Psychological Issues among Children with Cochlear Implants

The issue

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Hearing loss, whether temporary or permanent, mild or profound, is known to potentially have an impact on the psychological well-being of children. Research has shown that a significant proportion of deaf children will experience behavioural, emotional or learning difficulties at some point during childhood or adolescence. Identity and self-esteem issues are also more common than in hearing children. Although cochlear implants (CIs) can give deaf children access to environmental and speech sounds, the degree of benefit they receive from them varies enormously across children, and they remain at risk of the same range of psychological difficulties as those without implants. Factors that appear to be of great importance in vulnerability to psychological difficulties are children’s level of communication and language competency, and the ability of their families to communicate effectively with them.

What we know

Research has found associations among communication skills, language delay, and behavioural problems, particularly in the early years.  The less able a deaf or hard-of-hearing (DHH) child is able to understand and interact with the world around them, the greater the likelihood of problems.

Throughout childhood and adolescence, young people become increasingly aware of themselves in relation to their peers. Differences can be perceived positively, negatively or neutrally and it is this value judgement that results in a sense of self-worth or self-esteem. DHH children have the additional task of incorporating their deafness into their self-concept. The issues are likely to be different for those children with a progressive loss, and those deafened suddenly through meningitis or other illness/injury. In all cases, the young person may compare themselves with hearing peers or deaf peers with or without CIs.

There are commonalities between autistic behaviours and behaviours displayed by many children with hearing loss, which makes it difficult to diagnose Autism Spectrum Disorders (ASD) in children with hearing loss. There is an overlap of symptomatology/behaviours in the areas of communication, joint attention, play skills, response to others’ verbal and nonverbal cues, restricted behaviours and need for routine, and delay or impairment in Theory of Mind.  Language outcomes seem to be as variable for children with ASD and CIs as they are for children with ASD and normal hearing.

Cognitively, children with CIs have been found to differ from their hearing peers, deaf peers who use hearing aids, and deaf sign language users in a number of cognitive functions, and in their learning outcomes. Most notably, they typically have very poor auditory working memory skills. This means that they have difficulty retaining and then recalling information that is presented auditorily, leading to difficulties with, for example, mental arithmetic or following instructions. Working memory deficits are associated with poor reading skills, and difficulties in developing language. Other possible areas of difficulty include phonological processing deficits, attention and executive functions (e.g., planning and organising skills). All of these have the potential to impact learning across all areas of the curriculum, as well increasing the likelihood of behaviour problems and poor self-esteem.

What we don’t know

Unlike speech and language outcomes, psychological outcomes of children with CIs are comparatively poorly researched.  In particular, there is no clear evidence base for the effectiveness of psychological interventions with this group, and we do not know precisely what predicts good psychological outcomes.

Implications

The follow up children with CIs receive from their implant teams mean that professionals working with them are ideally placed to monitor their development and be alert to potential concerns regarding psychological difficulties, enabling prompt identification and appropriate intervention.

For younger children presenting with behavioural or emotional problems, a behavioural approach is likely to be helpful, working with parents to promote positive behaviours and to reduce challenging behaviours.  Intervention is likely to include similar strategies to those covered in evidence-based parenting programmes, making adaptations to account for the child’s hearing and language levels as necessary.

Older children presenting with behavioural, emotional, or identity difficulties may benefit from individual therapeutic input or family work. A range of interventions may be offered including individual cognitive-behaviour therapy, family therapy and solution-focused therapy.  Group intervention may also be appropriate, particularly for children presenting with self-esteem or identity issues related to their hearing loss, as it gives them the opportunity to meet other children or young people in a similar situation.

Cochlear implantation does not restore normal hearing, and many implanted children do not develop and function in the same way as their hearing peers at home or in the classroom. Continuing specialist educational support is therefore essential.

Posted on April 1, 2016 by
Fionna Bathgate and Lindsey Edwards
Cochlear Implant Programme
Great Ormond Street Hospital for Children NHS Foundation Trust
Fionna.Bathgate {at} gosh.nhs.uk
Lindsey.Edwards {at} gosh.nhs.uk

Further reading