Impact of Hearing Loss on Social Participation in Children: A Scoping Review

Abstract

Social participation can be defined as involvement in activities that provide a platform to interact with society and others. Untreated hearing loss effects communication skills, academic achievements, and peer-group interaction. Since a typical body structure and body functioning are essential to demonstrate day to day activities. Altogether these factors can influence the social participation in children with HL. The aim of this study is to systematically review the impact of hearing loss on social participation in children.A literature search was carried out to obtain studies exploring social participation among children with HL. Two authors independently searched four electronic databases, PubMed, Scopus, Embase, and Web of Science. The search strategy was designed by using six main terms ‘social participation’, ‘social engagement’, ‘social interaction’, ‘hearing loss’, ‘hearing impairment’, ‘hearing disorder’, and Boolean operators ‘AND’, ‘OR’ were used to make the search strings. The current review included four studies after meeting the eligibility criteria. Findings showed that social participation is affected in children with HL. Reduced hearing ability is one of the factors of reduced social participation in children. Children using hearing aids or cochlear implants, participate more frequently in social activities. The findings of this review suggest that HL is associated with reduced social participation. However, using hearing aids and cochlear implants followed by auditory verbal therapy has significant improvement in social participation. Future studies need to investigate whether early rehabilitation can increase social participation in children.

Introduction

Social participation is defined as “a person’s involvement in activities that provide interaction with others in society or the community” [1]. As per the International Classification of Function (ICF), social participation is defined as activities and responsibilities required to engage in social life outside of the family, and in society [2]. Social participation is determined by the following attributes such as sharing of resources, interpersonal communication, community-based activities, and active participation [3]. Social participation is associated with improved well-being [4], quality of life [5], and decreased depressive symptoms [6]. Normal body structures and functioning are essential to perform the activities proficiently and efficiently. Restricted execution of activities leads to insufficient involvement in daily routine work. Thus, an individual needs to be fit physically, functionally, and mentally to engage in social life with full competency.

Hearing loss (HL) is one of the leading disabilities across the globe. As per the World Health Organization (WHO), nearly 430 million individuals have disabling hearing loss, from which 34 million children have HL, affecting their health and quality of life [7]. The WHO-ICF aimed to define a principle for explaining and evaluating human physio-psycho-social functioning about disability [8]. The WHO-ICF framework defined disability as a condition with multiple dimensions that can affect the body structures and functions and restrict daily activities (difficulty in performing an individual task) and limit social participation (problems in involving in life situations) [9, 10]. Collectively, all these aspects have substantial consequences to a child’s overall health.

The effect of HL can be extensive across the all-age group including children, adults, and old age-population. Particularly in young age, reduced hearing ability is often associated with affected speech-language development, lower education achievements and limited social skills [11]. Besides this, children reported being unhappy in school while socializing with classmates, experiencing social isolation because of limited communication skills, and having a decreased quality of life at school [11, 12]. Children and adolescents with HL are more prone to develop emotional and behavioral issues and need support to maintain social bonds with peers [13]. Along with severe influence on the quality of life, social isolation, and loneliness are also accompanied by HL. A recent review explained that HL is one of the leading risk factors for social isolation and loneliness in children because of confined communication skills [14].

Social participation fosters a sense of belonging. Meaningful and effective participation provides opportunities for children to acquire new skills, develop self-confidence, and build peer group connections. Numerous studies showed disabilities like intellectual disability, autism spectrum disorder, and speech-language impairment constrict social participation [15–17]. It may rationalize that disabling HL limits social participation and causes social isolation and loneliness. Certainly, restoration and improving social participation is a crucial part of hearing rehabilitation. Despite the potential influence on social participation due to HL, only a limited number of studies have explored the connection between HL and social participation. In order to understand the influence of HL on social participation, this article aims to systematically review the current literature focusing on the impact of hearing loss on social participation in children.

Method

This study was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [17].

Search Strategy

A systematic search was performed to obtain the articles exploring social participation among children with HL. Four electronic databases were searched, based on relevance to the field: PubMed, Scopus, Web of Science, and Embase. The main search terms were social participation, social integration, social engagement, hearing loss, hearing impairment, and hearing disorder. The search string was created by using Boolean operators like ‘AND’, and ‘OR’ to make the different combinations.

Selection Criteria

The eligibility criteria were selected to determine the research question concerning participants, intervention, and outcome (PIO). Studies exploring the children (P) with HL (I) have an impact on social participation (O) were included in the study.

Inclusion Criteria

Studies that investigated social participation among children aged ≤ 19 years with HL were considered for the review.

Exclusion Criteria

Volta reviews, case studies, summaries, and studies carried out on adults and the old age population were excluded.

Data Extraction and Synthesis

The records were exported to an Excel sheet. Duplicates were identified and removed manually. Two independent authors screened the titles and read the abstract to check with eligibility criteria. Independently, both authors made the final study selection after reading the full articles. Disagreements were settled by discussion with the third author. A final list was selected after the third author’s evaluation.

Quality Assessment

The Mixed methods appraisal tool (MMAT) version 18 [18] was used to assess the quality of included studies.

Results

The initial search yielded 3808 articles. Followed by duplicate removal, two independent authors conducted title and abstract screening. Four articles met inclusion criteria after full-length reading. The PRISMA flowchart Fig. 1 depicts the total search outcome of initial search and selected relevant articles after duplicate removal and detailed screening procedure.

Fig. 1.

PRISMA flowchart explaining the steps followed in the review

A total of four studies were included in this review, reflecting the findings of articles published from February 1982 to January 2019. Of the included studies, one was in USA, one in Iran, other one in Austria and last on in New Zealand. Two studies were observational [19, 20], one study used a mixed-method approach [21], and the other one was a descriptive-analytical study [22]. Included studies were arranged according to the age of participants and the class they attended. The population size of included studies ranged from 30 to 56 participants. Table 1 represents the outcomes of the included studies.

Table 1.

Characteristics of included studies

S. No.	Author	Year	Country	Aim	Study type	Population	Outcomes
1.	Monshizadeh et al. [22]	2018	Iran	To evaluate the social participation between children with CI attended auditory verbal therapy and normal hearing children.	Descriptive-analytical study	30 children with cochlear implant (19 girls and 11 boys) Mean age: 7.96 years 30 normal-hearing children (18 girls and 12 boys) Mean age:7.16 years	Children with CI who attended auditory verbal therapy have the same social interaction abilities as normal hearing children. No significant difference was observed in children with CI followed by AVT and normal-hearing children.
2.	Antia [20]	1982	USA	To investigate the social participation of hearing and hearing-impaired children with their partially mainstreamed peers.	Observational study	32 children with HL and 84 normal-hearing children enrolled in grade one to six.	In special classes, children with HL interacted with teachers more frequently than normal-hearing children. Though, interaction with teachers was less in integrated classes. Also, children with HL and their peers showed the same interaction in both integrated and special classes.
3.	Schwab et al. [21]	2019	Austria	To examine the social participation of students with HL in inclusive classrooms.	Mixed-method study	62 children with HL enrolled in grade seven.	Children with HL had a higher risk of poor social participation. Further, they experienced less acceptance and were less socially integrated by their peers. However, as per teachers’ perspective, children with HL have average social participation.
4.	Goh et al. [19]	2016	New Zealand	To examine educational, vocational achievement, and social participation in children using cochlear implants after graduating from a pediatric cochlear implant program.	Observational Study	56 young children with cochlear implant Age: ≤ 19 years	The hearing participation scale reflected a higher score for social participation. Hence, cochlear implantation showed improvement in social participation. 78% of cochlear implant recipients were actively engaged.

Two of the four studies found an association between reduced hearing and social participation. Notably, children with HL experienced less social integration and were less accepted by their peers. Also, children with HL preferred interacting with teachers rather than their peers. However, teachers perceived average social integration, acceptance, and interaction among their students. Evidently, children with HL were at risk of lower social participation in school. The other two studies explored how hearing devices improve social participation. Children using hearing devices like hearing aids or cochlear implants have better social participation skills. Auditory verbal therapy after cochlear implantation showed positive changes and near-to-normal social participation.

Quality Assessment of Included Studies

The Mixed Methods appraisal tool (MMAT) version 2018 [18] was used to assess the quality of included studies. The Table 2 represents the critical appraisal of the included studies.

Table 2.

Represent the findings of the quality assessment

S. no.	Author	Q1 Is the sampling strategy relevant to address the research question?	Q2 Is the sample representative of the target population?	Q3 Are the measurements appropriate?	Q4 Is the statistical analysis appropriate to answer the research question?
1.	Antia [20]	Y	Y	Y	Y
2.	Schwab et al. [21]	Y	Y	Y	Y
3.	Monshizadeh et al. [22]	Y	Y	Y	Y
4.	Goh et al. [19]	Y	Y	Y	Y

Y Yes

Discussion

The findings of this study highlight association between HL and social participation. A total of four studies met inclusion criteria. Of the two studies investigated quality of social participation among children with HL [20, 21]. Improvement in social participation after usage of hearing devices such as hearing aids and cochlear implants were assessed by rest two studies [19, 22].

Quality of Social Participation

Social participation, findings are combined from majorly two studies [20, 21]. These studies suggested that there is a significant impact on social participation due to reduced hearing ability. Children with HL interacted with teachers often in special classes whereas, the interaction between peers remained limited [20]. Similarly, children with HL receive less acceptance from classmates [21]. The risk of lower social involvement has been observed in students with HL [23, 24]. Likewise, individuals with other disorders such as autism spectrum disorder and aphasia showed reduced participation in social activities [15, 25]. HL breakdown the communication cycle and increase the disruption in social and emotional ailments [26]. Besides this, children with severe to profound HL encountered educational and cognitive difficulties as well as social behavioral issues [27]. Previous research has observed HL make social situations more difficult to participate, less pleasurable, and reduce quality of life [28, 29].

Improvement in Social Participation

It has been observed hearing devices use increases participation in social activities [30]. Hearing aids and cochlear implants facilitate participation in the social life of individuals with HL [19, 22]. After hearing aid fitting, individual showed improvement in social activities and reduction in daily fatigue [31]. Cochlear implantation followed by auditory verbal therapy showed similar social participation like normal children [22]. Many studies have supported that hearing aids and cochlear implants are associated with better speech-language development, and educational outcomes in children [32–34]. Moreover, cochlear implants showed improvement in societal aspects such as participation, work, and autonomy [35]. A meta-analysis mentioned that individuals after cochlear implantation reported significant improvement in quality of life [36]. Hearing rehabilitation and active social participation altogether can be considered as an indicator of a better quality of life [37, 38].

Overall, included studies showed that social participation can be hampered because of decreased hearing. The association between HL and social participation has important implications. Especially, at a young age, children learn a lot from peer groups and make social relationships thus, identifying potential risk factors for social participation becomes important. However, decreased hearing limits the development of communication skills and can negatively impact social participation. Furthermore, the major limitation of this review is a smaller number of studies that were carried out on children with hearing loss and social participation.

Conclusion

To sum up, the findings of the included studies in this review suggest that children with HL are at risk of lesser and poor social participation. In the special classroom setting, children with HL frequently engage with teachers more than their peers. However, with hearing devices like hearing aids and cochlear implants, children became proficient in social participation. Also, children attending auditory verbal therapy after cochlear implantation showed similar social interaction abilities to normal children. It is necessary to guide audiologists and family members to consider the impact of HL on social life. Moreover, future research can explore the relationship between the age of aural rehabilitation and social participation in children with HL. It also required teachers to promote integration among typically developing children and children with HL.

Funding

None.

Declarations

Conflict of interest

There is no conflict of interest to disclose.

Ethical Approval

No procedures were involved on the participants; the study is a scoping review of existing published articles.

Informed Consent

Not applicable.