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The Journal of Deaf Studies and Deaf Education logoLink to The Journal of Deaf Studies and Deaf Education
. 2023 Jun 1;28(4):387–398. doi: 10.1093/deafed/enad015

Acculturative Stress, Mental Health, and Well-Being among Deaf Adults

Aileen Aldalur 1,✉, Lawrence H Pick 2
PMCID: PMC10516366  PMID: 37263967

Abstract

Acculturative stress is associated with negative mental health among culturally diverse individuals. Deaf and Hard-of-Hearing (DHH) individuals experience acculturative stress as they navigate within and between the Hearing and Deaf communities, yet, research has not examined the relationship between deaf acculturative stress and psychological functioning. This study examined the relationships between deaf acculturative stress, well-being, and symptoms of depression and anxiety. One hundred and ten DHH adults (71.6% female, 82.7% White, median age = 30–39) completed an online survey including the Multidimensional Inventory of Deaf Acculturative Stress (MIDAS), demographic questions, and measures of psychological functioning. After controlling for relevant sociodemographic factors, the MIDAS Stress from the Deaf and Hearing Community scales emerged as significant predictors of well-being and symptoms of anxiety and depression. Findings are discussed within the context of DHH sociocultural experiences, and suggestions for future research are offered to inform clinical work with DHH individuals.

The 1Deaf and Hard-of-Hearing (DHH) community in the United States consists of a group of over one million individuals with varied hearing statuses, language and communication preferences, and sociocultural norms (Leigh, Andrews, & Harris, 2018; Mitchell & Young, 2023). Despite the dominant hearing society’s view of DHH individuals as disabled, many DHH individuals view themselves as members of a sociolinguistic community (Leigh et al., 2018; Leigh & Lewis, 2010). The history, values, beliefs, language, and behavioral norms of Deaf culture differ from those of the majority 2Hearing culture (Best, 2016; Lambez, Nagar, Shoshani, & Nakash, 2020), and these cultural factors have a profound impact on the development and life of DHH individuals (Brice & Strauss, 2016; Maxwell-McCaw, 2001; Miller, 2010).

The DHH community shares many characteristics with other linguistically and culturally minoritized hearing groups in the United States including cultural identification with a minority community; shared organizational networks; and experiences of prejudice, stigma, and discrimination from the majority society (Lambez et al., 2020; Olkin, 2002). Cultural minority groups in the United States experience a lifelong process of acculturation in which they negotiate various strategies that will allow them to successfully adapt to their multicultural environment (Berry, Phinney, Sam, & Vedder, 2006; Maxwell-McCaw & Zea, 2011). During the process of acculturation, individuals determine the extent to which they wish to acquire the dominant culture’s language, values, and customs and the extent to which they wish to maintain their heritage culture’s language, values, and customs (Berry et al., 2006; Schwartz & Zamboanga, 2008). Conflicts may arise during acculturation as individuals encounter differences between the cultures, pressures from community members to adopt specific languages or cultural practices, and marginalization from family or community members (Castillo, Zahn, & Cano, 2012; Koneru, De Mamani, Flynn, & Betancourt, 2007; Rodriguez, Myers, Mira, Flores, & Garcia-Hernandez, 2002; Thompson, Lightfoot, Castillo, & Hurst, 2010). The stress that arises from such conflict is termed acculturative stress (Poulakis, Dike, & Massa, 2017).

An individual’s level of acculturative stress may significantly impact their functioning in everyday life. Researchers in cultural psychology have recognized acculturation and acculturative stress as key factors in understanding the psychological functioning of culturally diverse groups (Balidemaj & Small, 2019; Bulut & Gayman, 2020; Koneru et al., 2007; Zeiders, Umaña-Taylor, Updegraff, & Jahromi, 2015). Yet, DHH individuals have historically been excluded from cultural research in the field of psychology. Thus, little is known about how cultural factors may impact the psychological functioning of DHH individuals, one of the most understudied populations in behavioral health (Anderson, Chang, & Kini, 2018). This paper is one of the first to begin exploring the impact of deaf acculturative stress on the psychological functioning of DHH adults.

Deaf Acculturation

The culturally Deaf community in the United States consists of DHH individuals who share a language (American Sign Language; ASL); similar experiences and values; and ways of interacting with each other in their own schools, clubs, organizations, etc. (Edwards, 2005; Ladd, 2003; Leigh et al., 2018). Within Deaf culture, being DHH is often considered a positive attribute or “gain,” rather than a condition to be treated or cured (Bauman & Murray, 2014; Leigh et al., 2018). Not all DHH individuals identify with Deaf culture, however. Through their interactions within both Hearing and Deaf communities, DHH persons develop a unique deaf acculturation strategy in which they have the option of acculturating into the Hearing majority society, acculturating into Deaf culture, or adopting aspects of both cultures (Maxwell-McCaw & Zea, 2011). Thus, depending on the specific strategies a DHH individual chooses, they may be classified into one of four deaf acculturation strategies: Hearing (adopting Hearing culture and rejecting Deaf culture), Deaf (rejecting Hearing culture and adopting Deaf culture), Bicultural (acquiring and maintaining aspects of both Deaf and Hearing cultures), or Marginal (rejecting, or being rejected by, Deaf and Hearing cultures; Maxwell-McCaw & Zea, 2011).

Acculturation and Psychological Functioning

To date, little research has investigated the relationship between deaf acculturation and psychological functioning. In the few studies that have been conducted, results have been mixed. There is some evidence that DHH individuals with Bicultural or Deaf acculturation strategies have overall better psychological functioning including self-esteem, well-being, and satisfaction with life (Bat-Chava, 2000; Brice & Strauss, 2016; Jambor & Elliott, 2005; Maxwell-McCaw, 2001). However, other studies have found no differential effects on psychosocial outcomes between aligning with the Deaf community or aligning with the Hearing community (Chapman & Dammeyer, 2017; Leigh, Maxwell-McCaw, Bat-Chava, & Christiansen, 2009) or mixed results with Hearing, Bicultural, and Deaf strategies predicting more positive scores on different aspects of psychological functioning (Hintermair, 2008).

Thus, rather than the specific acculturation strategy a DHH person adopts, it may be other factors such as the amount of conflict they experience related to home communication, school setting, and acceptance and inclusion by peers that influence psychosocial outcomes among DHH individuals (Kushalnagar et al., 2011; Leigh et al., 2009). For instance, a DHH individual may struggle to communicate with their hearing family members, they may experience bullying at school, or they may experience conflict between their values as a DHH individual and the values and expectations of others in their environment. Conflict related to an individual’s preference for communication, identity, or cultural values increases the likelihood of negative psychological outcomes through the experience of acculturative stress (Balidemaj & Small, 2019; Hovey, 2000; Torres, Driscoll, & Voell, 2012). Thus, the levels of acculturative stress a DHH individual experiences during the acculturation process may be more important than the specific acculturation strategy they adopt at different points in their life.

Acculturative Stress

Acculturative stress represents the effects of the challenges and conflicts experienced during the process of acculturation (Poulakis et al., 2017), including pressures to retain or acquire the language, values, and customs of their heritage and the dominant culture of a society (Rodriguez et al., 2002; Schwartz & Zamboanga, 2008; Shin & Yoon, 2018). Levels of acculturative stress result from a balance between the challenges a person experiences during the acculturation process and the amount of personal and social resources (i.e., mental health, coping strategies, and social and familial support) they have for coping with those challenges. Thus, the more acculturative pressures within the environment and the fewer personal and social resources available, the more acculturative stress an individual is likely to encounter (Joiner & Walker, 2002; Torres et al., 2012).

Individuals who are more assimilated into the dominant culture generally experience more pressure from members of their heritage community to acquire or retain the language, values, and customs of their heritage culture (Rodriguez et al., 2002; Zeiders et al., 2015). They may also experience stress from conflict within their family because of acculturation differences between family members (Castillo et al., 2012; Lee, Choe, Kim, & Ngo, 2000; Thompson et al., 2010). Those who are less assimilated, on the other hand, are more likely to experience stress from pressure to acquire the dominant community’s language, values, and traditions (Rodriguez et al., 2002; Zeiders et al., 2015). In addition, individuals may feel torn between the conflicting social and behavioral norms of both cultures (Castillo et al., 2012; Lee et al., 2000; Poppitt & Frey, 2007; Thompson et al., 2010).

Recent research has highlighted the occurrence of acculturative stress among DHH individuals (Aldalur, Pick, & Schooler, 2021; Aldalur, Pick, Schooler, & Maxwell-McCaw, 2020). DHH individuals experience unique stressors during acculturation because of conflicting beliefs regarding the appropriate language, behavior, values, and customs to which they should adhere. Aldalur et al. (2021) conducted semi-structured focus group interviews with 13 DHH adults in the Washington, DC metropolitan area to investigate the unique sources of acculturative stress among DHH individuals. Several stressors were identified within both the Hearing and Deaf communities. Within the Hearing community, the major themes were Hearing, Speaking, and English Pressures; Hearing Cultural Expectations; and Family Marginalization. These themes covered a range of stressors including having limited fluency in English, barriers to communication in Hearing environments, and pressures to use auditory/oral methods of communication (Hearing, Speaking, and English Pressures); discomfort with Hearing cultural norms, pressures to adopt Hearing cultural social behaviors, and having to educate Hearing people about Deaf culture (Hearing Cultural Expectations); and feeling separated from hearing family members (Family Marginalization). Within the Deaf community, major themes included ASL Pressures, Deaf Cultural Expectations, and Small Community Dynamics. The stressors related to these themes included pressures to use and be fluent in ASL (ASL Pressures); pressures to adopt Deaf cultural values and behaviors and to match the prototypical characteristics of a culturally Deaf person, feeling conflicted about one’s Deaf identity (Deaf Cultural Expectations); experiencing discomfort with the limited privacy in the Deaf community, and fearing ostracization from the Deaf community (Small Community Dynamics). The participants also discussed stress arising from their intersecting marginalized cultural identities including their race, ethnicity, sexual identities, and hearing statuses. This theme was labeled Intersectionality, and it included stressors such as having one’s diverse identities ignored or dismissed by others, feeling uncomfortable with White Deaf culture, having to work twice as hard as other White DHH individuals, and experiencing discrimination (Aldalur et al., 2021).

Acculturative Stress and Psychological Functioning

Research among hearing individuals has consistently found that heightened levels of acculturative stress are associated with anxiety, depression, substance use, maladaptive eating behaviors, and lower well-being (Gordon, Castro, Sitnikov, & Holm-Denoma, 2010; Hunt, Martens, Wang, & Yan, 2017; Joiner & Walker, 2002; Sirin, Ryce, Gupta, & Rogers-Sirin, 2013; Torres et al., 2012; Wrobel, Farrag, & Hymes, 2009; Zeiders et al., 2015). In addition, these outcomes have been uniquely tied to acculturative stress above and beyond the effects of other general life stressors (Joiner & Walker, 2002; Zeiders et al., 2015). Among DHH individuals, studies suggest higher rates of anxiety, depression, substance use, trauma, and suicidal ideation and attempts (Anderson et al., 2018; Fox, James, & Barnett, 2020; Johnson, Cawthon, Fink, Wendel, & Schoffstall, 2018; Kushalnagar, Reesman, Holcomb, & Ryan, 2019; Schild & Dalenberg, 2012), but these outcomes have not been directly connected to the experience of deaf acculturative stress.

To date, only one study has investigated the relationship between deaf acculturative stress and psychological functioning among DHH adults. In the focus group study described above, the participants spoke in-depth about the psychological impact of the multiple demands and stressors they experienced related to their deaf acculturation process (Aldalur et al., 2021). Specifically, they discussed experiencing anger and resentment, depression, anxiety, trauma, and exhaustion. No direct tests were run to assess the frequency or intensity of the symptoms or whether they were directly related to the participants’ experiences of acculturative stress; however, the participants reported these feelings in response to dealing with the multiple challenges and pressures placed on them when navigating within and between the Deaf and Hearing communities. Thus, more research is needed to understand the experience of deaf acculturative stress among DHH individuals and how it relates to psychological functioning. It is imperative that we begin to understand some of the factors that may contribute to these experiences so that we may begin to effectively address and reduce existing behavioral health disparities.

The Current Study

The goal of the current study was to investigate the relationship between deaf acculturative stress and psychological functioning among a sample of DHH adults in the United States. Specifically, we assessed the relationships between stress from the Hearing community, stress from the Deaf community, intersectional stress, anxiety, depression, and well-being among DHH adults.

Hypothesis 1

First, we examined whether levels of deaf acculturative stress were associated with well-being. Previous research with hearing individuals has found that heightened levels of acculturative stress are associated with lower psychological well-being (Bae, 2020; Rodriguez et al., 2002). Thus, we predicted a negative relationship between all three forms of deaf acculturative stress on the MIDAS (i.e., stress from the Hearing community, stress from the Deaf community, and intersectional stress) and well-being, such that heightened levels of deaf acculturative stress would be associated with lower well-being.

Hypothesis 2

Second, we examined whether levels of deaf acculturative stress were associated with psychological distress. Considering previous research with hearing individuals highlighting the link between acculturative stress and psychological distress (Joiner & Walker, 2002; Sirin et al., 2013; Torres et al., 2012; Wrobel et al., 2009; Zeiders et al., 2015), we predicted that all three forms of deaf acculturative stress would be associated with heightened symptoms of anxiety and depression.

Methods

Procedures

The data used for this study were collected as part of a larger survey study on deaf acculturative stress (Aldalur & Pick, 2022). The original study was approved by Gallaudet University’s Institutional Review Board. An online English survey was used to collect data via a secure institutional REDCap account (Harris et al., 2009). Only relevant measures are included in this study (see below). Participants were recruited through English flyers and an ASL video announcement shared with organizations serving DHH individuals, Deaf clubs, and the Gallaudet University newsletter and posted on social media. The informed consent form was presented in written English and in ASL on the first page of the survey. Participants indicated their agreement to participate by clicking “yes” to continue the survey.

Participants

A total of 176 participants were screened for participation in the current study. Responses to the survey were screened to eliminate individuals who discontinued the survey (n = 66). Thus, a total of 110 participants were included in the current study. See Tables 1 and 2 for demographic and DHH background characteristics of the current sample.

Table 1.

Demographic characteristics (n = 110)

Category Variables Percent
Age 18–29 27.3%
30–39 26.4%
40–49 16.4%
50–59 15.4%
60–69 12.7%
70–79 1.8%
Gender Male 21.0%
Female 7.9%
Nonbinary 4.5%
Self-describe 2.7%
Prefer not to answer 0.9%
Race White 82.7%
Black 3.6%
Native American/Alaskan Native 1.8%
Asian 1.8%
Multiracial 4.6%
Self-describe 0.9%
Prefer not to answer 4.6%
Ethnicity Hispanic/Latinx 5.5%
Not Hispanic/Latinx 91.8%
Prefer not to answer 1.8%
Do not understand question 0.9%
Sexual orientation Straight 64.5%
Gay 8.2%
Lesbian 4.6%
Bisexual 9.1%
Pansexual 6.4%
Self-describe 3.6%
Prefer not to answer 3.6%
Geographical region Northeast 30%
Midwest 12.7%
West 25.5%
South 3.9%
Do not understand question 0.9%
Disability None 45.5%
Visual 5.4%
Physical 2.7%
Chronic illness 8.2%
Mental health 11.8%
Other 6.4%
Multiple 20%
Highest level of education Less than high school diploma 0.9%
High school diploma/equivalent 8.2%
Some college, no degree 15.4%
Associate degree 9.1%
Bachelor’s degree 26.4%
Master’s degree 31.8%
Doctorate/professional degree 8.2%
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Table 2.

Deaf and Hard-of-Hearing background characteristics

Category Variables Percent of sample
Hearing status Mild 5.5%
Moderate 17.3%
Severe 26.4%
Profound 44.5%
Do not know 4.5%
Prefer not to answer 0.9%
Do not understand question 0.9%
Assistive technology None 24.5%
Hearing aid(s) 56.4%
Cochlear implant(s) 8.2%
Other 0.9%
Multiple 9.1%
Prefer not to answer 0.9%
Self-label Deaf 49.1%
deaf 10%
Hard-of-hearing 3.9%
Hearing-impaired 4.5%
Bicultural 1.8%
Self-describe 3.6%
Family hearing status Only deaf family member 7.9%
All deaf 5.5%
One or more deaf family members 21.8%
Prefer not to answer 1.8%
Primary communication method Spoken English 5.9%
Written English 5.4%
ASL 32.7%
Pidgin Sign English 4.5%
Total communication/simultaneous communication 4.5%
Other signed language 0.9%
Other communication method 0.9%
Age of exposure to ASL Range 0–55 years
Mean 13.7 years
Standard deviation 12.2 years
Age of exposure to deaf culture Range 0–65 years
Mean 15.8 years
Standard deviation 14.7 years
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Measures

Demographic information

Demographic questions included age, gender, ethnicity, race, sexual identity, geographical region, disability status, level of education, hearing status, use of assistive hearing technology, primary communication method, deaf self-label (i.e., Deaf, deaf, and Hard-of-Hearing), family hearing status, and age of exposure to ASL and Deaf culture.

Multidimensional Inventory of Deaf Acculturative Stress

The Multidimensional Inventory of Deaf Acculturative Stress Inventory (MIDAS; Aldalur & Pick, 2022) was used to assess levels of deaf acculturative stress. The MIDAS is a 57-item, self-report, written English inventory divided into three separate scales: Stress from the Hearing Community, Stress from the Deaf Community, and Intersectionality. The Stress from the Hearing Community scale consists of 26 items divided across four subscales: Family Marginalization (stress because of marginalization from family members), Hearing Acculturation Pressures (pressures to acculturate to Hearing culture), Spoken English Pressures (pressures to use spoken English and other oral communication methods), and Limited Access to Communication (stress from having limited access to communication in Hearing cultural environments). The Stress from the Deaf Community scale consists of 19 items divided across three subscales: Deaf Identity Pressures (stress from internal pressures to match the prototypical characteristics of a culturally Deaf individual), ASL Evaluation (pressures to use and be fluent in ASL), and Deaf Acculturation Pressures (pressures to acculturate to Deaf culture). Finally, the Intersectionality scale consists of 12 items divided across two subscales: Intersectional Barriers (stress from societal barriers experienced by DHH People of Color) and Intersectional Identity (stress from maintaining multiple marginalized cultural identities).

For the items on each scale, participants were first asked to determine if they had experienced the event/situation described in the item in the past three months. If they had not experienced the event/situation, they were instructed to select 0 (does not apply). If the event/situation had been experienced, they were asked to rate the stressfulness of the event/situation using a 5-point Likert scale ranging from 1 (not at all stressful) to 5 (extremely stressful). Items within each subscale were summed, and then, the subscales within each scale were totaled to obtain scores for each of the three scales. Higher scores indicated higher levels of stress.

The three scales demonstrated strong internal consistency among the current sample (Cronbach alphas = .92; see Aldalur & Pick, 2022 for more detailed psychometric information). The subscales for each of the three primary scales also demonstrated acceptable-to-strong internal consistency. The alphas for the subscales of the Stress from the Hearing Community scale ranged from 0.79 (Limited Access to Communication) to 0.93 (Family Marginalization). The alphas for the subscales of the Stress from the Deaf Community scale ranged from 0.83 (ASL Evaluation and Deaf Acculturation Pressures) to 0.89 (Deaf Identity Pressures). Finally, the alphas for the subscales of the Intersectionality scale were 0.80 for Intersectional Identity and 0.93 for Intersectional Barriers.

Well-Being

The written English version of the World Health Organization—Five Well-Being Index (WHO-5; WHO, 1998) was used to assess participants’ well-being. The WHO-5 is a short, self-report measure of current well-being consisting of five statements rated on a 6-point Likert-type scale ranging from 0 (at no time) to 5 (all of the time). The raw scores for the five items are summed (range = 0–25) and then multiplied by four to obtain the final score ranging from 0 to 100. Higher scores indicate greater well-being. Good internal reliability for the WHO-5 has been reported across samples of adolescents (α = 0.82; De Wit, Pouwer, Gemke, Delemarre-Van De Waal, & Snoek, 2007) and adults (α = 0.90; Halliday et al., 2017). The Cronbach alpha for the current sample was 0.88.

Psychological distress

Psychological distress was measured using the written English versions of the Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001) and the Generalized Anxiety Disorder Scale-7 (GAD-7; Spitzer, Kroenke, Williams, & Löwe, 2006). The PHQ-9 is a nine-item, self-report measure of depressive symptoms based on the DSM-IV criteria for depression. Each item is rated on a Likert-type scale ranging from 0 (not at all) to 3 (nearly every day). Total scores range from 0 to 27, with greater scores indicating greater severity of depressive symptoms. Internal reliability for the PHQ-9 has been demonstrated across samples of adults in primary care and Obstetrics-Gynecology settings with Cronbach alphas of 0.86 and 0.89, respectively (Kroenke et al., 2001). The Cronbach alpha for the current sample was .90.

The GAD-7 is a seven-item, self-rated, screening, diagnostic, and severity assessment tool for generalized anxiety disorder. The items describe some of the most salient features of GAD such as feeling nervous, anxious, or on edge and worrying too much about different things. Items are rated on a 4-point Likert-type scale ranging from 0 (not at all) to 3 (nearly every day). Scores range from 0 to 21 with higher scores indicating more severe symptoms of anxiety. The GAD-7 has demonstrated reliability and validity among population-based samples (α = 0.89; Löwe et al., 2008), psychiatric samples (α = 0.91; Beard & Björgvinsson, 2014), and addiction treatment (α = 0.91; Delgadillo et al., 2012). The Cronbach alpha for the current sample was 0.93.

Data Analyses

Missing data procedures

To minimize the amount of missing data, each item on the larger survey required a response. However, participants were given the option of selecting “Prefer not to answer,” or “I do not understand this question,” which were treated as missing data. The overall percentage of missing data values across the larger data set was minimal (0.71%) and well below suggested cut-off values for problematic missing data (Bennett, 2001; Peng, Harwell, Liou, & Ehman, 2006; Schafer, 1999). In addition, Little’s Missing Completely at Random (MCAR) test was non-significant, X2 (4,766, N = 110) = .000, p = 1.000. The selected measures for this study had even lower percentages of missing data. The MIDAS scale had 0.3% missing values, the WHO-5 had complete data across all five items, and the PHQ-9 and the GAD-7 scales each had 0.3% missing values.

When <10% of the overall data are missing, and the data are missing randomly, single imputation using the Expectation Maximization (EM) algorithm provides unbiased parameter estimates and improves statistical power (Scheffer, 2002). Thus, considering the very small rate of missing data in the larger data set (0.71%), and the benefits of maximizing power, EM was deemed adequate as a missing data imputation procedure. We conducted EM (Schlomer, Bauman, & Card, 2010) to impute missing values in the larger data set with IBM SPSS, Version 19.0 (IBM Corp., 2010). All variables were included in the EM algorithm, but missing data for demographic values were not imputed. The EM converged in under 200 iterations.

Analyses

To examine the general relationships between deaf acculturative stress, well-being, and psychological distress, we first obtained correlation coefficients for all of the factors and total scores on the MIDAS scales and the WHO-5, PHQ-9, and GAD-7. Prior to running the analyses, the data were scanned to ensure that the assumptions of linearity and normality were met. Scatterplots revealed linear relationships between all variables. However, several variables were not normally distributed. Therefore, Spearman’s correlation coefficient with bootstrapping was calculated for confidence intervals. Because of the large number of relationships tested, we applied the Bonferroni correction (α/# of comparisons) to avoid producing Type 1 errors. As we tested 36 different correlations, we adjusted our significance level to .05/36 = .001.

Next, three separate hierarchical regressions were conducted to examine whether levels of deaf acculturative stress would predict well-being and psychological distress after controlling for relevant sociodemographic characteristics. The WHO-5, PHQ-9, and GAD-7 served as the dependent variables in the separate regression analyses. Only the sociodemographic characteristics with significant correlations with the dependent variables (i.e., age, sexual orientation, disability status, and education) were included as covariates in the first step. Next, the total scores for the MIDAS Stress from the Hearing Community and Stress from the Deaf Community scales were entered as predictors in the second step. The Intersectionality scale was not entered as a predictor since the total score was not significantly correlated with the measures of well-being or psychological distress.

Transparency and Openness

This study was not preregistered. All de-identified data for this study are available upon request by emailing the corresponding author.

Results

Descriptive Statistics

The item means for the scales and subscales of the MIDAS and the total scores for the PHQ-9, GAD-7, and WHO-5 are displayed in Table 3. Mean scores on the PHQ-9 and the GAD-7 were below the clinical thresholds for moderate levels of symptoms (score < 10), suggesting that the current sample resembles a community sample rather than a clinical sample (Kroenke et al., 2001; Rutter & Brown, 2017). The sample’s mean scores on the WHO-5 were close to the mid-range of possible scores that range from 0 (absence of well-being) to 100 (maximum well-being). This mean is above the clinical cut-off for suboptimal well-being suggestive of a depressive disorder (score of 51) but below the general population mean (Topp, Østergaard, Søndergaard, & Bech, 2015).

Table 3.

Descriptive statistics for the MIDAS factors and measures of mental health and well-being

Variable Max score Range Mean SD
MIDAS stress from the hearing community (item means)
Family marginalization 5 0–4.9 1.9 1.4
Hearing acculturation pressures 5 0–4.7 2.1 1.2
Spoken English pressures 5 0–5 .09 1.4
Limited access to communication 5 0–5 3.0 1.3
Total 5 0.1–4.5 2.0 0.9
MIDAS stress from the deaf community (item means)
Deaf identity pressures 5 0–5 1.5 1.4
ASL evaluation 5 0–4.7 0.9 1.1
Deaf acculturation pressures 5 0–4.7 1.1 1.2
Total 5 0–3.7 1.2 1.0
MIDAS intersectionality (item means)
Intersectional barriers 5 0–5 0.5 1.0
Intersectional identity 5 0–4.5 0.4 0.8
Total 5 0–4.1 0.5 0.8
Psychological functioning
Depression (PHQ-9) 27 0–27 9.0 6.7
Anxiety (GAD-7) 21 0–21 7.5 6.4
Well-being (WHO-5) 100 8–100 55.0 21.5
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Note. MIDAS, Multidimensional Inventory of Deaf Acculturative Stress; PHQ-9, Patient Health Questionnaire-9; GAD-7, General Anxiety Disorder-7; WHO-5, The World Health Organization-Five Well-Being Index.

Main Analyses

The correlation analyses are presented in Table 4. In line with Hypothesis 1, the total scale score for Stress from the Deaf Community was significantly associated with well-being such that higher levels of acculturative stress from the Deaf community were associated with a lower sense of well-being. Examining the factor scores for Stress from the Deaf Community, only the Deaf Identity Pressures factor was significantly associated with well-being. Thus, the association between stress from the Deaf community and well-being appears to be related to experiencing identity conflicts. The total scale scores for the Stress from the Hearing Community and the Intersectionality scales were not significantly associated with well-being. However, one factor score from the Stress from the Hearing Community scale, Limited Access to Communication, was significantly associated with well-being such that higher levels of stress from communication difficulties were associated with a lower sense of well-being. None of the factors from the Intersectionality scale were associated with well-being among the DHH adults.

Table 4.

Correlations of the MIDAS Subscales with well-being and mental health variables

MIDAS Subscale Well-being (WHO-5) Depression (PHQ-9) Anxiety (GAD-7)
Stress from the Hearing community
Family marginalization -.217 0.476* 0.351*
Hearing acculturation pressures -.262 0.406* 0.381*
Spoken English pressures 0.151 .083 .030
Limited access to communication -.357* 0.410* 0.402*
Total -.242 0.464* 0.376*
Stress from the Deaf community
Deaf identity pressures -.477* 0.572* 0.482*
ASL evaluation -.293 0.271 0.206
Deaf acculturation pressures -.251 0.302* 0.235
Total -.422* 0.467* 0.380*
Intersectionality
Intersectional barriers -.024 0.198 0.133
Intersectional identity -.120 0.188 .095
Total .026 0.112 .018
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Note. MIDAS = Multidimensional Inventory of Deaf Acculturative Stress; PHQ-9 = Patient Health Questionnaire-9; GAD-7 = General Anxiety Disorder-7; WHO-5 = The World Health Organization-Five Well-Being Index.

* p < .001

Consistent with Hypothesis 2, the total scale scores for the Stress from the Hearing Community and the Stress from the Deaf Community were significantly associated with symptoms of depression and anxiety. In terms of the factor scores, all but one of the factors (Spoken English Pressures) from the Stress from the Hearing Community scale was significantly associated with symptoms of depression and anxiety. On the Stress from the Deaf Community scale, all but one of the factors (ASL Evaluation) was significantly associated with symptoms of depression, and the Deaf Identity Pressures factor was significantly associated with symptoms of anxiety. The Intersectionality total scale score and factor scores were not significantly associated with either symptoms of depression or anxiety.

Next, three separate hierarchical regression analyses were computed to examine whether levels of stress from the Hearing Community and from the Deaf Community could predict well-being and psychological distress after controlling for relevant sociodemographic characteristics. As can be seen in Table 5, consistent with Hypothesis 1, the model predicting well-being was significant, and combined, the predictor variables accounted for 22% of the variance in well-being. However, only the Stress from the Deaf Community scale emerged as a significant predictor of well-being in the model after controlling for sociodemographic factors. Higher levels of stress from the Deaf community were associated with lower well-being among the DHH participants.

Table 5.

Hierarchical regression analysis of well-being with sociodemographic characteristics and MIDAS Scales as predictors

Step 1 Step 2
Variable B B 95% CI
Constant 65.66*** 75.38*** (58.59, 92.16)
Age 0.65 0.36 (−2.26, 2.98)
LGBTQ -1.38 0.21 (−8.68, 9.11)
Disability -18.13*** -13.42** (−21.96, −4.88)
Education -.37 -.89 (−3.30, 1.51)
Hearing community stress -.06 (−.22, 0.10)
Deaf community stress -.28* (−.48, −.07)
R  2 0.20 0.26
Adjusted R2 0.16 0.22
F 6.16*** 5.80***
R  2 change .06
F change 4.29*
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* p < .05,

** p < .01,

*** p < .001

In line with Hypothesis 2, the models predicting symptoms of depression (see Table 6) and anxiety (see Table 7) were both significant. Combined, the variables accounted for 35% of the variance in depressive symptoms and 27% of the variance in symptoms of anxiety. Both Stress from the Deaf Community and Stress from the Hearing Community emerged as significant predictors of depressive symptoms among the DHH adults, such that higher levels of acculturative stress were associated with increased symptoms of depression. However, only stress from the Hearing community emerged as a significant predictor of symptoms of anxiety. The DHH participants who reported higher levels of stress from the Hearing community had increased symptoms of anxiety.

Table 6.

Hierarchical regression analysis of depression with sociodemographic characteristics and MIDAS Scales as predictors

Step 1 Step 2
Variable B B 95% CI
Constant 10.59*** 4.77 (−.17, 9.71)
Age -.37 -.29 (−1.06, 0.49)
LGBTQ 1.92 0.68 (−1.94, 3.29)
Disability 4.95*** 3.13* (0.62, 5.64)
Education -.81* -.47 (−1.18, 0.24)
Hearing community stress .07** (.02, 0.16)
Deaf community stress .08** (.02, 0.14)
R  2 0.26 0.38
Adjusted R2 0.23 0.35
F 8.98*** 10.22***
R  2 change 0.12
F change 9.63***
Open in a new tab

* p < .05,

** p < .01,

*** p < .001

Table 7.

Hierarchical regression analysis of anxiety with sociodemographic characteristics and MIDAS Scales as predictors

Step 1 Step 2
Variable B B 95% CI
Constant 7.87*** 3.77 (−1.11, 8.64)
Age -.85* -.81* (−1.57, −.05)
LGBTQ 1.01 .08 (−2.51, 2.66)
Disability 5.08*** 3.97** (1.49, 6.45)
Education -.25 -.01 (−.71, 0.69)
Hearing community stress .05* (.01, 0.10)
Deaf community stress .04 (−.02, 0.11)
R  2 0.25 0.32
Adjusted R2 0.22 0.27
F 8.52*** 7.57***
R  2 change .06
F change 4.50*
Open in a new tab

* p < .05,

** p < .01,

*** p < .001

Discussion

Acculturative stress has consistently been linked to negative mental health outcomes among diverse samples of hearing individuals (Gordon et al., 2010; Joiner & Walker, 2002; Sirin et al., 2013; Wrobel et al., 2009; Zeiders et al., 2015). However, research has not explored the relationship between acculturative stress and psychological functioning among DHH adults. This study aimed to begin understanding the relationships between deaf acculturative stress, well-being, and psychological distress among a sample of DHH adults across the United States.

Overall, results were consistent with previous research among hearing individuals such that higher levels of acculturative stress were associated with lower well-being and increased symptoms of anxiety and depression among the DHH participants. Higher levels of stress from the Deaf community were associated with a lower sense of well-being among the DHH participants. This association seems to be primarily related to experiencing identity conflicts within the Deaf community and not feeling “culturally Deaf enough.” Scores on the Stress from the Hearing Community scale were not significantly associated with well-being among the DHH participants. However, one factor score, Limited Access to Communication, was significantly associated with well-being. It is possible that the lack of significant associations on the other factors of the scale, such as the Family Marginalization factor, could be because of the time frame of the MIDAS and the characteristics of the sample. The MIDAS asks about stressful experiences within the past 3 months. As the current sample consisted of DHH adults who were likely living apart from their hearing families, it is possible that they may have been experiencing less stress from their families of origin and thus, this would have less of an effect on their overall well-being. In fact, the mean for the Family Marginalization factor (1.9) was lower than the mean for the Limited Access to Communication factor (3.0), which had more of an influence on the participants’ well-being.

All of the factors on the Stress from the Hearing Community scale except for the Spoken English Pressures factor were associated with psychological distress as expected. On the Stress from the Deaf Community scale, two of the three factors (Deaf Identity Pressures and Deaf Acculturation Pressures) were associated with symptoms of depression, and one factor (Deaf identity Pressures) was associated with symptoms of anxiety as expected. The fact that the Spoken English Pressures and ASL Evaluation factors were not associated with any of the psychological functioning variables could be because of the limited variability in scores. The item means on these subscales were below 1 (not stressful), suggesting that many of the participants did not experience stress from pressures to perfect their spoken English or ASL skills. This study focused on DHH adults in their everyday environments in which they are likely to have established their primary communication method and may not experience many challenges or pressures related to language and communication. These factor scores may be more important when assessing individuals in unique situations such as the initial exposure of DHH individuals to a Deaf cultural community (e.g., DHH adults taking ASL classes and attending Deaf events or enrolling in Gallaudet University or the National Technical Institute for the Deaf without fluency in ASL) or DHH individuals in auditory/oral programs involved in speech therapy.

In the Hearing community, instead of language skills per se, access to communication (in any form) may be more important for DHH adults. In fact, the Limited Access to Communication subscale had the highest item mean of all of the subscales on the Stress from the Hearing Community scale and was significantly associated with well-being and symptoms of depression and anxiety. Thus, rather than speech abilities, it seems that communication barriers and the resulting isolation within the Hearing community influence the psychological functioning of DHH adults. A DHH person may use many different communication methods to connect with hearing individuals including sign language (for those hearing individuals who can sign), gestures, cued speech, written English, texting, and using an interpreter; however, these forms of communication are not always employed effectively by hearing individuals and this may lead to difficulties communicating and forming meaningful relationships. Many DHH individuals report a lack of willingness from hearing people to accommodate to their specific communication needs, and this attitude cuts across multiple situations including social outings, educational and employment settings, and within the family (Aldalur et al., 2021; Kersting, 1997; Murray, Klinger, & McKinnon, 2007; Stapleton, 2015). Common experiences include being told “I will tell you later”; a lack of willingness to communicate through writing or use telephone relay systems; not signing when talking in front of DHH individuals; not providing needed accommodations; and asking the DHH person’s spouse, child, sibling, family member, or friend to interpret a message rather than communicating with the DHH person directly (Aldalur et al., 2021;Murray et al., 2007; Smith, 2013; Stapleton, 2015).

The factors of the Intersectionality scale were not associated with well-being or symptoms of depression and anxiety. It is likely that the lack of significant associations in this study was because of the limited variability of scores on the preliminary version of this scale. For example, the large majority of participants in the current study were non-Latinx White individuals. Thus, scores on the Intersectionality scale were positively skewed, with limited variability, as most of the scores clustered around 0 (not applicable). Further analyses of how this scale relates to psychological functioning is needed with large and unique samples of ethnically and racially diverse DHH individuals.

In examining the deaf acculturative stress scales as predictors of psychological functioning after controlling for relevant sociodemographic characteristics, Stress from the Hearing community emerged as a significant predictor of symptoms of depression and anxiety. The acculturative stressors experienced in the Hearing community are likely to lead to isolation and loneliness (Jambor & Elliott, 2005; Murray et al., 2007; Rogers, Muir, & Christine, 2003; Stapleton, 2015), especially for DHH individuals without significant involvement in the Deaf community. Language differences and communication barriers create a great divide between DHH and hearing individuals (Murray et al., 2007) as most hearing individuals are not able to communicate fully in ASL and may not be willing to accommodate to different communication needs (Murray et al., 2007; Smith, 2013; Stapleton, 2015). In addition, DHH individuals who are acculturated to Deaf culture may feel pressure from hearing individuals, including their own family members, to reject their Deaf cultural values and instead adhere to Hearing cultural norms and values (Best, 2016; Stapleton, 2015). These communication barriers and cultural conflicts make it difficult for many DHH individuals to form meaningful relationships with hearing individuals and can lead to marginalization from one’s family, resulting in limited social and familial support (Murray et al., 2007; Smith, 2013; Stapleton, 2015). Limited social and familial support have been identified as significant contributors to depression in the general hearing society (Brooks, Madubata, Jewell, Ortiz, & Walker, 2021; Chatters, Taylor, Woodward, & Nicklett, 2015; Eagle, Hybels, & Proeschold-Bell, 2019; Grey et al., 2020; Thompson, McBride, Hosford, & Halaas, 2016).

In terms of anxiety, being in hearing environments with limited access to communication; missing important information; and having to deal with discrimination in education, employment, and healthcare settings (Gournaris & Aubrecht, 2013; Murray et al., 2007; Smith, 2013; Stapleton, 2015) are likely to produce anxiety for DHH individuals. DHH individuals often find themselves carrying the burden of communication, and this can be anxiety-provoking in situations where they may have limited control and/or expect negative outcomes from hearing individuals such as impatience, anger, dismissing attitudes, embarrassment, rejection, and/or the ascription of negative stereotypes (e.g., lower intelligence or ability; Best, 2016; Gournaris & Aubrecht, 2013; Murray et al., 2007; Stapleton, 2015). The general lack of accommodations and opportunities places pressure on DHH adults to find ways to overcome these barriers or cover their DHH identity to be successful within the Hearing community (Bouton, 2013). Covering refers to the strategy of DHH individuals who attempt to pass as hearing (Jambor & Elliott, 2005). This coping strategy may lead to additional stress because of the constant fear of their hearing status being identified and the fatigue that is likely to arise from the energy put forth to maintain communication through lip and body language reading (Jambor & Elliott, 2005). Other DHH individuals may feel the need to “prove themselves” by demonstrating their intelligence, skill, and worth to overcome the stereotypes and assumed deficits ascribed to them by the Hearing community (Aldalur et al., 2021). These experiences are all forms of acculturative stress that may contribute to heightened symptoms of anxiety as they potentially result in DHH individuals adopting Hearing cultural standards, values, and behaviors to be perceived as successful.

Stress from the Deaf community emerged as a significant predictor of well-being and symptoms of depression among the DHH adults. Major sources of stress from the Deaf community include not feeling culturally “Deaf enough,” feeling cultural shock after entering Deaf community spaces, and questioning one’s Deaf identity (Aldalur et al., 2021). Early exposure to ASL and the Deaf community may serve as protective factors against experiencing acculturative stress from the Deaf community. However, many DHH individuals are not raised within the Deaf community and they may not be exposed to Deaf culture or ASL until their late adolescence or early adulthood. This is noted within the current sample as the average age of exposure to ASL and the Deaf community was 13.7 and 15.8 years, respectively. Miller (2010) states that a number of DHH individuals who are raised within the Hearing community may struggle to fit in and begin to develop the feeling that something is missing from their lives. It is then that, in the search to gain a better understanding of themselves as a DHH person, they encounter Deaf culture and the Deaf community. Through these interactions, they realize that they share a culture of common experiences, which, combined with the linguistic and social culture of the Deaf community, may begin to shape their worldviews (Miller, 2010). However, the transition to the Deaf community is not always a smooth journey. DHH individuals may experience “cultural shock” as they learn the language, values, and social norms of Deaf culture (Aldalur et al., 2021). In addition, they may experience rejection from their DHH peers since they are not fluent in ASL and do not have the same cultural background and knowledge (Leigh & Lewis, 2010; Napier & Leeson, 2016). These negative thoughts and emotions may be particularly damaging for DHH individuals who already struggled to fit in the Hearing community and were hoping to find refuge within the Deaf community. In addition, the increased access to communication within the Deaf community from access to visual forms of language could increase the odds of DHH individuals experiencing more overt conflict and or rejection from their DHH peers than with their hearing peers. Questioning one’s identity, experiencing conflict and rejection, and lacking social support and meaningful relationships may be more likely to lead to a reduced sense of well-being and increased symptoms of depression.

Constraints on Generality

There are several constraints on the generality of the results from this study. First, the sample size was small and this likely limited the power of the analyses. Second, the sample was limited in diversity. Eighty-three percent of the sample was White, and the majority of participants were highly educated with 66% having attained a bachelor’s degree or higher. The limited ethnic and racial diversity of the sample did not allow for an adequate examination of the relationship between mental health and potential intersectional stressors, given the limited variability of scores on the Intersectionality scale of the MIDAS. Furthermore, the online survey was only provided in written English and this further limited the diversity of the sample as it excluded DHH individuals with limited English fluency. Participants were not provided any incentive to complete the survey that required ~30 min to an hour of their time. The lack of incentive and the English requirements of the study may have led to an oversampling of DHH individuals who are college-educated and from a higher socioeconomic status.

This study did not examine protective factors, coping resources, or other factors contributing to resilience or mental well-being among DHH adults. These factors are important topics for future investigations as research among hearing individuals has identified several factors (e.g., social and familial support and cognitive attributes) that may buffer the negative effects of acculturative stress (Paukert, Pettit, Perez, & Walker, 2006; Poppitt & Frey, 2007; Yeh & Inose, 2003; Zeiders et al., 2015). Finally, the mental health measures used in this study were limited in that they did not capture the nuances of the individual’s symptoms or examine other types of pathology or distress experienced by DHH individuals such as substance use and trauma, which research has shown are experienced at higher rates among DHH individuals (Anderson et al., 2018; Johnson et al., 2018).

Conclusions

This study demonstrated that many DHH individuals experience significant levels of acculturative stress as they navigate within and between the Deaf and Hearing communities and that this stress is related to their well-being and psychological functioning. Thus, it is imperative to consider and assess deaf acculturative stress when conducting clinical work with DHH individuals. Further research may explore how deaf acculturative stress affects the development, severity, and course of mental health problems among DHH individuals. Research examining risk, protective factors, and coping resources for dealing with deaf acculturative stress could inform potential interventions for preventing or reducing levels of acculturative stress among DHH individuals.

Funding

This work was supported by a Small Research Grant from the Gallaudet University Office of Research Support and International Affairs (grant number 3655) and a Diversity Supplement from the National Institute on Alcohol Abuse and Alcoholism (grant number R01AA026815-03S1, to A.A.). The funding sources had no other role other than financial support. We have no known conflicts of interest to disclose.

Conflicts of Interest

No conflicts of interest were reported.

Data Availability

All de-identified data for this study are available upon request by emailing the corresponding author.

Footnotes

1

A capital “D” is used throughout this paper when referring to Deaf culture and the Deaf community in a manner similar to the capitalization of other cultural groups (i.e., Asian, Black, and Latinx) to signify the existence of a group of individuals with unique values, customs, and language. However, a lowercase “d” is used when referring to the general condition of being deaf, as not all deaf individuals identify with Deaf culture.

2

The capitalization of “H” in Hearing culture and the Hearing community is used to acknowledge the social norms and generic standard adhered to by the majority hearing society. The capitalization of the reference majority group is meant to parallel ethno-racial relations experts’ use of a capital “W” to represent White culture in the literature (Closson & Henry, 2008; Thompson et al., 2010) and to provide similar insight to the chasm of power and privilege that separates these minority cultures from the majority (Foster & Kinuthia, 2003). The capitalization of Hearing culture also serves to reject the notion of hearing as the neutral or standard and instead portray it as a culture (Nguyễn & Pendleton, 2020).

Contributor Information

Aileen Aldalur, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.

Lawrence H Pick, Department of Psychology, Gallaudet University, Washington, DC, USA.

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Data Availability Statement

All de-identified data for this study are available upon request by emailing the corresponding author.

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