Terrible Twos or Early Signs of Psychopathology? Developmental Patterns in Early Identified Preschoolers With Cochlear Implants Compared With Hearing Controls.

OBJECTIVE: Cochlear implants (CIs) have dramatically improved the lives of children who are deaf or hard of hearing; however, little is known about its implications for preventing the development of psychiatric symptoms in this at-risk population. This is the first longitudinal study to examine the early manifestation of emotional and behavioral disorders and associated risk and protective factors in early identified preschoolers with CIs compared with hearing peers. DESIGN: Participants were 74 children with CIs and 190 hearing controls between ages 1 and 5 years (mean age, 3.8 years). Hearing loss was detected using the Newborn Hearing Screening in The Netherlands and Flanders. Parents completed the Early Childhood Inventory-4, a well-validated measure, to evaluate the symptoms of DSM-IV-defined psychiatric disorders, during three consecutive years. Language scores were derived from each child's medical notes. RESULTS: Children with CIs and hearing controls evidenced comparable levels of disruptive behavior and anxiety/depression (which increased with age in both groups). Greater proficiency in language skills was associated with lower levels of psychopathology. Early CI and longer duration of CI use resulted in better language development. In turn, higher early language skills served as a protective factor against the development of disruptive behavior symptoms. CONCLUSIONS: This longitudinal study uniquely shows that improvement in language skills mitigates the development of early signs of psychopathology. Early identification of hearing loss and CIs help children improve their language skills.

Concern for Others: A Study on Empathy in Toddlers with Moderate Hearing Loss.

Empathy, the ability to feel the emotions of others and respond affectively to these emotions, is an important factor in the development of social competence. The purpose of this study was to examine empathy levels in toddlers with moderate hearing loss (MHL) compared to toddlers with no hearing loss (nHL), and to explore the relation between language ability and empathy. We focused on affective empathy and the precursors of cognitive empathy. A total of 23 toddlers with MHL and 21 toddlers with nHL participated in the study. Parent report (ITSEA) and observation measures were used to rate the toddlers' levels of empathy. The results showed that the levels of affective empathy in toddlers with MHL and with nHL were similar on both measures. Toddlers with MHL lagged behind their peers with nHL on some precursors of cognitive empathy (intention understanding and joint attention). Language ability was unrelated to empathy levels in both groups of toddlers. In conclusion, toddlers with MHL seem to be at risk for problems in their empathy development. Although they are aware of the emotions of others, the development of more complex skills needed for an adequate empathic response is delayed in comparison with their hearing peers.

Children With Cochlear Implants and Their Parents: Relations Between Parenting Style and Children's Social-Emotional Functioning.

OBJECTIVES: Parenting a child who has a severe or profound hearing loss can be challenging and at times stressful, and might cause parents to use more adverse parenting styles compared with parents of hearing children. Parenting styles are known to impact children's social-emotional development. Children with a severe to profound hearing loss may be more reliant on their parents in terms of their social-emotional development when compared with their hearing peers who typically have greater opportunities to interact with and learn from others outside their family environment. Identifying the impact which parenting styles pertain on the social-emotional development of children who have cochlear implants (CIs) could help advance these children's well-being. Therefore, the authors compared parenting styles of parents with hearing children and of parents with children who have a CI, and examined the relations between parenting styles and two key aspects of children's social-emotional functioning: emotion regulation and empathy. DESIGN: Ninety-two hearing parents and their children (aged 1 to 5 years old), who were either hearing (n = 46) or had a CI (n = 46), participated in this cross-sectional study. Parents completed questionnaires concerning their parenting styles (i.e., positive, negative and uninvolved), and regarding the extent to which their children expressed negative emotions (i.e., anger and sadness) and empathy. Furthermore, an emotion-regulation task measuring negative emotionality was administered to the children. RESULTS: No differences in reported parenting styles were observed between parents of hearing children and parents of children with a CI. In addition, negative and uninvolved parenting styles were related to higher levels of negative emotionality in both groups of children. No relation was found between positive parenting and children's social-emotional functioning. Hearing status did not moderate these relationships. Language mediated the relationship between parenting styles and children's social-emotional functioning. CONCLUSIONS: Children's hearing status did not impact parenting styles. This may be a result of the support that parents of children with a CI receive during their enrollment in the rehabilitation program preceding and after implantation. Rehabilitation programs should dedicate more attention to informing parents about the impact of parenting behaviors on children's social-emotional functioning. Offering parenting courses as part of the program could promote children's well-being. Future longitudinal research should address the directionality of the relations between parenting styles and children's social-emotional functioning.

The Understanding of Intentions, Desires and Beliefs in Young Children with Autism Spectrum Disorder.

This study provides a comprehensive picture of three core elements (Intentions, Desires, Beliefs) of Theory of Mind (ToM) in young children with autism spectrum disorder (ASD, n = 63, Mage = 55 months) and typically developing children (TD, n = 69, Mage = 54 months). Outcomes showed that ASD and TD children understood intentional actions equally well. Yet, children with ASD lacked the social interest to share intentions. Additionally, children with ASD had more difficulties in understanding others' desires and beliefs compared to their TD peers. It is discussed whether the ToM delay seen in children with ASD is a motivational or a conceptual problem.

Preliminary findings on associations between moral emotions and social behavior in young children with normal hearing and with cochlear implants.

Moral emotions such as shame, guilt and pride are the result of an evaluation of the own behavior as (morally) right or wrong. The capacity to experience moral emotions is thought to be an important driving force behind socially appropriate behavior. The relationship between moral emotions and social behavior in young children has not been studied extensively in normally hearing (NH) children, let alone in those with a hearing impairment. This study compared young children with hearing impairments who have a cochlear implant (CI) to NH peers regarding the extent to which they display moral emotions, and how this relates to their social functioning and language skills. Responses of 184 NH children and 60 children with CI (14-61 months old) to shame-/guilt- and pride-inducing events were observed. Parents reported on their children's social competence and externalizing behavior, and experimenters observed children's cooperative behavior. To examine the role of communication in the development of moral emotions and social behavior, children's language skills were assessed. Results show that children with CI displayed moral emotions to a lesser degree than NH children. An association between moral emotions and social functioning was found in the NH group, but not in the CI group. General language skills were unrelated to moral emotions in the CI group, yet emotion vocabulary was related to social functioning in both groups of children. We conclude that facilitating emotion language skills has the potential to promote children's social functioning, and could contribute to a decrease in behavioral problems in children with CI specifically. Future studies should examine in greater detail which factors are associated with the development of moral emotions, particularly in children with CI. Some possible directions for future research are discussed.

Symptoms of Psychopathology in Hearing-Impaired Children.

OBJECTIVES: Children with hearing loss are at risk of developing psychopathology, which has detrimental consequences for academic and psychosocial functioning later in life. Yet, the causes of the extensive variability in outcomes are not fully understood. Therefore, the authors wanted to objectify symptoms of psychopathology in children with cochlear implants or hearing aids, and in normally hearing peers, and to identify various risk and protective factors. DESIGN: The large sample (mean age = 11.8 years) included three subgroups with comparable age, gender, socioeconomic status, and nonverbal intelligence: 57 with cochlear implants, 75 with conventional hearing aids, and 129 children who were normally hearing. Psychopathology was assessed by means of self- and parent-report measures. RESULTS: Children with cochlear implants showed similar levels of symptoms of psychopathology when compared with their normally hearing peers, but children with hearing aids had significantly higher levels of psychopathological symptoms, while their hearing losses were approximately 43 dB lower than those of children with implants. Type of device was related with internalizing symptoms but not with externalizing symptoms. Furthermore, lower age and sufficient language and communication skills predicted less psychopathological symptoms. CONCLUSIONS: Children who are deaf or profoundly hearing impaired and have cochlear implants have lower levels of psychopathological symptoms than children with moderate or severe hearing loss who have hearing aids. Most likely, it is not the type of hearing device but rather the intensity of the rehabilitation program that can account for this difference. This outcome has major consequences for the next generation of children with hearing loss because children with profound hearing impairment still have the potential to have levels of psychopathology that are comparable to children who are normally hearing.

Social competence and empathy in young children with cochlear implants and with normal hearing.

OBJECTIVES: To examine the levels of social competence and empathic behavior in children with cochlear implants in comparison with normal-hearing children, and to determine whether empathy predicts social competence to the same extent in both groups of children. STUDY DESIGN: Retrospective cohort study. METHODS: A total of 150 children (mean age 39 months) participated in the study; 61 with cochlear implants and 89 without hearing loss. Parent reports and observation measures were employed to measure empathy and social competence. RESULTS: Levels of empathy and social competence in children with cochlear implants and normal-hearing children were similar. Empathic behaviors were predictive of social competence in both groups alike. Emotion acknowledgment was more predictive of social competence for children with cochlear implants than for normal-hearing children. Language skills were unrelated to social competence or empathic behaviors in children with cochlear implants. CONCLUSIONS: Children with cochlear implants showed no delay concerning social competence or empathic behavior. The factors contributing to social competence, however, differed between the groups. This should be kept in mind when developing rehabilitation programs for children with cochlear implants.

Emotion understanding in deaf children with a cochlear implant.

It is still largely unknown how receiving a cochlear implant affects the emotion understanding in deaf children. We examined indices for emotion understanding and their associations with communication skills in children aged 2.5-5 years, both hearing children (n = 52) and deaf children with a cochlear implant (n = 57). 2 aspects of emotion understanding were examined: (a) emotion recognition in facial expressions and (b) emotion attribution in a situational context. On all emotion-understanding tasks, children with a cochlear implant were less proficient than children with normal hearing. In children with normal hearing, performance and language skills were positively associated. In children with cochlear implants, language was positively associated only with tasks in which a verbal demand was made on children. These findings indicate that hearing loss in children, despite a cochlear implant, affects all aspects of emotion understanding measured in this study, including their nonverbal emotion-understanding skills.

Does hearing lead to understanding? Theory of mind in toddlers and preschoolers with cochlear implants.

OBJECTIVE: Theory of Mind (ToM) refers to the ability to understand the subjectivity of people's intentions, desires, and beliefs. Research shows that ToM in deaf children is delayed, yet the few studies that examined ToM in deaf children with a cochlear implant (CI) report contradictory results. This study examined multiple aspects of ToM in early-implanted children. METHODS: 3 intention tasks were administered to 72 children with CI and 69 normal-hearing children (age, 12-60 months). Furthermore, 3 desire and belief tasks were administered to a subsample of children aged 30 months or over. RESULTS: Children with CI showed intention-understanding skills equal to normal-hearing children, but lagged behind on desire and belief understanding, even after excluding children with language delays. CONCLUSIONS: Children with CI appear to master the initial stages of ToM development, but fall behind on more advanced ToM abilities. Yet, both groups showed similar patterns of development.

Predicting social functioning in children with a cochlear implant and in normal-hearing children: the role of emotion regulation.

OBJECTIVE: The purpose of the present study was to compare children with a cochlear implant and normal hearing children on aspects of emotion regulation (emotion expression and coping strategies) and social functioning (social competence and externalizing behaviors) and the relation between emotion regulation and social functioning. METHODS: Participants were 69 children with cochlear implants (CI children) and 67 normal hearing children (NH children) aged 1.5-5 years. Parents answered questionnaires about their children's language skills, social functioning, and emotion regulation. Children also completed simple tasks to measure their emotion regulation abilities. RESULTS: Cochlear implant children had fewer adequate emotion regulation strategies and were less socially competent than normal hearing children. The parents of cochlear implant children did not report fewer externalizing behaviors than those of normal hearing children. While social competence in normal hearing children was strongly related to emotion regulation, cochlear implant children regulated their emotions in ways that were unrelated with social competence. On the other hand, emotion regulation explained externalizing behaviors better in cochlear implant children than in normal hearing children. While better language skills were related to higher social competence in both groups, they were related to fewer externalizing behaviors only in cochlear implant children. CONCLUSIONS: Our results indicate that cochlear implant children have less adequate emotion-regulation strategies and less social competence than normal hearing children. Since they received their implants relatively recently, they might eventually catch up with their hearing peers. Longitudinal studies should further explore the development of emotion regulation and social functioning in cochlear implant children.