The following article reflects the experiences of a pediatric audiologist in a large children's hospital. It is excerpted from the March 2007 issue (Vol. 17, No. 1, pp. 8–11) of Perspectives on Hearing and Hearing Disorders in Childhood, the publication of ASHA Special Interest Division 9, Hearing and Hearing Disorders in Childhood. The first of two articles (Sept. 4) focused on clinical tools to assess the development of auditory milestones in children with hearing loss. This article focuses on fostering the psychosocial development of children with hearing loss.
Erik Erikson described psychosocial development as a series of stages or developmental challenges. At each of these stages, success or failure is dependent upon "the interaction between the individual's characteristics and whatever support is provided by the social environment" (Berger, 2003, p. 38). With positive experiences, children work through their challenges and develop skills (e.g., autonomy, trust, initiative) to help them positively resolve the developmental challenges still ahead. If, however, children's attempts at problem resolution result in consistent failure, they will not be prepared for future challenges.
Hearing loss has a negative impact on communication skills and, therefore, creates additional challenges. Audiologists can support successful experiences at each of Erikson's developmental stages by working with the child and family to:
- Ensure that a child has the opportunity to fully participate in the environment by providing access to auditory and/or visual environmental cues
- Inform families about developmental milestones
- Provide the tools for the child, family, and educators to develop good communication skills, including amplification, assistive devices, and instruction on creating effective listening environments
- Encourage the development of appropriate social skills
- Coach caregivers on creating positive and successful experiences when the child attempts new skills
From birth through approximately 3 years of age, Erikson postulates that children experience two distinct stages of psychosocial development. In the first stage, children learn whether they can trust their environment and if their basic needs will be consistently met (Berger, 2003). When caregivers meet children's basic needs, children learn to trust them and their environment in general. Children with hearing loss may be at a disadvantage in this stage of development because of several factors. For example, their parents may not be able to respond consistently to their needs because they are experiencing grief over their child's diagnosis. A child may not have access to the auditory cues that signal that a parent's attention may be diverted (e.g., doorbell or ringing telephone) or not be aware of the auditory stimulation a parent is using to comfort the child or to show affection.
The audiologist can support psychosocial development at this stage by:
- Working with families toward healthy acceptance of and adaptation to their child's hearing loss so that the parents are emotionally prepared to meet their child's needs
- Reminding parents that children with hearing loss may perceive a situation very differently from a child with normal hearing sensitivity
- Ensuring that the child has access—either visual or auditory—to the parents' communication with the child and his/her environment (e.g., consistent use of amplification during waking hours, visual alerting devices for the home) and teaching parents about the characteristics of good listening environments, effective communication strategies, and appropriate attention-getting skills
Erikson's second stage is the development of autonomy versus shame and doubt. At this stage, children from about 1 to 3 years of age are challenged to explore their environment and start to take some control over it. Children will develop a sense of autonomy if their attempts at manipulating their world are successful or if they are reassured and encouraged when their attempts fail. Shame and doubt may develop if their attempts at independence are met with disapproval, if every need is anticipated and provided, or if they are prevented from exploring their world. Children with hearing loss may be at a disadvantage for developing independence because they do not have access to developmentally appropriate tools in their environment such as the telephone, household alarms, door-knockers, or television. They may be overprotected and not encouraged to try new activities or exert their independence (Berger, 2003). This overprotection teaches children to be helpless.
Audiologists can support positive experiences by:
- Ensuring a child's access to age-appropriate stimulation, including television, noise-making or musical toys, visual alerting devices, and the telephone through use of amplification; assistive listening devices; and visual alerting devices
- Counseling parents to encourage and support age-appropriate activities
For example, even at this young age, children can take some control of their hearing aids by putting them in the dehumidifier at night or participating in daily hearing aids checks (by bringing the hearing aid to the parent and by using the child's voice for the listening check). Audiologists should gently reinforce that a child with hearing loss is not fragile; parents do not need to protect their child from experiencing failures, but should instead provide reassurance when their child makes mistakes.
Erikson's challenge for 3 to 6 years of age is the development of a sense of "initiative." Children with initiative will begin and successfully complete tasks, accept limitations without guilt, and develop a sense of pride in their accomplishments (Berger, 2003). Children at this stage believe they will be successful in anything. With positive reinforcement and appropriate and consistent limitations, children will succeed in this stage. If their attempts result in failure or criticism, they can develop a sense of guilt for seeking independence and shame and doubt in their abilities.
Again, children with hearing loss are at a disadvantage in this developmental stage if they lack adequate access to their environment and consistent, effective, and meaningful communication with their peers, parents, teachers, and family. Access to their environment needs to be extended to areas outside of the home (e.g., school, playmate's home, playground, extracurricular/community activities). Linda Hodgdon (2000) provides excellent suggestions for increasing the amount of visual information for a child in home and educational settings that don't rely on the child's literacy or the signing skills of the child or others. Visual redundancy and abundance of information in the child's environment—in particular of family plans and expectations of the child—will increase the child's ability to confirm communication when he or she has to "fill in the blanks" when communicating with family members, teachers, or peers.
Audiologists play a key role in encouraging the development of initiative. They can:
- Ensure that patients have access to age-appropriate activities such as community groups, extracurricular activities, religious services, computers, safe outdoor play, and telephones
- Encourage use of effective communication skills in and out of the home environment and the educational setting
- Teach children what does and does not comprise a good listening environment and how to seek out and state their needs for good communication
- Teach children how to use effective attention-getting, communication strategies, and compliments and thankful expressions with peers and adults in their lives
- Encourage parents to promote a child's responsibility for care of his or her equipment, such as changing batteries and taking responsibility for putting hearing aids on
- Teach the child and family about necessary accommodations for children who choose to be involved in sports, such as those suggested in Time Out! I Didn't Hear You (Palmer, Butts, Lindley, & Snyder, 1996).
During these early years, children typically have very favorable opinions of themselves and their abilities (Berger, 2003). To support the development of a positive self-concept, the audiologist can respond affirmatively to a child's seemingly endless need to demonstrate or "show-off" his or her abilities. In doing so, the child is in fact repeating his or her performance, which eventually leads to mastery, which then leads to competence, which eventually results in healthy self-esteem. We can encourage their families to support these behaviors as well.
Beginning social skills (e.g., following instructions and basic social introductions) should be mastered during this period. If a child is demonstrating problem behaviors (e.g., temper tantrums, biting), the audiologist can help assess whether communication problems (e.g., poor listening environments, limited auditory access, delayed language) may be contributing factors. Gresham (1994) suggests that parents be encouraged to differentiate between skills a child is not able to perform ("can't do") versus those they are unwilling to perform ("won't do"). If a child is unable to perform them, parents can turn to social skills training guides, such as Teaching Social Skills to Youth: A Curriculum for Child-Care Providers (Dowd & Tierney, 1995). If the child is unwilling to use appropriate social skills, the family can be encouraged to employ behavior modification techniques such as charts, positive reinforcement, effective praise, and noticing (and describing) good behaviors to elicit the desired social skills (Gresham).
The widespread use of universal newborn hearing screening and earlier identification of hearing loss puts audiologists in a unique position: we need to continue to examine ways to validate the interventions we recommend for our patients with hearing loss and to support and promote the healthy psychosocial development of our very young patients.