1. Counseling Guidelines: Supporting Children with Hearing Loss
Eileen Rall, Au.D., CCC-A
Louise A. Montoya, MA, LPC, CSC
The Center for Childhood Communication

2. Session Objectives Understand the impact of
the diagnosis of hearing loss on a family system
hearing loss on psycho-social development of a child
Become familiar with a pediatric counseling guideline and understand how to integrate it into your practice

3. Child Developmental Model
Teacher, Speech
Language Pathologist
Audiologist,
Physician
Cognitive ?
Social-Emotional
Physical

4. Pediatric Counseling Guidelines
Birth through transition to school

5. Pediatric Counseling Guidelines
Impact of diagnosis
Psycho-Social development
Erik Erikson’s model of development
Development of self-concept (15 mos+)
Development of social skills

6. Pediatric Counseling Guidelines
Diagnosis
Birth to Three years
Three to Six years
Six to Eleven years
Eleven through Adolescence

7. Erikson’s Stages of Psycho-Social Development
Trust vs. Mistrust (birth – 18 months)
Autonomy vs. Shame and Doubt
(18 mos – 2 years)
Initiative vs. Guilt (3 – 6 years)

8. Psycho-Social Development Self-Concept
An individual’s understanding of who they are
No self
Self-awareness
Factual self-concept
Egocentric view of self-concept
Self-confidence and self-esteem emerging
Comparative
Peer-pressure
Individuation

9. Psycho-Social Development Social Skills
Healthy Attachment
Basic
Intermediate
Advanced

10. Developmental Index of Audition and Listening (DIAL)
Functional auditory
milestones
Palmer and Mormer (1999)

11. Impact of Diagnosis Sharing information
Recognizing emotional reactions
Promoting healthy attachment
Positively impacting family systems

12. Sharing Information Family Centered Model Medical Model The child
Diagnose
Family's Needs
Child's Needs
and Treat
The child

13. What are the benefits of Family-Centered Care
What are the benefits of Family-Centered Care? (not specific to hearing impairment)
Improved teaching skills of parent
Better behavior from child as a result of improved parental teaching skills
Decreased parental stress
Improved satisfaction of services

14. Recognizing Emotional Reactions Feelings Involved with Grief
Shock/Denial/ Numbness
Anger/Fear/Panic
Sadness/Hopeless
Guilt/Bargaining
Healthy acceptance/adaptation

15. Grief Core pain can’t be taken away.
Feelings must be acknowledged, expressed in a safe, caring environment.
Some emotions have an important purpose in helping parents adjust to the diagnosis
Potential Pitfall: Because parents may have strong feelings of inadequacy
Many parents happy to turn over their child to “the experts”
Professionals eager to rescue
Luterman (1999)

16. Feelings Involved with Grief
Shock/Denial/Numbness - protects parents from deep pain and allows parents to build up energy for the work ahead of them
Anger - Parents feel cheated. Anger hides their fear. Many professionals are very afraid of the anger and respond defensively. Need to help parents capture and direct their energy effectively.

17. Feelings Involved with Grief
Sadness/Hopelessness – expressing grief – moving forward
Guilt:
Fathers for not protecting the family
Mothers because she secretly believes she’s at fault for the hearing loss
Comes between the marriage, family becomes unbalanced (Mother+child, father+work)
Danger is overprotection of child. Conveys helplessness to the child.

18. The Hearing Healthcare Professional
a.k.a.
“The Healer”
A vicious cycle begins when parental helplessness and powerlessness intersects with professionals’ need to help, save, assume the powerful, “expert” role with families
Results in parents who are:
Over-controlling Lack self-confidence
Self-serving Don’t feel competence
Passive
Children internalize this powerlessness, helplessness, and head down a path of life long poor self-esteem

19. Parents with Unresolved Grief Can Be:
Emotionally overwhelmed
Stuck in anger
Frequently suppressing their emotions
Depressed or passive
Unrealistic or stuck in denial
Disorganized, confused
Actively searching for the cause of the hearing loss
Yoshinaga-Itano (2001)

20. What can you do? Provide immediate, appropriate support
Have appropriate counseling skills
Have expert knowledge and experience with living with hearing loss
Actively listening
No judging the family
Build parental self-esteem, self-confidence
Yoshinaga-Itano (2001)

21. What can you do? Help families understand
The etiology, emphasizing that cause was not parents’ intention
Their child is not fragile
Their child can do anything, but, may have to do some things differently
That taking good care of themselves and their marriage = taking good care of their child
Luterman (1999)

22. What can you do? Inform parents that:
Children with congenital and pre-lingual onset of hearing loss do not experience grief until sometime between 7 – 9 years of age
Parents need to keep their grief away from child. Child will misunderstand and misattribute parents’ grief
Child has best chance of resolving their initial grief if parents have positively resolved their initial grief

23. Healthy Acceptance/Adaptation
Acknowledge their preference that their child not be deaf/hard of hearing
Accept the permanence of the hearing loss
Understand and have entire family take consistent action to make necessary changes create accessible/effective communication environment for deaf/hard of hearing child

24. Healthy Attachment Between Parents and Children
Deep enduring connections established between child and caregiver
Occurs between birth and age 3
Learned ability
Result of ongoing reciprocal interactions characterized by protection, need fulfillment, limits, love and trust
Levy (2000)

25. Healthy Attachment Can Lead to Development of:
Basic trust and reciprocity
Self-regulation of affect and behavior
Healthy identity = healthy self-worth + autonomy
Morality based upon empathy, compassion and conscience
Resourcefulness and resilience for response to future stress
Stimulating experiences required for healthy brain development
Levy, (2000)

26. Potential Consequences of Insecure Attachment:
Self-regulation deficits:
Impulse control
Self-soothing
Initiative
Perseverance
Inhibition
Patience
Levy (2000)

27. Potential Consequences of Insecure Attachment:
Development of problem behaviors:
Impulsiveness
Hyperactivity
Inattention
Seeking stimulation
Poor self-image
No friends
Oppositional and defiant
Disruptive
Manipulative
Blames others (internalized helplessness)
Levy (2000)

28. What can you do? Inform parents that:
Teach parents about the importance of healthy attachment
Support them through the feelings associated with grief
Help them understand the impact hearing impairment has on communication – avoid misunderstanding communication difficulties

29. Healthy Family System Feels empowered
High self-esteem (especially for the mother)
Feeling that burdens are shared
Achieved healthy acceptance of the diagnosis
Luterman (2001)

30. Healthy Family System Community Extended Family Family Marriage Child
Parent
Parent
Child
Child

31. Unhealthy Family System
Community
Extended Family
Family
Marriage
Child
Parent
Parent
Grandma
Child
Child

32. What can you do? Inform parents Be a sounding board
Listen
Coach
Acknowledge
Brainstorm
Support
Model strategies
Refer to professionals when needed

33. Child Developmental Model
Teacher
Audiologist,
Physician
Insert your
picture here
Cognitive
YOU!!
Social-Emotional
Physical

34. Psycho-Social Development Erikson’s Stages
Trust versus Mistrust
(birth – 18 months)
Babies learn to:
Trust their world if they are kept well-fed, warm, dry, and receive regular human touch
Mistrust their world if they are left hungry, cold, wet, and unattended

35. Psycho-Social Development Erikson’s Stages
Autonomy versus Shame and Doubt
(18 months – 2 years)
Toddlers want to rule their own actions and bodies
With success develop Autonomy
With failure develop Shame and Doubt in their own abilities

36. Self-Concept Birth – 14 months
No sense of self
Child views themselves as extension of their parent/caregiver
Classic test: red nose in the mirror; All children 12 months and younger do not know they are seeing themselves in a mirror

37. Self-Concept 15 months – 2 years
Self awareness emerges
Recognize self in a mirror
Classic test: red nose in the mirror; Most children 15 – 24 months will notice the red on their nose and be curious or embarrassed

38. Self-Concept 2 - 3 years Self concept emerges
Child identifies themselves as:
A “girl” or a “boy”
A “baby” or “big boy/girl”
A “brother” or “sister” or only child
By religious affiliation
By ability

39. What can you do? Evaluate and support access to alerting devices
Include the child in conversations about hearing loss - positive
Support families in developing relationships with other families with children with hearing loss and with D/HoH adults and older children

40. Psycho-Social Development Erikson’s Stages
Initiative versus Guilt
(3 – 6 years)
Initiative:
Increased awareness of self and world outside of home
Eagerly attempts new tasks and play activities
Successful attempts at new tasks help children learn and master many things, which becomes self-reinforcing (proud of themselves) and self-controlling to gain the approval of adults

41. Psycho-Social Development Erikson’s Stages
Initiative versus Guilt
(3 – 6 years)
Guilt:
When attempts result in failure or criticism, the child feels:
Guilty
Incompetent
Helpless

42. Self-Concept 3 - 6 years Ego-centric thinking
“I am the world and the world is just like me!”
Repetition/Practice Mastery
Mastery Competence
Competence Self-confidence
Self-confidence Self-esteem

43. Professional as Coach Professionals support and
Parents teach their child.
Professionals support and
coach parents as they teach their child.
Professional
Parent
Child

44. Development of Social Skills/Interaction
Provide information to parents on:
Lack of incidental learning due to hearing loss
Often deaf/hard of hearing children need specific training on basic and more advanced social skills
Use of social skills books
Discriminating between “Can’t Do” or “Won’t Do” behavior problems
Gresham (1995)

45. Frequent Teaching of Social Skills
For “Can’t do” behavior problems: Use Modeling, coaching, practice
For “Won’t do” behavior problems: Use behavior charts, positive
reinforcement, effective praise, and
noticing (and describing) good behavior
Gresham (1995)

46. Examples of Basic Social Skills
Eye contact
Smiling
Listening (for friendship)
Introducing yourself
Meeting new people
Joining a group
Giving compliments

47. What can you do?
Promote effective communication strategies - for all (including YOU!)
Evaluate and support access to age-appropriate activities
Talk to families about social skill development
Foster development of initiative

48. Thank you! Eileen Rall, Au.D., CCC-A
(215) or
Center for Childhood Communication at
The Children’s Hospital of Philadelphia
34th and Civic Boulevard, Room 112
Philadelphia, PA 19104
Thank you!