social relations: At the hearing age of 5 years, the children with the lowest CAP scores
were reported to have no friends or only one friend visiting them weekly, and they either did not visit other
children at all or visited only one child weekly.
Children’s independence.
Five years after implantation, the parents were asked to describe how independent their child was compared
with age peers. To let the parents freely write their views, we did not operationalize this concept in any way in
the questionnaire. Using content analysis, the parental responses were grouped into three categories:
independence in activities of daily living (e.g. dressing and eating), communicative independence (child’s
ability to rely on spoken language), and socioemotional independence (social tenderness/courage, ability to
independently play with age peers). The parents of one child (6%) perceived this child as more independent
than age peers. This child used sign language as the main communication mode. The parents of 12 children
(67%) judged their child to be at his age level in independence. They mentioned, for example, the child’s
independent functioning outside the home, independence in doing schoolwork, and ability to be alone without
supervision at home after school, when necessary. The parents of five children (28%) reported that their
children were less independent than their age peers. In these cases, the reasons were itemized as, for example,
the need to confirm that the child has really understood what she has heard and what has been agreed on, or the
child’s dependence on sign language interpretation because of insufficient hearing ability. Three of these five
children who were rated by their parents as not being at their age level in independence used speech and signs
and one used sign language. Eight children in this sample had concomitant problems. Three of them were rated
as less independent than their age peers. Independence rated by the parents seemed to be somewhat related to
the child’s functional hearing: Of the three children whose CAP score was more modest than that of the others
(i.e., less than 7), two were rated as less independent than their age peers.
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Discussion
The present study was a 5-year prospective follow-up of 18 consecutively unilaterally implanted children and
their families concerning changes in communication, auditory and speech and language development, and
changes in socioemotional development, assessed by means of parental questionnaires in everyday life. In this
sample of children, we noticed that a major change toward the use of spoken language took place between 1
and 2 years after implantation. The communication mode of the parents and siblings of the implanted child
changed accordingly. The parents also reported eased communication, increased use of audition, and a
decrease in signing and dependence on eye contact in communication. Several socioemotional benefits were
also detailed by the parents: The child’s increased self-confidence and sense of safety, expanded social life,
and positive changes in the child’s behavior were most often mentioned. Five years after activation, a majority
of the parents were satisfied or very satisfied with their child’s auditory and spoken language development, and
two thirds perceived their child to be as independent as their age peers. At this time point, the existence of at
least one concomitant problem was often related to the main communication mode of the child, and functional
hearing ability seemed to be at least somewhat associated with the child’s peer relations and independence.
With the small number of children, our results cannot, however, be considered conclusive.
Although it is sometimes difficult to compare the results of longitudinal data with those of cross-sectional
studies reporting on outcomes of implantation from variable time points, our results on communication,
auditory and spoken language development, and psychosocial development seem to be well in line especially
with those of, for example,Chmiel, Sutton, and Jenkins (2000), Archbold, Lutman et al. (2002),Incesulu et al.
(2003), Sach and Whynes (2005), Archbold et al. (2008), and Huttunen et al. (2009).
With our longitudinal study design, it was possible to explore individual profiles of the changes of the main
communication mode of the children with an implant and of the people in the children's environment. In our
study, the main communication mode of the children clearly started to change between 1 and 2 years after
implantation. This result is similar to information found in the studies by Watson et al. (2006, 2008), Sume
(2008), and Huttunen et al. (2009), in particular. For example, in the study by Watson et al. (2006), the
children’s communication mode changed between 1 and 3 years after implantation. In her longitudinal study of
15 Finnish children, Sume (2008) also found that children started to use speech as their main communication
mode at the hearing age of around 2 years. Most of the children in her study were somewhat younger than the
children in our study; they were usually implanted between 2 and 3 years of age. In a cross-sectional study of
36 Finnish children from several implant centers (Huttunen et al.), it was found that 67% of the children
studied used speech as their main communication mode at 2 or 3 years after implantation (the children were
implanted at the average age of 3 years 5 months). Speech and signs were used by 22% and sign language by
11% of the children. In the present study, we were additionally interested in changes of the communication
mode of the people in the child’s environment. One clear finding in our study was that the communication
mode of the parents closely followed that of the children. Hence, it seems that the changes of communication
mode in our sample were child led. This finding is quite well in line with the study by Watson and colleagues
(2008) and Wheeler and colleagues (2009), who reported similar trends: As soon as the child’s auditory and
spoken language development allowed, the families changed to using speech.
The communication mode of the child is a rather straightforward and easily obtainable outcome of
implantation, which is found to be associated with speech reception (O'Donoghue et al., 2000), language
development (Cullington, Hodges, Butts, Dolan-Ash, & Balkany, 2000), speech intelligibility (Huttunen,
2008; Tobey, et al., 2004), and the educational setting selected for the child (Tobey et al.), among other things.
In our study, the change of communication mode was also related to child-specific characteristics, namely the
existence of concomitant problems and functional hearing ability (CAP score). For example, three of the eight
children with concomitant problems used speech and signs, and one used sign language as the main
communication mode 5 years after activation of the implant. Moreover, 77% of the children scoring the
highest level on the CAP scale used an oral communication mode 5 years after implantation. Clinicians, who
consult new parents, while pointing out the rather wide variance often found in implanted children’s
development, could use the time point of roughly 2 years after implantation as some kind of a milestone in the
change of communication mode for children who have used signs or sign language before implantation. We
base this view on our own results and accumulating similar data from other studies (see Huttunen et al., 2009;
Sume, 2008; Watson et al., 2006; Watson et al., 2008). If a child’s main communication mode has not changed
by that time point, it would be important to assess the functioning and programming of the speech processor,
judge the need for more intensive habilitation, and explore whether possible underlying language difficulties
could explain the child’s slow development. However, it is important to note that nowadays, especially if the
children are implanted at a very young age (for example, before 18 months of age), parents may not adopt the
use of signs at all because they expect the spoken language development of their child to be rapid.
Additionally, children themselves may quite often acquire spoken language rather than signs. It has to be borne
in mind, however, that variation does exist in children’s development, and use of signs may be important for
some children.
It is obvious that the communication skills of children with impaired hearing usually develop with increasing
age (Blamey et al., 2001). However, we can quite safely assume that the change of the main communication
mode of the children in the present study resulted from their enhanced auditory function, not from age and
maturation alone. Namely, in the study by Huttunen (2000) on Finnish children (N = 14) without a cochlear
implant and who have a profound hearing impairment, 14% were observed to use speech; 8%, speech and
signs; and 79%, sign language as their main communication mode. The average age of the children was 12
years. In the present data, the communication mode was speech in 70% of the children, speech and signs in
12%, and sign language in 6% of the children 5 years after activation. At that time point, the mean age of the
children was 8 years. It has indeed been clearly shown that cochlear implantation provides profoundly hearing
impaired children an effective way to acquire spoken language, and without an implant over time they would
lag more and more behind their hearing age peers in spoken language development (Svirsky, Robbins, Kirk,
Pisoni, & Miyamoto, 2000). However, we did not have a control group of children with a profound hearing
impairment who used hearing aids, as some researchers have had. This is a clear limitation of our study. Such a
group would be very difficult to recruit because, in Finland, nearly all children with a profound hearing
impairment are implanted. Additionally, to be ultimately sure about the validity of our results, use of a control
group of hearing children would have been important to enable us to show the share of socioemotional changes
that were related to age and maturation rather than implant outcomes. In addition to information on child’s
development given by the parents, use of objective measures is important. Recent reports (Lee, Chiu, van
Hasselt, & Tong, 2009; Thal, DesJardin, & Eisenberg, 2007) have, however, shown that related to children
with impaired hearing, parental reports on linguistic milestones correspond reasonably well with objective test
measures.
In our study, the parents reported increased self-confidence in their children and a sense of safety as well as
expanded social life, with an average of two children visiting the child weekly and the implanted child visiting
about 1.5 friends weekly. The parents also judged 67% of the children to be as independent as their age peers
when 5 years had elapsed from implantation. Stacey, Fortnum, Barton, and Summerfield (2006) have also
reported improved social independence and socialization after implantation. Their large survey of more than
400 implanted children was based on parental and teacher reports. Wauters and Knoors (2008) studied 344
hearing children and 18 children with a severe or profound hearing impairment. Of these 18 children attending
school in an inclusive setting, 9 used a cochlear implant. Hearing impaired children scored lower than their
hearing age peers in social competence, although the two groups did not differ from each other in social
relations (peer acceptance and friendship relations). Children with an implant did not differ in these respects
from children using hearing aids. Nicholas and Geers (2003) studied a large (N = 181) group of implanted
children and indicated that most of the children had a good self-image and were socially well adjusted. In both
these studies, the children explored were attending school. Because educational options and emphasis on either
inclusion or segregation of children with impaired hearing vary from country to country (Wauters & Knoors,
2008), research results on the impact of implantation on socioemotional development may rather strongly
depend on the school system and traditional attitudes toward special populations in the child’s living
environment. Although a child with impaired hearing would develop good social skills, the values and views
of people in the environment may lead to a situation where a child with a hearing impairment may not have
friends at all or exhibits withdrawn behavior. In addition to the social competence of an implanted child and
the values of the people in his environment, fluency of communication is also a key issue. Nunes, Pretzlik, and
Olsson (2001) described some implanted children as being lonely, presumably because of communication
problems between them and their hearing peers.
Several studies have reported that spoken language development is one of the major expectations of parents
deciding to have an implant for their child (Nikolopoulos et al., 2001; Richter et al., 2000). We found that
parental expectations regarding their child’s auditory and spoken language development were met in 39% and
exceeded in 44% of the cases. The combined figure of met or exceeded expectations (83%) is similar to that of
many other studies (Archbold, Lutman et al., 2002; Archbold et al. 2008; Nikolopoulos et al.; Richter et al.). In
the present sample, the degree of parental expectations met can be considered high if we bear in mind that 44%
of the children had concomitant problems (many of which became evident only when several years had
elapsed from implantation) and the average age of implantation was more than 3 years. To our mind, studying
clinical samples of consecutively implanted children is of inherent value. With this kind of sample, it is
possible to show effectiveness of implantation (effects of implantation in real, clinical samples and conditions).
With selected samples, excluding children with concomitant problems, only the efficacy of implantation (i.e.,
maximal effects of implantation in optimal samples and optimal conditions) can be shown. We feel that the
generalizability of results is more restricted in efficacy studies than in effectiveness studies.
Some background and outcome factors were related to the changes perceived by the parents, which may also
partly explain the more modest development of some children we studied. For example, 5 years after activation
of the device, a minority (parents of three children, 17%) was disappointed with their child’s auditory and
speech and language development compared with their original, retrospectively viewed expectations before
implantation. All three children had at least one concomitant problem in addition to their profound hearing
impairment. However, the parents of these children reported an increase in their child’s self-confidence 5 years
after activation. It seems that even if implantation does not enhance satisfactory spoken language development
because of child-dependent factors, positive gains can still be achieved in the socioemotional domain. Auditory
development may not always suffice for good spoken language development, but it may enhance development
of a sense of safety, bring joy to the child, and give the parents the possibility to guide their child with speech.
Of the outcome factors, functional hearing ability (as judged by the parents with the CAP measure 5 years after
activation) seemed to be associated with the children’s social relations: The children with better hearing ability
visited more friends weekly than did the children with more modest functional hearing. The children with
better hearing were also visited by more friends per week than were those with a lower CAP score. It seems
that improved hearing enhanced the child’s integration into the hearing world, and it also improved the
independence of the child. In many areas of sparsely populated countries like Finland, children with a
profound hearing impairment rather seldom have signing people in their neighborhood. One child in particular
in our sample deserves a closer look: This child with lower functional hearing ability was dependent on sign
language interpretation during the whole follow-up period, and she had no friends to visit and no friends
visited her 5 years after implantation. The variation in age at implantation was rather wide (1:7–8:6) in our
study. Because age at implantation was not associated with parental satisfaction with spoken language
development, it seems that the parents of children who were implanted at an older age (4 years and older) had
relatively low expectations regarding their child’s development.
About 30%–40% of all children with a hearing impairment are known to have at least one concomitant
problem, most often learning difficulties (Fortnum, Marshall, & Summerfield, 2002), or problems in
ophthalmic functions (Fortnum et al., 2002; Nikolopoulos et al., 2006), or in motor (Gheysen, Loots, & van
Waelvelde, 2008) or neurological development (Schlumberger, Narbona, & Manrique, 2004). In our study,
eight (44%) children had at least one other problem in addition to their hearing impairment. The existence of
concomitant problems is known to be associated with more modest implant outcomes in spoken language
development (Wiley et al., 2005). That is why, in the beginning, there were fewer children with concomitant
problems among the implanted children than among children with hearing impairments in general (Fortnum et
al.). However, important implant outcomes that improve the quality of life of both children and their families
have also been reported in many studies on multihandicapped children (Berrettini et al., 2008; Wiley et al.).
Because our study sample was comprised of consecutively implanted children from monolingual families, but
was unselected in all other ways, our study results can be generalized to many clinical samples of unilaterally
implanted children. However, after the launch of universal hearing screening of newborn children, the age at
diagnosis of severe and profound hearing impairments and the age at implantation are nowadays expected to
be lower than in our study. In that respect, our results may not be fully representative of children receiving a
cochlear implant today.
Studies on the outcomes of implantation rather often report data of heterogeneous groups of children using
cross-sectional study designs. Age at implantation, the age of the children studied, duration of implant use, and
follow-up periods may vary in the same study even up to 10 or 15 years. In our prospective study, the length of
the follow-up was 5 years for all but one child (for whom it was 4 years), and we were therefore able to obtain
information and combine the strengths of both cross-sectional and longitudinal analyses. Our self-constructed
measure was developed in the late 1990s, when no valid, reliable questionnaires had been published for
measuring changes in communication and quality of life after implantation. Although the validity and
reliability of our measure has not been explored, it was constructed on the basis of information on main
implant outcomes published in scientific papers and clinical experience in communication and psychosocial
development of children with impaired hearing. Additionally, our results are so concordant with those on
parental views published in other countries that we expect our questionnaire to have tapped important issues in
the development of implanted children. Other studies have also used qualitative research methods, for
example, interviews (Bat-Chava & Deignan, 2001; Sach & Whynes, 2005; Sume, 2008; Wheeler et al.,
2009; Wiley et al., 2005) and open-ended (Archbold, Lutman et al., 2002; Kelsay & Tyler, 1996) and closedended questionnaires (Archbold et al., 2008; Nikolopoulos et al., 2001), which provide nonrestricted insights
into parental opinions, but which are very time-consuming in terms of both research and clinical work.
Nevertheless, qualitative research is mandatory in order to obtain direct information from parents and children
with implants. Because of changing interventions and changes in society, versatile information on emerging
new phenomena can often be obtained only with open-ended questions. All levels of human functioning, as
specified by the ICF classification (International Classification of Functioning, Disability and Health; World
Health Organization, 2001), can also be measured effectively especially with qualitative research.
We need to consider whether our results would have been the same if it would have been possible to ask the
children themselves. In some studies, the perceptions of parents and their children with a hearing impairment
have not always been very concordant. Before the era of cochlear implants, Gregory, Bishop, and Sheldon
(1995, p. 265), for example, reported that most young people with impaired hearing (using or not using a
hearing aid) perceived themselves to be happiest in secondary school, whereas their parents viewed them to be
happiest in primary school. Additionally, the views of young people and their parents differed on the number
and quality of social contacts; parents had a more pessimistic view of their child’s social life than did
adolescents or young adults themselves. Some differing views have also been found between parents and their
children on the advantages and disadvantages of the implant (Cunningham, 1990), education, social
relationships (Chmiel et al., 2000; Huber, 2005), and quality of life (Nicholas & Geers, 2003; Huber;WarnerCzyz et al., 2009). Therefore, the children’s own perceptions should also be asked with appropriate and valid
instruments as soon as the children are able to answer questions about communication, socioemotional
development, and quality of life. To date, unfortunately, no consensus has been reached on the minimum age
of children studied with self-report instruments and on appropriate measures to be used (Warner-Czyz et al.). It
is important to use low-verbal instruments with younger children and with children with low communicative
competence. Some reports concentrating on the views of adolescents with cochlear implants are fortunately
already available (Huber; Wheeler et al., 2009;Leigh, Maxwell-McCaw, Bat-Chava, & Christiansen, 2009). In
studies that look at children’s development, teacher reports are also very helpful in getting a more versatile
view.
Our study covered the first 5 years after implantation until, for more than two thirds of the children, the first
years in school. Summerfield and Marshall (1999) outlined the cascade of benefits of implantation affecting
the child’s life into adulthood. For a majority of the children we followed up, implantation enhanced spoken
language development based on auditory information and brought many positive changes in the
socioemotional domain as well as the possibility for inclusive education–a new option in primary education in
Finland for children with a profound hearing impairment. Given the challenges of advanced language levels
needed in learning, school as a social environment, and identity formation in teenage, further research on
communication and socioemotional development after implantation is warranted.
Previous SectionNext Section
Funding
Academy of Finland (201785 and 80834 to K.H.) and the Niilo Helander Foundation.
Previous SectionNext Section
Conflict of Interest
No conflicts of interest were reported.
Previous SectionNext Section
Acknowledgments
The authors kindly acknowledge the views shared by and the support of Professor Martti Sorri and Petri
Karinen during the planning and conducting of this study.

© The Author 2010. Published by Oxford University Press. All rights reserved. For Permissions, please email:
journals.permissions@oxfordjournals.org
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Renée Punch1 and
Merv Hyde*,2
+ Author Affiliations
1.1Griffith University
2.2University of the Sunshine Coast
1.
↵ *Correspondence should be sent to Mery Hyde, School of Science and Education, University of the Sunshine Coast,
Maroochydore 4558 QLD, Australia (e-mail: mhyde@usc.edu.au).

Received September 12, 2010.

Revision received January 5, 2011.

Accepted January 6, 2011.
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Abstract
Psychosocial factors, including socioemotional well-being, peer relationships, and social inclusion with
hearing and deaf peers, are increasingly becoming a focus of research investigating children with cochlear
implants. The study reported here extends the largely quantitative findings of previous research through a
qualitative analysis of interviews with parents, teachers, and pediatric cochlear implant users themselves in
three eastern states of Australia. We interviewed 24 parents, 15 teachers, and 11 children and adolescents. The
findings displayed commonalities across the three groups of participants, indicating positive experiences
around the children's psychosocial development with their cochlear implants, but also ongoing difficulties
communicating in groups of people and problems related to social skills. Some children had little contact with
other deaf children (with or without cochlear implants) despite parents and teachers perceiving such contact
beneficial. Children attending schools where there were other deaf children valued friendships with both deaf
and hearing peers. Adolescence was a particularly difficult time for some as they struggled with feelings of
self-consciousness about their deafness and external cochlear implant equipment and worries around
friendships, dating, and their future place in the world. Recommendations for practice and further research are
made.
Cochlear implants can give access to audition and, often, levels
of spoken language communication not otherwise accessible to
children with severe or profound deafness. The outcomes of
implants in the areas of audition, speech production and
perception, and spoken language development have been
widely reported. There have been fewer studies into broader
psychosocial outcomes, particularly those reporting how
children with implants are faring over time in the areas of
psychological well-being and social inclusion, particularly with
hearing peers (Thoutenhoofd et al., 2005). However, in recent years,
children's social outcomes have begun to receive more research
attention. As pediatric cochlear implantation has been
proceeding for over 20 years in many countries, it is becoming
more possible to report on longer-term outcomes across a
wider range of domains related to children's functioning in
everyday life at home, at school, and in the community (Beadle et
al., 2005; Geers, Tobey, Moog, & Brenner, 2008). The current paper
reports findings about children and young people in the area of
their social functioning, socioemotional well-being, and social
participation with hearing and deaf peers. We use the term
“social participation” to refer to the nature and extent of
children's engagement in social activities and interactions with
peers appropriate to the child's age and environment (Hyde &
Power, 2004; Power & Hyde, 2002).
There are concerns that even those deaf or hard-of-hearing
children who, with the help of cochlear implants or hearing
aids, develop good spoken language and can successfully
conduct conversations in optimal conditions may be at a
disadvantage in situations that are difficult for them to hear or
speechread. This has been termed “social deafness” in some
European contexts (Vonen, 2007). It is not used in any
audiological or cultural sense and refers to difficulties in social
interactions involving groups of people or in noisy
environments, in contrast to one-to-one interactions, which are
generally easier for people who are deaf or hard of hearing to
manage. In children and adolescents, social deafness can
impede social interactions such as play and conversations with
peers. Potential barriers to easy social interactions with hearing
peers include not only deaf and hard-of-hearing children's
communication difficulties in challenging listening
environments but also a misunderstanding on the part of
hearing children of these difficulties, and the sometimes
inadequate social skills of children who are deaf or hard of
hearing (Martin & Bat-Chava, 2003).
Many studies have investigated the social participation and
psychosocial well-being of deaf and hard-of-hearing children
and adolescents and their hearing peers (e.g., Byrnes, Sigafoos,
Rickards, & Brown, 2002; Kent, 2003; Stinson & Liu, 1999). Studies of
children based in resource units or classes for deaf students in
mainstream schools have found that the children experienced
difficulties with social participation with their hearing peers
(Charlson, Strong, & Gold, 1992; Stinson & Liu, 1999;Stinson, Whitmire, &
Kluwin, 1996). Studies of children educated in general classes
with support from itinerant teachers of the deaf have revealed
difficulties with social participation and feelings of loneliness at
school (Byrnes & Sigafoos, 2001; Byrnes et al., 2002; Eriks-Brophy et al.,
2006; Kent, 2003; Kent & Smith, 2006; Most, 2007; Power & Hyde,
2002,2005). Research investigating the mental health of deaf and
hard-of-hearing students in a variety of educational settings
has reported higher rates for social problems among deaf and
hard-of-hearing children and adolescents (Fellinger, Holzinger,
Beitel, Laucht, & Goldberg, 2009) and for peer relationship problems
among deaf and hard-of-hearing teenagers (Remine & Brown,
2010) than published norms for hearing students.
Recently, several studies investigating psychosocial aspects,
including social inclusion, social functioning, social well-being,
loneliness, and quality of life (QOL), of children with cochlear
implants have been reported. Many of these studies’ findings
have reported largely positive social outcomes. For
instance, Nicholas and Geers (2003) investigated the social
adjustment of 181 children aged 8 and 9 years using parents’
ratings on the Meadow-Kendall Social-Emotional Assessment
Inventory for Deaf and Hearing Impaired Students (MeadowOrlans, 1983) and children's self-ratings on a pictorial
assessment scale of self-image modified by the researchers for
use with children with cochlear implants. Findings from both
parents’ and children's ratings indicated that the children had
good levels of social-emotional adjustment and competence in
most areas of everyday life. Bat-Chava, Martin, and Kosciw
(2005)conducted a longitudinal study of 29 primary school
children before and after receiving cochlear implants. Parents’
responses to questions on a standardized psychological
measure indicated that implantation appeared to be effective in
improving communication and social skills. However, there was
considerable variability in functioning between children, with
some of the children functioning well below their age level in
communication and socialization, even after years of cochlear
implant use.
A Danish study reported high levels of social well-being among
children with cochlear implants. The researchers used a
parental questionnaire to compare the self-esteem and social
well-being of 164 children, aged 2–17 years, with cochlear
implants with nation-wide data from the same questionnaire
for over 2000 normally hearing children in the same age range.
The cochlear implant children scored equal to or better than the
normally hearing children on all areas of self-esteem and social
well-being, including confidence, independence, sociability,
and happiness (Percy-Smith, Caye-Tomasen, Gudman, Jensen, &
Thomsen, 2008).
However, Dammeyer (2010) found that deaf children, both with
and without cochlear implants, had more psychosocial
difficulties, as rated on a standardized measure completed by
the children's teachers, than a normative population of hearing
children. This group of 334 deaf and hard-of-hearing children
aged 6–19 years, 92 of whom had cochlear implants, attended
schools for the deaf or classes for deaf students within
mainstream schools. The children who had low abilities in
communication, whether sign language or oral, had
significantly more psychosocial difficulties than those whose
communication abilities were high. Cochlear implant use was
not significantly related to psychosocial difficulties. The author
concluded that good communication, regardless of the
modality, substantially decreases the risk of psychosocial
difficulties.
Some researchers have used measures of loneliness with
children who use cochlear implants. Schorr (2006) measured
levels of loneliness among 37 children aged 5–14 years, nearly
all of whom were educated exclusively in general education
classes. The study found that these children with cochlear
implants did not differ significantly from a matched comparison
group of hearing children in their feelings of loneliness at
school as measured by self-report on the Loneliness Scale
(Asher & Wheeler, 1985). A significant relationship between age at
implantation and loneliness was found, with higher age at
implantation associated with higher loneliness scores. Speech
perception and language skills were not found to be mediating
factors in this relationship. The author suggested that an earlier
age at implantation might provide children with feelings of
“belonging and inclusion in their school settings in a similar
manner as the participants with normal hearing” (p. 375).
Children who received their cochlear implants at later ages may
take longer or find it more difficult to reach a feeling of
belonging at school.
Leigh, Maxwell-McCaw, Bat-Chava, and Christansen (2009) also
investigated loneliness, along with other psychosocial factors
such as self-esteem, social functioning, and satisfaction with
life. The researchers compared deaf adolescents with and
without cochlear implants, using standardized, published
measures completed by parents, teachers, and the adolescents
themselves. They found no differences between the two groups
on the psychosocial variables and suggested that the use of
cochlear implants per se does not significantly affect
psychosocial functioning.
Researchers have also used measures of health-related QOL
with children who have cochlear implants. QOL is a
multidimensional construct embracing physical, mental, and
social functioning that has relevance to children's social wellbeing. Recent studies using QOL instruments have found few
differences between children and adolescents with cochlear
implants and hearing children on their ratings of QOL. Loy,
Warner-Czyz, Tong, Tobey, & Roland (2010) used both parental and
child report on a generic QOL instrument to measure QOL
among 88 children. They found no significant difference
between overall QOL and norms for hearing peers in either their
younger (aged 8–11 years) or older (aged 12–16 years) group of
children with cochlear implants. However, the older group rated
their QOL less positively than normally hearing peers on
the friendssubscale of the instrument. The researchers also
found that the younger group rated QOL more positively than
the older group and suggested that these differences may be
related to the pressures of adolescence to which the older
group would be subject. However, Huber (2005), using the same
instrument also completed by both parents and children, found
significantly less positive QOL ratings in a group of children
aged 8–12 years with cochlear implants compared with hearing
norms, whereas an older group (aged 13–16 years) was within
the norms for hearing peers. A similar study with children aged
between 4 and 7 years found no differences between the
children with cochlear implants and hearing peers (Warner-Czyz,
Loy, Roland, Tong, & Tobey, 2009).
Archbold and colleagues (Archbold, Sach, O'Neill, Lutman, & Gregory,
2006, 2008; O'Neill, Lutman, Archbold, Gregory, & Nikolopoulos, 2004)
have developed and validated a questionnaire specifically for
use with parents of children with cochlear implants. Using this
instrument, they found that parents were largely satisfied with
their children's outcomes in well-being and social relations 3
years postimplantation (Archbold et al., 2008). Using the same
instrument, researchers reported similar findings from a study
of Finnish children (Huttunen et al., 2009).
The studies discussed so far have, in the main, used
standardized instruments to measure constructs such as social
adjustment, social well-being, and loneliness in children with
cochlear implants. Research using qualitative methods is less
common, but a small number of qualitative studies have been
conducted. Preisler, Tvingstedt, and Ahlstrom (2005)interviewed 11
children with cochlear implants aged 8–10 years attending
mainstream schools and schools for deaf and hard-of-hearing
children. Findings indicated that the children in mainstream
schools reported difficulties hearing and understanding what
teachers and other children said in both classroom and
playground settings. Most of the children attending schools for
the deaf used sign language and felt that they needed sign to
communicate fully with their friends. The same researchers
examined the psychosocial experiences of 22 preschool
children between 1 and 4 years after implantation through
interviews with parents and teachers and observations of the
children (Preisler, Tvingstedt, & Ahlstrom, 2002). Eight of the children
attended preschools for deaf and hard-of-hearing children
using sign, 10 attended preschools for deaf and hard-ofhearing children using mainly speech (with some sign), and 4
were at mainstream preschools. The investigators found
adequate communication among children in the signing
preschool, difficulty communicating with nonsigning children in
the preschool using mainly speech, and limited social
interactions between deaf and hearing children in the
mainstream preschool. Through interviews with parents, BatChava and Deignan (2001) found that oral communication and
relationships with hearing peers had improved following
implantation for the majority of the 25 children, aged 5–10
years, in the study. In addition, many parents reported
continuing communication difficulties for their children,
particularly in group situations and with hearing children who
were unfamiliar to them or impatient.
In a qualitative study with adolescent cochlear implant
users, Wheeler, Archbold, Gregory, and Skipp (2007) interviewed 29
young people, aged 13–16 years, and reported findings
covering a number of areas such as the decision to implant,
using the technology, and communication. The young people
appreciated their improved interaction with family and friends
and reported difficulties hearing speech in noisy environments
but said little more about their social relations.
Overall, these research studies have reported many positive
findings related to the social functioning and social well-being
of children and adolescents with cochlear implants but suggest
that difficulties continue to exist in these areas for many
children. Although some studies have reported no difference
between children with cochlear implants and normative samples
of hearing children in social well-being and QOL ratings (Loy et
al., 2010; Percy-Smith et al., 2008; Schorr, 2006; Warner-Czyz et al., 2009),
others have reported less positive ratings for children or
adolescents with cochlear implants (Dammeyer, 2010; Huber,
2005; Loy et al., 2010 [for the adolescent group in their study]). In
addition, qualitative findings have revealed ongoing difficulties
in the area of social interactions with hearing peers (Bat-Chava &
Deignan, 2001; Preisler et al., 2002, 2005; Wheeler et al., 2007). The
studies that compared children with cochlear implants with deaf
children who did not use cochlear implants found no significant
differences on psychosocial measures between the two groups
(Bat-Chava et al., 2005; Dammeyer, 2010; Leigh et al., 2009).
Most of these studies investigating social outcomes for children
with cochlear implants have used questionnaires or structured
interviews based on standardized measures. The majority of the
scales and questionnaires used were generic instruments
assessing psychosocial difficulties or health-related QOL. There
are limitations in using generic measures that do not include
issues specifically related to deafness and the use of cochlear
implants (Huber, 2005; Loy et al., 2010). Although the findings of
these quantitative studies are valuable, qualitative methods
such as in-depth, semi-structured interviews can capture more
of the lived experience in real-world environments of children
and teenagers with hearing loss (Byrnes et al., 2002; Thoutenhoofd et
al., 2005). In addition only a small number of studies, either
quantitative or qualitative, have included adolescent cochlear
implant users, and the findings of some of these studies
suggest that social and peer issues might worsen during
adolescence.
In the current study, we used semi-structured interviews with
the aim of extending what is known from existing research to
provide more depth of understanding about how children and
adolescents with cochlear implants are faring socially and
emotionally. The children who were discussed in these
interviews had been implanted at several implant clinics and
attended a variety of educational settings across a range of
urban, regional, and rural locations in Australia. They included
children and adolescents of varying ages and lengths of time
since implantation, thus enabling us to gain a picture of the
social functioning and socioemotional well-being of children
throughout childhood and adolescence.
We interviewed parents, teachers, and some children and
adolescents themselves. Researchers have suggested the
benefits of using multiple sources of data, such as the reports
of children, their parents, and their teachers (Bat-Chava et al.,
2005; Leigh et al., 2009). Parental report is particularly important in
the assessment of the outcomes of implantation in children and
can provide critical information about the children's functioning
in everyday situations (Knoors, Meuleman, & Klatter-Folmer, 2003). It
is also valuable to have teachers’ reports of children's
psychosocial functioning at school. Although most studies
reporting on schooling aspects of children's outcomes with
cochlear implants have used fixed-choice survey instruments,
the gathering of teachers’ views through semi-structured
interviews can add detail and depth to the picture of children's
social functioning and participation in the school environment.
It is also important to gather the perspectives of the young
people themselves where possible, and although the major
focus of this study was on the perspectives of parents and
teachers, we included a number of children and adolescents
with cochlear implants in the interview study.
The study reported here is part of a larger study of the
communication, social, and educational outcomes of children
with cochlear implants in the eastern Australian states of
Queensland, New South Wales, and Victoria. Australia has a
particularly high rate of general class placement for deaf and
hard of hearing children, with an estimated 83% educated in
general classroom settings with itinerant teacher support (Hyde
& Power, 2003). Most of the remaining children attend schools
with “units” or “facilities” for deaf students, where a form of
signed communication (either Australian Sign Language
[Auslan] or Signed English) may be used. Students in these
facilities attend the schools’ general classes to varying degrees.
A very small number attend schools offering bilingualbicultural programs involving instruction in Auslan, with English
taught as a second language (Hyde, Ohna, & Hjulstadt,
2005/2006; Power, 2009). Official placement data for children with
cochlear implants in Australia are not yet available, but a recent
study suggests that their educational placement patterns reflect
those of deaf and hard-of-hearing students in general, with a
majority in general classes with itinerant teacher support (Hyde,
Punch, & Komesaroff, 2010).
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Methods
The larger study employed a mixed methods approach to data collection and analysis by administering a
survey instrument to parents and teachers of children with cochlear implants, followed by in-depth interviews
with a subsample of these parents and teachers and a number of children and adolescents with cochlear
implants. The study's quantitative findings and other aspects of its qualitative findings have been reported
elsewhere (Hyde & Punch, in press; Hyde, Punch, & Grimbeek, in press; Hyde, Punch, & Komesaroff,
2010a, 2010b; Punch & Hyde, 2010a, 2010b).
Participants
We interviewed 25 parents; 24 of these were mothers and 1 was a father. One interviewee was deaf; the others
were hearing. Four of the parents had two children with cochlear implants; consequently, the number of
children discussed in the interviews was 29 (14 females and 15 males). For 24 of the children (83%), their
deafness was congenital. The other five children had lost their hearing due to illness, two at the age of 18
months, two at age 2 years, and one at almost 4 years. Table 1 shows further details about the children's age at
data collection, age at implantation, duration of implant use, and educational situation. Although the age range
extended to 25 years, the 25-year-old was the only subject in the study who had left school; all the others
discussed in the parent interviews were under the age of 18 years.
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Table 1
Characteristics of children in parent interviews (N = 29)
Of the 15 teacher interviewees, 7 worked as itinerant teachers of the deaf, 5 were based in support classes or
deaf facilities in mainstream schools, and 3 were early childhood teachers or early intervention specialists
working in early intervention centers for deaf children. Details of the children (9 females and 6 males) on
whom the teachers’ interviews were based can be seen in Table 2. Data about the precise age at onset of
deafness were not available from the teachers but it was apparent from the teacher interviews that deafness was
prelingual for all the children discussed.
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Table 2
Characteristics of children in teacher interviews (N = 15)
Eleven children and adolescents (seven males and four females) were interviewed. Deafness was congenital for
all except one, whose hearing was lost due to illness at 2 years of age. Table 3 shows further demographic
details of the child and adolescent interviewees. Those at mainstream schools with support from itinerant
teachers of the deaf all experienced an auditory-oral communication mode at their schools; those attending
schools with support units for deaf children also experienced Auslan to varying degrees.
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Table 3
Characteristics of children in child interviews (N = 11)
Procedure
Approval for the project was gained from the Human Research Ethics Committees of the universities involved
in the study and of Departments of Education, early intervention centers, and hospitals with cochlear implant
clinics in Queensland, New South Wales, and Victoria. Cochlear implant clinics, early intervention centers,
and state education departments issued invitations to participate in the study and facilitated distribution of
copies of the survey to the families and teachers of all children in their databases who had been implanted
under the age of 18 years.
Almost 80% of the 247 parents and 151 teachers who completed the larger study's survey instruments agreed
to be contacted for an interview, and so we needed to make a selection of participants to contact and invite to
be interviewed. In keeping with the aims and qualitative approach of this phase of the study, sampling was
purposeful. Purposeful sampling is designed to select information-rich cases likely to best illuminate the
questions being investigated and yield insights and in-depth understanding, rather than empirical
generalizations (Patton, 2002). However, we sought to include a range of parents and teachers in terms of
location (metropolitan, regional, rural), age of child at data collection, age of child at implantation, and the
type of educational setting the child attended, so that there would be structured representation across the range
of situations of children. This “maximum variation sampling” makes it likely that common patterns emerging
from the data are of particular value in capturing the “central, shared dimensions of a setting or phenomenon”
(Patton, p. 235). The child interviewees were those whose parents had agreed for their children to be
interviewed, and they formed a heterogeneous group varying in age, location, type of educational setting, and
use of oral or signed communication methods.
Interview Procedure With Parents and Teachers
Parent and teacher interviews were conducted over the telephone. Researchers have found telephone
interviews to be a legitimate and useful data collection method for qualitative research, producing data that are
comparable in quality to those obtained from face-to-face interviews (Carr & Worth, 2001; Stephens,
2007; Wilson & Roe, 1998). In the current study, a major reason for choosing to interview by telephone was
the geographic size of the area in which the study's participants lived, and the long distances between many
cities and regional cities in these three states of Australia. The three states cover a size of approximately
1,200,000 square miles. Telephone interviewing made it possible to include parents and teachers in a wide
range of locations, including regional centers and rural and remote areas. Telephone interviews can be
convenient not only for the researcher but also for the interviewees who can participate in their home or
workplace with the least amount of disruption to their day. They can also involve greater feelings of security
and anonymity for the participants and perhaps a lower tendency to be influenced by social desirability factors
(Carr & Worth, 2001). All the teacher interviews and 19 of the 24 parent interviews were conducted by the
first author, who has training in counseling and experience in interviewing for qualitative research; the
remaining 5 parent interviews were conducted by a research assistant experienced in interviewing who was
also given training specific to this project's interviews.
The interviewer made initial contact with each parent and teacher by telephone or email, depending on the
contact details each person had given in their survey response to arrange dates and times for the interviews.
Through this contact, dates and times were arranged for the interview to take place. In the case of the deaf
parent (who lived approximately 600 miles away from the interviewer), after discussion with her by e-mail
about her preferences, the interview was conducted by telephone in the following manner. She was situated in
a room at her workplace with a sign language interpreter of her choice. The interpreter, using a hands-free
telephone, interpreted the interviewer's questions and remarks to the parent. The parent's responses, spoken by
the interpreter, were heard and recorded by the interviewer. This proved to be a satisfactory and productive
method of interviewing this highly articulate deaf parent.
Although telephone interviewing can have drawbacks, in particular the lack of visual cues, the parents and
teachers interviewed in this study spoke freely and in depth about their experiences with their children or
students. Interviews ranged in length from 35 min to 1 hr 45 min for parents and from 30 to 45 min for
teachers.
Interview Procedure With Children
As telephone interviewing was likely to be too difficult with interviewees with hearing loss, it was planned to
conduct children's interviews face-to-face wherever possible, using sign language interpreters where necessary.
Because the interview participants were geographically scattered, we also considered conducting interviews
online using an instant messaging service. Many young people are very comfortable with this communication
method, which has become popular in recent years and has been embraced by teenage Internet users as a
communication and social exchange tool (Lewis & Fabos, 2005). In addition, it has been found that many deaf
people embrace new communication technologies sooner than hearing people (Breivik, 2005). After
discussions with the parents about the children's preferred interview method, six interviews were conducted
face-to-face (one with a sign language interpreter), four were conducted via an instant messaging service, and
one was conducted over the telephone by voice alone. The telephone interview was with a teenage boy who,
his mother reported, was able to hear well, and was comfortable communicating, on the telephone. This
interview proceeded well and the boy seemed to understand all questions with minimal difficulty. As well, his
speech was such that the interviewer had no trouble understanding him. Interviews with the children and
adolescents lasted from 20 min to 1 hr.
Interview Questions
The interviews incorporated an initial list of questions serving as a guideline only, so that unanticipated
information can emerge (McCracken, 1988). We asked parents and teachers an open-ended question to start
with, modified according to the child's age, but along the lines of “what about the social side of life—how does
the child go with friends and playing with other children?” followed, if necessary, with more specific questions
about the child's social interactions and use of communication modes. In the teacher interviews, the questions
fell into two categories: first, questions that related to the specific child about whom the teacher had completed
the survey and, second, questions relating more generally to the teacher's experience of working with children
with cochlear implants. Children and adolescents were asked mostly open-ended questions about their
friendships, experiences at school, communication modes, use of telecommunications technology, and feelings
about their cochlear implants.
Analysis of Interview Data
Telephone and face-to-face interviews were audio-taped, with the participants’ consent, and transcribed in full
for analysis; the online interviews generated text that could be directly used in the analysis. The interview data
were analyzed according to the constant comparative method (Glaser & Strauss, 1967; Lincoln & Guba, 1985).
Analysis involved the coding of data in order to generate categories, with the constant comparison of units of
data in order to discover similarities, differences, patterns, and consistencies of meaning that identified themes.
As a validity check, 14 (28%) of the interview transcripts were reviewed and coded by an informed academic
external to the research team (Creswell & Plano Clark, 2007). The interview data analysis was facilitated by
the use of the NVivo 8 computer program. Themes reported in the results are a result of that process and
represent commonalities of similar responses among the groups of participants. The direct quotations of
participants’ words selected are those that best illustrate these themes.
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Results
The interview findings identified commonalities of responses across the parent, teacher, and child participants,
and all three groups of participants expressed much that was positive about the role of cochlear implants in the
children's lives. In addition, the findings indicated that difficulties remained for these children with cochlear
implants in the area of social participation and socioemotional well-being. The major themes that emerged
from the data analysis concerned social deafness (i.e., the effects of hearing loss in social situations, including
the use of the telephone), lack of awareness of nuances in social situations, friendship patterns, and a range of
issues that pertained particularly to adolescence.
Social Deafness
Interview participants across the three groups talked about the kinds of issues associated with the construct of
social deafness. Most commonly, they reported that the children struggled to hear and follow conversations in
groups of peers and said that one-to-one interactions were easier for them.
Parents.
Some parents of primary school children said that the playground at school was difficult; one mother reported
of her daughter “she actually says, I don't like the playground.” Another mother, who had two children with
implants, saidThey do well in one-on-one situations. School tends to be noisy and difficult and they tend to
almost be loners. They look like they are loners; you might think they don't have a friend, but I think they
actually choose to remove themselves from a really noisy situation and go off to the library and do that sort of
thing.
Parents spoke about certain play situations that were particularly difficult for the children. One mother said that
her two daughters, who had received implants at the ages of 13 months and 19 months, respectively, were
“quite social when they were little,” and thenaround about nine—it wasn't that they weren't liked, they were,
but both my children found it a little bit hard because most girls, particularly, around about nine start to talk a
lot more and play less …. So, yeah, I think again it does become a bit harder when girls get into that groupygirly-talkie bit.
Some parents said that their children were rarely invited to play or to sleepovers at other children's houses and
felt that they were left out at times; others described their children as being well liked and experiencing happy
relationships with hearing peers. Parents spoke about positive social experiences for children who tended to be
particularly outgoing and friendly, as this mother described:[Name of child] is the type of kid that will go in
and play with a group of kids—whenever we go to caravan parks and whatnot, you'll always find him playing
with someone. They'll ask him what's on his head and he'll tell them, and that's fine, he'll play with them and
such. He's a people person. He doesn't tell us that he finds it embarrassing or limiting at the moment, but he's
not a teenager yet either.
In addition, some parents said that the cochlear implant played a part in the development of confidence and a
more outgoing “personality” in their children. The mother of one small boy, aged 2 years at the time of the
interview and with bilateral implants received before 9 months of age, referred to his implants’ external
equipment as his “ears” and saidHis personality comes out and he's different when he's got his ears on. He's
much more confident …. With his ears off, he's timid and shy and won't venture about if he sees other people
around. If he's eating a meal or something, and he doesn't have his ears on, he'll just sit there and he's so quiet,
and then you put them on and he's happy, and he talks to us and laughs.
A mother of two children with cochlear implants described them as happy and outgoing and said “it's that
personality that will get them the distance, makes you say they'll be alright.” However, it appeared that even in
the most positive cases, children of school age needed friends to be understanding of their hearing limitations.
It was common for parents to describe their children's friends in terms of being supportive, helpful, or
protective. A parent of a primary school child explained:She's got a great support system at school with her
friends …. I think because they are in a small school, everybody knows everybody; she has friends here, they
are so switched on, if she hasn't understood what they've said … they will actually repeat it and explain it to
her.
The presence of supportive friends continued to be important for older children, as one mother's description of
the experiences of her son in high school indicates:And he has a really good small group of school friends who
are very protective and very supportive and they play soccer together and hang around in the school yard ….
He's had a bit of a hard time this year from a few kids because, as he said, he'll listen to a conversation and
he'll answer what he thinks they are asking when in fact it's totally unrelated. And they'll say ‘what do you
think you are talking about?’ But there's a couple of kids who are fairly protective and they'll fill him in on
what's happening, so he's got a support system around him although he's come under a bit of flack.
The telephone, and in particular the mobile/cell phone, plays a major role in the social lives of many children
and most adolescents, being an integral part of their relationships with friends. The findings indicated that
many of the children and adolescents, even when they had been using cochlear implants since their first or
second year of life, had difficulties using the telephone. Parents reported that their children would use the
telephone with people they knew well, but struggled to converse, and lacked confidence, with strangers on the
telephone. For older adolescents, this could also apply in employment situations. This parent described her
teenage daughter's experiences with her first job:She's had a job, she's worked at the local little supermarket
down the road, and that was, oh, that was a big test for her really. She was expected to answer the phone there,
and you know, she can talk on the phone here at home, but somewhere else—and people who don't know she's
deaf won't speak clearly on the phone, and so she was put in situations where she really had to speak up for
herself and say “I can't do this”, and she wasn't quite mature enough to take that step.
Another mother pointed out the benefits her son gained from current telecommunications technology, “because
he's not totally reliant on the phone, because we have SMS and text messages and emails and things now, it's
become easier for him.”
Teachers.
The teachers interviewed had largely positive views of cochlear implants and appreciated the increased
hearing, speech development, and social participation opportunities that implantation offered for deaf children.
Nevertheless, they considered that psychosocial issues constituted a continuing challenge in the lives of the
children. One teacher said “I think the greatest benefit and greatest challenge [for children with cochlear
implants] is the social integration.”
Like parents, teachers described social situations in which their students with cochlear implants struggled. As
found in the parent interviews, teachers also indicated that the children's social participation was facilitated by
factors such as the child being outgoing and friendly and having supportive friends. The teacher of a 7-year-old
girl said:I think she's socially very well accepted, and she's got a lovely nature, a very friendly little girl, and I
think that's going exceptionally well. Her peers will acknowledge that, you know, they have to think of her in
terms of some situation or they know why she sits in the place she does or whatever, but I think there's a lovely
acceptance by her peers, and I think by [name of child] too, I think that she just sees herself as one of the
children in the class.
Teachers described ways in which they tried to facilitate students’ social inclusion at school. These involved
educating the children's peers about their hearing loss and cochlear implants, encouraging friendships, and
teaching social skills to the deaf children.
Children.
In the child interview data, too, there was evidence of difficulties in groups of people and challenging listening
environments. A boy, aged 11 years, said:[In the playground] it's just [name of friend] and me, basically. I'd
like to have more people around, but I just like quiet.
A 17-year-old boy attending a school with a facility for deaf students explained:
Sometimes if the hearing people are in groups, it's a bit difficult. I work best one-to-one with hearing people.
Reflecting the views of parents who spoke about their children having supportive friends, some of the children
also talked about friends being supportive and understanding of their hearing difficulties. One girl, aged 10
years, said:Most of my school friends have been with me since kinder or prep, so they sort of get the things
that are hard for me and help me when they can.
In talking about their telephone use, most of the children said they did speak on the telephone but that it was
sometimes difficult. A 16-year-old boy said:If I need to take a call I will. It takes time to recognize the voice
and understand what they are saying.
A 17-year-old girl said that she used “the loudspeaker on phone. I still have trouble listening on phone.” The
boy who chose to be interviewed by telephone said he sometimes had trouble hearing on the phone, but
generally felt confident using the phone and, indeed, he managed the whole interview well with only
occasional requests for the interviewer to repeat what she had said. Adolescents also spoke about their
enjoyment of visual communications methods such as emailing and instant messaging on the Internet and text
messaging on cell phones.
Thus, findings from the three groups of interview participants indicated that difficulties in groups of people
and challenging listening conditions, including on the telephone, were common among the children and
adolescents. The child being friendly and confident and having supportive friends were factors that seemed to
facilitate the children's social participation and inclusion with their hearing peers.
Awareness of Nuances in Social Interactions
Parents.
Some parents had observed that part of their children's social participation difficulties arose from their lack of
awareness of some of the subtleties involved in peer interactions. A mother of a 12-year-old boy coined the
term “social withitness” to describe this:The biggest thing that he struggles with, I believe, is social withitness,
you know, just knowing the right thing to do in all social settings because he doesn't always pick up on
everything that's going on …. If somebody tells a joke, a group of kids are standing round and somebody tells
a joke and they say it quickly, he might miss half of it, and he won't get it, but he's not stupid so he knows he
has to laugh and he might check the joke later.
Similarly, this parent of a 6-year-old girl said:She's a very social child, she doesn't have any issues with her
implants, and she's very proud of them and all that sort of stuff, but I feel sometimes she doesn't quite
understand that whole, um, I guess it's a social awareness of little kids in groups, and understanding; like, she
would never understand teasing. There's some subtleties that happen in groups of children, and all through life
in groups, and I think it's those subtleties that she misses.
Teachers.
Some of the teachers also spoke about this issue of social awareness, sometimes mentioning a need for social
skills to be taught and the role of the teacher of the deaf in facilitating social inclusion at school, as in this
example:She has to be taught the social skills because she doesn't hear the nuances of behaviour, what's
expected, in the intonation but having been taught that, she can fit in and if the people are patient with her, as
long as they talk to the right side of her and don't get upset when she ignores them because she hasn't heard
them - they are all issues that have to be always smoothed over because the other children aren't confident
enough to say, “well are you ignoring me because you can't hear me, or are you just being a snob?” They are
not going to say that. They put their own interpretations, so you are forever putting out little fires: “well she
didn't hear you,” rather than “I'm not going to be your friend anymore.”
Children.
Some of the older adolescents realized that their responses in group conversations were not always appropriate.
A 17-year-old girl explained:I do sometimes say something that someone else already said which I didn't hear
… Some [people] understand. It does bother me but I'm OK when the subject is changed.
Friendship Patterns
When interviewees were asked about the children's friendship patterns and with whom they were friends, a
common response was that they had few or no friends who were deaf, either with or without cochlear implants.
Sometimes this was because there were no other deaf children of their age group in their school or locality;
however, some children were reluctant to mix with others who were deaf.
Parents.
Most of the parents thought it was, or would be, a good thing for their children to have friends who were deaf,
and in particular who had cochlear implants, and had tried to encourage such friendships. This mother
related:A deaf camp used to be offered to them from about Year 4 onwards, and he never wanted to go until he
went to one, he must have gone to one in Year 6, I think … and he suddenly realized there were … other kids
his age, you know, with the implant, and he met other kids with hearing aids, and I think that was a bit more
accepting for him, you know, to realize there were other kids his age out there. It was probably a good thing,
and then he wanted to go back to those camps.
One mother of a teenager described how she and a few other parents of children with implants would
occasionally organize get-togethers for their children:The kids with the implants just—[child's name] just
comes away and feels so good, you know, it's just such a good thing for her to do that and to mix with these
kids. Because there's no-one at her school like that and they do feel very isolated sometimes, and it's very
difficult when all of her friends who've got implants, none of them live near us, so we just don't see them ….
They're all older now, so they can email each other and they talk on the MSN, and that's fantastic, but prior to
that she did feel very isolated from her cochlear friends, and that's a big thing for her.
Some of the children did regularly see friends who were deaf, some with and some without cochlear implants,
and these tended to be children who used sign and attended schools where there were other deaf children.
Although their deaf friends were important to them, these children also wanted to have hearing friends. The
mother of a 10-year-old boy explained:I've always been really worried he wouldn't mix with hearing people
and they wouldn't accept him, but given he's in the deaf facility of a hearing school, it hasn't been too bad. His
deaf friends are still his security blanket, you could say, but he's very sports-minded and that's his way of being
with his hearing friends. As long as he's got a football in his hands or a soccer ball, he's always going to have a
hearing person near him or that he's interacting with, so he's had that strategy all along .…. His way into the
hearing world is often through sport.
The parent of a girl who chose to have an implant when she was 16 spoke of her daughter's desire to
communicate more easily with her hearing friends:I asked her about the reasons she wanted the cochlear; she
said she wanted to be able to understand her friends better. She's got her deaf friends, but a lot of those are in
[name of city]; she's got one girl, a signing deaf girl, you know, they've had a very strong friendship, but she
also has her hearing friends as well.
Teachers.
Teachers also believed that it was beneficial for children and adolescents to mix with others with cochlear
implants and spoke about the difficulties involved, particularly for children living in rural or regional areas
where there are unlikely to be other deaf children. As one teacher explained:His mother constantly says in
[name of major city] they had the program [for deaf and hard-of-hearing teenagers] and she's constantly saying
is there anything, anything like that we can do for these regional areas? But there's not a lot we can do because
there's limited numbers. For them to access a program like that, they would still have to drive an hour and a
half to [name of regional city] where's there's other like children.
Children.
Of the children interviewed, those attending schools where there were other deaf children described having
friends among both hearing and deaf peers. A 10-year-old girl attending a school with a support unit for deaf
children said:I've got eight hearing friends and they all learned ABC and 1 to 10 in sign language. Sometimes
they know a complete word, and they can sign, like that sign means animal, all the different names of animals.
Interviewer: And do you have deaf friends as well? Lots. About 50!
A teenager attending a school with a support unit for deaf students explained that she had friends among both
deaf and hearing peers, and said “my deaf friends sign, my hearing friends talk to me.”
In some cases, children who attended mainstream schools where there were no other deaf children did not
identify themselves as deaf in any cultural or group way, and valued what they perceived as the “normality” of
being part of the mainstream. A 17-year-old boy, implanted at 22 months and having always been in fully
mainstream school settings, had attended “deaf camps” organized regularly by school districts. He said that he
had one particular deaf friend from these camps, butThe other deaf kids, they just like mucking around with
deaf kids, but I like being with normal people a bit more.
Thus, friendship patterns varied depending largely on whether children were at school with others who were
deaf. It appears that although it could be beneficial for the children to mix with others who were deaf, this was
often difficult to achieve, either due to distance factors or because of children's reluctance.
Issues Related to Adolescence
Although the issues reported so far in relation to social deafness, social skills, and friendship patterns applied,
in varying ways, to both children and adolescents, it was clear that there was a range of issues specific to
adolescents and that the period of adolescence could be particularly challenging for these young people with
cochlear implants. For some, the transition to high school was especially difficult because they moved to a
school with a support unit for deaf students rather than going to the high school where the majority of their
primary school peers were going. Another issue affecting this age group was feeling self-conscious about their
deafness, specifically with the appearance of their cochlear implant equipment, using FM systems at school,
and the sound of their speech to other people. In addition, the tendency of teenagers to socialize in noisy
venues with loud music presented a challenge to these young people.
Parents.
The parent interviews were the richest source of data about adolescent issues, with some parents showing an
acute awareness of their teenagers’ feelings of loneliness and worries about friendships and dating. One mother
saidHe's going through all those—what do I look like, what do people see me as, I talk differently, and you
know he's been affected by those things, the way girls interact with him ….We've had lots of heart-to-hearts
and girls do treat him differently because he has it in. He sampled that. He went to a rock festival in December
and he said that no one would talk to him, he took it out and put it in his pocket, and the girls were all over
him. He said the only trouble was he couldn't hear what they were saying!
A parent of a young adult spoke of the psychosocial difficulties her son had experienced at high school:We
were really worried about his mental health at the later end of high school, he seemed to get quite depressed on
and off, and we're so pleased to see him come through it and come to terms with it and move on. But it's really
hard for young people, they're bombarded with images of perfection all the time; it's hard to come to terms
with a disability, I think.
Another parent said of her teenage son:He hates being deaf, and we're having a lot of trouble with him at the
moment .... He thinks, you know, like, his deafness will impede on him getting a girlfriend, you know, that
nobody will want him because of his disability, and you can't get through to him that you can still have, you
know, a normal life … he's actually been suffering from depression …. and won't accept his deafness.
Teachers.
Teachers were also aware of the difficulties experienced by many adolescents with cochlear implants.
According to one teacher:
When they hit the 13, 14, 15-year-old stage they still want to be like the others. It's quite obvious to them they
have an implant. When they're little, they think it's quite good. “This is my ear, I'm taking my ear off” and
things like that they say. When they become more self-conscious when they're older, there's a challenge there
for being accepted.
Some teachers expressed the view that adolescents with implants experienced similar psychosocial issues to
adolescents with less than profound hearing losses who used hearing aids. Discussing high school students
whom she supported, one teacher explained:I think it's all that mental health stuff that's such a big area for
hearing-impaired kids that, you know, do the kids know where they sit, do the feel that they belong in a
hearing group or a deaf group, or can they go between one and the other, do they see themselves as being as
good as everybody else? All the self-esteem stuff that you talk about with kids - are they happy there? And I
think that's a really big issue … for the cochlear implant kids too. Particularly the ones who are achieving
because you presume everything's going well.
Teachers were also aware that adolescents faced the difficulty of coping in the particularly noisy environments
that are typical of teenagers’ social gatherings, as this teacher explained:Even for the really successful kids, I
still think the hard part is the social connection. And I know with this student here, he's great one-on-one, but
as soon as he's in a room with a group of people, at a party, at a barbecue, that's really, really hard, he can't
hear what's going on in a group …. Even though the student lip-reads really well, you know, it's that social
stuff, you're at a party and the lights aren't real good and there's lots of music in the background, and I think
that side for adolescent kids is really, really difficult.
Children.
There was evidence in the interviews with adolescents of self-consciousness about their deafness and their
external implant equipment. In the case of one adolescent, this self-consciousness influenced the decision
about having a second, bilateral implant. When asked if having a bilateral implant was an option for him, this
boy said “yeah, and it would be better but I just wouldn't like it. It looks funny with two.”
For one girl, aged 16 years, the good friendships she had enjoyed with hearing friends at primary school led to
her choosing to go to a high school with no specific facilities for deaf or hard of hearing students, despite
contrary advice from educators. She saidI was really meant to be going to [name of high school] that had a unit
for the deaf, but I really wanted to be at a school with my friends from primary.
It seems that for adolescents in this study, the common challenges of adolescence, such as struggling with
feelings of self-consciousness and fitting in with peers, were exacerbated by the pressure of being deaf in a
hearing world. Findings from the parent interviews in particular indicated that for some adolescents their
teenage years were a difficult time when, it seems, they were re-evaluating their deafness and thinking about
its place in their future lives.
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Discussion
This qualitative analysis identified commonalities of responses and themes across parent, teacher, and child
participants and provided insight into the experiences, perceptions, and opinions of these participants around
the topic of social participation and social well-being. The findings showed that children struggled in situations
involving groups of people and that keeping up with conversations with their hearing peers was often difficult.
Even children with excellent outcomes in spoken language development experienced problems in difficult
listening environments such as in groups of people and on the telephone. In addition, the social skills involved
in understanding nuances in conversational interactions were lacking in some of the children. These findings
are consistent with those of several studies that have reported variability in functioning in social skills and
participation and continuing communication difficulties in (non-signing) group situations for children with
cochlear implants (Bat-Chava & Deignan, 2001; Bat-Chava et al., 2005; Preisler, 2007; Preisler et al., 2002).
They also reflect this article's quantitative findings where only approximately 60% and 40% of children with
cochlear implants were reported, by parents and teachers, respectively, to be able to follow a spoken
conversation with a group of people (Hyde et al., 2010). The findings suggest that the construct of social
deafness (Vonen, 2007) pertains to these young cochlear implant users. They also suggest that it is important
for professional staff in implant programs to discuss this with parents, so that they have a realistic
understanding of the discordance that can exist between the relative ease of spoken communication in one-toone situations and the difficulties in groups and noisy social environments for cochlear implant users.
All three groups of interview participants spoke about the importance of supportive hearing friends who could,
it seems, ameliorate the social consequences of the children's hearing difficulties. It appears that the
importance of this kind of peer support persisted into adolescence. Teachers of the deaf who recognized this
importance made attempts to encourage these types of supportive friendships with hearing peers. In the case of
children supported by itinerant teachers of the deaf, it may be necessary for these teachers to maximize their
communication and collaboration with the children's general class teachers in order to increase the general
teachers’ understanding of the children's difficulties and promote strategies that they can use to improve the
children's social participation.
The findings indicate that the personal characteristics of some children had a role in the nature of their social
participation; that is, children who were confident, outgoing, and friendly seemed to have relatively good peer
acceptance and social relationships with hearing peers. This finding is not surprising and is consistent with
reports in the literature of a relationship between peer acceptance and positive affect, optimism, and resilience
(Oberle, Schonert-Reichl, & Thomson, 2010). Although the precise assessment of the effect of confounding
variables is more the function of quantitative than qualitative research, our findings do suggest that traits such
as confidence and friendliness can improve social functioning for children with cochlear implants. As well, the
findings indicated that the increased access to sound and oral communication provided by their cochlear
implants contributed to some children becoming more confident and outgoing in their social interactions. BatChava and Deignan reported similar findings among children with cochlear implants. Although these types of
personal characteristics may or may not be related to cochlear implant use and to children's social outcomes,
they should be further explored in quantitative studies designed for that purpose.
Communication difficulties in groups of people and when using the telephone, as found in the current study,
also have implications for future career and workplace situations, as has been reported in studies of deaf and
hard-of-hearing people (Punch, Creed, & Hyde, 2006; Punch, Hyde, & Power, 2007; Schroedel & Geyer,
2001). It is important that young people with cochlear implants receive appropriate career guidance and
transition planning assistance in high school in order to be able to manage any barriers they might encounter
and so maximize their career opportunities.
Adolescence is typically a time of great importance attached to friendships and dating, conformity to peer
groups, and sensitivity about one's appearance. Peer relations become more complex as both best friendships
and the formation of a wider circle of friends assume greater value, and the importance of intimacy and
openness in friendships increases (Eder & Nenga, 2003). For parents in the current study, worries about their
children's social participation and emotional well-being increased as their children approached and reached
adolescence and appeared to struggle with issues around being deaf and fitting in with hearing peers. Parents,
teachers, and the adolescents themselves reported that some adolescents were self-conscious about aspects of
their deafness and the external implant equipment they needed to wear. These findings are consistent with
others reported in the literature about the social participation and social self-concept of adolescents who use
hearing aids (Kent, 2003; Kent & Smith, 2006; Punch & Hyde, 2005). Studies investigating what has been
called the ‘hearing aid effect,” involving perceptions of stigma associated with wearing hearing aids, have
reported that some young adults reject their hearing aids for reasons of cosmetic appearance or peer acceptance
(Cameron et al., 2008;Cienkowski & Pimentel, 2001). The current study's findings indicate that these concerns
are also felt by young people with cochlear implants. In addition, some parents reported that their teenagers
were, or had been, depressed. For these young people, the challenges of adolescence were particularly difficult,
and anxieties about their place in the world and how they would be accepted by other people surfaced at this
time. These findings are consistent with those of Loy et al. (2010) whose QOL findings suggested that
adolescence was a particularly difficult period for pediatric cochlear implant users. Together, these findings
suggest the need for a level of preparedness on the part of parents and professionals as children approach
adolescence so that any emerging psychosocial or mental health problems can be met with early intervention
strategies and support. It is important for school counselors and school psychologists to be aware of these
issues and to consider a range of programs for young people with cochlear implants and their peers.
The emphasis on speech development and oral-aural communication during their early years may lead
children, particularly as they move into the sensitive adolescent years, to feel that it is important for them to fit
in as much as possible to the hearing world and perhaps to discount or devalue deafness and people who are
deaf. The findings from the interview data indicate that some of the children with cochlear implants were
reluctant to mix with other deaf children, but parents and teachers generally perceived benefits for children and
adolescents from contact with others who are deaf, with or without cochlear implants. It may be beneficial,
therefore, for children with cochlear implants to have early exposure to sign language and to deaf adults and
children. We have reported our larger study's findings related to issues of identity and the use of sign language
among this group of children and adolescents in another paper (Hyde & Punch, in press). Those findings
indicated that, although the children and adolescents generally saw themselves as deaf in an audiological but
not a cultural sense, some of them wanted to explore Deaf language and culture when they reached
adolescence or young adulthood.
The current study's findings showed that often distance meant that it was difficult for children to get together
with others who were deaf, even when, as reported in some cases, they felt isolated and wanted to stay in touch
with friends they had made when they had travelled to attend implant clinics and early intervention centers.
These findings suggest that psychosocial benefits are likely to result from contact and meetings among
children and adolescents with cochlear implants and indicate the importance of parents and professionals
persisting in efforts to arrange such interactions.
These qualitative findings about children's social participation and well-being experiences have added to the
growing body of knowledge reported in the literature about this important area in the lives of deaf children and
adolescents with cochlear implants. The inclusion of children with relatively long duration of implant use in
the study meant that it was possible to gain insight into the long-term functioning and experiences of young
people throughout childhood and adolescence. Generalization is not necessarily an expected outcome of
qualitative studies, which are more suited to developing insights and understanding about particular individuals
in specific contexts, with information provided about the individuals helping the reader to judge the relevance
of the findings to their own circumstances or needs (Brantlinger, Jimenez, Klingner, Pugach, & Richardson,
2005). The study's maximum variation sampling (Patton, 2002) of interview participants meant that it was
possible to gain valuable insights into the commonalities of experiences across a range of children in terms of
age, age at implant, location, educational setting, and communication modes.
Although multivariate quantitative analyses can reveal the complexity and interactions among variables,
qualitative analyses provide a richness and contextualization that can build a greater understanding of findings
from quantitative findings. In this way, quantitative and qualitative analyses may be complementary. The
current study's qualitative analysis cannot accurately determine the influence of confounding factors on the
children's social participation and well-being; that task is more the role of quantitative research. Quantitative
studies have reported on the relative impact of some potentially confounding variables, particularly age of
implantation, duration of implant use, and level of speech production and reception, on the social outcomes of
children with cochlear implants, with inconsistent findings (e.g., Dammeyer, 2010; Leigh et al.,
2009; Nicholas & Geers, 2003; Schorr, 2006). Further research into the relationships between variables of this
nature continues to be necessary.
In the current study, the inclusion of three sources of data—reports from parents and teachers and children's
self-reports—provided a means of validating one source of information against other sources. We found that
the parent data were particularly rich as these parents showed a sensitive awareness of their children's feelings
and social and emotional experiences. The teacher findings provided valuable insights about the children's
experiences at school, and many of the teachers’ observations and perceptions of children with whom they
worked were in close concordance with the parents’ reports. Even though the small corpus of data that was
able to be gathered from interviews with children and adolescents was not a major feature of this study, we
thought it important to include it in this report. Gathering data through child self-report is valuable but involves
particular challenges. Children and adolescents may lack high levels of self-awareness, the ability to express
clearly their perceptions and feelings, or indeed the will to do so—for instance, adolescents generally like to be
seen as socially acceptable and accepted among their peers and may prefer not to admit to having few friends
or to experiencing social difficulties. Children and teenagers cannot always be encouraged to provide more
than brief responses in an interview situation (Bassett, Beagan, Ristovski-Slijepcevic, & Chapman,
2008; Preisler et al., 2005). Our inclusion of online interviewing via instant messaging had the advantage of
using a medium with which the young people were comfortable but involved the challenges of this type of
medium for qualitative interviewing, such as the difficulties of developing rapport (Mann & Stewart, 2002). In
future research, other interview methods or combinations of methods may be more productive with this
population. Group interviews along the lines of focus groups can work well with children and adolescents,
bringing advantages such as a reduction in the power imbalance between adult interviewers and child
participants and an enhanced naturalness of the interview context (Eder & Fingerson, 2002). The use of
methods specifically designed to allow adolescent cochlear implant users to elaborate on their experiences,
feelings, and concerns could be particularly helpful. Even preparing deaf children and adolescents as
interviewers of their peers may provide insights not readily available when children and adolescents are
answering questions posed by adult interviewers. Kellett (2009, 2010) described recent research studies
successfully conducted by children and teenagers who had been trained and supported to conduct their own
research with their peers.
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Conclusion
Overall, the participants in this study displayed a relatively common set of experiences and perceptions
regarding the social experiences of deaf children and adolescents who use cochlear implants. The three groups
of participants in these interviews expressed appreciation of the cochlear implant and its role in extending
opportunities for communication and social interaction between these profoundly deaf children and hearing
people. However, nearly all the parents and teachers expressed concerns about the social side of the children's
lives, and the reports of all three groups elucidated the types of difficulties and limitations remaining for these
young people. Overall, it seems that issues around friendship and “fitting in” with hearing peers were as real
for these children with cochlear implants as for other deaf or hard-of-hearing children without cochlear
implants for whom these social problems have been reported in the literature (Antia, Sabers, & Stinson,
2007; Bat-Chava & Deignan, 2001;Most, 2007; Punch & Hyde, 2005).
To some extent, the proficiency that many of the children had in one-to-one spoken communication situations
seemed to mask the difficulties that they encountered within group and multiple participant contexts. These
difficulties appeared to be sustained across the various ages of the children involved in the study and they
resemble the findings of earlier studies of hard-of-hearing students in mainstream schools and in other social
contexts. That is, the children with implants functioned socially as hard of hearing, and from an educational
standpoint would seem to warrant the same accommodations of class organization, communication, and
learning that are extensively reported for these students.
Although the earlier implantation of infants and young children and improved speech processors with better
noise filters may ameliorate some of the difficulties observed in this article, there can be no general assumption
that implantation of itself will allow the social learning and participation of these children to proceed without
considered support. There needs to be an active, structured focus by parents and teachers on children's
development in this important area of human functioning, so that the potential of implantation may be more
fully realized.
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Funding
Australian Research Council (Linkage Research Project LP0562224); and Deaf Children Australia.
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Conflicts of Interest
No conflicts of interest were reported.
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Acknowledgments
We wish to acknowledge the outstanding cooperation that we received from the parents, teachers, deaf students
and organizations involved in this study.

© The Author 2011. Published by Oxford University Press. All rights reserved. For Permissions, please email:
journals.permissions@oup.com
Previous Section
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