Special Issue: Australian Hearing Hub
Psychosocial Development in 5-Year-Old
Children With Hearing Loss Using Hearing
Aids or Cochlear Implants
Trends in Hearing
Volume 21: 1–19
! The Author(s) 2017
DOI: 10.1177/2331216517710373
journals.sagepub.com/home/tia
Cara L. Wong1,2,3, Teresa Y. C. Ching1,2, Linda Cupples3,
Laura Button1,2, Greg Leigh4, Vivienne Marnane1,2,
Jessica Whitfield1,2, Miriam Gunnourie1,2, and Louise Martin1,2
Abstract
This article reports on the psychosocial development and factors influencing outcomes of 5-year-old children with cochlear
implants (CIs) or hearing aids (HAs). It further examines differences between children with CIs and HAs with similar levels of
hearing loss. Data were collected as part of the Longitudinal Outcomes of Children with Hearing Impairment study—a
prospective, population-based study. Parents/caregivers of children completed the Strengths and Difficulties Questionnaire
(n ¼ 333), the Social Skills subscale from the Child Development Inventory (n ¼ 317), and questionnaires on functional
auditory behavior (Parents’ Evaluation of Aural/oral performance of Children), and demographics. Children completed
assessments of nonverbal cognitive ability (Wechsler Non-verbal Scale of Ability) and language (Preschool Language
Scale - fourth edition). On average, parent-rated Strengths and Difficulties Questionnaire scores on emotional or behavioral
difficulties were within 1 SD of the normative mean; however, Child Development Inventory scores on social skills were
more than 1 SD below the norm. Children with severe-to-profound hearing losses using HAs had significantly more behavioral problems than children with CIs. Regression analyses showed that non-verbal cognitive ability, language, and functional
auditory behavior were significantly associated with psychosocial outcomes for children with HAs, whereas outcomes for
children with CIs were associated with functional auditory behavior and the presence of additional disabilities. Age at hearing
intervention, severity of hearing loss, and communication mode were not associated with outcomes. The results suggest that
even children who develop good language ability with the help of a HA or CI may have psychosocial problems if they exhibit
difficulties with listening and communicating in everyday environments. The findings have implications for developing
interventions for young children with hearing loss.
Keywords
deaf or hard of hearing, hearing aids, cochlear implant, pediatric, psychosocial, social skills, language, functional communication skills, Parents’ Evaluation of Aural/oral performance of Children, Strengths and Difficulties Questionnaire, Child
Development Inventory
Date received: 17 June 2016; revised: 22 February 2017; accepted: 20 April 2017
Introduction
Hearing loss, the most common congenital sensory
impairment, can have lifelong developmental consequences on communication, language, social, and academic functioning. The literature has reported that, on
average, children who are deaf or hard of hearing
(DHH) have higher rates of psychosocial problems
including emotional disorders (e.g., anxiety and depression), behavioral problems (e.g., hyperactivity and conduct problems), and social difficulties compared with
1
National Acoustics Laboratories (NAL), Macquarie University, NSW,
Australia
2
HEARing CRC, The University of Melbourne, Carlton, Australia
3
Macquarie University, NSW, Australia
4
Royal Institute for Deaf and Blind Children (RIDBC), Sydney, Australia
Corresponding author:
Cara L. Wong, National Acoustic Laboratories, Level 4, Australian Hearing
Hub, 16 University Avenue, Macquarie University, NSW 2109, Australia.
Email: Cara.Wong@nal.gov.au
Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/)
which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open
Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
2
their hearing peers (Fellinger, Holzinger, Sattel, &
Laucht, 2008; Hindley, 2005; Mejstad, Heiling, &
Svedin, 2009; Netten et al., 2015). These problems have
typically been associated with delays in language and
communication abilities (Barker et al., 2009; Stevenson,
McCann, Watkin, Worsfold, & Kennedy, 2010).
Although recent advances in hearing device technology
and universal newborn hearing screening have led to
improvements in language development, there has been
little up-to-date research to conclude whether these
advancements have led to improvements in psychosocial
functioning (Moeller, 2007; Sorkin, Gates-Ulanet, &
Mellon, 2015).
A recent meta-analysis of 45 studies investigated
psychosocial difficulties in DHH children or adolescents compared with hearing controls (Stevenson,
Kreppner, Pimperton, Worsfold, & Kennedy, 2015).
The majority of studies reviewed did not provide information about the hearing device used, or did not
report outcomes separately for children with cochlear
implants (CIs) or hearing aids (HAs). In general, there
appear to be more studies that focus specifically on the
psychosocial outcomes of children with CIs, but very
few that include only children with HAs, particularly
those with milder hearing losses. To address this
imbalance, this article examines outcomes and potential mediating factors separately for DHH children
using CIs or HAs. The aim is to enhance understanding of how hearing device can influence psychosocial
outcomes, with the ultimate goal of informing evidence-based interventions.
Psychosocial Outcomes of Children With CIs
Cochlear implantation has now become the dominant
choice of hearing device for children with profound hearing loss (Punch & Hyde, 2011a). Unlike HAs, which
amplify sounds, CIs provide direct electrical stimulation
to the user’s auditory nerve (Bat-Chava, Martin, &
Kosciw, 2005; Svirsky, Robbins, Kirk, Pisoni, &
Miyamoto, 2000). A number of studies have demonstrated the benefits of cochlear implantation for oral language development and integration into mainstream
schools (Ching et al., 2009; Geers, Nicholas, & Sedey,
2003). Others have reported that the language and cognitive development of young children with CIs does not
differ significantly from that of hearing children (Khan,
Edwards, & Langdon, 2005; Svirsky et al., 2000). The
enhancement of oral language skills is likely to have positive effects on psychosocial adjustment.
Accordingly, studies looking at parent perceptions of
psychosocial function from pre- to postimplantation
have found improved quality of life (QoL), self-esteem,
and peer relationships (Bat-Chava & Deignan, 2001;
Bat-Chava et al., 2005; Leigh, Maxwell-McCaw, Bat-
Trends in Hearing
Chava, & Christiansen, 2009; Nicholas & Geers, 2003).
A number of studies focusing on the outcomes of children with CIs have found comparable scores to typically
developing children on the Strengths and Difficulties
Questionnaire (SDQ), a screen of emotional, behavioral,
and peer problems (Anmyr, Larsson, Olsson, & Freijd,
2012; Huber & Kipman, 2011). However, these studies
have typically used small sample sizes (n ¼ 22–35) and
older children or adolescents (ages 9 to 17 years;
Anmyr et al., 2012; Huber & Kipman, 2011; Leigh
et al., 2009; Nicholas & Geers, 2003).
Furthermore, not all studies have reported positive
effects of CIs on psychosocial development
(Dammeyer, 2010; Huber, 2005; Huber et al., 2015;
Peterson, 2004; Pulsifer, Salorio, & Niparko, 2003),
and residual difficulties have been reported postimplantation due to delays in oral communication, difficulties
in group situations, and attitudes of hearing peers
(Bat-Chava & Deignan, 2001; Punch & Hyde,
2011b). Some researchers have also reported that use
of CI is not linked directly to improved social competence but influences it via improved communication,
increased identification with the hearing world, and
mainstream schooling (Bat-Chava & Deignan, 2001;
Leigh et al., 2009).
Although it is still unclear whether children with CIs
are comparable to their hearing peers in psychosocial
development, there is evidence that they have fewer psychosocial problems when compared with DHH children
without CIs (Bat-Chava et al., 2005; Theunissen et al.,
2012; Theunissen et al., 2014a). For example, when compared with children who have moderate to profound
hearing loss and use HAs, children with CIs were
reported to have lower levels of general anxiety, social
anxiety, and behavioral problems (including aggression,
attention, and conduct disorders) and were rated as
being more similar to their hearing peers (Theunissen
et al., 2012; Theunissen et al., 2014a). The authors suggested that the advantage of a CI may lie in its restoring
auditory input and lowering social barriers but also that
children with CIs may receive more counselling and
rehabilitation than those with HAs.
After reviewing the literature, Dammeyer (2010) and
Theunissen et al. (2014c) concluded that the psychosocial well-being of DHH children with CIs lay somewhere between that of DHH children without CIs and
that of hearing children. However, the majority of
studies investigating the psychosocial outcomes of children with CIs specifically are limited by small sample
sizes and do not include relevant control groups. Many
studies have not considered the possible influence of
children’s chronological age, intelligence, age at
implantation, duration of implant use, communication
mode, oral abilities, additional disabilities, and family
background (Dammeyer, 2010; Stevenson et al., 2015).
3
Wong et al.
Without controlling for these potential mediating variables, the effect of hearing device on psychosocial outcomes is difficult to establish.
Factors Influencing Outcomes in Children With CIs
Language and communication ability have long been
linked to psychosocial development in both typically
developing (Benner, Nelson, & Epstein, 2002; Petersen
et al., 2013) and DHH children (Barker et al., 2009;
Stevenson et al., 2010). In the hearing population, clinically significant language deficits have been found in
approximately three out of four children with diagnosed
emotional or behavioral disorders (Benner et al., 2002).
Conversely, children with language disorders have a
higher incidence of social, emotional, and behavioral
problems (Conti-Ramsden & Botting, 2008; St Clair,
Pickles, Durkin, & Conti-Ramsden, 2011). Similarly, studies investigating children with CIs have found that
better language skills (including speech understanding,
speech production, vocabulary, and syntactic proficiency) are significantly associated with better psychosocial outcomes (Percy-Smith, Hedegaard Jensen, et al.,
2008; Remmel & Peters, 2009). Notwithstanding this
association, evidence has also shown that DHH children
are still at higher risk of psychosocial problems such as
low self-esteem and empathy after controlling for language ability (Netten et al., 2015; Theunissen et al.,
2014b); however, these studies have not looked separately at children with CIs and HAs.
An important consideration relating to successful communication and social interactions in DHH children is
their ability to use their devices to listen effectively and
communicate in everyday environments, hereon referred
to as ‘‘functional auditory behavior.’’ Compromised ability to hear speech or detect subtle cues in conversation can
negatively affect social interactions (Batten, Oakes, &
Alexander, 2014) and may result in particular difficulties
for children with CIs in noisy environments such as the
playground or in groups of people (Punch & Hyde,
2011b). Consistent with this view, Huber and Kipman
(2011) reported that adolescents with CIs who had good
speech perception ability in both quiet and noisy environments were more likely to have SDQ scores within the
normal range. Further evidence comes from a recent
study of younger DHH children with either CIs or HAs
(Leigh et al., 2015). Leigh et al. (2015) reported that children whose parents rated them as being able to listen and
communicate well in a range of different quiet and noisy
environments, as measured on the Parent Evaluation of
Aural/Oral Performance of Children (PEACH) scale, also
had more highly developed social skills on the Child
Development Inventory (CDI).
For children with CIs, a number of studies have found
that younger age at implantation or longer duration
of implant use was associated with improved social relationships, communication, self-esteem, and QoL (BatChava & Deignan, 2001; Martin, Bat-Chava, Lalwani,
& Waltzman, 2010; Percy-Smith, Cayé-Thomasen,
Gudman, Jensen, & Thomsen, 2008; Theunissen et al.,
2014b; Yoshinaga-Itano, 2001). Theunissen et al. (2012)
reported that children who were implanted earlier and
had a longer duration of CI use had less generalized and
social anxiety. However, associations between earlier age
at implantation and psychosocial outcomes have not
been found consistently (Nicholas & Geers, 2003;
Percy-Smith, Hedegaard Jensen, et al., 2008).
There are a number of other child- and family-related
demographic and social factors that may directly or
indirectly impact on psychosocial outcomes (as well as
developmental outcomes in general) and consequently
should be controlled for when examining the effects of
hearing device on psychosocial outcomes. Child-related
factors include the presence of additional disabilities
(Cupples et al., 2014; Dammeyer, 2010) and non-verbal
cognitive ability (Geers & Moog, 1987; Nicholas &
Geers, 2003). Family-related factors include child’s communication mode at home (Percy-Smith, Hedegaard,
Jensen, et al., 2008), socioeconomic status (SES; Geers,
2002), and maternal education (Ching, Dillon, et al.,
2013). Although there is evidence that child-related
factors impact directly on psychosocial outcomes, the
evidence is less clear for these family-related factors,
which may only be indirectly related through their influence on language development and communication
(Wong et al., 2016).
Outcomes of Children With HAs
There are very few studies focusing specifically on the
psychosocial outcomes of children with mild to moderate hearing losses who use HAs. Not surprisingly,
research has shown that children with severe to profound losses who use HAs (e.g., preimplant CI candidates) have significantly more psychosocial problems
than their hearing peers (Barker et al., 2009;
Hoffman, Quittner, & Cejas, 2015). However, there is
also evidence that children with all degrees of hearing
loss experience psychosocial problems (Bess, DoddMurphy, & Parker, 1998; Kouwenberg, 2013). Thus,
for a sample of DHH children using HAs, Davis,
Elfenbein, Schum, and Bentler (1986) reported no differences in emotional, behavioral, or social problems
between children with mild, moderate, and severe
losses, despite all children having significantly more
social and behavioral problems than expected by comparison with norms.
Focusing on studies that have used the SDQ with participant samples composed predominantly of children
with HAs, the majority have found significantly higher
4
rates of psychosocial difficulties compared with hearing
children and no significant effect of degree of hearing loss
(Dammeyer, 2010; Fellinger et al., 2008; Hintermair,
2007; Stevenson et al., 2010). An Australian population
study (Wake, Hughes, Collins, & Poulakis, 2004) looking
at outcomes of DHH children with mild to profound
loses (86% using HAs) found that, on average, the children had significantly more parent- and teacher-rated
behavioral problems on the Child Behavior Checklist
(CBCL), and lower adaptive skills and health-related
QoL compared with the normative population. This
pattern was found, despite the children having normal
intellect, no additional disabilities, early amplification,
and receiving ongoing intervention and support.
Overall, it appears that children with HAs who have
mild to profound levels of hearing loss may all be at risk
of poor psychosocial development. Some researchers
have argued that partial or mild degrees of hearing loss
may even affect self-concept more because being ‘‘so
close to normal’’ makes acceptance of disability more
difficult (Mykleburst, 1960, cited in Polat, 2003).
Again, however, before drawing strong conclusions, the
contribution of other potential mediating factors needs
to be examined.
Factors Influencing Outcomes in Children With HAs
Language ability, functional auditory behavior, childrelated (i.e., additional disabilities, non-verbal cognitive
ability), and family-related (i.e., home communication
mode, maternal education, and SES) factors may contribute to psychosocial outcomes for all DHH children
regardless of hearing device (Leigh et al., 2015; Polat,
2003; Theunissen et al., 2014c). Similar to children with
CIs, earlier age of intervention in the form of HA fitting
may also contribute to better psychosocial outcomes
(Hind & Davis, 2000; Hoffman et al., 2015; YoshinagaItano, Sedey, Coulter, & Mehl, 1998), although such an
advantage has not consistently been found (Stevenson
et al., 2011).
A factor that is relevant for children with HAs specifically and has been shown to influence language outcomes is the child’s degree of hearing loss. Studies
looking at the relationship between severity of hearing
loss and psychosocial development have been varied.
Wake et al. (2004) found that, although severity of hearing loss was related to language ability, it was not significantly associated with psychosocial outcomes. It is
worth noting, however, that while the differences were
not significant, children with mild losses were rated as
having the lowest QoL and the most behavior problems.
In contrast, Fellinger et al. (2008) found that although
the differences did not reach significance, children with
severe levels of hearing loss had a higher incidence
of externalizing problems (e.g., conduct and
Trends in Hearing
hyperactivity) on the SDQ compared with those with
moderate or profound losses (including children with
HAs and CIs). In their review of the evidence,
Theunissen, Reiffe, Netten, et al. (2014b, 2014c) reported
that most literature has reported no significant influence
of degree of hearing loss on psychosocial outcomes.
Summary of Evidence
In summary, the majority of previous literature has
reported psychosocial difficulties in DHH children compared with hearing children. There are relatively few
studies focusing on children with HAs compared with
those with CIs. Although a number of studies have
found that children with CIs perform at similar levels
to hearing children on psychosocial measures (Anmyr
et al., 2012; Huber & Kipman, 2011), this pattern has
not been found consistently (Dammeyer, 2010; Huber,
2005; Peterson, 2004). A number of researchers have
concluded that the psychosocial well-being of children
with CIs lies somewhere between that of hearing children, and that of children with similar levels of hearing
losses using HAs (Dammeyer, 2010; Theunissen et al.,
2012; Theunissen et al., 2014a). In regard to factors
that influence outcomes, there is little evidence that
severity of hearing loss influences psychosocial development. In contrast, there is more substantial evidence that
age at intervention, and child- and family-related factors
influence outcomes for DHH children using CIs or HAs.
However, many of these factors may only indirectly
impact psychosocial outcomes through their influence
on language and functional auditory behavior (Wong
et al., 2016).
In regard to the published literature, it is noteworthy that few population studies have examined psychosocial development in pre-school age DHH children
who have had access to early intervention. Previous
studies have included children with a wide age range,
despite the fact that age has been significantly associated with psychosocial outcomes in DHH children
(Nicholas & Geers, 2003; Polat, 2003). Furthermore,
outcome measures have been heterogeneous (although
the SDQ is most consistently used), and prevalence
rates may be inflated due to the use of different cutoff scores or sampling of participants from schools for
the deaf. Finally, very few studies have looked at psychosocial functioning at a range of levels from basic
social skills to peer relations and emotional or behavioral difficulties (Batten et al., 2014). Although these
psychosocial factors are interrelated, they are theoretically separate constructs. Exploring psychosocial outcomes at these different levels is, therefore, important.
Although a DHH child may have inferior social skills
or few friends, it will not necessarily be reflected in
poor mental health or QoL.
5
Wong et al.
Aims
Measures
To address the issues raised earlier, the aims of the current study were to as follows (a) examine the psychosocial outcomes of 5-year-old DHH children compared
with normative data separately for those using CIs or
conventional HAs, (b) compare the outcomes of children
with CIs to those with similar levels of hearing losses
using HAs, and (c) investigate the factors influencing
psychosocial outcomes separately for children with CIs
or HAs.
Based on the balance of evidence, it was hypothesized
that (a) both children with CIs and HAs would show
more psychosocial problems compared with normative
data, (b) for children with similar levels of hearing loss,
those using CIs would be rated as having fewer psychosocial problems than children with HAs, and (c) the same
factors would influence psychosocial outcomes in children with CIs and HAs, with the influence of hearing
loss mediated predominantly by variation in language
and functional auditory behavior.
Psychosocial measure: CDI. The CDI (Ireton, 1992) is a
parent-rated standardized questionnaire designed to
assess children’s development from 15 months to 6
years of age. Although the CDI has eight subscales, we
focus on one CDI subscale that describes aspects of
social skills development. The Social subscale of the
CDI (40 items) measures aspects of personal and group
interaction and social behaviors, including care and concern for others (e.g., ‘‘shows sympathy to other children’’), initiative (e.g., ‘‘asks for help in doing things’’),
independence (e.g., ‘‘shows leadership among children
his/her age’’), and social interaction (e.g., ‘‘makes or
builds things with other children’’).
Published normative data (Ireton & Glascoe, 1995)
were used to recalculate children’s individual results
into developmental ages, which were then used to
derive Z scores. Z scores were calculated by subtracting
the child’s chronological age from developmental age
and dividing this by 1 SD (i.e., 15% of the chronological
age norms according to Ireton & Glascoe, 1995). There
were 317 completed forms returned for the CDI. Missing
data were most commonly due to the forms not being
returned.
Method
Participants
The data presented here were collected as part of the
Longitudinal Outcomes of Children with Hearing
Impairment (LOCHI) study—a longitudinal study that
has prospectively measured the language, psychosocial,
and educational outcomes of a large cohort of
Australian children with hearing loss. Detailed information about the LOCHI study has been presented previously by Ching, Leigh, and Dillon (2013). In brief,
families with children born between May 2002 and
August 2007 in the Australian states of New South
Wales, Victoria, and Queensland who were identified
with hearing loss and fitted with amplification before 3
years of age were invited to participate in the study. All
children in this study had access to the same hearing
service provider (Australian Hearing) before 3 years of
age. Written parental consent was obtained for each participant, and ethics was approved for the study from the
Australian Hearing human research ethics committee
(EC00109).
Data on at least one psychosocial measure were available for 356 children enrolled in the LOCHI study when
they were turning 5 years old (M ¼ 61.6 months,
SD ¼ 1.9; range 58–73 months). There were 317 CDI
forms and 333 SDQs completed by parents, with 294
parents completing both measures. Children who were
no longer using hearing devices at 5 years (n ¼ 3) were
excluded from the current analyses. In total, the study
cohort comprised of 194 males and 162 females. More
children wore HAs (66.3%) than CIs (33.7%).
Psychosocial measure: SDQ. The SDQ (Goodman, 1997) is
a 25-item screening measure designed to identify behavioral and emotional problems in children. The instrument consists of five subscales: conduct problems (e.g.,
fights with others), hyperactivity (e.g., restless or easily
distracted), emotional symptoms (e.g., many worries,
often unhappy), peer problems (e.g., picked on or bullied), and prosocial behavior (e.g., considerate of others
feelings). Each subscale consists of five items rated on a
3-point response scale from 0 ¼ not true, 1 ¼ somewhat
true to 2 ¼ certainly true. Scores from each domain
(excluding prosocial behavior) were summed to make a
‘‘total difficulties score.’’ Higher scores on the prosocial
domain reflect strengths, whereas higher scores on the
remaining subscales and total difficulties scores indicate
more emotional and behavioral problems. Z scores were
calculated from recent Australian normative data of children aged 5 years (Kremer et al., 2015). All difficulties
scores were reversed so that higher Z scores reflected
better psychosocial functioning. There were 333 completed forms returned for the SDQ. Missing data were
most commonly due to the forms not being returned.
Language: Preschool Language Scale—fourth edition. The
Preschool Language Scale—fourth edition (PLS-4;
Zimmerman, Steiner, & Pond, 2002) is a standardized
language test used to identify language disorders between
birth and 6 years 11 months. The test contains two subscales of Expressive Communication (EC) and Auditory
6
Comprehension (AC), which are combined to derive a
‘‘total language score.’’ The EC subscale items for preschool age include naming of common objects, using
concepts to describe objects, defining words, and using
grammatical constructions. The AC subscale includes
items that assess comprehension of vocabulary, concepts, complex sentences, and drawing inferences.
Standard scores and age-equivalent scores were calculated using normative data. There were 25 children in
the study who were not able to complete the PLS-4
due to various reasons, which included the following:
being from a non-English speaking background, not
wearing their CI or HA on the day of testing, not
being available for testing, compliance issues, or being
unable to cope with the level of testing. An additional
21 children required the PLS-4 to be administered using
simultaneous communication methods (i.e., a combination of sign and oral) making calculation of standard
scores inappropriate for this small subset of children.
Functional auditory behavior: The Parents’ Evaluation of Aural/
Oral Performance of Children. The Parents’ Evaluation of
Aural/Oral Performance of Children (PEACH; Ching
& Hill, 2007) is a measure of functional auditory and
communicative performance in everyday life as judged
by caregivers. The test contains 13 questions, 2 of
which address the child’s use of sensory devices. The
remaining 11 questions solicit information about the
child’s ability to listen and communicate in quiet and
in noise, to use the telephone, and to respond to environmental sounds in everyday situations. An overall functional performance score was calculated using the
summed ratings provided by caregivers in response to
the 11 questions. Higher scores reflect better listening
outcomes for all sounds. Z scores were derived from
published normative data on children with normal hearing (Ching & Hill, 2007). There were 299 PEACH forms
completed and returned. Missing data were mostly due
to the forms not being returned.
Non-verbal cognitive ability: Wechsler Non-Verbal Scale of
Ability. Non-verbal cognitive ability was assessed using
the Wechsler Non-Verbal Scale of Ability (WNV;
Wechsler, Naglieri, & Petermann, 2006). The WNV is a
standardized assessment specifically devised for linguistically diverse populations, including people with hearing
loss. The assessment comprises four subtests—matrices,
coding, object assembly, and recognition (for children
ages 4years–7 years and 11 months), which combine to
provide a full-scale IQ score. WNV scores were obtained
from 288 children. There were 68 children who were
unable to complete the WNV test: 22 were unable
to cope with the demands of the test, 38 were unavailable for testing, and 8 failed to complete for ‘‘other’’
reasons.
Trends in Hearing
Procedure
Each child’s caregiver completed the earlier questionnaires and a custom-designed demographic questionnaire. The demographic questionnaire included
questions concerning the child’s diagnosed disabilities in
addition to hearing loss, communication mode used at
home and in early intervention (spoken only, sign only,
or a combination), location of residence (residential postcode), and the caregivers’ own educational experience.
SES was measured using the Index of Relative Socio-economic Advantage and Disadvantage (Australian Bureau
of Statistics, 2006), which is expressed as a decile from 1 to
10 with higher scores indicating greater advantage.
Data regarding children’s age at first HA fitting,
degree of hearing loss (i.e., better ear 4 frequency average, 4FA), type of hearing device, and age at CI switchon, were provided by Australian Hearing (the Australian
Government agency which provides audiological services
for all Australian children who are residents or citizens).
The child’s most recent available audiogram was used
(i.e., within 6 months of the child completing the
LOCHI language or cognitive assessment and parents
completing questionnaires). The PLS-4 was administered
as part of the larger LOCHI study when children were
between 56 and 70 months (Mean age ¼ 61.64,
SD ¼ 1.87). A speech pathologist administered the test
at the child’s home or school. Non-verbal cognitive ability was also assessed at this time by a psychologist using
the WNV.
Analyses
All statistical analyses were conducted using SPSS
Statistics Package 21 (IBM Corp, 2012). With respect
to device, children were grouped into those with HAs
or CIs. A single child who used only sign language to
communicate was grouped with children who used a
combination of speech and sign communication for
analysis purposes. All test scores for the CDI (Ireton &
Glascoe, 1995) and SDQ (Kremer et al., 2015) were converted to Z scores to allow for direct comparison
between DHH children and normative data. To investigate for any group difference in psychosocial scores
according to hearing device, one-way analyses of variance (ANOVAs) were conducted to compare children
with CIs or HAs who had similar levels of hearing loss
(i.e., 560dBHL). Non-parametric Chi square analyses
were used to examine any demographic differences
between groups of children with HAs or CIs.
To reduce the effect of measurement error and other
random variations in individual test scores across the
SDQ and CDI, the two scales were combined to make
an aggregate ‘‘global psychosocial score’’ for the purpose
of identifying the factors mediating psychosocial
7
Wong et al.
performance. This approach was supported by a factor
analysis which indicated one underlying factor that
accounted for 62% of the variance. The global score
was calculated by averaging the Z scores from SDQ
total difficulties score, SDQ prosocial score, and CDI
social skills score. In total, there were 294 children who
had completed both CDI and SDQ scales to make a
global score.
Spearman Rho correlations were used to examine
associations between child, family, audiological factors,
language, functional auditory behavior, and the global
psychosocial scores for children with HAs and CIs. To
examine the unique associations between specific factors
and psychosocial outcomes while controlling for other
factors, hierarchical multiple regression analyses were
run separately for children wearing HAs versus CIs,
with the global psychosocial score as the dependent variable. However, there were only 67 children with CIs and
138 children with HAs who had complete data for all
predictor variables.
Most common missing values were for direct child
assessments of PLS-4 (n ¼ 55) and WNV (n ¼ 65), as
well as PEACH forms (n ¼ 58). More children with CIs
had missing PLS-4 scores compared with those with HAs
(2 ¼ 10.53, p ¼ .001), but there was no difference
between groups for WNV or PEACH. Little MCAR’s
test was significant for the predictor variables which indicated the data were not ‘‘missing completely at random.’’
Some of the missing data in this cohort may be related to
other known characteristics of the participants (e.g., additional disabilities, communication mode, etc.).
Accordingly, significantly more children who used combined communication mode (2 ¼ 69.18, p < .001) and
had additional disabilities (2 ¼ 9.16, p ¼ .002) had missing PLS-4 scores. Missing WNV scores were also significantly more common in children with additional
disabilities (2 ¼ 5.88, p ¼ .015), but there was no difference in missing scores between children who used spoken
or combined communication mode. Children from
English-speaking and Non-English speaking backgrounds (NESB) did not differ with respect to completion of either PLS-4 or WNV. Due to these inconsistent
results, as well as the wide range of variables collected
from parents and children, it seemed reasonable to
assume that most data were ‘‘missing at random.’’
As removing cases with incomplete data introduces
bias and a drop in statistical power, a multiple imputation technique was used to handle missing data for the
regression analyses. First, attempts were made to manually impute missing scores for children who were unable
to cope with testing. For missing data on WNV, basal
scores (i.e., scaled score of 30) were assigned to three
children who were unable to complete the tests due to
severe intellectual disabilities. For the PLS-4, a basal
score was assigned to one child who was unable
to cope with the test demands, and who received a
basal score in the CDI language subscale as rated by
parents. A multiple imputations method (with 10 imputations) was used to handle the remaining missing data
for the predictor variables. The variables used for imputing scores included gender, presence of additional
disabilities, non-verbal cognitive ability, device, age of
intervention, severity of hearing loss, maternal education, SES, PLS-4 language score, PEACH, CDI social
skills, and SDQ prosocial and total scores. The outcome
psychosocial variables themselves were not imputed to
avoid introducing unnecessary noise to the estimates
(Von Hippel, 2007).
Regression models were run in two steps to investigate
the effect of language and functional auditory behavior
on psychosocial outcomes after controlling for the effects
of age at intervention, child- and family-related demographics. For children with HAs, the predictors in Model
1 included age at first HA fit, degree of hearing loss
(better ear 4FA), non-verbal cognitive ability, presence
of additional disabilities, maternal education, and communication mode. For children with CIs, predictors in
Model 1 included age at CI switch on, non-verbal cognitive ability, presence of additional disabilities, maternal
education, and communication mode. For both groups,
Model 2 included the child’s language (PLS-4 total) and
functional auditory behavior (PEACH) scores in addition to all variables in Model 1. The pooled analyses
from 10 imputations were used and a significance value
of p < .05 was used for all analyses.
Results
Demographics
Table 1 presents the demographic information relating to
children in the HA and CI groups and their caregivers.
Significant differences between the HA and CI groups
are evident for communication mode (2 ¼ 14.19,
p < .001) where a significantly higher proportion of children with CIs used a combination of sign and spoken
communication mode (32.2%) compared with children
with HAs (15%). In addition, significantly more children
with HAs had parents with hearing loss (2 ¼ 10.01,
p ¼ .002).
Psychosocial Functioning of Children With CIs
Compared With Normative Data
Table 2 shows the means and SDs, expressed in terms of
Z scores derived from published normative data (Ireton
& Glascoe, 1995; Kremer et al., 2015), for each psychosocial measure, language ability, functional auditory
behavior, and non-verbal cognitive ability. Results are
presented separately for three groups of children: all
8
Trends in Hearing
Table 1. Demographic Information of Children With HAs
and CIs.
HA (n ¼ 236)
CI (n ¼ 120)
Gender
Male
137 (58.1%)
57 (47.5%)
Female
99 (41.9%)
63 (52.5%)
Age at assessment (CDI)
Mean months
61.51 (1.93) 61.85 (1.85)
(SD)
Range
58–73
59–67
Additional Disabilities
No
145 (62.5%)
76 (63.3%)
Yes
87 (37.5%)
39 (32.5%)
Missing
4 (1.7%)
5 (4.2%)
Communication mode
Speech only
199 (84.3%)
80 (66.7%)
Speech and sign
35 (14.8%)
37 (30.8%)
Sign only
0
1 (1.7%)
Missing
2 (0.8%)
2 (1.7%)
Severity of hearing loss (4FA in the better ear)
Mild (440 dB HL)
60 (25.4%)
0
Moderate
120 (50.8%)
2 (1.7%)
(41–60 dB HL)
Severe
48 (20.3%)
9 (7.5%)
(61–80 dB HL)
Profound
8 (3.4%)
109 (90.8%)
(>80 dB HL)
Age at HA fit
Mean months (SD) 10.68 (10.37) 6.44 (7.17)
Range
1–35
1–34
Age at CI switch on
Mean months (SD)
N/A
16.27 (8.17)
Range
4–59
Maternal education
High school
68 (28.8%)
38 (31.7%)
Diploma
60 (25.4%)
28 (23.3%)
University
96 (40.7%)
45 (37.5%)
Missing
12 (5.1%)
9 (7.5%)
Socio-economic status (IRSAD Decile)
Mean (SD)
7.02 (2.56)
6.98 (2.63)
Range
1–10
1–10
Native language of parents
English
117 (75%)
84 (70%)
NESB
42 (17.8%)
21 (17.5%)
Missing
17 (7.2%)
15 (12.5%)
Parental hearing status
No HL
190 (80.5%) 111 (92.5%)
HL in one parent
43 (18.2%)
4 (3.3%)
HL in both parents
3 (1.3%)
4 (3.3%)
Missing
1 (0.8%)
pa
(HA vs. CI)
ns
ns
ns
P <.001
P <.001
HA users, HA users with a severe to profound hearing
loss (560 dBHL), and all CI users. On average, SDQ
subscale scores for children with CIs were between .02
and .40 SDs below the norm. Individual subscale ratings
indicate the fewest problems with emotional difficulties,
and the most with conduct. In contrast, the mean CDI
social skills score fell 1.40 SDs below the norm. There
were no significant gender differences on SDQ or CDI
subscales with the exception of peer problems: boys were
rated as having significantly more peer problems
(Z ¼ .57) than girls (Z ¼ .06). Overall, the global psychosocial score was .60 SDs below the norm.
Table 2 also shows the proportion of children falling 2
SDs or below age norms. These low scores are considered to reflect clinically significant emotional or
behavioral difficulties (i.e., 4 2nd percentile). Nine percent of children with CIs fell more than 2 SDs below the
norm on the SDQ total score and 41.1% fell below
expected age level on the CDI social skills (compared
with 2.5%–3% in the general population). Overall, children with CIs fell 1.35 SDs below the norm on expressive
and receptive language skills. PEACH scores fell
approximately .60 SDs lower than hearing children.
Non-verbal cognitive ability was on average, close to
the norm (Z ¼ .024).
Psychosocial Functioning of Children With HAs
Compared With Normative Data
ns
ns
ns
p ¼ .002
Note. HA ¼ hearing aid; CI ¼ cochlear implant; 4FA ¼ 4 frequency average;
dB HL ¼ decibel hearing level, NESB ¼ non-English speaking background.
a
Chi square or ANOVA test (ns p > .05).
Similar to children with CIs, children with HAs scored
on average between .03 to .60 SDs below norms on SDQ
subscales, whereas the mean score on the CDI social
skills scale was 1.45 SDs below norms. On the SDQ,
individual subscale ratings indicate the fewest problems
with emotional difficulties, and the most problems with
conduct and hyperactivity. There were no significant
gender differences on any psychosocial measure.
Overall, the mean global psychosocial score was .69
SDs below the norm. As shown in Table 2, the proportion of children falling 52 SDs below the norm was 13%
on the SDQ total score, and 45% on CDI social skills. In
regard to language and functional auditory behavior,
children had language scores that fell close to 1 SD
below normative data on expressive and receptive language skills overall. Functional auditory behavior
(PEACH) scores fell approximately .70 SDs below
those of hearing children. On average, non-verbal cognitive ability fell within the normal range.
Differences Between CIs and HAs for Children
With Similar Levels of Hearing Loss
Differences between CI and HA groups (using ANOVA
or 2 analyses) are shown in Table 2. When comparing
children with CIs to those in the HA-severe group
9
Wong et al.
Table 2. Mean Z scores (SDs) of Psychosocial, Language, and Functional Communication Scores for Children With HAs and CIs.
HA-all HL
HA-severe
CI
pa (HA-all vs. CI)
pa (HA-severe vs. CI)
SDQ
Emotion
Conduct
Hyperactivity
Peer problems
Prosocial
Total
n (%) 52SDs norm
n ¼ 223
.031 (.985)
.607 (1.20)
.436 (1.20)
.270 (1.22)
.272 (1.17)
.513 (1.08)
29 (13%)
n ¼ 54
.037 (1.02)
.685 (1.40)
.809 (1.44)
.384 (1.12)
.232 (1.30)
.697 (1.14)
8 (14.8%)
n ¼ 110
.019 (1.07)
.409 (1.10)
.235 (.991)
.297 (1.22)
.216 (1.17)
.374 (1.01)
10 (9.1%)
n.s
n.s
n.s
n.s
n.s
n.s
n.s
n.s
p ¼ .039
p ¼ .02
n.s
n.s
n.s
n.s
CDI
Social skills
n (%) 52SDs norm
Global Psychosocial Score
n ¼ 210
1.45 (1.98)
95 (45.2%)
n ¼ 197
.692 (1.04)
n ¼ 49
1.69 (2.13)
28 (57.1%)
n ¼ 47
.805 (1.13)
n ¼ 107
1.37 (1.90)
44 (41.1%)
n ¼ 97
.590 (1.06)
n.s
n.s
n.s
n.s
n.s
n.s
n ¼ 212
.978 (1.29)
.964 (1.22)
1.01 (1.31)
n ¼ 192
.722 (.884)
n ¼ 196
.168 (1.14)
n ¼ 44
1.45 (1.25)
1.45 (1.21)
1.55 (1.25)
n ¼ 46
.912 (.975)
n ¼ 42
.027 (1.18)
n ¼ 93
1.14 (1.38)
1.38 (1.48)
1.35 (1.50)
n ¼ 106
.621 (.923)
n ¼ 95
.024 (1.12)
n.s
p ¼ .014
p ¼ .049
n.s
n.s
n.s
n.s
n.s
n.s
n.s
Language
PLS-4 AC
PLS-4 EC
Total
Func Aud Beh
PEACH
Non-verbal cog
WNV
Note. SDQ ¼ Strengths and Difficulties Questionnaire; CDI ¼ Child Development Inventory; PLS-4 ¼ Preschool Language Scale-4; AC ¼ auditory comprehension; EC ¼ expressive communication; Func Aud Beh ¼ Functional auditory behavior; PEACH ¼ Parent Evaluation of Aural/Oral Performance of
Children; WNV ¼ Wechsler Non-Verbal Scale of Ability. pa ANOVA or Chi square tests; ns ¼ not significant (p > .05); 42 SDs norm ¼ proportion falling
more than 2 SD below same-age peers. Due to missing data for some variables, scores are based on different numbers of participants as specified.
(i.e., 560 dBHL), analyses of variance revealed significant differences on the SDQ behavioral subscales of
hyperactivity, F (1, 161) ¼ 4.31, p ¼ .039, and conduct
difficulties, F (1, 161) ¼ 5.48, p ¼ .02, with more difficulties evident for children using HAs. By contrast, these
groups did not differ significantly on CDI social skills, F
(1, 152) ¼ 1.01, p ¼ .317, emotional difficulties, F (1,
161) ¼ .110, p ¼ .740, peer problems, F (1, 161) ¼ .386,
p ¼ .535, or prosocial behavior, F(1, 161) ¼ .037,
p ¼ .848, and no significant group difference was seen
in the proportion of children who fell 52 SDs below
norms on either the SDQ or the CDI. When comparing
the group of CI users to the group of all HA users
(HA-all), there were no significant differences on any
psychosocial measure.
Factors Influencing Psychosocial Outcomes
for Children With CIs
Table 3 presents the correlations between demographic
variables, language, functional auditory behavior, and
global psychosocial outcomes for children with CIs and
HAs separately. In the group of children with CIs, higher
global psychosocial outcomes were significantly correlated with an absence of additional disabilities, use of
spoken only communication, better language, and
better functional auditory behavior. By contrast, there
was no significant association with non-verbal cognitive
ability (WNV), age at CI switch on, or maternal
education.
Multiple regression analyses were conducted to identify variables accounting for unique variance in global
psychosocial functioning. When all child, family-, and
intervention-related factors were included in Model 1,
the only significant demographic variable was the presence of additional disabilities (B ¼ .707, 95%CI [1.2,
.2], p ¼ .006, see Table 4). Children with additional
disabilities scored on average .7 SDs lower on global
psychosocial functioning than children without additional disabilities after controlling for other demographic factors. In contrast, non-verbal cognitive
ability, age at CI switch on, communication mode, and
maternal education did not account for significant
unique variance in outcomes. Together, all demographic
variables explained 14.3% of the variance in global psychosocial function. The addition of language and
10
Trends in Hearing
Table 3. Spearman Rho Correlations Between Child, Audiological, Family Factors, Language, Functional Auditory Behavior and
Psychosocial Scores for Children With CIs and HAs.
Age CI
switch
on
Comm
Mode
Mat
Ed
WNV
.359** 0.033
Disabil
0.054
CI switch on
Comm Mode
Mat ed
Language
Func Aud Beh
CDI social
SDQ Total
.247*
.446**
0.158
.198*
0.134
.236*
0.008
HA children
Comm
Mode
4FA
CI children
Disabil
N:Y
Disabil
N:Y
Age
First
HA fit
Language
Func
Aud
Beh
.487**
0.111
.393** 0.182
.293** 0.087
.307** .240*
.245*
0.155
.347**
Mat
Ed
Language
CDI
social
skills
SDQ
total
.256*
.124
.306** .328**
.037
.020
.233* .220*
.006
.230*
.397**
.305**
.413**
.407**
.367**
Func
Aud
Beh
WNV
.394** 0.059 .144* 0.102
.248**
.534**
.286**
Disabil
0.107
.215**
0.049
0.105
.347** .304**
First HA fit
0.047
.194** 0.076
0.130
.210**
Comm Mode
.188** 0.029
.194** 0.126
4FA
.188** 0.013
.258**
Mat ed
.264**
.296**
Language
.346**
Func Aud Beh
CDI social
SDQ Total
Global
psychosocial
0.178
.357**
0.038
.230*
0.115
.361**
.463**
.880**
.656**
CDI
Social
Skills
SDQ
Total
Global
Psychosocial
.511**
.384**
123
.247**
.108
.202**
.570**
.384**
.399**
.235**
.108
.162*
.119
.291**
.439**
260**
.459**
.483**
.340**
0.123
.172*
.154*
.285**
.546**
.383**
.870**
.736**
Note. Disabilities (no [reference], yes); 4FA ¼ better ear 4 frequency average; Comm Mode ¼ communication mode (spoken only [reference], combined);
Mat ed ¼ maternal education; Func Aud Beh ¼ functional auditory behavior (PEACH).
*p < .05. **p < .001.
functional auditory behavior in Model 2, substantially
and significantly increased the proportion of variance
explained by 17.3% (to a total R2 ¼ .316). However,
only functional auditory behavior accounted for significant unique variance in global psychosocial functioning
(B ¼ .479, 95%CI [.251, .706], p < .001), whereas language score did not. Presence of additional disabilities
remained a significant factor after controlling for language and functional auditory abilities. To examine the
independent variance explained by functional auditory
behavior, a simple linear regression was conducted with
PEACH score as the only predictor: This single variable
uniquely explained 22% of the variance in global psychosocial functioning (B ¼ .590, p < .001).
Factors Influencing Psychosocial Outcomes
for Children With HAs
For HA users, global psychosocial outcomes were significantly correlated with nearly all demographic and
audiological variables including non-verbal cognitive
ability, presence of additional disabilities, communication mode, degree of hearing loss, and maternal education (See Table 3). Only age of first HA fit was not
significantly correlated. Results from multiple regression analyses summarized in Table 4 show that three
demographic variables were significant associated with
better global psychosocial function after controlling for
all other variables. These associated variables were
higher non-verbal cognitive ability (B ¼ .026, 95%CI
[.017, .034], p < .001), absence of additional disabilities
(B ¼ .312, 95%CI [.6, .025], p ¼ .033) and higher
levels of maternal education (B ¼ .25, 95%CI [.06, .37],
p ¼ .006). There was no significant effect of age at first
fit, 4FA, or communication mode. All variables in
Model 1 accounted for 33.2% of the variance in
global psychosocial function. The addition of language
and functional auditory behavior in the second model
significantly increased the proportion of variance
explained by 8.1% (total R2 ¼ .417). Both language
11
Wong et al.
Table 4. Regression Analyses Predicting Global Psychosocial
Functioning for Children With HAs and CIs.
Model 1
B
CI children
WNV SS
Disabilities
Age switch on
Comm mode
Maternal Ed
Language
Func Aud Beh
Adjusted r2
HA children
WNV SS
Disabilities
Age first fit
4FA
Comm Mode
Maternal Ed
Language
Func Aud Beh
Adjusted R2
.003
.707**
.007
.394
.197
.143
.026**
.312*
.002
.007
.257
.215**
.332
95%CI
Model 2
B
.017 .023 .000
1.214 .200 .560*
.009 .022 .006
.866 .079 .199
.056 .450 .062
.073
.479**
.316
.017 .034 .018**
.600 .025 .140
.010 .006 .004
.018 .004 .003
.614 .100 .119
.060 .370 .063
.230**
.233**
.417
95%CI
.018 .019
1.058 .061
.009 .020
.639 .241
.173 .297
.115 .261
.251 .706
.008
.419
.003
.014
.462
.092
.107
.072
.027
.139
.012
.007
.223
.217
.353
.394
Note. SS ¼ scaled score; Disabilities (no [reference], yes); 4FA ¼ better ear
4 frequency average; Comm Mode ¼ communication mode (spoken only
[reference], combined); Func Aud Beh ¼ functional auditory behavior
(PEACH).
*p < .05. **p < .001.
(B ¼ .230, 95%CI [.107, .353], p < .001) and functional
auditory behavior scores (B ¼ .233, 95%CI [.072, .394],
p < .001) were significantly associated with global psychosocial function, although functional auditory behavior had a slightly stronger effect size (i.e., a larger
regression coefficient and 95%CI). In the final model,
only non-verbal cognitive ability remained a significant
demographic mediator of global psychosocial function,
whereas additional disabilities and maternal education
were no longer significant. To examine the independent
variance explained by language and functional auditory
behavior alone, we conducted simple linear regressions
predicting global psychosocial scores. Functional auditory behavior uniquely explained 13.5% of the variance
in global scores (B ¼ .475, p < .001), whereas language
ability uniquely explained 26.9% of the variance
(B ¼ .423, p < .001).
Discussion
The aims of this study were to (a) examine the psychosocial functioning of 5-year-old DHH children and compare their outcomes to normative data separately for
children with CIs and children with HAs, (b) compare
the outcomes of children with similar levels of hearing
loss who use CIs or HAs, and (c) investigate the potential
factors influencing outcomes separately for children with
CIs and children with HAs. Our first hypothesis, that
both children with CIs and children with HAs would
show more psychosocial problems compared with normative data were only somewhat supported. On average,
DHH children in this cohort with CIs or HAs scored
within 1 SD of the norm in regard to emotional or
behavioral problems on the SDQ; however, they
showed delayed social skill development on the CDI,
with ratings on average falling 1.4 SDs below the typical
norm. The second hypothesis was also partially supported for children with severe to profound hearing
losses, where children with HAs showed significantly
more parent-rated behavioral problems (hyperactivity
and conduct) than children with CIs, but no differences
were found in social skills or emotional difficulties.
Against our final hypothesis, some differences between
the two hearing device groups were apparent in regard to
demographic and audiological factors associated with
global psychosocial outcomes. For children with HAs,
significant correlates of better global psychosocial functioning included higher non-verbal cognitive ability, language abilities (PLS-4), and functional auditory behavior
(PEACH), after controlling for all other variables. For
children with CIs, the presence of additional disabilities
and functional auditory behavior significantly mediated
psychosocial outcomes, whereas language scores did not.
Only functional auditory behavior was a strong and consistent mediator of global psychosocial outcomes for
both children with CIs and HAs.
Psychosocial Functioning of Children With CIs
The current results show that, on average, DHH children
with CIs scored within 1SD of typically developing children on the SDQ and the global psychosocial score. This
result is in line with previous studies (Anmyr et al., 2012;
Huber & Kipman, 2011; Percy-Smith, Cayé-Thomasen,
et al., 2008), showing that children with CIs are comparable to their hearing peers on psychosocial measures.
Improvements in early identification, intervention and
education efforts for the current generation of DHH children might partly explain these findings. On the SDQ
total difficulties score, children scored .37 SDs lower
than norms. This outcome is consistent with the recent
review by Stevenson et al. (2015), which found that
DHH children (with HAs and CIs) fell .23 SDs below
hearing children across included SDQ studies. On the
other hand, borderline delays were reported on the
CDI social skills subscale, on which children with CIs
fell an average of 1.37 SDs below age-norms. The difference in outcomes between the SDQ and CDI is likely due
to their tapping different aspects or levels of psychosocial
12
functioning, as well as the age of the current sample. The
social skills subscale of the CDI was designed specifically
for children under 6 years of age, and covers more specific early interactive skills (e.g., plays physical games
with other children, plays ‘‘pretend’’ games with other
children) and many items that rely on verbal or communicative skills (e.g., ‘‘greets people with ‘hi’’’; ‘‘says
‘I can’t’, ‘I don’t know,’ or ‘You do it’’’). By contrast,
the SDQ covers domains related to more clinical problems, such as emotional and behavioral disorders, and
is targeted at school-aged children aged 4 and 17 years.
The CDI also has a much higher number of items, and a
bimodal response choice compared with the SDQ. These
differences may partly explain why children were rated as
having more difficulties on the CDI than the SDQ.
Although average scores on the SDQ fell within the
range of typically developing children, 9% of children
with CIs had scores more than 2SDs below the mean,
indicating problems of potential clinical significance.
This proportion is higher than would be expected in
the general population (2.5%). Indeed, it is more similar
to findings from previous studies that have used the proportion of children who fall below clinical ‘‘cut-off’’
scores to identify emotional or behavioral problems
rather than using average scores or effect sizes
(Fellinger et al., 2008; Hintermair, 2007). However,
Remine and Brown (2010) cautioned that some previous
studies identified children with both borderline and clinical scores (i.e., bottom 20%) as having mental health
problems, which may have artificially inflated prevalence
rates. Given the wide variability evident in psychosocial
outcomes within DHH children, it is important to consider the heterogeneity within this group.
The language outcomes of the current cohort of children with CIs, fell on average 1.3 SDs below the general
population, in line with their language outcomes at
3 years of age (Ching, Dillon, et al., 2013). This result
indicates that, on average, children with CIs still lag
behind their hearing peers in language development, despite early identification. More in-depth investigation of
the language outcomes of the LOCHI children at 5 years
of age is presented in Cupples et al. (in press). In the
context of the current findings, however, delayed language scores may have an immediate and direct impact
on early social skills, whereas emotional and behavioral
problems may arise later as the children grow older and
enter formal schooling. In addition, as the current cohort
is young and outcomes are dependent on parent ratings,
it is not clear whether ratings may differ when the children are older and able to provide self-report. Anmyr
et al. (2012) found that DHH adolescents tended to
rate themselves as having more problems on the SDQ
compared with parents and teachers. Overall, however,
ratings were still within the range of typically developing
children. The prospective nature of the LOCHI study
Trends in Hearing
will allow us to determine whether changes in psychosocial functioning and mediating factors occur as the
demands of social and school dynamics become more
complex.
Psychosocial Functioning of Children With HAs
On average, children with HAs (and all levels of hearing
loss) performed similarly to children with CIs. Their
scores were within 1SD of the norm on the SDQ
(.5 SDs below norms for total difficulties), but 1.45
SDs below norms on the CDI social skills scale. The
mean global psychosocial score for the group of all children with HAs fell within the range of typically hearing
children (.69 SDs below norms). These results indicate
that, regardless of hearing device, 5-year-old DHH
children do not have significantly more emotional or
behavioral problems on average than their hearing agematched peers, although they are at increased risk of
delayed social skill development. This finding is consistent with a number of previous studies that have examined DHH children with HAs and CIs and found them to
be comparable to the hearing population in regard to
internalizing and externalizing problems, but to show
evidence of significantly more peer problems (Huber
et al., 2015; Remine & Brown, 2010; Stevenson et al.,
2015). It has been posited that delays in strategic and
pragmatic language and communicative skills might contribute to peer problems (Huber et al., 2015; Stevenson
et al., 2015), but regardless, peer and social skill problems in DHH children do not necessarily equate to
increased mental health problems. The longitudinal
nature of the LOCHI study will, however, enable a
better understanding of whether poor social skills at
5 years of age increase the risk for later psychosocial
problems.
Differences Between Children With HAs and CIs
With Similar Levels of Hearing Loss
In line with our second hypothesis, children with HAs
who had severe to profound losses showed evidence of
significantly more psychosocial problems than children
with CIs, but only in the areas of hyperactivity and conduct. As such, the findings are partly consistent with
those reported in Theunissen et al. (2014a), who found
increased rates of behavioral problems (including aggression, psychopathy and conduct disorder as measured on
the Child Symptom Inventory) for children with HAs
(who had moderate to profound losses) but not for children with CIs. Behavioral difficulties in typically
developing children as well as children with other disorders such as ADHD and conduct disorder are typically
thought to manifest from poor communication and selfregulatory abilities (Barkley, 1997; Clark, Prior, &
Wong et al.
Kinsella, 2002). The benefits of cochlear implantation
may include enhanced speech perception skills, communication, and a greater number of social opportunities
(Bat-Chava et al., 2005), thus in turn reducing behavioral
problems. This interpretation receives some limited support from the current finding that children with HAs in
the severe to profound range scored lower on functional
auditory behavior (PEACH scores) and language scores
compared with those in the CI group, although this difference did not reach significance.
In contrast to Theunissen et al. (2012) who investigated internalizing problems in DHH children, we did
not find any differences in regard to emotional problems.
However, compared with the current study, Theuniessen
et al. included an older sample (mean age ¼ 11 years,
range 9–16) and used a more comprehensive screen of
emotional disorders (Child Symptom Inventory). Again,
emotional difficulties may increase with age and ability
to self-report internalized issues (Hymel, Rubin,
Rowden, & LeMare, 1990; Roza, Hofstra, van der
Ende, & Verhulst, 2003). It will be important to monitor
these aspects in the LOCHI sample because early behavioral problems have been linked to later mental health
disorders (Caspi, Moffitt, Newman, & Silva, 1996).
Factors Influencing Psychosocial Outcomes
for Children With CIs
In the present investigation, factors influencing outcomes
were examined separately in children with HAs and children with CIs. Some differences were found regarding
the child and family-related variables that were associated with outcomes. For children with CIs, only the
presence of additional disabilities was associated with
lower global psychosocial function, whereas non-verbal
cognitive ability, age of CI switch on, communication
mode, and maternal education were not. For this
group, all child-, family-, and intervention-related factors together explained 14.3% of the variance in global
psychosocial functioning. This proportion of explained
variance was smaller than for the group of HA users,
perhaps because of the smaller sample size and the
non-significant correlations between psychosocial outcomes and WNV, age at intervention and maternal education. Previous studies that found an effect of age at
implantation in children with CIs were carried out in
older children who had been implanted later (e.g.,
mean age 4 years) (Bat-Chava et al., 2005; PercySmith, Hedegaard Jensen, et al., 2008; Theunissen
et al., 2012). In contrast the current CI cohort had
their first CI switched on at 16 months of age, on average, and their first HA fitted at 6 months. The overall
earlier age at intervention compared with previous studies may have reduced the impact of this variable on
psychosocial outcomes. Although communication mode
13
was not significantly associated with outcomes in the
regression models, the direction was such that children
with spoken only communication scored better than
those using a combined mode. It is important to acknowledge, however, that children with CIs who use a combined communication mode may do so for other reasons
such as the presence of additional disabilities or later
implantation. Thus, once these factors are controlled,
communication mode does not influence psychosocial
outcomes.
Previous research has found that children with CIs
and additional disabilities are more likely to have significant delays in expressive and receptive language
(Meinzen-Derr, Wiley, Grether, & Choo, 2010), which
may in turn, impact on social development. However,
the current results show that the presence of additional
disabilities remained a significant mediator of psychosocial outcomes after controlling for language in the
final regression model. Interestingly, presence of additional disabilities was only significant for children with
CIs but not HAs. Our future research will investigate in
greater detail the psychosocial outcomes achieved by
DHH children with additional disabilities to see whether
there are specific additional disabilities or comorbidities
that lead to higher risk of psychosocial dysfunction.
When language and functional auditory behavior
scores were added into the regression model for children
with CIs, the proportion of explained variance in global
psychosocial outcomes increased by 17.3%, to a total of
31.6%. However, only functional auditory behavior (and
not language) accounted for significant unique variance
in global psychosocial outcomes for children with CIs.
A simple linear regression including functional auditory
behavior as the only predictor accounted for 22% of the
variance in global psychosocial outcomes. The finding
that language scores did not account for significant
unique variance in psychosocial outcomes for this
group may be attributed to the fact that more children
with CIs had imputed PLS-4 standard scores, thus
increasing variability. Nevertheless, the current findings
are consistent with Huber & Kipman’s (2011) study,
which found that CI users with good auditory performance had fewer problems on the SDQ. Ketelaar,
Wiefferink, Frijns, Broekhof, & Rieffe (2015) also
found that general language skills were not related to
emotional or social functioning in children with CIs,
although their emotional vocabulary did show an association. Ketelaar et al. (2015) concluded that it is not just
the ability to understand and produce language that is
critical for good social functioning, but rather the ability
to communicate and use emotional language.
Children with CIs have been reported to show ‘‘social
deafness’’ (Punch & Hyde, 2011b), which means that
they have more difficulties in challenging listening environments, such as talking in a group of people, or in
14
a classroom or playground situation, compared with oneon-one interactions. As social situations generally occur
in informal settings where there may be background noise
and distractions, children with hearing loss may have difficulty entering or participating in conversations, or
detecting subtle cues in conversation. These difficulties
can, in turn, lead to other children viewing their behavior
as abnormal or negative, and ultimately to social isolation
(Sorkin et al., 2015). The current findings indicate that the
PEACH may be a useful screening tool for these children,
as it is easy to administer and has the benefit of being
applicable for even very young children, or children
who cannot complete standardized testing due to additional disabilities or NESB.
Factors Influencing Psychosocial Outcomes
for Children With HAs
For children with HAs, non-verbal cognitive ability,
presence of additional disabilities and maternal education were significantly associated with global psychosocial outcomes in the first regression model. All child,
family, and intervention factors explained 33.3% of the
variance in global psychosocial outcomes. However, the
impact of most of those demographic variables on psychosocial functioning appeared to be indirect and driven
through their influence on language and functional auditory behavior. When language and functional auditory
behavior scores were entered into the final model, additional disabilities and level of maternal education were
no longer significantly associated with outcomes for children with HAs.
Only non-verbal cognitive ability remained a significant and direct mediator of global psychosocial functioning. This result might indicate that higher intellectual
ability is a protective factor for psychosocial development, possibly because children with higher cognitive
ability are more adaptive in different situations
(Kushalnagar et al., 2007). The finding that non-verbal
cognitive ability is positively associated with social–emotional development in DHH children is consistent with a
number of previous studies (Theunissen et al., 2014a;
Van Eldik, 2005). However, previous studies have combined children with HAs and children with CIs. In the
current study, non-verbal cognitive ability was significantly associated with psychosocial outcomes only for
children with HAs and not for children with CIs,
although variability was similar between groups.
Potential reasons include differences in sample size and
higher parental expectations for children with CIs and
normal IQ to achieve outcomes similar to their hearing
peers (Spahn, Richter, Burger, Löhle, & Wirsching,
2003).
Maternal education was significantly associated with
global psychosocial outcomes for children with HAs
Trends in Hearing
in the first regression model. This result is consistent
with the literature on hearing children, which indicates
that low maternal education is a risk factor for child
behavior problems (Fox, Platz, & Bentley, 1995;
Gortmaker, Walker, Weitzman, & Sobol, 1990).
However, this variable was no longer significant after
accounting for children’s language ability and functional
auditory performance, suggesting that maternal education influences psychosocial outcomes only indirectly.
This result is in line with evidence from the general developmental literature, showing that maternal education
and SES influence child language outcomes through
maternal speech input that was higher in quantity, lexical
richness, and sentence complexity (Hoff, 2003).
There was no effect of age at intervention or communication mode on psychosocial outcomes for children
with HAs at 5 years of age. Similar to children with
CIs, the current cohort received intervention for hearing
loss much earlier compared with previous studies.
Consistent with findings from a systematic review of psychopathology risk factors (Theunissen et al., 2014c), the
current study also found no effect of severity of hearing
loss on psychosocial outcomes in children with HAs after
controlling for other factors.
When language and functional auditory behavior
scores were added to the regression model for children
with HAs, the proportion of explained variance in psychosocial outcomes increased significantly by 8.5%.
Both language and functional auditory behavior were
significantly associated with global psychosocial outcomes for children with HAs. The findings support previous literature showing that the development of
language and the ability to listen and communicate in
various everyday environments are the strongest and
most direct mediators of psychosocial functioning
(Barker et al., 2009; Batten et al., 2014; Stevenson
et al., 2010). Interestingly, the PEACH had a slightly
larger effect size, indicating that good language alone
may not be enough to improve psychosocial outcomes
if the ability to communicate and listen at a functional
level is poor. Fellinger et al. (2009) found that DHH
children who had difficulties making themselves understood at home were 9.61 times more likely to have a
lifetime diagnosis of a mental health disorder. The findings emphasize the importance of functional auditory and
communicative behavior for healthy psychosocial development in both children with HAs and children with CIs,
and suggest once again that the PEACH may be a potential screener for early psychosocial problems in DHH
children.
Future Directions and Limitations
Although a limitation of this study is its reliance on
parent report for assessing child outcomes, this method
15
Wong et al.
is typically used for identifying psychosocial problems in
young children. Furthermore, it is not known whether
parents who completed the questionnaire in their nonnative language had difficulties answering questions.
However, the present study offered translated versions
of the CDI and SDQ for families from NESB in an
attempt to overcome any problems with language comprehension. Typically, clinical diagnoses of childhood
emotional and behavioral disorders would require the
child to show difficulties across multiple contexts (e.g.,
at home and school) and would use cross-informant
ratings from parents and teachers (Achenbach,
McConaughy, & Howell, 1987). The prospective nature
of the LOCHI study will allow us to measure self-report
when the children are older, and the data collected from
teacher ratings will be reported in future studies.
An unavoidable limitation is the amount of missing
data from the population-based study, and the use of
multiple imputations in the analyses. While this
method is one of the most commonly used approaches,
not all variables were ‘missing at random’ thus introducing possible biases. Only independent variables were
imputed and a large number (10) of imputations were
created to reduce sampling variability. In addition, the
CI group was much smaller than the HA group, reducing
the power for this group in the regression analyses.
However, a smaller number of predictor variables was
used in this group, and the sample is still much larger
than previous studies looking at psychosocial outcomes
in children with CIs.
Finally, there was still a large proportion of unexplained variance, particularly for children with CIs, indicating that other variables may be contributing directly
to psychosocial outcomes. There is some literature showing that factors such as parental mental health and
resources (Hintermair, 2006; Kushalnagar et al., 2007),
parental involvement (Calderon, 2000), the child’s executive function (Hintermair, 2013), motor skills (Fellinger,
Holzinger, Aigner, Beitel, & Fellinger, 2015), and theory
of mind ability (Peterson, Slaughter, Moore, & Wellman,
2016) are linked to psychosocial outcomes. Other factors, including the abovementioned, could be examined
in future research.
Conclusions
In conclusion, on average, 5-year-old DHH children
with CIs or HAs did not show significant emotional
or behavioral difficulties compared with norms (SDQ),
although they did score more than 1SD below the
norm on social skills development (CDI). For children
with similar levels of hearing loss, children with HAs
were rated as having significantly more behavioral
problems compared with children with CIs. Some differences were seen in regards to the factors influencing
global psychosocial functioning for the two device
groups. For children with CIs, presence of additional disabilities and functional auditory behavior were significantly associated with global psychosocial outcomes,
whereas non-verbal cognitive ability, language, and functional auditory behavior were significant factors for children with HAs. The only consistent influential factor for
both groups was functional auditory behavior. The findings have implications for developing interventions that
focus on improving early social skills, and improving the
ability to listen and communicate at a functional level
(e.g., ability to listen in noise, detect subtle social cues,
and engage in turn-taking or conversational skills) to
enhance psychosocial well-being in children with HAs
and CIs.
Acknowledgments
The National Acoustic Laboratories is part of the Australian
Hearing Hub, an initiative of Macquarie University that brings
together Australia’s leading hearing and health-care organizations to collaborate on research projects. The authors gratefully thank all the children, their families, and their teachers for
participation in this study. The authors are also indebted to the
many persons who served as clinicians for the study participants or assisted in other clinical or administrative capacities
at Australian Hearing, Catherine Sullivan Centre, Hear and
Say Centre, National Acoustic Laboratories, Royal Institute
for Deaf and Blind Children, Royal Victorian Eye and Ear
Hospital Cochlear Implant Centre, the Shepherd Centre, and
the Sydney Cochlear Implant Centre.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
The Australian Hearing Hub, an initiative of Macquarie
University and the Australian Government, provided financial
support for the publication of this research article. The project
described was partly supported by the National Institute on
Deafness and Other Communication Disorders (Award
Number R01DC008080). The content is solely the responsibility of the authors and does not necessarily represent the official
views of the National Institute on Deafness and Other
Communication Disorders or the National Institutes of
Health. The authors acknowledge the financial support of
the HEARing CRC, established and supported under the
Cooperative Research Centres Program—an initiative of the
Australian Government. The project was also partly supported
by the Commonwealth of Australia through the Office of
Hearing Services. The authors also acknowledge the support
provided by New South Wales Department of Health,
Australia; Phonak Ltd.; the Oticon Foundation, and the
Australian Hearing Hub.
16
References
Achenbach, T. M., McConaughy, S. H., & Howell, C. T.
(1987). Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psychological Bulletin, 101(2), 213.
Anmyr, L., Larsson, K., Olsson, M., & Freijd, A. (2012).
Strengths and difficulties in children with cochlear
implants–comparing self-reports with reports from parents
and teachers. International Journal of Pediatric
Otorhinolaryngology, 76(8), 1107–1112.
Australian Bureau of Statistics. (2006). Measures of
Socioeconomic Status. Cat No 1244.0.55.001. http://www.
ausstats.abs.gov.au/Ausstats/subscriber.nsf/0/367D3800605
DB064CA2578B60013445C/$File/1244055001_2011.pdf
Barker, D. H., Quittner, A. L., Fink, N. E., Eisenberg, L. S.,
Tobey, E. A., & Niparko, J. K. (2009). Predicting behavior
problems in deaf and hearing children: The influences of
language, attention, and parent–child communication.
Development and Psychopathology, 21(02), 373–392.
Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying
theory of ADHD. Psychological Bulletin, 121(1), 65.
Bat-Chava, Y., & Deignan, E. (2001). Peer relationships of
children with cochlear implants. Journal of Deaf Studies
and Deaf Education, 6(3), 186–199.
Bat-Chava, Y., Martin, D., & Kosciw, J. G. (2005).
Longitudinal improvements in communication and socialization of deaf children with cochlear implants and hearing
aids: Evidence from parental reports. Journal of Child
Psychology and Psychiatry, 46(12), 1287–1296.
Batten, G., Oakes, P. M., & Alexander, T. (2014). Factors
associated with social interactions between deaf children
and their hearing peers: A systematic literature review.
Journal of Deaf Studies and Deaf Education, 19(3), 285–302.
Benner, G. J., Nelson, J. R., & Epstein, M. H. (2002).
Language skills of children with EBD: A literature review.
Journal of Emotional and Behavioral Disorders, 10(1), 43–56.
Bess, F. H., Dodd-Murphy, J., & Parker, R. A. (1998).
Children with minimal sensorineural hearing loss:
Prevalence, educational performance, and functional
status. Ear and Hearing, 19(5), 339–354.
Calderon, R. (2000). Parental involvement in deaf children’s
education programs as a predictor of child’s language,
early reading, and social-emotional development. Journal
of Deaf Studies and Deaf Education, 5(2), 140–155.
Caspi, A., Moffitt, T. E., Newman, D. L., & Silva, P. A. (1996).
Behavioral observations at age 3 years predict adult psychiatric disorders: Longitudinal evidence from a birth cohort.
Archives of General Psychiatry, 53(11), 1033–1039.
Ching, T. Y., Dillon, H., Day, J., Crowe, K., Close, L., Chisholm,
K., . . . Hopkins, T. (2009). Early language outcomes of children with cochlear implants: Interim findings of the NAL
study on longitudinal outcomes of children. Cochlear
Implants International, 10(Supplement-1), 28–32.
Ching, T. Y., Dillon, H., Marnane, V., Hou, S., Day, J., Seeto,
M., . . . Van Buynder, P. (2013). Outcomes of early-and lateidentified children at 3 years of age: Findings from a prospective population-based study. Ear and Hearing, 34(5),
535–552.
Trends in Hearing
Ching, T. Y., & Hill, M. (2007). The parents’ evaluation of
aural/oral performance of children (PEACH) scale:
Normative data. Journal of the American Academy of
Audiology, 18(3), 220–235.
Ching, T. Y., Leigh, G., & Dillon, H. (2013). Introduction to
the Longitudinal Outcomes of Children with Hearing
Impairment (LOCHI) study: Background, design, sample
characteristics. International Journal of Audiology, 52(S2),
S4–S9.
Clark, C., Prior, M., & Kinsella, G. (2002). The relationship
between executive function abilities, adaptive behaviour,
and academic achievement in children with externalising
behaviour problems. Journal of Child Psychology and
Psychiatry, 43(6), 785–796.
Conti-Ramsden, G., & Botting, N. (2008). Emotional health in
adolescents with and without a history of specific language
impairment (SLI). Journal of Child Psychology and
Psychiatry, 49(5), 516–525.
Cupples, L., Ching, T. Y., Button, L., Seeto, M., Zhang, V.,
Whitfield, J., . . . Marnane, V. (in press). Spoken language
and everyday functioning in 5-year-old children using hearing aids or cochlear implants. International Journal of
Audiology.
Cupples, L., Ching, T. Y., Crowe, K., Seeto, M., Leigh, G.,
Street, L., . . . Thomson, J. (2014). Outcomes of 3-year-old
children with hearing loss and different types of additional
disabilities. Journal of Deaf Studies and Deaf Education,
19(1), 20–39.
Dammeyer, J. (2010). Psychosocial development in a Danish
population of children with cochlear implants and deaf and
hard-of-hearing children. Journal of Deaf Studies and Deaf
Education, 15(1), 50–58.
Davis, J. M., Elfenbein, J., Schum, R., & Bentler, R. A. (1986).
Effects of mild and moderate hearing impairments on language, educational, and psychosocial behavior of children.
Journal of Speech and Hearing Disorders, 51(1), 53–62.
Fellinger, J., Holzinger, D., Sattel, H., & Laucht, M. (2008).
Mental health and quality of life in deaf pupils. European
Child and Adolescent Psychiatry, 17(7), 414–423.
doi:10.1007/s00787-008-0683-y.
Fellinger, J., Holzinger, D., Sattel, H., Laucht, M., &
Goldberg, D. (2009). Correlates of mental health disorders
among children with hearing impairments. Developmental
Medicine and Child Neurology, 51(8), 635–641.
Fellinger, M. J., Holzinger, D., Aigner, M., Beitel, C., &
Fellinger, J. (2015). Motor performance and correlates of
mental health in children who are deaf or hard of hearing.
Developmental Medicine and Child Neurology, 57(10),
942–947.
Fox, R. A., Platz, D. L., & Bentley, K. S. (1995). Maternal
factors related to parenting practices, developmental expectations, and perceptions of child behavior problems. The
Journal of Genetic Psychology, 156(4), 431–441.
Geers, A. E. (2002). Factors affecting the development of
speech, language, and literacy in children with early cochlear implantation. Language, Speech, and Hearing Services
in Schools, 33(3), 172–183.
Geers, A. E., & Moog, J. S. (1987). Predicting spoken language
acquisition of profoundly hearing-impaired children.
Journal of Speech and Hearing Disorders, 52(1), 84–94.
Wong et al.
Geers, A. E., Nicholas, J. G., & Sedey, A. L. (2003). Language
skills of children with early cochlear implantation. Ear and
Hearing, 24(1), 46S–58S.
Goodman, R. (1997). The Strengths and Difficulties
Questionnaire. Journal of Child Psychology and Psychiatry,
38(5), 581–586.
Gortmaker, S. L., Walker, D. K., Weitzman, M., & Sobol, A.
M. (1990). Chronic conditions, socioeconomic risks, and
behavioral problems in children and adolescents.
Pediatrics, 85(3), 267–276.
Hind, S., & Davis, A. (2000). Outcomes for children with permanent hearing impairment. In R. Seewald (Ed.), A sound
foundation through early amplification: Proceedings of an
international conference (pp. 199–212). Stafa Switzerland:
Phonak, AG.
Hindley, P. A. (2005). Mental health problems in deaf children.
Current Paediatrics, 15(2), 114–119.
Hintermair, M. (2006). Parental resources, parental stress, and
socioemotional development of deaf and hard of hearing
children. Journal of Deaf Studies and Deaf Education,
11(4), 493–513.
Hintermair, M. (2007). Prevalence of socioemotional problems
in deaf and hard of hearing children in Germany. American
Annals of the Deaf, 152(3), 320–330.
Hintermair, M. (2013). Executive functions and behavioral
problems in deaf and hard-of-hearing students at general
and special schools. Journal of Deaf Studies and Deaf
Education, 18(3), 344–359.
Hoff, E. (2003). Causes and consequences of SES-related differences in parent-to-child speech. In M. H. Bornstein, & R.
H. Bradley (Eds.), Socioeconomic status, parenting, and child
development (pp. 147–160). New Jersey, NJ: Lawrence
Erbaum Associates.
Hoffman, M. F., Quittner, A. L., & Cejas, I. (2015).
Comparisons of social competence in young children with
and without hearing loss: A dynamic systems framework.
Journal of Deaf Studies and Deaf Education, 20(2), 115–124.
Huber, M. (2005). Health-related quality of life of Austrian
children and adolescents with cochlear implants.
International Journal of Pediatric Otorhinolaryngology,
69(8), 1089–1101.
Huber, M., Burger, T., Illg, A., Kunze, S., Giourgas, A.,
Braun, L., . . . Becker, A. (2015). Mental health problems
in adolescents with cochlear implants: Peer problems persist
after controlling for additional handicaps. Frontiers in
Psychology, 6, 953. doi:10.3389/fpsyg.2015.00953.
Huber, M., & Kipman, U. (2011). The mental health of deaf
adolescents with cochlear implants compared to their hearing
peers. International Journal of Audiology, 50(3), 146–154.
Hymel, S., Rubin, K. H., Rowden, L., & LeMare, L. (1990).
Children’s peer relationships: Longitudinal prediction of
internalizing and externalizing problems from middle to
late childhood. Child Development, 61(6), 2004–2021.
IBM Corp. (2012). IBM SPSS Statistics for Windows (Version
21). Armonk, NY: Author.
Ireton, H. (1992). Child development inventory manual.
Minneapolis, MN: Behavior Science Systems.
Ireton, H., & Glascoe, F. P. (1995). Assessing children’s development using parents’ reports: The Child Development
Inventory. Clinical Pediatrics, 34(5), 248–255.
17
Ketelaar, L., Wiefferink, C. H., Frijns, J. H., Broekhof, E., &
Rieffe, C. (2015). Preliminary findings on associations
between moral emotions and social behavior in young children with normal hearing and with cochlear implants.
European Child and Adolescent Psychiatry, 24(11), 1369–1380.
Khan, S., Edwards, L., & Langdon, D. (2005). The cognition
and behaviour of children with cochlear implants, children
with hearing aids and their hearing peers: A comparison.
Audiology and Neurotology, 10(2), 117–126.
Kouwenberg, M. (2013). Social-emotional factors underlying
internalizing problems and peer relations in deaf or hard of
hearing youth. Leiden, Netherlands: Developmental and
Educational psychology, Faculty of Social and
Behavioural Sciences, Leiden University.
Kremer, P., Silva, A., Cleary, J., Santoro, G., Weston, K.,
Steele, E., . . . Waters, E. (2015). Normative data for the
Strengths and Difficulties Questionnaire for young children
in Australia. Journal of Paediatrics and Child Health, 51(10),
970–975.
Kushalnagar, P., Krull, K., Hannay, J., Mehta, P., Caudle, S.,
& Oghalai, J. (2007). Intelligence, parental depression, and
behavior adaptability in deaf children being considered for
cochlear implantation. Journal of Deaf Studies and Deaf
Education, 12(3), 335–349.
Leigh, G., Ching, T. Y., Crowe, K., Cupples, L., Marnane, V.,
& Seeto, M. (2015). Factors affecting psychosocial and
motor development in 3-year-old children who are deaf or
hard of hearing. Journal of Deaf Studies and Deaf Education,
20(4), 331–342.
Leigh, I. W., Maxwell-McCaw, D., Bat-Chava, Y., &
Christiansen, J. B. (2009). Correlates of psychosocial adjustment in deaf adolescents with and without cochlear
implants: A preliminary investigation. Journal of Deaf
Studies and Deaf Education, 14(2), 244–259.
Martin, D., Bat-Chava, Y., Lalwani, A., & Waltzman, S. B.
(2010). Peer relationships of deaf children with cochlear
implants: Predictors of peer entry and peer interaction success. Journal of Deaf Studies and Deaf Education, 16(1),
108–120. doi:10.1093/deafed/enq037.
Meinzen-Derr, J., Wiley, S., Grether, S., & Choo, D. I. (2010).
Language performance in children with cochlear implants
and additional disabilities. The Laryngoscope, 120(2),
405–413.
Mejstad, L., Heiling, K., & Svedin, C. G. (2009). Mental health
and self-image among deaf and hard of hearing children.
American Annals of the Deaf, 153(5), 504–515.
Moeller, M. P. (2007). Current state of knowledge:
Psychosocial development in children with hearing impairment. Ear and Hearing, 28(6), 729–739. doi:10.1097/
AUD.0b013e318157f033.
Netten, A. P., Rieffe, C., Theunissen, S. C., Soede, W., Dirks,
E., Briaire, J. J., & Frijns, J. H. (2015). Low empathy in deaf
and hard of hearing (pre) adolescents compared to normal
hearing controls. PloS One, 10(4), e0124102.
Nicholas, J. G., & Geers, A. E. (2003). Personal, social, and
family adjustment in school-aged children with a cochlear
implant. Ear and Hearing, 24(1), 69S–81S.
Percy-Smith, L., Cayé-Thomasen, P., Gudman, M., Jensen, J.
H., & Thomsen, J. (2008). Self-esteem and social well-being
of children with cochlear implant compared to normal-
18
hearing children. International Journal of Pediatric
Otorhinolaryngology, 72(7), 1113–1120.
Percy-Smith, L., Hedegaard Jensen, J., Cayé-Thomasen, P.,
Thomsen, J., Gudman, M., & Garcia Lopez, A. (2008).
Factors that affect the social well-being of children with
cochlear implants. Cochlear Implants International, 9(4),
199–214.
Petersen, I. T., Bates, J. E., D’Onofrio, B. M., Coyne, C. A.,
Lansford, J. E., Dodge, K. A., . . . Van Hulle, C. A. (2013).
Language ability predicts the development of behavior
problems in children. Journal of Abnormal Psychology,
122(2), 542.
Peterson, C. C. (2004). Theory-of-mind development in oral
deaf children with cochlear implants or conventional hearing aids. Journal of Child Psychology and Psychiatry, 45(6),
1096–1106.
Peterson, C. C., Slaughter, V., Moore, C., & Wellman, H. M.
(2016). Peer social skills and theory of mind in children with
autism, deafness, or typical development. Developmental
Psychology, 52(1), 46–57.
Polat, F. (2003). Factors affecting psychosocial adjustment of
deaf students. Journal of Deaf Studies and Deaf Education,
8(3), 325–339.
Pulsifer, M. B., Salorio, C. F., & Niparko, J. K. (2003).
Developmental, audiological, and speech perception functioning in children after cochlear implant surgery. Archives
of Pediatrics and Adolescent Medicine, 157(6), 552–558.
Punch, R., & Hyde, M. (2011a). Communication, psychosocial,
and educational outcomes of children with cochlear
implants and challenges remaining for professionals and
parents. International Journal of Otolaryngology.
doi:10.1155/2011/573280.
Punch, R., & Hyde, M. (2011b). Social participation
of children and adolescents with cochlear implants:
A qualitative analysis of parent, teacher, and child interviews. Journal of Deaf Studies and Deaf Education, 16(4),
474–493.
Remine, M. D., & Brown, P. M. (2010). Comparison of the
prevalence of mental health problems in deaf and hearing
children and adolescents in Australia. Australian and New
Zealand Journal of Psychiatry, 44(4), 351–357.
Remmel, E., & Peters, K. (2009). Theory of mind and language
in children with cochlear implants. Journal of Deaf Studies
and Deaf Education, 14(2), 218–236.
Roza, S. J., Hofstra, M. B., van der Ende, J., & Verhulst, F. C.
(2003). Stable prediction of mood and anxiety disorders
based on behavioral and emotional problems in childhood:
A 14-year follow-up during childhood, adolescence, and
young adulthood. American Journal of Psychiatry, 160(12),
2116–2121.
Sorkin, D. L., Gates-Ulanet, P., & Mellon, N. K. (2015).
Psychosocial aspects of hearing loss in children.
Otolaryngologic Clinics of North America, 48(6),
1073–1080.
Spahn, C., Richter, B., Burger, T., Löhle, E., & Wirsching, M.
(2003). A comparison between parents of children with
cochlear implants and parents of children with hearing
aids regarding parental distress and treatment expectations.
International Journal of Pediatric Otorhinolaryngology,
67(9), 947–955.
Trends in Hearing
St Clair, M. C., Pickles, A., Durkin, K., & Conti-Ramsden, G.
(2011). A longitudinal study of behavioral, emotional and
social difficulties in individuals with a history of specific
language impairment (SLI). Journal of Communication
Disorders, 44(2), 186–199.
Stevenson, J., Kreppner, J., Pimperton, H., Worsfold, S., &
Kennedy, C. (2015). Emotional and behavioural difficulties
in children and adolescents with hearing impairment: A systematic review and meta-analysis. European Child and
Adolescent Psychiatry, 24(5), 1–20. doi:10.1007/s00787015-0697-1.
Stevenson, J., McCann, D., Watkin, P., Worsfold, S., &
Kennedy, C. (2010). The relationship between language
development and behaviour problems in children with hearing loss. Journal of Child Psychology and Psychiatry, 51(1),
77–83.
Stevenson, J., McCann, D. C., Law, C. M., Mullee, M., Petrou,
S., Worsfold, S., . . . Kennedy, C. R. (2011). The effect of
early confirmation of hearing loss on the behaviour in
middle childhood of children with bilateral hearing impairment. Developmental Medicine and Child Neurology, 53(3),
269–274.
Svirsky, M. A., Robbins, A. M., Kirk, K. I., Pisoni, D. B., &
Miyamoto, R. T. (2000). Language development in profoundly
deaf
children
with
cochlear
implants.
Psychological Science, 11(2), 153–158.
Theunissen, S., Rieffe, C., Kouwenberg, M., De Raeve, L.,
Soede, W., Briaire, J. J., & Frijns, J. H. (2012). Anxiety in
children with hearing aids or cochlear implants compared to
normally hearing controls. The Laryngoscope, 122(3),
654–659.
Theunissen, S., Rieffe, C., Kouwenberg, M., De Raeve, L. J.,
Soede, W., Briaire, J. J., & Frijns, J. H. (2014a). Behavioral
problems in school-aged hearing-impaired children: The
influence of sociodemographic, linguistic, and medical factors. European Child and Adolescent Psychiatry, 23(4),
187–196.
Theunissen, S., Rieffe, C., Netten, A. P., Briaire, J. J.,
Soede, W., Kouwenberg, M., & Frijns, J. H. (2014b).
Self-esteem in hearing-impaired children: The influence of
communication, education, and audiological characteristics.
PloS One, 9(4), e94521.
Theunissen, S., Rieffe, C., Netten, A. P., Briaire, J. J., Soede,
W., Schoones, J. W., & Frijns, J. H. (2014c).
Psychopathology and its risk and protective factors in hearing-impaired children and adolescents: A systematic review.
JAMA Pediatrics, 168(2), 170–177.
Van Eldik, T. (2005). Mental health problems of Dutch youth
with hearing loss as shown on the Youth Self Report.
American Annals of the Deaf, 150(1), 11–16.
Von Hippel, P. T. (2007). Regression with missing Ys: An
improved strategy for analyzing multiply imputed data.
Sociological Methodology, 37(1), 83–117.
Wake, M., Hughes, E. K., Collins, C. M., & Poulakis, Z.
(2004). Parent-reported health-related quality of life in children with congenital hearing loss: a population study.
Ambulatory Pediatrics, 4(5), 411–417.
Wechsler, D., Naglieri, J. A., & Petermann, F. (2006). Wechsler
Nonverbal Scale of Ability: WNV. San Antonio, TX:
PsychCorp.
Wong et al.
Wong, C. L., Ching, T. Y., Leigh, G., Cupples, L., Button, L.,
Marnane, V., . . . Martin, L. (2016). Psychosocial development of 5-year-old children with hearing loss: Risks and protective factors. International Journal of Audiology.
doi:10.1080/14992027.2016.1211764.
Yoshinaga-Itano, C. (2001). The social-emotional ramifications of universal newborn hearing screening, early identification and intervention of children who are deaf or hard of
19
hearing. In R. C. Seewald & J. S. Gravel (Eds.), A sound
foundation through early amplification..
Yoshinaga-Itano, C., Sedey, A. L., Coulter, D. K., & Mehl, A.
L. (1998). Language of early-and later-identified children
with hearing loss. Pediatrics, 102(5), 1161–1171.
Zimmerman, I. L., Steiner, V. G., & Pond, R. E. (2002).
Preschool language scale (vol. 3). San Antonio, TX:
Psychological Corporation.