Parental Decision-Making and Deaf Children: A Systematic Literature Review

Preliminary Validation of Stigma Measures Among Parents of Children Who Are d/Deaf or Hard of Hearing in the United States and Ghana

OBJECTIVES

Parents are integral to the development and overall well-being of their child. Previous research has studied the emotional effects parenting experiences have on parents. However, parents caring for children with disabilities have unique parenting experiences, filled with both victories and challenges. Parenting a child with disabilities can bring additional responsibilities as parents respond to their child's special needs. Specifically, parents of children who are d/Deaf or hard of hearing (d/DHH) are required to make ongoing life-changing decisions about their child's life, including mode of communication, medical care, and education. Across the world, many adults who are d/DHH experience stigma. However, less is known about the stigma faced by children who are d/DHH and their parents. Measuring the nature and magnitude of stigma-affecting parents of children who are d/DHH could offer insights into how to additionally support these parents. Nonetheless, there is a gap in validated scales to measure stigma among parents of children who are d/DHH. In response, we developed and preliminarily validated five measures of stigma among parents of children who are d/DHH.

DESIGN

Measures were developed through a mixed-method process: (1) a scoping literature review, (2) a modified Delphi process consisting of two group discussions (n = 3, n = 4) and two individual discussions with parents of children who are d/DHH from high-income countries (HICs) and low- and middle-income countries (LMICs), (3) cognitive interviews with parents of children who are d/DHH in the United States (U.S.) (n = 5) and Ghana (n = 5), and (4) a pretest of the survey in the U.S. (n = 28) and Ghana (n = 30). Modifications to the measures were made after each stage. This article focuses on evaluating the psychometric performance of the developed measures. Parents were recruited in the U.S. (n = 100) and Ghana (n = 173). Convenience sampling was used in both countries. In Ghana, survey administration was in-person with trained interviewers collecting data on tablets. In the U.S. data were collected online through self-administered surveys.

RESULTS

The final five scales measured: (1) parental observation of stigma their child experiences (seven items), (2) parental perceptions of stigma toward their child (eight items), (3) parental secondary experienced stigma (eight items), (4) perceived parental secondary stigma (five items), and (5) parental internalized stigma (seven items). All scales performed strongly and similarly across both country samples. The scales had ordinal αs ranging from 0.864 to 0.960, indicating strong reliability.

CONCLUSIONS

This study provides a set of preliminarily validated stigma measures to capture the experience of parents of children who are d/DHH. Measuring stigma among parents is critical to understanding parental mental health, as parental well-being affects the health and development of their child. Furthermore, measuring observed stigma by parents can allow the researcher to gain an understanding of the stigma experienced by children who are d/DHH that they may not be able to communicate. Further studies testing these measures across other countries and with more diverse samples are needed.

Are Deaf College Students More Sensitive to Unfair Information? Evidence from an ERP Study

To better understand the individual differences in fairness, we used event-related potentials (ERPs) to explore the fairness characteristics of deaf college students through the ultimatum game task. Behaviorally, the significant main effect of the proposal type was found, which meant both deaf and hearing college students showed a lower acceptance rate for the more unfair proposal. Interestingly, we found a significant interaction between group and proposal type in the early stage (N1). Moreover, in the deaf college group, N1 (induced by moderately and very unfair proposals) was significantly larger than that of fair proposals. However, we found that deaf college students had smaller amplitudes on P2 and P3 than hearing college students. These results suggested that deaf college students might pursue more equity strongly so they are more sensitive to unfair information in the early stage. In a word, we should provide more fair allocations for deaf college students in our harmonious society.

Family-Centered Early Intervention Deaf/Hard of Hearing (FCEI-DHH): Cultural & Global Implications

This article is the third in a series of eight articles that comprise this special issue on family-centered early intervention for children who are deaf or hard of hearing and their families (FCEI-DHH). It highlights the origins of FCEI-DHH in Western contexts and well-resourced locations and emphasizes the role of culture(s) in shaping FCEI-DHH. This article also cautions against the direct application of the 10 FCEI-DHH Principles presented in this issue across the globe without consideration of cultural implications. Cultural perceptions of decision-making processes and persons who can be decision-makers in FCEI-DHH are explored. Deaf culture(s) and the benefits of exposure to DHH adults with diverse backgrounds are introduced. Structural inequities that impact families' access to FCEI-DHH programs/services and systems, within and among nations and regions, are noted. The need to consider the cultural influences on families is emphasized; this applies to all levels of FCEI, including the development of systems through implementation of supports.

Family-Centered Early Intervention Deaf/Hard of Hearing (FCEI-DHH): Foundation Principles

This article is the fifth in a series of eight articles that comprise a special issue on Family-Centered Early Intervention (FCEI) for children who are deaf or hard of hearing (DHH) and their families, or FCEI-DHH. The 10 FCEI-DHH Principles are organized conceptually into three sections (a) Foundation Principles, (b) Support Principles, and (c) Structure Principles. Collectively, they describe the essential Principles that guide FCEI for children who are DHH and their families. This article describes the Foundation Principles (Principles 1 and Principle 2). The Foundation Principles emphasize the essential elements of ensuring that families with children who are DHH can access early intervention (EI) and other appropriate supports, as well as highlight the need for provision of EI that is family-centered. Implementation of these FCEI-DHH Principles is intended to improve the lives and the outcomes of children who are DHH and their families around the globe.

Family-Centered Early Intervention Deaf/Hard of Hearing (FCEI-DHH): Support Principles

This article is the sixth in a series of eight articles that comprise a special issue on Family-Centered Early Intervention (FCEI) for children who are deaf or hard of hearing (DHH) and their families, or FCEI-DHH. The Support Principles article is the second of three articles that describe the 10 Principles of FCEI-DHH, preceded by the Foundation Principles, and followed by the Structure Principles, all in this special issue. The Support Principles are composed of four Principles (Principles 3, 4, 5, and 6) that highlight (a) the importance of a variety of supports for families raising children who are DHH; (b) the need to attend to and ensure the well-being of all children who are DHH; (c) the necessity of building the language and communication abilities of children who are DHH and their family members; and (d) the importance of considering the family's strengths, needs, and values in decision-making.

Speech, Sign, or Both? Factors Influencing Caregivers' Communication Method Decision Making for Deaf/Hard of Hearing Children

PURPOSE

Caregivers of deaf/hard of hearing infants are faced with challenging decisions regarding their child's communication method. The purpose of the current research note is to characterize the advice that caregivers receive and value as well as the factors that influence caregivers' decision making.

METHOD

The current study enrolled 105 caregiver-child dyads, including children between 12 and 18 months of age with bilateral, congenital hearing loss. All children were exposed to spoken language, and 63.81% of children were also exposed to sign language. Caregivers completed the "Making Decisions About Sign, Speech, and Multilingualism Survey" (Crowe et al., 2014).

RESULTS

Caregivers most frequently received advice to use both speech and sign and highly valued advice from speech-language pathologists. When considering the use of speech, the factors that caregivers most frequently rated as very important were "My child's future academic success" (96.19%), "My child's future literary success" (95.24%), and "My child's future access to higher education" (95.19%). When considering the use of sign, the factors that caregivers most frequently rated as very important were "My child's ability to form friendships and future relationships" (82.52%), "My child's future literary success" (81.37%), and "My child's future academic success" (81.37%).

CONCLUSIONS

Results of the current study suggest that throughout the decision-making process, caregivers' highest priority is understanding how their decisions will influence their child's future access to opportunities and relationships. Providers may consider discussing these factors early in the decision-making process to support caregivers' ability to make an informed choice regarding their child's communication method.

High General Health Literacy Does Not Ensure Hearing Loss Health Literacy in Mothers of Children Who Are Deaf and Hard of Hearing

PURPOSE

The purpose of this study was to characterize general health literacy and hearing loss health literacy for mothers of children who are deaf and hard of hearing (DHH).

METHOD

Participants included 25 mothers of 2-year-old and 3-year-old children who had a diagnosis of permanent, bilateral hearing loss for at least 1 year. Measures of general health literacy and hearing loss health literacy were collected.

RESULTS

Results indicated that mothers had high general health literacy but had lower hearing loss health literacy skills than expected. Although mothers had high education and experience of at least 1 year of having a child with hearing loss, performance on hearing loss health literacy measures was low.

CONCLUSION

Caregiver understanding of hearing loss terminology and concepts is essential for decision making regarding their child's hearing loss health care.

Hearing parents learning American Sign Language with their deaf children: a mixed-methods survey

Hearing parents with deaf children face difficult decisions about what language(s) to use with their child. Sign languages such as American Sign Language (ASL) are fully accessible to deaf children, yet most hearing parents are not proficient in ASL prior to having a deaf child. Parents are often discouraged from learning ASL based in part on an assumption that it will be too difficult, yet there is little evidence supporting this claim. In this mixed-methods study, we surveyed hearing parents of deaf children (n = 100) who had learned ASL to learn more about their experiences. In their survey responses, parents identified a range of resources that supported their ASL learning as well as frequent barriers. Parents identified strongly with belief statements indicating the importance of ASL and affirmed that learning ASL is attainable for hearing parents. We discuss the implications of this study for parents who are considering ASL as a language choice and for the professionals who guide them.

Experiences of parents of children with cochlear implants in South Africa: an exploratory study

PURPOSE

Cochlear implantation is a well-established option for early intervention. Children with hearing impairment and their parents are users of intervention services, with parents being more suited to provide insight into their experiences. The purpose of the current study was to describe the experiences of parents of children with cochlear implants (CIs) in the South African context.

METHODS

A qualitative research design was employed. Non-probability, purposive sampling was used. Seven, online semi-structured interviews were conducted with parents of children with CIs. Data were analysed using inductive thematic analysis.

RESULTS

Participants expressed feelings of certainty and assurance in the CI journey. Participants extended gratitude to the healthcare professionals involved in their children's CI journey. Feelings of doubt and stress were noted when coming to terms with the decision of cochlear implantation and financial stressors were noted as a challenge. Many participants found it challenging transitioning their children into school.

CONCLUSIONS

Parents conveyed having no regrets with their decision of cochlear implantation for their child and were grateful for the support provided by healthcare professionals. However, financial, and educational challenges remain. Findings suggest the need for more financial support for cochlear implantation in South Africa, and for adequate inclusive educational settings.

Systems that support hearing families with deaf children: A scoping review

BACKGROUND

Over 90% of deaf children are born to hearing parents who have limited knowledge about deafness and require comprehensive support and information to support and communicate with their deaf child. However, little is known about the systems that support hearing families with deaf children. We performed a scoping review to provide an overview of current literature on the topic.

METHODS

The protocol of the scoping review was prepared using the PRISMA statement guidelines for scoping reviews. Relevant search terms were used to identify eligible studies following discussion with the study's steering group. Databases searched were CINAHL, Medline, ProQuest Central and ASSIA, as well as grey literature from relevant journals and online sources. Included were studies published from 2000 to 2021 and available in English.

RESULTS

A search of databases identified 1274 articles. After excluding duplicates, screening titles and abstracts and full texts, 65 papers matched the identified inclusion criteria. Results included 1 RCT, 7 comparative studies, 6 literature reviews, 4 PhD theses, and 47 further empirical studies.

CONCLUSION

There is limited quality evidence on what supports hearing parents with deaf children. It is evident that further studies are needed to ensure comprehensive support is accessible and effective for hearing parents of deaf children.

Cochlear implant decision-making for children with residual hearing: Perspectives of parents

PURPOSE

Cochlear implant (CI) decision-making is particularly challenging for families of children who have residual hearing. Parents of these children may be uncertain about whether the potential benefits of CIs outweigh the risks. This study aimed to understand parents' decisional needs during the decision-making process for children with residual hearing.

METHOD

Semi-structured interviews were conducted with parents of 11 children who had received CIs. Open-ended questions were asked to encourage parents to share their experiences about the decision-making process, their values/preferences, and their needs. The interviews were transcribed verbatim and analyzed using thematic analysis.

RESULTS

Data were organized according to three key themes: (1) Parents' decisional conflict, (2) values and preferences, (3) decision support and parents' needs. We found that overall parents were satisfied with their decision-making process and the decision support from practitioners. However, parents stressed the importance of receiving more personalized information that considers their specific concerns, values and preferences related to family's circumstances.

CONCLUSIONS

Our research provides additional evidence to guide the CI decision-making process for children with residual hearing. Additional collaborative research with audiology and decision-making experts specifically on facilitating shared decision-making is needed to provide better decision coaching for these families.

Estimating Early Language Input in Deaf and Hard of Hearing Children With the Language Access Profile Tool

PURPOSE

The purpose of this study was to describe the Language Access Profile Tool (LAPT) and its psychometric properties with the aim of evaluating its suitability as an alternative to the deaf or hard of hearing (DHH) Language Exposure Assessment Tool (D-LEAT) in clinical practice with DHH children age 12 years and younger.

METHOD

We administered both the LAPT and D-LEAT to the caregivers of 105 DHH children 12 years old and younger from across the United States, 40% of whom were interviewed again after a delay of at least 1 month. Each interview resulted in a child-specific estimate of their cumulative experience with language input, expressed as a proportion divided across eight categories.

RESULTS

Participants in the sample reported experience with all eight input categories, but four categories were common and four were rare. Estimates for all input categories were consistent at both initial and follow-up interviews. Estimates for each input category were also strongly correlated with the corresponding estimates from the D-LEAT, although correlations for the rare categories should be interpreted cautiously.

CONCLUSIONS

The LAPT demonstrates sufficient test-retest reliability and convergent validity to be a useful and more user-friendly alternative to the D-LEAT. We provide recommendations for how the LAPT and the D-LEAT can be best used in their current form.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20669001.

Analysis of Health Disparities in the Screening and Diagnosis of Hearing Loss: Early Hearing Detection and Intervention Hearing Screening Follow-Up Survey

PURPOSE

The purpose of this study was to (a) provide introductory literature regarding cultural constructs, health disparities, and social determinants of health (SDoH); (b) summarize the literature regarding the Centers for Disease Control and Prevention (CDC) Early Hearing Detection and Intervention (EHDI) Hearing Screening Follow-Up Survey (HSFS) data; (c) explore the CDC EHDI HSFS data regarding the contribution of maternal demographics to loss-to-follow-up/loss-to-documentation (LTF/D) between hearing screening and audiologic diagnosis for 2016, 2017, and 2018; and (d) examine these health disparities within the context of potential ethnoracial biases.

METHOD

This is a comprehensive narrative literature review of cultural constructs, hearing health disparities, and SDoH as they relate to the CDC EHDI HSFS data. We explore the maternal demographic data reported on the CDC EHDI website and report disparities for maternal age, education, ethnicity, and race for 2016, 2017, and 2018. We focus on LTF/D for screening and diagnosis within the context of racial and cultural bias.

RESULTS

A literature review demonstrates the increase in quality of the CDC EHDI HSFS data over the past 2 decades. LTF/D rates for hearing screening and audiologic diagnostic testing have improved from higher than 60% to current rates of less than 30%. Comparisons of diagnostic completion rates reported on the CDC website for the EHDI HSFS 2016, 2017, and 2018 data show trends for maternal age, education, and race, but not for ethnicity. Trends were defined as changes more than 10% for variables averaged over a 3-year period (2016-2018).

CONCLUSIONS

Although there have been significant improvements in LTF/D over the past 2 decades, there continue to be opportunities for further improvement. Beyond neonatal screening, delays continue to be reported in the diagnosis of young children with hearing loss. Notwithstanding the extraordinarily diverse families within the United States, the imperative is to minimize such delays so that all children with hearing loss can, at the very least, have auditory accessibility to spoken language by 3 months of age. Conscious awareness is essential before developing a potentially effective plan of action that might remediate the problem.

The Struggle to Fit in: A Qualitative Study on the Sense of Belonging and Well-being of Deaf People in Ipoh, Perak, Malaysia

The sense of belonging plays an important role in a person's well-being. It also acts as a protective factor against mental distress. Deaf people struggle to fit into the dominant hearing society due to communication barriers. The multi-languages used in Malaysian families add to this communication challenge. Communication breakdown leaves the deaf person socially excluded while a poor sense of belonging also increases their vulnerability to mental health issues. Hence, this study explored the deaf person's sense of belonging and well-being through their social experiences in Malaysia. Baumeister's need-to-belong theory served as the theoretical framework of this study. An Ethnographic approach with in-depth interviews and participant observation was used to explore the social experiences of six Chinese deaf adults, aged 20-37, residing in Ipoh. Their hearing parents were interviewed as well to obtain parents' perspective of the child's well-being in the earlier years. Participants were selected using the purposive and snowballing sampling method. Upon data saturation, thematic analysis was used to identify themes, patterns, and interpret its meanings. The main themes that emerged from the data was the "struggle to fit in", "emotional effect", and "quality social connections". Findings of this study can be used in the formation of policies and strategies to ensure that deaf individuals are not excluded from their communities. Cultivating an inclusive community and developing the deaf community offers a better sense of belonging, which would help increase well-being of deaf people. Future research may focus on deaf identity and well-being of deaf youth in Malaysia.

Vinculación de políticas para niños/as con discapacidad auditiva: Percepciones en País Vasco de España y Chile

La vinculación de políticas públicas y el trabajo intersectorial entre salud, educación y servicios sociales ha cobrado relevancia en el abordaje temprano y biopsicosocial en personas con discapacidad. En el campo de la discapacidad auditiva infantil, existirían controversias en dicha vinculación debido a las discrepancias existentes entre los enfoques clínico y sociocultural, referentes incluso a las modalidades de acceso al lenguaje para esta población. Este estudio de tipo cualitativo analiza entrevistas semi-estructuradas buscando describir las percepciones de diferentes actores en País Vasco de España y Región Metropolitana de Chile. Fueron analizados 565 minutos de entrevistas de 27 participantes, a partir de 3 categorías emergentes: políticas y áreas existentes, intersectorialidad entre áreas, y servicio ofrecido por áreas. Los resultados muestran una percepción positiva sobre la vinculación política y trabajo intersectorial, pero persiste la preferencia del modelo biomédico y enfoque clínico de la discapacidad por sobre el modelo biopsicosocial y el desarrollo del enfoque sociocultural. Esto ocurriría toda vez que el éxito se asocia al desarrollo normal a través de la adquisición de la lengua oral por sobre la diversidad de otras intervenciones en esta población. Las percepciones de los profesionales de las áreas estudiadas difieren en torno a los logros considerados como indicadores de éxito. Un centro coordinador de políticas y trabajo intersectorial, junto con la determinación de momentos de mayor relevancia de cada área en el proceso de atención podrían beneficiar el trabajo hacia este grupo.

Decision-making following identification of an infant's unilateral hearing loss: Parent and professional perspectives

BACKGROUND

Parents of infants identified with unilateral hearing loss (UHL) make decisions about managing their infant's hearing loss based on limited evidence and before knowing whether their infant will require additional support.

OBJECTIVES

The decision-making processes of parents and clinicians regarding the management of UHL following newborn hearing screening were examined.

PROCEDURE

Two convenience samples were recruited: 15 parents of children with permanent UHL aged under 4 years, and 14 clinicians. Applied thematic analysis of the semi-structured interviews elicited insight into the complexities surrounding decision-making from a parent and clinician perspective.

RESULTS

Three main themes captured the decision-making process: motivation for decision-making, limited evidence creates uncertainty, and available evidence builds certainty. The diverse experiences and opinions of parents and clinicians highlight the complexity of decision-making when there are contested opinions and no clear best management option.

CONCLUSIONS

The choices parents make about the management of their child's UHL can have lifelong implications for their child. Many questions need answering before parents can effectively evaluate the short- and long-term consequences of their options and whether the advantages outweigh the disadvantages in the long-term. This uncertainty is challenging for professionals and parents and risks cognitive biases influencing clinical and parental decision-making.

Exploring how parents of children with unilateral hearing loss make habilitation decisions: a qualitative study

OBJECTIVE

This study sought to explore the decision making needs of parents managing the hearing and communication needs of children with unilateral hearing loss.

DESIGN

An inductive, qualitative method was used. The data were analysed using a constant comparative approach, consistent with Grounded Theory method.

STUDY SAMPLE

Twenty one families participated in interviews yielding data on twenty two children. Each of these families had at least one child with unilateral hearing loss. The age range of the children varied from four months to sixteen years old. All parents were English speaking and received care from National Health Service Audiology departments across the United Kingdom.

RESULTS

Parents valued professionals' opinions, but information provision was inconsistent. As their children mature, parents increasingly valued their child's input. Parent-child discussions focussed on how different management strategies fit their child's preferences. Parents were proactive in obtaining professional advice, and integrating this with their own iterative assessment of their child's performance.

CONCLUSIONS

Decision making is an iterative process. Parents make nuanced decisions which aim to preserve a sense of what is normal for them. Clinicians need to recognise the parental view, including where it may contrast with a medicalised or clinical view.

Exploring factors influencing the use of an eHealth intervention for families of children with hearing loss: An application of the COM-B model

BACKGROUND

Prior to developing a successful eHealth intervention, it is important that we explore stakeholders' capacity to adapt to eHealth.

OBJECTIVE

To explore what factors influence the use eHealth services from the perspectives of families of children with hearing loss and professionals who support families as they transition into early intervention.

METHODS

A qualitative study incorporating semi-structured in-depth interviews was conducted with families (n = 17) and professionals (n = 11). Interview topic guides were developed based on the COM-B model of behaviour change to explore barriers and facilitators related to capability, opportunity, and motivation.

RESULTS

The COM-B model captured several factors that may influence the use eHealth interventions for families of children with hearing loss. The capability factors included computer literacy and familiarity with social media. The opportunity factors were access to online resources, reliable Internet, and affordable equipment. Professionals' and families' preferences and a culture of face-to-face services were also identified as barriers for using eHealth. The motivation factors included families' and professionals' confidence in using technology and beliefs that there were benefits (e.g., saving travel) associated with using eHealth services. In contrast, beliefs that eHealth may be difficult to set up and not able to replace in-person communication identified as barriers to families and professionals adopting eHealth interventions.

CONCLUSION

Findings of this study indicated that implementation of an eHealth intervention could be facilitated by addressing the barriers in stakeholders' capabilities, opportunities (e.g., equipment and social support), and motivation (e.g., negative beliefs about eHealth) before developing eHealth services.