Young Children's Attitudes Toward Peers Who Wear Hearing Aids

Abstract

Purpose

This study examined whether young children with normal hearing demonstrated negative attitudes toward peers wearing hearing aids, often described as the “hearing aid effect.” The effect of age on these attitudes was also examined.

Method

Forty-five typically developing children with normal hearing, aged 6–11 years, were recruited to answer questions about and rate photos of children with and without hearing aids in areas of peer acceptance as well as physical and cognitive competence. Participants completed a forced-choice task, a perceived competence rating task, and a sociometric rating task.

Results

Children in this study perceived their peers who wore hearing aids as having less physical competence and less peer acceptance than peers without hearing aids, thus confirming a hearing aid effect in children as young as 6 years of age. Both younger and older children were more likely to choose pictures of children wearing hearing aids as having less peer acceptance than pictures of children who were not wearing hearing aids. Older children were also more likely to choose a picture of a child with hearing aids as having less physical competence than a picture of a child without hearing aids.

Conclusion

These findings should serve to alert professionals who work with children who have hearing loss that additional support and education might be warranted for these children and their peers with normal hearing.

The Individuals with Disabilities Education Act (PL 101-476) mandates that children with disabilities receive a free and appropriate public education in the least restrictive educational environment. Thus, when appropriate, children with disabilities should receive educational instruction in classroom environments with their nondisabled peers. The terms that have been associated with this least restrictive environment have included “mainstreaming,” “integration,” and, more recently, “inclusion.” One of the goals of inclusionary educational environments is social integration of children with disabilities in classrooms with nondisabled peers, which should lead to improved understanding of disabilities by nondisabled peers and increased friendships between those with and without disabilities.

Children become aware of and understand physical and sensory disabilities that have observable cues (e.g., wheelchairs, hearing aids, glasses) during their preschool years (Diamond & Hestenes, 1996; Smith & Williams, 2001), but understanding of less obvious handicaps, such as developmental delays, intellectual disability, or problems with social and emotional regulation, occurs later during elementary school (Diamond & Hestenes, 1994; Smith & Williams, 2001). Typically developing preschool children might be less able to identify disabilities that have few physical cues, but they demonstrate linguistic sensitivity because they can identify when they need to code switch or simplify communication exchanges with chronologically or developmentally younger social partners (Diamond & Hestenes, 1994; Guralnick et al., 1996). Furthermore, preschool and school-age children who have past interactions with peers who have disabilities tend to show greater acceptance of children with disabilities than children without similar experiences (Diamond & Hestenes, 1994) and are better able to define the disability they have encountered (Diamond & Hestenes, 1994; Guralnick et al., 1996; Maras & Brown, 2000).

Negative attitudes or perceptions of hearing loss can prevent the full social inclusion of these children in the classroom, affecting their peer interactions and, potentially, their psychosocial development. A consequence of negative attitudes of peers could be fewer social interactions between children who wear hearing aids and their peers with normal hearing (Nabors, 1996). The negative attitude toward those who use hearing aids has been coined the “hearing aid effect” (Blood et al., 1977). Blood et al. speculated that the hearing aid effect could compound the challenges children who use hearing aids might experience when developing relationships with their peers with normal hearing.

The hearing aid effect has been observed in adults and older children (ages 10–18 years; Blood et al., 1977; Brimacombe et al., 1983; Danhauer et al., 1980; Dengerink & Porter, 1984; Fischer & Brooks, 1981; Haley & Hood, 1986; Silverman & Klees, 1989). These findings have been replicated a number of times using different groups of observers (adolescents, teenagers, college students, adults, and professionals who work with individuals with hearing loss) and similar photographed populations. Collectively, pictures of children and teens wearing hearing aids were rated more negatively than children and teens not wearing hearing aids, and the larger the size of the aid, the greater the negative perception (Blood et al., 1977; Brimacombe et al., 1983; Danhauer et al., 1980; Dengerink & Porter, 1984; Fischer & Brooks, 1981; Haley & Hood, 1986; Silverman & Klees, 1989); however, these studies are now decades old. Furthermore, recent studies with adults and older children have suggested the hearing aid effect has diminished compared to earlier studies (Clucas et al., 2012; Rauterkus & Palmer, 2014; Silverman & Largin, 1993).

If children perceive that peers have negative attitudes toward their hearing devices, it could negatively impact their self-esteem and their amplification use. Speech and language outcomes are known to be better for consistent users of amplification than for children who inconsistently use their amplification (Tomblin et al., 2014). Moreover, recent studies suggest that consistent hearing aid use declines as children go from early childhood into school age, especially in middle school (Gustafson et al., 2015).

Research evaluating young children's (under 10 years old) attitudes toward their peers who wear hearing aids is limited. Preschoolers are more likely to select playmates of the same sex, race, age, and hearing status (Lederberg et al., 1986), and those with hearing loss play longer and have more interactive turns with their peers who also have hearing loss relative to their peers with normal hearing (Vandell & George, 1981). Preschool children without hearing loss are less likely to initiate interactions with their peers with hearing loss or to reciprocate initiations made by peers with hearing loss (DeLuzio & Girolametto, 2011). Although preschoolers appear to prefer playing with like-peers, when children with hearing loss engage in play with peers with normal hearing in a mixed play group, they engage in more complex and imaginative play requiring greater complexity in social communication, language, and engagement than when they play with only peers with hearing loss, suggesting that peer interactions are a useful intervention and therapeutic goal for enhancing language development (Levine & Antia, 1997).

Moreover, some have suggested that the novelty of a child wearing hearing aids might serve as an initial attraction for preschoolers with normal hearing who will seek to increase their exploratory interactions with peers who have hearing loss to resolve this anomaly in their experience (Diamond & Hestenes, 1994). These interactions could provide more opportunities for preschool children to characterize these disabilities and integrate them with their own experiences.

Smith and Williams (2001) evaluated typically developing young children's perceptions of a variety of handicaps using a modified version of the Pictorial Scale of Perceived Competence and Social Acceptance for Young Children, a measure designed to elicit children's perceptions of their own abilities and about other children's abilities of cognitive competence, physical competence, and peer acceptance (Harter & Pike, 1984). Findings revealed that young children perceived significant consequences of physical and cognitive disabilities but not hearing loss. Furthermore, children's perceptions of the consequences of disabilities were different across age. Preschoolers generalized negative consequences to all types of disabilities, whereas primary school children were capable of differentiating the expected consequences of different types of disabilities.

The purpose of the current investigation was to examine the attitudes of young school-age children (6–11 years old) toward peers who wear hearing aids. Specifically, the following questions were addressed:

1. Do children with normal hearing perceive children who wear hearing aids more, less, or equally positive than children who do not wear hearing aids?

2. Is there an effect of age on the attitudes toward children who wear hearing aids by those who do not?

Method

Participants

Forty-five children (21 girls, 24 boys) with normal hearing were enrolled in this study and completed data collection. Participants were divided into two groups: 21 children (M _age = 7.5 years, range: 6.8–8.3 years) comprised the younger group, and 24 children (M _age = 9.7 years, range: 8.9–11.0 years) comprised the older group. Racial and ethnic distribution was reflective of the geographical area of the United States where the study was conducted (see Table 1 for demographic information). None of the participants had any significant disabilities beyond correctable vision problems and minor misarticulations. In addition, no children who had siblings or parents who wore hearing devices (i.e., hearing aids, bone anchored hearing aids, or cochlear implants) were included. Children with other relatives (e.g., grandparents), classmates, or friends with hearing devices were not excluded. Participants were in general education classrooms in their neighborhood public or private schools. Participants were excluded if they were homeschooled. Participants were recruited according to procedures approved by the Vanderbilt University Medical Center Institutional Review Board. Parents provided consent, and children provided assent to participate.

Table 1.

Demographics.

Characteristic	Younger children (n = 21)	Older children (n = 24)
Age (years)
Mdn	7.5	9.6
Range	6.8–8.3	8.9–11
Gender
Female	12	9
Male	9	15
Race
Caucasian	18	22
Asian American	2	1
African American	0	1
Other (multiracial)	1	0
Ethnicity
Non-Hispanic	21	22
Hispanic	0	2

Materials

Photo Dyads

Twenty typically developing boys, none of whom was enrolled in the study, were photographed. Ten of the boys photographed were in the younger age range (6–7 years), and 10 boys were in the older age range (9–11 years). To reduce potential biases that could be introduced by race, gender, or specific physical characteristics, all of the photo dyads included Caucasian boys of the same age with similar hair color and cuts, as well as eye color, and were photographed in tight headshots to minimize the effect of clothing style. All boys were photographed with and without a hearing aid in place. Twenty photos were selected by one of the investigators and were then reviewed and matched by similarity (e.g., facial features, hair color and style, and expression) in 10 photo dyads by a committee of three individuals who were not familiar with the boys who were photographed. Each photo dyad included a photo of one child with a hearing aid and a photo of a different child without a hearing aid (see Figures 1a and 1b for examples of the photos).

Figure 1.

Example of two photos in a photo dyad. The photos are examples of a child without a hearing aid and a child with a hearing aid.

Modified Pictorial Scale of Perceived Competence and Social Acceptance for Young Children

Questions from the Pictorial Scale of Perceived Competence and Social Acceptance for Young Children (Harter & Pike, 1984) and the Adapted Pictorial Scale of Perceived Competence and Social Acceptance for Young Children (Smith & Williams, 2001) were utilized. Questions were categorized into three domains: (a) cognitive competence, (b) physical competence, and (c) peer acceptance. Each domain included five questions, for a total of 15 questions for each question format type. These 15 questions were presented in two formats for a total of 30 questions over a test session: (a) two-alternative forced-choice (2AFC) format (see Table 2 for all forced-choice questions; e.g., cognitive competence: “Which child is better at math?”; physical competence: “Which child is better at swinging?”; and peer acceptance: “Which child has more friends?”) and (b) perceived competence rating format (see Table 3 for all perceived competence rating questions; e.g., cognitive competence: “Is he good at math or not good at math?”; physical competence: “Is he good at swinging or not good at swinging?”; and peer acceptance: “Does he have lots of friends or not have lots of friends?”). Perceived competence rating questions utilized the format of the 4-point ordinal scale of the Pictorial Scale of Perceived Competence and Social Acceptance for Young Children with an either/or format question followed by a clarification either/or format question (Harter & Pike, 1984). For example, “Is he good at math or not good at math?”, followed by a clarification question of “Is he kind of good or really good?” or “Is he kind of not good or really not good?”, depending on the child's first response.

Table 2.

Forced-choice questions.

Cognitive competence

1. Which child is better at math?  2. Which child knows more in school?  3. Which child is better at reading alone?  4. Which child is better at writing words?  5. Which child is better at spelling?

Physical competence

1. Which child is better at swinging?  2. Which child is better at climbing?  3. Which child is better at bouncing balls?  4. Which child is better at running?  5. Which child is better at jump-roping?

Peer acceptance

1. Which child has more friends?  2. Which child gets invited to more parties?  3. Which child gets asked to play with others?  4. Which child do other children sit next to?  5. Which child do other children share their toys with?

Table 3.

Perceived competence rating questions.

Cognitive competence

1. Is he good at math or not good at math?  2. Does he know a lot in school or not know a lot in school?  3. Is he good at reading alone or not good at reading alone?  4. Is he good at writing words or not good at writing words?  5. Is he good at spelling or not good at spelling?

Physical competence

1. Is he good at swinging or not good at swinging?  2. Is he good at climbing or not good at climbing?  3. Is he good at bouncing balls or not good at bouncing balls?  4. Is he good at running or not good at running?  5. Is he good at jump-roping or not good at jump-roping?

Peer acceptance

1. Does he have lots of friends or not have lots of friends?  2. Does he get invited to parties or not get invited to parties?  3. Does he get asked to play with others, or does he not get asked to play with others?  4. Do other children sit next to him or not sit next to him?  5. Do other children share their toys with him or not share their toys with him?

Sociometric Rating Scale

The Sociometric Rating Scale (Dion & Berscheid, 1974) to assess popularity was used incorporating the photos from the previous task.

Hearing Aid Exposure Questionnaire

Each participant completed a questionnaire designed for use by this study to determine their exposure to people with disabilities, in particular, those who use hearing aids. The questionnaire consisted of 12 questions targeting whether the participant had any experiences with disabilities or hearing aids in classroom environments or from family, friends, books, movies, and television (see Appendix A). Each participant's parent also completed a 10-item questionnaire to confirm the validity of their child's responses to the questionnaire (see Appendix B).

Procedure

Participants were told they were going to play some games looking at photographs and answering questions about them. They were instructed that there were no right or wrong answers. Participants were not told that their attitudes about children with disabilities, specifically those with hearing loss, were being evaluated. Children were seated across from the examiner with photo dyads (two photos presented at the same time) placed in front of them on a small table. Over the course of a session, participants viewed seven different photo dyads. Five of these photo dyads were target photo dyads and included photos of children with and without hearing aids. The photo of children wearing hearing aids was randomized (either first or second) within the dyad for each presentation. Two foil photo dyads were also included and featured a pair of photos, each of a different child not wearing hearing aids. The purpose of the foil dyads was to serve as practice for the participants with the task and to divert attention from the hearing aids as being the distinguishing factor between the photos. Foil dyads were presented in the first and fourth presentation order; otherwise, photo dyads were counterbalanced.

Each participant viewed photo dyads and answered questions from the Modified Pictorial Scale of Perceived Competence and Social Acceptance for Young Children. A question from each domain area (cognitive, physical, and peer acceptance) for each photograph dyad was asked in random order for target dyads only. Participants were first asked the question in a 2AFC format and asked to choose which child was better at the task described by the question. Following the 2AFC task, participants reviewed each photo in the dyad individually and were asked to rate each photo independently. Each perceived competence rating question was asked twice (once for a photograph with a child wearing a hearing aid and once for a photograph with a child not wearing a hearing aid). All 15 questions, five from each of the three domains, were asked once over the course of a session in both question formats, for a total of 30 questions. If, during data collection, one of the participants would ask about the hearing aid in the photo, such as “What's that?”, the examiner would acknowledge the question and ask, “What do you think it is?” If a participant persisted with questioning, the participant was told that it was a hearing aid, no further clarification was offered, and the examiner would move on to the next question. During trials with foil dyads, six questions (two from each domain) from the original 15 questions were repeated over the course of a session and asked in both question formats. Responses for foil dyads were not included in the analysis.

Next, the 10 photos from the target photo dyads used in the previous task were placed in front of the participant in random order, and a sociometric rating for popularity was completed for each. Specifically, participants were asked, “Find a photograph of someone you especially like.” The selected photo was removed from the table when chosen. This was repeated two more times. After selecting three photos of children they liked, participants were asked, “Find a child you don't like very much” from the remaining seven photos. This question was repeated two more times. The frequency that photos with hearing aids and without hearing aids were “liked” and “not liked” was tracked for each participant.

The Hearing Aid Exposure Questionnaire was always administered last so as to prevent the participants from being alerted to a focus on hearing aids prior to data collection. The questionnaire was read to participants by the examiner, and participants provided a verbal response, which was transcribed by the examiner. Parents completed their questionnaires independently and provided written responses while their child was completing the study.

Statistical analyses for the forced-choice task included a between-groups repeated-measures analysis of variance (RM-ANOVA) to examine the effects of age and gender on choices made by study participants. Follow-up t tests were completed to examine any differences in choices for each domain. Statistical analyses for the individual rating task included a two-way between-groups RM-ANOVA to examine the effects of age and gender on ratings made by study participants. Follow-up two-way between-groups ANOVAs were completed to examine any differences in rating for each domain. Statistical analyses for the sociometric rating task included a between-groups RM-ANOVA to examine the effects of age and gender on choices made by study participants. Follow-up t tests were completed to examine differences in choices for each sociometric rating task. A Huynh–Feldt correction was applied for all ANOVAs completed. A significance level of > .05 was used in the analysis to describe significant findings for all measures.

Results

Forced-Choice Task

For the 2AFC task, the frequency that photos of children with hearing aids were selected for each question was compiled for each domain area. Each dependent variable had a count of 0–5 (i.e., continuous variable). A between-groups RM-ANOVA was completed with the frequency of the photo of a child with a hearing aid selected as the dependent variable. Within-subject factors included domain (cognitive competence, physical competence, peer acceptance), and between-subjects factors included age group (younger children, older children) and gender (male, female). There was a significant effect of domain area, F(1.981, 81.22) = 4.737, p = .012, and a significant interaction between domain area and age, F(1.981, 81.22) = 3.981, p = .023, was present. No effects of gender were revealed; thus, data were collapsed for additional analysis. A follow-up RM-ANOVA was completed separately for each age group with domain (cognitive competence, physical competence, peer acceptance) as the within-subject factor. Younger children were more likely to select photos of children without hearing aids as having more competence than children who wore hearing aids across all three categories. Older children demonstrated differences in the frequency that they selected photos of children with hearing aids across the different domains, F(1.865, 42.902) = 7.580, p = .002. Specifically, although older children were less likely to select photos of children with hearing aids as having greater physical competence or peer acceptance, they were more or equally likely to select photos of children with hearing aids as having greater cognitive competence.

When age groups were collapsed, children were equally likely to choose a picture of a child with or without a hearing aid as having greater cognitive competence (see Figure 2). However, participants were less likely to select a picture of a child with a hearing aid as having greater physical competence relative to a picture of a child without a hearing aid (M = 1.8222, SD = 1.15383), t(44) = −3.941, p = .000, or peer acceptance (M = 1.7556, SD = 1.29957), t(44) = −3.843, p = .000.

Figure 2.

Forced-choice responses by competency area. The error bars reflect standard deviation. The dotted line reflects 50%. *p < .05.

As seen in Figure 2, older children did not demonstrate a preference for photos of children with hearing aids versus those without for questions related to cognitive competence and peer acceptance but were less likely to choose photos of children with hearing aids as having greater physical competence than those without hearing aids (M = 1.5000, SD = 1.25109), t(23) = −3.916, p = .001. Younger children were equally likely to choose photos of children wearing hearing aids and without hearing aids as having greater cognitive and physical competence but were less likely to choose photos of children with hearing aids as having greater peer acceptance (M = 1.6190, SD = 0.97346), t(20) = −4.147, p = .000.

Perceived Competence Rating Task

A between-groups two-way RM-ANOVA was completed with perceived competence ratings as the dependent variable. Each dependent variable had a count of 0–20 (i.e., continuous variable). Within-subject factors included area subscale (cognitive competence, physical competence, peer acceptance) and presence of hearing aid. Between-subjects factors included age group and gender. Participants rated photos of children wearing hearing aids less positively than those of children not wearing hearing aids, F(1, 41) = 32.767, p = .000. An interaction between domain area and the presence of a hearing aid, F(2, 82) = 5.069, p = .008, showed participants were more negative in their ratings of children with hearing aids and more positive in their ratings of children without hearing aids, specifically in the areas of physical competence and peer acceptance.

No effects of age or gender were revealed; thus, data were collapsed for additional analysis. A between-groups RM-ANOVA for each domain was completed with perceived competence ratings as the dependent variable. Each dependent variable had a count of 0–20 (i.e., continuous variable). Within-subject factors included presence of hearing aid, and between-subjects factors included age group. Participants rated photos of those wearing and not wearing hearing aids similarly for questions related to cognitive competence. Photos of children wearing hearing aids were rated less positively than those without hearing aids in areas of physical competence, F(1, 43) = 20.070, p = .000 (see Figure 3), and peer acceptance, F(1, 43) = 21.748, p = .000 (see Figure 3).

Figure 3.

Perceived competence ratings by competency area. Participants rated the perceived competence of children with and without a hearing aid (HA) in the photos as “really good” (4), “kind of good” (3), “kind of not good” (2), or “really not good” (1). The error bars reflect standard deviation. *p < .05.

Sociometric Rating Task

Participants were prompted three times to identify photos of children they “liked” and “didn't like.” The selection frequency of photos of children who were “liked” and “not liked” was then calculated for photos of children with a hearing aid, and each dependent variable had a count of 0–3 (i.e., continuous variable). A between-groups RM-ANOVA with selection frequency as the dependent variable with selection task (like vs. not liked) as a within-subject factor was completed. Between-subjects factors included age group and gender. One female participant in the younger group completed the forced-choice questions and rating questions on all the photos but then refused to choose any photos in the sociometric rating task because she reported she did not like any boys. Therefore, her data for this task were excluded in the analysis. Selection task was a significant within-group factor, F(1, 40) = 8.969, p = .005, with photos of children with hearing aids being chosen more often in the “not liked” task and less often chosen for the “liked” task.

No effects of age or gender were present; thus, data were collapsed for further analyses. A one-sample t test was conducted to determine if a statistically significant difference was present in how often photos of children with hearing aids were selected for each sociometric task compared to a null hypothesis (1.5). Participants selected photos of children with hearing aids for the “liked” task less often than photos of children without hearing aids (M = 0.9545, SD = 0.77623), t(44) = −4.661, p = .000. Significant differences were not observed in participant choices during the “not liked” task.

Hearing Aid Exposure Questionnaires

All participants and parents of participants completed their respective questionnaires and provided responses to all questions on the questionnaires. The Hearing Aid Exposure Questionnaire was used to gain a broad understanding of children's exposure to disabilities and hearing aids. Child participants' responses to the Hearing Aid Exposure Questionnaire are illustrated in Figure 4. Almost all children had exposure to disabilities through classmates, friends, family, or media consumption. Ninety percent of younger children reported exposure to disabilities, and this increased to 100% for older children. Similarly, 81% of younger children had exposure to hearing aids through classmates, friends, family, or media consumption, which increased to 96% of older children. Most older children were able to describe what hearing aids do (92%) and state who might wear hearing aids (92%). In contrast, only 62% of younger participants could describe what hearing aids do, and only 67% could state who might wear hearing aids.

Figure 4.

Hearing Aid Exposure Questionnaire. Percentage of responses by participants to queries about their experiences with and knowledge of disabilities and hearing aids. See Appendix A for the specific questions asked of participants. HA = hearing aid.

Spontaneous Comments

This study did not explicitly explore the rationale behind the participants' responses to the children depicted by the photos. However, some participants spontaneously offered comments that served to elucidate their thoughts. For example, when viewing a photo dyad that included a child with a hearing aid, a participant responded to the question “Which child knows more in school?” with “This boy doesn't do as well in school because of that thing in his ear,” while pointing at the hearing aid. Another participant responded to “Which child knows more in math?” with “Not him because he probably can't hear the teacher,” while pointing to the child wearing a hearing aid. Another participant responded to “Which child has more friends?” by pointing to the child without a hearing aid and said, “Him, because he has no hearing aid or anything.” In response to “Which child gets asked to play with others?”, a participant said, “He can't because he has a hard time hearing.” Another participant elaborated on their thinking in response to the question, “Which child has more friends?” with “He has more friends,” pointing to the child without hearing aids, “but he has better friends,” pointing to the photo of the child with hearing aids. “He looks different from other people and people who were friends with him would be better friends.”

Discussion

We sought to examine the current state of the hearing aid effect in children and determine if it is influenced by age. Given that there is now a greater presence of persons with disabilities, including those with hearing loss, in popular media (e.g., television and movies, children's books) than in past decades, it is reasonable to think that perhaps widespread prejudices against those with disabilities would be reduced relative to attitudes of the past. The results of this study suggested that the attitudes of typically developing school-age children toward their peers with hearing loss still reflect some bias. Specifically, the hearing aid effect negatively influenced the participants' perceptions of physical competence and peer acceptance of their peers with hearing loss. However, no negative biases regarding cognitive competence were revealed by this cohort. The hearing aid effect was present in both age groups examined. Younger and older children displayed similar hearing aid effects for peer acceptance and sociometric ratings; however, older children were more likely to have negative attitudes toward their peers wearing hearing aids when judging physical competence. Given that there were some limited effects of age in this study, these attitudes might still be formulating during this window of development as suggested by Smith and Williams (2001).

These findings are consistent with much of the early literature demonstrating the hearing aid effect in young school-age children, adolescents, teenagers, and adults (Blood et al., 1977; Brimacombe et al., 1983; Fischer & Brooks, 1981; Haley & Hood, 1986; Silverman & Klees, 1989). In contrast, Smith and Williams (2001) examined young children's perceptions of disabilities and found that young children did not make negative judgments about children with hearing loss. Differences in findings could be the result of methodological differences in that Smith and Williams used stories describing a child with a particular disability along with a photograph depicting the characters. Use of amplification was not addressed in the vignette, and it is unclear if there were visual representations of hearing loss (i.e., hearing aids).

Spontaneous comments from the participants in the current study suggested that the motivation behind some of the participants' responses might not be negative toward those with hearing aids but, rather, might reflect their understanding and perception of some of the challenges faced by these children. For example, in pointing to a picture of a child wearing a hearing aid, a participant said, “He looks different from other people and people who were friends with him would be better friends.” Further examination of the thoughts of children with normal hearing about their peers with hearing loss might assist in efforts to improve socialization among these children in inclusionary environments.

Parental observations of daily activities of children with hearing loss have also suggested that young children with hearing loss are less likely to engage in group activities as compared to their peers with typical hearing and are more likely to engage in one-on-one or solitary play (Ching et al., 2009). It is reasonable to speculate that the hearing aid effect might be mitigated when children with hearing loss have clear speech and age-appropriate language skills. However, preschool children with hearing loss remain more likely to be excluded from interactions with their peers with normal hearing even if their language is age appropriate (DeLuzio & Girolametto, 2011), thus suggesting that the hearing aid effect is a multifaceted construct that has yet to be fully understood.

Interventions to improve children's attitudes toward peers with disabilities in classroom settings and to increase social interactions between those groups can take many forms. Programs that are targeted to children with typical hearing are most successful when they provide actual social contact and interaction with peers who have disabilities or simulations that can aid in understanding the impact of disabilities over multiple sessions (Diamond & Hestenes, 1994; Lindsay & Edwards, 2013). Curriculums focused on only increasing awareness of disabilities without interactive components have been relatively unsuccessful in improving such attitudes (Lindsay & Edwards, 2013). Educators and other partners in a child's team at school can also receive training to identify signs of social exclusion and bullying of children with hearing loss (Lindsay & Edwards, 2013).

Children entering kindergarten with hearing aids and cochlear implants are at risk for delays with social skill development compared to typically developing peers (Wong et al., 2017). Social communication and competence should be considered in a whole child approach when developing a child's individualized education plan. A targeted intervention for children with hearing loss to help boost social skills and self-esteem might help to mitigate the impacts of the hearing aid effect. A commonly used curriculum, Knowledge Is Power (Mississippi Bend Area Educational Agency–Special Education Division, 2003), is a resource for school-age children to learn about their hearing loss and is designed to build their self-esteem and self-reliance through that knowledge. Although anecdotally these types of programs have helped children with hearing loss, the effectiveness of these types of programs has not been established. School-age children might also benefit from peer and adult mentorship to boost social development. Recent options include electronic mentoring programs that have been shown to be effective in boosting social skills and psychosocial development for older school-age children with disabilities (Lindsay et al., 2018).

The current study had some limitations. The photo dyads used in the study were created to be as homogenous as possible so that gender, race, and perceived socioeconomic status of the photographed subjects would not influence the choices made. Implicit bias can be present in young children and adults for a variety of reasons, and we sought to reduce any confounding variables for this study. As such, we can only discuss the perceived hearing aid effect in male children.

Conclusion

The results of this study suggest that a hearing aid effect is still evident in children as young as 6 years of age and that negative attitudes toward children with hearing aids have persisted over the last several decades. In addition, findings from this study suggest that children who use hearing aids are viewed by their peers with normal hearing as being less physically capable and less socially accepted than those with normal hearing.

These findings lend support to professionals who work with children who have hearing loss that time spent providing additional support to encourage social relationships between those with and without hearing loss could be of benefit to both children with and without hearing loss. That is, teachers or early interventionists might create social situations that facilitate social interactions and friendships between children with and without hearing loss, particularly in inclusionary educational environments. Although additional research is needed to determine the most effective methods for mitigating the hearing aid effect in children, intervention likely will need to include educational instruction to peers with normal hearing supported with real interactions with individuals with hearing loss, parent education programs, and self-advocacy and mentoring programs for children with hearing loss.

Appendix A

Questionnaire of Children's Exposure With Disabilities and Hearing Aids

1. Is there anyone in your classroom with a disability “or who needs extra help”? For example, is there anyone who has trouble seeing, walking, or talking? If yes, what kind?

2. Is there anyone in your classroom with hearing aids?

3. Have you read any books that had a character with a disability? If yes, what kind?

4. Have you read any books that had a character with hearing aids?

5. Have you watched any movies or TV shows with a character with a disability? If yes, what kind?

6. Have you watched any movies or TV shows with a character with hearing aids?

7. Does anyone in your family have a disability? If yes, what kind?

8. Does anyone in your family wear hearing aids?

9. Do you have any friends with a disability? If yes, what kind?

10. Do you have any friends who wear hearing aids?

11. Do you know what hearing aids do?

12. Why would someone wear hearing aids?

Appendix B

Questionnaire for Parents of Children's Exposure With Disabilities and Hearing Aids

1. Is there anyone in your child's classroom with a disability “or who needs extra help”? For example, is there anyone who has trouble seeing, walking, or talking? If yes, what kind?

2. Is there anyone in your child's classroom with hearing aids?

3. Have you read any books with your child that had a character with a disability? If yes, what kind?

4. Have you read any books with your child that had a character with hearing aids?

5. Have you watched any movies or TV shows with your child that had a character with a disability? If yes, what kind?

6. Have you watched any movies or TV shows with your child that had a character with hearing aids?

7. Does anyone in your family have a disability? If yes, what kind?

8. Does anyone in your family wear hearing aids?

9. Does your child have any friends with a disability? If yes, what kind?

10. Does your child have any friends who wear hearing aids?

Funding Statement

This research was supported in part by grants from the National Institute on Deafness and Other Communication Disorders (T35DC008763), Maternal Child Health Bureau (Vanderbilt Leadership Education in Neurodevelopmental Disabilities), and Department of Education–Personnel Development to Improve Services and Results for Children With Disabilities–Preparation of Audiologists to Serve Infants and Toddlers With Hearing Loss (CFDA 84.325K; awarded to Lindsey R. Wheeler).