Influence of Hearing Loss on Child Behavioral and Home Experiences

Abstract

Objectives. To assess the influence of hearing loss on child behavioral diagnoses, and socioemotional and behavior status.

Methods. We analyzed US National Health Interview Survey (NHIS) child data, years 2011 to 2015, for associations between reported hearing loss and relevant NHIS items.

Results. Compared with hearing children, NHIS respondents with a deaf child were more likely to report developmental delays (adjusted odds ratio [AOR] = 11.1; 95% confidence interval [CI] = 3.8, 32.4), attention-deficit disorder (AOR = 3.1; 95% CI = 2.5, 3.9), autism diagnoses (AOR = 2.9; 95% CI = 1.8, 4.9), and minor to severe socioemotional difficulties (AOR = 3.9; 95% CI = 3.2, 4.7). When asked if their child was well behaved, respondents were more likely to reply “somewhat true” or “not true” (AOR = 2.7; 95% CI = 2.2, 3.4).

Conclusions. Hearing loss increases likelihood of reporting child behavioral diagnoses, behavior issues, and socioemotional difficulties. Although etiology and professional misdiagnoses likely contribute to elevated prevalence, lack of attention toward language deprivation as a public health issue prevents any further epidemiological insights.

Public Health Implications. Despite widespread use of cochlear implants, concerns about deaf children’s well-being remain significant. Language deprivation requires investigation and awareness as a social determinant of health.

Most newborns in the United States are screened for prelingual hearing loss, and approximately 1.4 per 1000 children are identified as deaf.¹ Because deaf children (90%–95%) are typically born into hearing families that do not know a natural sign language,² the immediate priority is usually acquisition of spoken language. Despite increasing use of cochlear implants (neuroprotheses that provide limited access to sounds), desired outcomes continue to be highly variable and unpredictable in many nonsigning children (i.e., not achieving optimal outcomes relative to their hearing peers).³

Language acquisition issues have various developmental implications, including general delays, behavior problems, and diminished social skills.⁴ Given the increased risk of developmental issues, and interaction of language and communication difficulties, we hypothesized that National Health Interview Survey (NHIS) respondents with a deaf child in the household were more likely to report some type of behavioral diagnosis, behavior issues, and socioemotional difficulties than were respondents with hearing children.

METHODS

The NHIS is conducted by the Center for Disease Control and Prevention’s National Center for Health Statistics. NHIS, a cross-sectional household interview survey, is the primary source of US population health information. Sampling and interviewing are continuous throughout each year through a multistage area probability design, which allows a representative sampling of US households. We used 2011 to 2015 NHIS data with sampled children who had complete information on both independent and dependent variables in our analysis; sampled children with answers such as “refused/not ascertained/don’t know” were excluded from the analysis.

We used multivariable logistic regression models to examine associations between hearing loss and health variables of interest. The study definition of “deaf” was a combined category of what NHIS reported as “moderate hearing loss,” “a lot of trouble hearing without a hearing aid,” and “deaf.” Socioemotional difficulty was measured by 4 answers (“no”; “yes, minor difficulties”; “yes, definite difficulties”; and “yes, severe difficulties”) to the item “Difficulties w/emotions/concentration/behavior/getting along.” The NHIS complex sampling design was accounted for through survey-specific procedures in SAS version 9.4 (SAS Institute, Cary, NC); this procedure allows the strata, cluster, and final weight to be accounted for in the data analysis and allows for population generalizability. The final model weight was calculated as an average of 5 years (accounting for 5 years of data) to ensure correct population size in the analysis.

RESULTS

Overall results were controlled for age, gender, race, and total birth weight (ounces) in a total sample of 1179 deaf children and 63 949 hearing children.

As seen in Table 1, compared with hearing children, NHIS respondents with a child classified as deaf were more likely to report a possible diagnosis of developmental delay (adjusted odds ratio [AOR] = 11.1; 95% confidence interval [CI] = 3.8, 32.4), attention-deficit disorder (AOR = 3.1; 95% CI = 2.5, 3.9), autism (AOR = 2.9; 95% CI = 1.8, 4.9), and minor to severe socioemotional difficulties (AOR = 3.9; 95% CI = 3.2, 4.7). Furthermore, when asked if the deaf child was generally well behaved and usually did what an adult requested over the past 6 months, respondents were more likely (AOR = 2.7; 95% CI = 2.2, 3.4) to reply “somewhat true” or “not true.”

TABLE 1—

Likelihood of Reported Behavioral Conditions, Behavior Issues, and Socioemotional Difficulties Among Deaf Children as Compared With Hearing Children: National Health Interview Survey (NHIS), United States, 2011–2015

NHIS Item	No. of Children	AORa (95% CI)
Ever told selected child had other developmental delay
Deaf	45	11.1 (3.8, 32.4)
Hearing	7 502	1 (Ref)
Ever told selected child had ADHD or ADD
Deaf	1 126	3.1 (2.5, 3.9)
Hearing	56 349	1 (Ref)
Ever told child had autism, Asperger’s disorder, pervasive development disorder, or autism spectrum disorder
Deaf	648	2.9 (1.8, 4.9)
Hearing	33 838	1 (Ref)
Not true or somewhat true that child was well behaved and did what was requested in past 6 mo
Deaf	1 062	2.7 (2.2, 3.4)
Hearing	48 688	1 (Ref)
Minor to severe difficulties with emotions/concentration/behavior/getting along
Deaf	1 062	3.9 (3.2, 4.7)
Hearing	48 663	1 (Ref)

Note. ADD = attention-deficit disorder; ADHD =attention-deficit/hyperactivity disorder; AOR = adjusted odds ratio; CI = confidence interval. Adjusted for complex survey design.

^aOdds ratios adjusted for age, gender, race (White only, Black/African American only, American Indian/Alaska Native only, Asian only, multiple race), and total birth weight (in ounces).

DISCUSSION

NHIS respondents were more likely to report a behavioral diagnosis, behavior issues, and socioemotional difficulties for deaf children than for hearing children. Several possible and potentially overlapping explanations for elevated prevalence include both biological and psychosocial factors, and professional influence.

The underlying cause of hearing loss may cause other associated conditions like those reported in the NHIS, such as associations between pregnancy-related causes of hearing loss and higher prevalence of autism diagnoses.⁵ Psychosocially, parent-child communication difficulties are associated with poor social competence and elevated rates of mental health disorders.⁶ Finally, professional misdiagnoses are more likely when clinicians are unfamiliar with the deaf population and, thus, what developmentally healthy deaf people look like.⁶ An unexplored possible contributing or confounding factor is the quality of early childhood language experiences.

Because cochlear implants do not ensure optimal language outcomes and parents overwhelmingly do not sign with their deaf child, deaf children are especially at risk for nonoptimal language trajectories (i.e., language deprivation) and subsequent developmental consequences. The risk of language deprivation is not strictly because of deaf children’s hearing loss but the result of primary intervention services frequently centered around oral communication outcomes and speech skills, and commonplace withholding of a fully accessible natural language in American Sign Language during the critical period of language acquisition (a time-limited period of heightened neurosensitivity for language development).⁷ American Sign Language—as a primary intervention—is underscored by preliminary research indicating better (and equal to their hearing peers) language and communication outcomes (including speech skills) by native-signing children with cochlear implants when compared with nonsigning children with cochlear implants.^8,9

In essence, greater prevalence of pathology in deaf children may be because of and connected to language deprivation (not experiencing fully accessible language exposure and presenting with rigid, uneven language and social development). Language deprivation is not an all-or-nothing proposition and can range in severity from negligible to clinically severe. That is, deaf children may acquire some language through the cochlear implant or other means, but this language acquisition and its resulting presentation likely vary for each child¹⁰ with a commensurate risk of being insufficient for healthy human development. To date, language deprivation is a confounding factor that has not been explored in-depth in relation to deaf children’s overall development, behavioral conditions, and socioemotional difficulties but has already been linked to learning delays and a psychiatric syndrome in ongoing research efforts.^11,12

Although this may not be the case for every deaf child not exposed to a natural sign language, epidemiological evidence of language deprivation would suggest that current attempts to “include” deaf children in mainstream society—via exclusive use of the cochlear implant for language acquisition, prioritization of speech and communication strategies, and absence or withholding of American Sign Language exposure—may actually promote lifelong exclusion through associated developmental consequences. Further attention to language deprivation is critically needed because it provides a vector for innovative preventive interventions and strategies that may avoid or remediate what are traditionally considered intractable consequences of hearing loss.

Caution should be taken when generalizing the findings discussed here. As a nationwide survey, definitive determination of what language is used in the home is not possible. Furthermore, the NHIS is an in-person, door-to-door survey using spoken language; thus, households with deaf adults that primarily use American Sign Language likely were excluded. Additionally, our classification of “deaf” and analysis of associated NHIS item responses relied on self-reports of adult respondents because of the nature of the survey collection.

PUBLIC HEALTH IMPLICATIONS

More public health attention is needed to assess risk and protective factors in deaf child development and language acquisition, particularly in distinguishing separate and overlapping epidemiological factors including (1) etiology of hearing loss, (2) parent-child communication, (3) accuracy of developmental and behavioral diagnoses, and (4) possible influences of language deprivation. Long-standing concerns about deaf children’s behavior issues and socioemotional well-being remain significant despite increasing use of the cochlear implant. Attention toward ensuring fully accessible and bidirectional language use between parents and deaf children, promoting healthy development through fully accessible language exposure, and further understanding of deaf children’s experiences in hearing families is necessary.