I Feel Good! A Guide to Support the Mental Health and Well-Being of Children and Youth who are Deaf/deaf and Hard of Hearing in Ontario's Schools

Transcription

1 I Feel Good! A Guide to Support the Mental Health and Well-Being of Children and Youth who are Deaf/deaf and Hard of Hearing in Ontario's Schools

2 Table of Contents Section 1: A Message from the Collaborators... 3 Section 2: Guiding Principles... 4 Section 3: How to Use this Guide... 5 Section 4: What is meant by Mental Health and Well-Being?... 5 Section 5: Mental Health Disorders and Risk factors for children and youth who are Deaf/deaf or hard of hearing Section 6: Mental Health and Deafness Section 7: The Developing Child Section 8: Tools and Strategies for Parents/Teachers Preschool-K K Section 9: Collaborators and Contributors Section 10: Resources

3 Section 1: A Message from the Collaborators I Feel Good!": A Guide to Support the Mental Health and Well-Being of Children and Youth Who Are Deaf/deaf and Hard of Hearing in Ontario s Schools (Guide) was developed collaboratively by VOICE for Hearing Impaired Children and the Canadian Hearing Society. This guide offers a compilation of information, strategies, and resources that promote healthy social and emotional development and is relevant to all adults who are part of the lives of children who are Deaf/deaf or hard of hearing. This resource, funded by the Ministry of Education 1, is designed to help parents and educators distinguish among problems that are age-related and developmentally appropriate, those related to the impact of a hearing loss 2, and those behaviors that may be indicative of more serious mental health and social/emotional concerns. This guide was developed to complement Supporting Minds: An Educator s Guide to Promoting Students Mental Health and Well-being, a resource developed by the Ministry of Education which provides educators with information on the early signs of mental health and addictions problems, along with strategies that can be used in the classroom to support students. This document can be accessed at It is essential that all children be given the best start in childhood and adolescence in terms of their mental health and well-being. We hope that you find information and resources in this guide to better understand children and the impact of their hearing loss in order to make good decisions that will promote healthy social and emotional development. This Guide has been developed to offer proactive and pro-social strategies as well as tools to educators and parents of children who are Deaf/deaf and hard of hearing who may be experiencing social and/or emotional problems related to their hearing loss. Mental health exists on a continuum and if you have any serious concerns about a 1 The views and opinions expressed in this guide are those of the author(s) and do not necessarily reflect those of the Province, Ministry of Education and its staff. 2 For the purposes of the 'I Feel Good' guide, the term 'hearing loss' may refer to either a partial or total inability to hear. 3

4 child s mental health, we encourage you to consult with your family doctor and school resource team. In addition, if you would like advice from or referrals to professionals who have experience with students who are Deaf/deaf or hard of hearing, contact VOICE at ww.voicefordeafkids.com or the Canadian Hearing Society at Both VOICE and CHS obtained significant support in the researching and writing of the information contained in this document through contributions from researchers in the Childhood Hearing Loss Laboratory at the University of Toronto and the Department of Psychology King's University College at the University of Western Ontario. Section 2: Guiding Principles "I Feel Good!": A Guide to Support the Mental Health and Well-Being of Children and Youth Who Are Deaf/deaf and Hard of Hearing in Ontario's Schools (Guide) represents a collaboration between the Canadian Hearing Society and VOICE for Hearing Impaired Children to create a resource for parents, educators and families of children who are Deaf/deaf and hard of hearing, and is funded by the Ministry of Education. This Guide has been designed to increase awareness and understanding of potential social and emotional issues related to being Deaf/deaf or hard of hearing. Some of these issues are interrelated to language development and ability and its effect on healthy social interaction, however this Guide is not intended to instruct parents and professionals in specific techniques that address language acquisition in children who are Deaf/deaf or hard of hearing. The Guide s focus is on providing tools, strategies and resources that promote mental health and well-being of students who are Deaf/deaf or hard of hearing. The Ministry of Education uses the terminology children who are Deaf/deaf and hard of hearing to identify children who have a range of hearing losses. Other terms that are used to address this population include culturally Deaf, deaf, deafened, hard of hearing, hearing impaired, or oral deaf," and this list is not exhaustive. For clarity, in this Guide the terminology children who are Deaf/deaf or hard of hearing will be used to 4

5 refer to a broad range of children who are using either a spoken language, a signed language, or both, and includes both audiological and cultural perspectives. Section 3: How to Use This Guide I Feel Good! : A Guide to Support the Mental Health and Well-Being of Children and Youth Who Are Deaf and Hard of Hearing in Ontario's Schools is an online resource for parents and professionals supporting children who are Deaf/deaf or hard of hearing at different stages of social and emotional development. Each section addresses a different topic and can be read as a stand-alone. The sections do not have to be read in sequence. As such, since each section can be read separately, readers might find that some information is repeated. The sections have been divided according to developmental stages; if your child is not exhibiting behaviors expected for a certain age, refer to the previous section and focus on reinforcing the development of those skills. Parents and professionals are encouraged to use this Guide in whatever order is best suited for the children they are supporting. This Guide is one among many resources available. Throughout the Guide, we have provided links to relevant guides and resources where appropriate. Section 4: What is meant by Mental Health and Well Being? The World Health Organization defines mental health as, "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community" (WHO, 2007). Rather than focusing on how negative interactions affect mental health, this perspective emphasizes the positive qualities that allow individuals to 5

6 succeed and thrive in society, many of which involve elements of healthy child and family support systems and the development of strong social and interpersonal communication skills. Characteristics of Positive Mental Health: Courage, optimism, hope, honesty, interpersonal skills, work ethic and perseverance. Ability to enjoy life Living in the moment, appreciating the now." Ability to learn from the past and plan for the future without dwelling on things that can t be changed or predicted. Resilience Ability to bounce back from hard times, manage stress without loss of optimism. Balance Ability to juggle many aspects of your life. Ability to make changes to restore balance when necessary. Self-actualization Recognition and development of individual strengths to reach one s full potential. Flexibility Ability to feel and express a range of emotions. Ability to solve problems and revise expectations. Parents play a very important role in guiding the development of these attributes of positive mental health in their children. Each child (and parent) is unique with their own temperament, personality, strengths and weaknesses and the interactions of these factors with the environment, genetics, and the challenges of life make each parent/child relationship a little bit different. There may not be an absolute recipe for success, but authors such as Paul Tough ( How Children Succeed Grit, Curiosity, and the Hidden Power of Character ") outline seven character traits key to childrens' success, especially at school: 6

7 Grit Curiosity Self-control Social intelligence Zest Optimism Gratitude Child Development The developmental years (the time period between birth and the end of adolescence) are marked by the achievement of multiple developmental milestones. Developmental milestones are functional skills or age-specific tasks that most children can do within a certain age range. Each milestone that a child reaches is like a building block or stepping-stone fostering the next phase of change. Child development typically progresses through four major skill areas, which are: Language: Expressing needs, wants and thoughts; using body language and gestures; and understanding what others communicate. Movement and muscle coordination: Using the body s large muscles (sitting, standing, walking, running, keeping balance, and changing positions) as well as small muscles (eating, drawing, playing, dressing, colouring) and developing hand-eye coordination. Play and social: Having relationships with others, cooperating, and responding to the feelings of others. Thinking and reasoning: Learning, understanding, problem-solving and remembering. It is natural for parents to compare their child s progress with other children. However, 7

8 although most children meet milestones within an average range, every child develops in a unique way and at a different rate. There are clearly wide variations in what is considered normal, influenced by factors such as genetics, intellectual stimulation, family history, parenting skills, physical and mental health, culture, nutrition, as well as environmental and educational factors. While recognizing that each child develops differently, a general knowledge of expected developmental benchmarks may help alert parents and/or clinicians of development that is atypical for children who are Deaf/deaf and hard of hearing. Children who are late in achieving developmental milestones may be showing delays in one or more areas of development. Language, play/social and thinking/reasoning all have important influences on the child s mental well-being. Language Development Communicating with a child is one of the most important things parents can do. This, however, can be one of the most difficult challenges facing Deaf/deaf and hard of hearing children. Regardless of whether parents decide to provide hearing technology such as hearing aids or cochlear implants to assist with their child s effective communication, it is very important that a child learns language whether spoken, signed or a combination of the two from a very early age. Language has a significant impact on the development of positive mental well-being and health. Play and Social Development Age-appropriate social language skills are required in order for children to develop positive social relationships (Gallagher, 1993). The inability to develop social networks has been shown to result in an increased incidence of psychosocial and mental health problems. Furthermore, poor social skills and self-concept in the early years are strong predictors of adult outcomes. 8

9 Social and interpersonal skills that have been linked to promoting positive self-esteem and well-being include: thinking independently developing self-control understanding the feelings, needs and motivations of oneself and of others understanding and expressing a range of emotions learning from past experiences in planning for the future responding to challenges and obstacles through effective problem solving recognizing and developing one s strengths through self-actualization self-advocacy effectively navigating diverse social situations managing communication breakdowns maintaining healthy relationships with others Research has shown that Deaf/deaf children of hearing parents may lag several years behind hearing children of hearing parents in terms of their development of theory of mind (Lundy, 2002) which is part of social development. Du Feu & Chovaz (2014) describe how baffling it must be for Deaf/deaf and hard of hearing children to make sense of their parents or friends behaviour if they cannot understand the thoughts and feelings of another person (theory of mind). A delay in the development of theory of mind may result in reduced consequential thinking (Gray, Hosie, Russell, & Ormel, 2003), less developed emotional vocabularies, less understanding and recognition of emotion and emotional regulation, and weaker coping skills (Johnson, 2012). It is encouraging to know that these constructs are currently being studied by researchers to help us better understand how best to support these children. Being Deaf/deaf or hard of hearing does not mean that a child cannot successfully master social development milestones, but access to language is key. Developing 9

10 language is an interactive process that allows Deaf/deaf and hard of hearing children to participate fully in their environment. It is never too early to begin to work on these areas of social competence. Even very young children can be guided by their parents and teachers to develop these skills at an age-appropriate level. Developing these competencies may prevent the development of negative social consequences and reduced feelings of well-being and self-esteem. The link below provides an article for more information on the impact of being Deaf and hard of hearing on psychosocial development: Thinking and reasoning Children who are Deaf/deaf and hard of hearing have the capacity to reach the same cognitive and developmental milestones as children who have normal hearing. As with hearing children, some Deaf/deaf and hard of hearing children may be within the average range of intelligence, some may be intellectually gifted and some may be developmentally delayed. Children who are Deaf/deaf or hard of hearing may struggle with reading and writing, resulting in delays in academic achievement and literacy skills, which have been shown to negatively affect children's mental health and self-esteem (Hindley, 2005). These struggles may be related to language issues as well as difficulties accessing the world around them and not to intelligence. Having a Hearing Loss versus Having a Mental Health Problem Children who are Deaf/deaf or hard of hearing can and do live emotionally healthy lives. Similar to children with typical hearing, some will excel in their academics and their relationships and some will know hardship including poor education, poor choices and offences against society. Parents and educators want the best for their children and students, so it is vital to become aware of potential risk factors that might increase the 10

11 chances of the child or youth developing a mental health difficulty, learn strategies to promote better health, and know where to turn if concerns arise. Having a hearing loss is not a mental health issue and does not necessarily predispose a child to having a mental health disorder. As with any child, risk factors such as genetics, biology, environment, parent-child relationships, infections, and disease may increase the risk of mental health problems. Having a hearing loss does not cause disorders nor is it a disorder. However, there are various consequences that may be associated with hearing loss that may indirectly or directly heighten the risk of mental health issues. Some of these include etiology or the cause of the hearing loss. For example, a toddler who loses hearing due to meningitis (an infection of the lining of the brain) may also experience difficulty in areas that affect learning or reasoning. In this way it can be seen that having a hearing loss did not cause the mental health disorder yet it is associated with it. Other risk factors associated with being Deaf/deaf or hard of hearing include: Prematurity High fevers Infections Genetic syndromes Language delays Maternal rubella Cytomegalovirus (CMV) Late identification of hearing loss All of these risk factors may have an effect on a child s mental health and well-being. As such, parents who are aware of these risk factors are in a better position to support their children in their developmental years. 11

12 Mental Health Issues Some research has shown that children with hearing loss may be more vulnerable to mental health and psychosocial problems than their peers with typical hearing. Children s Mental Health Ontario estimates that 1 in 5 Canadian children will experience a mental health disorder. It is not difficult then to predict that Deaf/deaf and hard of hearing children facing potentially more challenges may have higher rates of distress (Du Feu & Chovaz, 2014). Research cites the incidence of emotional difficulties to be 3-6 times higher in school-aged children who are Deaf/deaf or hard of hearing than in their peers with typical hearing (Health Canada, 1994; Hindley, 1997; 2000; 2005). Children who are Deaf/deaf or hard of hearing may have any of the mental disorders experienced by all children including behavioural disorders (impulsivity, hyperactivity) or social-emotional difficulties (anxiety, depression). In addition, children with hearing loss are also 3-4 times more likely to experience additional handicapping conditions than children with typical hearing. These include visual impairments, motor difficulties, and learning difficulties all of which may impact mental health. The child who uses hearing aids faces unique challenges in family, social and school situations. Existing hearing technology is not a perfect replacement for typical hearing, and children with hearing loss continue to face many challenges in accessing and processing auditory information. Situations such as multi-talker conversations in small and large group interactions, and situations involving background noise or other difficult listening conditions can cause extreme difficulties for children wearing even the most sophisticated hearing technology and are particularly problematic for children who are in the language learning period (Flexer, 2011). With current trends toward educating children in their local communities, it is often the case that there is only a single child with a hearing loss in a particular school. Children who use spoken language and wear hearing technology may also see themselves as being less attractive and less socially accepted than their peers with typical hearing as a result of their need to wear hearing technology (Cappelli et al., 1995). Hearing technology itself is often visible on the head and may draw attention to itself, requiring 12

13 verbal explanation. These children and their parents may be asked unwanted questions about their technology and their hearing loss. The lack of awareness in the general public regarding hearing loss in general and hearing loss in children in particular may make this situation especially challenging. Children need to be given the language and the confidence to be able to respond to these questions in a socially acceptable and self-affirming manner. Children who sign and use a sign language interpreter in the classroom face similar challenges regarding their unique and highly visible situation. In addition, these children may feel left out of peer interactions during recess, breaks or on the bus when the interpreter is not available. This may contribute to feelings of loneliness and isolation as well as affording fewer social learning opportunities. In summary, Deaf/deaf and hard of hearing children in integrated settings may have less opportunity and more difficulty to develop the age-appropriate social skills necessary for friendships and interactions with their peers. Families Families who have a Deaf/deaf or hard of hearing child experience many of the same successes and challenges as other families. For some families, learning that their baby is Deaf/deaf or hard of hearing may change family dynamics and impact many different areas of family life. Effects may be experienced in the marital relationship, interactions between parent and child, relationships with siblings, relationships with extended family members, family gatherings, and everyday family routines. For example, having a Deaf/deaf or hard of hearing child may affect paternal career choices and limit family leisure time due to additional related responsibilities. Siblings may feel neglected or resentful of the amount of attention given to their Deaf/deaf or hard of hearing sibling. Extended family members may experience similar grieving and acceptance processes following the child s identification. Conflict between the child s parents may occur due to different levels of perceived responsibility or due to different views, priorities, or preferences during times of decision making. 13

14 The following are key factors that hearing parents can focus on to create a family environment that will establish social and emotional development of their Deaf/deaf and hard of hearing children: Early identification of deafness or hearing loss and professional involvement markedly improve overall functioning and increase feelings of self-esteem. Promote early attachment, family support, and acceptance of the child. Provide adequate life experiences for your child to learn behaviours and attitudes appropriate to family and society. Find a balance when encouraging your child s exploration (restriction and overprotection may hinder independence). Reinforce strengths in your child to promote feelings of competency rather than inferiority. Encourage the use of technology and the Internet that can provide access to information and social contacts. Provide opportunities for social relationships, building social networks at school, but also within the home and community. Encourage social experiences with Deaf peers that can lead to comfort and identification with Deaf culture. Encourage participation in extracurricular activities. Expose your child to Deaf/deaf and hard of hearing adults, role models and mentors. Seek out skilled, educated and caring professionals to work with the child and family. 14

15 Section 5: Mental Health Disorders and Risk factors for children and youth who are Deaf/deaf or hard of hearing A differential diagnosis is the term used when identifying the presence of one disorder where there are multiple alternatives possible. This method is essentially the process of obtaining information that identifies the presence of an additional condition aside from the hearing loss. The challenge for the professional is to be familiar with the development of children with hearing loss in order to identify the possibility of other disorders, especially those with a language component (e.g. delays and disorders in speech and language unrelated to hearing loss). When a parent or educator is concerned about the development of the child who is Deaf/deaf or hard of hearing, it is imperative to seek out the knowledge of those professionals who are experienced with this population. Below are some descriptions and symptoms of disorders often showing comorbidity with hearing loss. Developmental Disorders Autism Spectrum Disorder (ASD) ASD is a complex neurodevelopmental disorder that affects the way the child s brain functions. Children with ASD typically have difficulties with social behaviours, communication, and exhibit restricted, repetitive, and stereotyped behavioural patterns. The cause of ASD is not entirely known, though there is considerable evidence that genetics play a part. Children with ASD typically show delays and disturbances in their language development. Deaf/deaf children may display language deprivation, which can present like a language delay, but which is, in fact, due to a mismatch between the language used in the home and the language the child can access. The important and fairly consistent difference, however, is that a Deaf/deaf child typically shows communicative 15

16 attempts, whereas typically the child with autism does not. If concerns arise, it is essential that parents seek out clinicians with an understanding of how ASD presents itself in a Deaf/deaf or hard of hearing child to ensure accurate diagnoses and avoid both missed and mis-identifications. Intellectual Disability (also called developmental delay) An Intellectual Disability involves delays in everyday living (i.e. adaptive behaviours) and lower scores on formal intelligence tests. Examples of adaptive behaviours include communication competence, personal care skills, functional reading and writing, and social skills. These delays must be apparent during childhood. A Deaf/deaf or hard of hearing child may have an intellectual disability as a result of associated risk factors. For example, many children with Down syndrome have both some degree of hearing loss and an intellectual delay, and a child who suffered from meningitis may have changes or damage to the brain, resulting in lowered intellectual functioning as well as damage to the auditory system. Since these children present with signs of both an intellectual disability and hearing loss, a comprehensive psychological assessment is essential to accurately identify both. Unfortunately, Deaf/deaf and hard of hearing children without an intellectual disability may show lack of communication skills related to their language deprivation in the early years rather than deficits in their ability to think and reason. Mainstream testing of IQ typically utilizes tests of intelligence that are language-loaded meaning the child needs a good grasp of language for mastery of the tests. These tests may be both inappropriate and unfair for use with Deaf and hard of hearing children depending on factors such as their exposure to and mastery of language. Use of these tests of intelligence by uninformed clinicians may yield both false negatives (concluding that Deaf/deaf children are intellectually intact when they are not) and more commonly false positives (concluding that Deaf/deaf children have an intellectual disability when, in fact, they do not). It is important to differentiate a true developmental delay from the far- 16

17 reaching effects that lack of language access may have on childhood development of cognitive (thinking) and linguistic (language) skills. Parents are urged to ensure any formal testing of their child is done by clinicians knowledgeable of these issues. Affective Disorders Affective disorders refer to mental health disorders that affect moods such as anxiety and depression. These are among the most common mental disorders among children and there appears to be an even greater prevalence of these emotional and behavioral disorders in children who are Deaf/deaf or hard of hearing. Although being Deaf/deaf or hard of hearing in itself does not cause these disorders, it is again likely that risk factors such as language deprivation, neurological vulnerability, family issues, and barriers created by society all influence the child s overall development. The outcome of this may potentially have an important impact on how children who are Deaf/deaf and hard of hearing experience and react to the world around them. Anxiety Disorders Anxiety disorders are one of the most common mental health disorders among all children. Some of the manifestations of anxiety in children include the following: avoiding school or extracurricular activities repeated requests for reassurance from parents becoming easily upset frequently experiencing sleep difficulties and nightmares complaining of stomach cramps, light-headed, headaches, vomiting and diarrhea sleep difficulties and nightmares Feeling angry, sad, hopeless, embarrassed out of proportion to the situation 17

18 Some research studies suggest that children who are Deaf/deaf and hard of hearing may be more vulnerable to developing anxiety disorders given a more limited understanding of the world around them (incidental learning, theory of mind), difficulties communicating, and feelings of isolation. In a world that does not make sense (i.e., language, theory of mind, emotions etc.) in addition to the behaviours seen above, children who are Deaf/deaf and hard of hearing may seek to impose order upon their chaos through engaging in preservative and obsessive behaviours. Suggestions for parents to minimize anxiety in children who are Deaf/deaf and hard of hearing include the following: 1. Respond to issues associated with being Deaf/deaf and hard of hearing in an adaptive way that will positively influence the child s self-esteem. 2. Strive for clear, meaningful and accessible communication. 3. Expose the child who is Deaf/deaf or hard of hearing frequently to Deaf/deaf and hard of hearing role models to foster a stronger sense of belonging and a better understanding of the world. 4. Observe your child for behaviours and/or emotions that indicate they are feeling anxious. 18

19 Depression Some studies report that Deaf/deaf children show higher rates of depression than hearing children. However, this higher rate of depression is not directly related to the actual hearing loss. These children may share the same risk factors of being teased, mistreated, or neglected, but Deaf/deaf and hard of hearing children may also have significant problems making themselves understood to hearing peers and adults, which contributes to the overall higher rate of depression. Once again, this highlights the association between language and the manifestation of psychiatric disorders such as depression. Some of the following are signs of depression in hearing children: Frequent vague, non-specific physical complaints such as headaches, muscle aches, stomach aches or tiredness Frequent absences from school or poor performance in school Talk of or efforts to run away from home Outbursts of shouting, complaining, unexplained irritability, or crying Being bored Lack of interest in playing with friends Alcohol or substance abuse Social isolation, poor communication Fear of death Extreme sensitivity to rejection or failure Increased irritability, anger, or hostility Reckless behaviour Difficulty with relationships 19

20 Parents need to be aware of how and why these signs of depression may be expressed by Deaf/deaf and hard of hearing children. For example, a Deaf/deaf or hard of hearing child who was deprived of language during their early years may have difficulty communicating thoughts of running away from home, fearing death, or expressing nonspecific physical complaints. Deaf/deaf and hard of hearing children who feel isolated attending a school program with hearing peers, may not have close relationships, feel somewhat bored and not have any regular playmates. In such cases, even greater care must be taken when parents and/or clinicians consider depression to ensure accurate identification. Behaviour Regulation Disorders Attention Deficit Hyperactivity Disorder (ADHD) ADHD is a common neurobiological disorder characterized by: hyperactivity (difficulty regulating activity level) impulsivity (difficulty inhibiting behaviour) and/or inattention (difficulty attending to the task at hand). Teachers and parents often report that Deaf/deaf and hard of hearing children are fidgety, easily distracted and not able to maintain attention on task. It is important to recognize, however, that these behaviours do not necessarily lead to higher rates of ADHD among Deaf/deaf and hard of hearing children, especially when these children are assessed using accessible and appropriate measures. It appears that children with a hereditary cause of hearing loss are not at a greater risk of developing ADHD, yet children with acquired hearing loss are at a significantly higher risk of doing so. This difference is likely related to the medical conditions causing the hearing loss, the family dynamics, and the language delays which distinguish these two groups. If a child becomes Deaf/deaf or hard of hearing as a result of an infection, disease, or trauma, parents should be vigilant in observing and understanding their 20

21 behaviour. However; children who exhibit symptoms of ADHD do not always have the disorder; their behaviours may be related instead to communication difficulties, boredom, and isolation from mainstream activities. Oppositional Defiant Disorders (ODD) and Conduct Disorders (CD) ODD and CD are a group of behavioural and emotional problems in children and youth. ODD is characterized primarily by aggressiveness and a tendency to purposefully bother and irritate others, while children and adolescents with CD have great difficulty following rules, accepting authority, and behaving in a socially acceptable way. The list of risk factors that contribute to the development of behavioural disorders in hearing children is the same as for many Deaf/deaf and hard of hearing children and adolescents. In addition to these risk factors experienced by both groups, children with sensorineural (nerve) hearing loss rather than a conductive (bone) loss seem to show significantly higher rates of these types of behaviour problems than hearing children. This is likely because some causes of hearing loss, such as meningitis, may contribute to negative behaviours even though being Deaf/deaf or hard of hearing is not the cause. Other risk factors for Deaf/deaf and hard of hearing children associated with ODD and CD are as follows: academic difficulties vulnerability to maltreatment (e.g. bullying, abuse) communication difficulties with parents overly harsh, controlling and intrusive parenting practices. It should be noted that in addition to the above risk factors, there appear to be strong links between language and behaviour problems for both hearing and Deaf/deaf and hard of hearing children. It is not clear whether problems in language development lead to behaviour problems, if language problems are the result of behaviour problems or whether both language and behaviour problems are actually both part of an overall 21

22 developmental delay. It is clear, however, that Deaf/deaf and hard of hearing children of hearing parents are considered at even a greater risk of behaviour problems as either a direct or indirect function of the language deprivation they may have experienced in addition to other known risk factors. It should be noted that Deaf children of Deaf parents can also have behaviour problems, but likely for different reasons. Substance Abuse The principles underlying addiction are the same for hearing adolescents as for Deaf/deaf and hard of hearing adolescents. The difference, however, is that Deaf/deaf and hard of hearing youth may experience higher levels of stress in their lives related to communication difficulties, isolation, relationships, educational and employment opportunities. As a result, Deaf/deaf and hard of hearing adolescents may turn to alcohol or drugs as a way of coping with their stress. The Deaf/deaf and hard of hearing adolescent who abuses substances may not have information on alcohol/drugs and treatment programs in a way which is accessible to their hearing peers. Frequently, recovery programs are group-based and support systems are offered through peer telephone contact, which may pose difficulties for Deaf/deaf and hard of hearing individuals. 22

23 Self-Harm and Suicide Self-harm can be a child or youth s way of coping with emotional pain. Emotional pain might include feelings such as sadness, frustration, confusion, self-loathing, guilt or rage. Self-inflicted pain can sometimes be a way of expressing feelings that the child doesn t know how to express using language. For example, the action of cutting seems to temporarily provide a distraction from emotional pain; children often report that it makes them feel better, at least for a short time. However, the feelings return and the cycle repeats with the urge to hurt themselves again. It is important for all parents to understand that self-harm behaviour is not just looking for attention, as this may trivialize the depth and extent of the pain their child is actually feeling. Deaf/deaf and hard of hearing children may experience more risk factors than hearing children, which may contribute to overwhelming feelings which may lead to selfharm. These risk factors include communication issues, isolation, loneliness, and difficulties accessing mental health services. Although there is a significant gap in the research literature in terms of absolute numbers of Deaf/deaf and hard of hearing children who self-harm, the more important point is that parents must be aware of these behaviours and risk factors leading to it. Children who die by suicide may be feeling so much emotional pain that they feel they have no other option. Young people, including those who are Deaf/deaf and hard of hearing, may feel tremendous pressure in many areas of their lives, including home, school, and peer groups and often are unable to see solutions to their problems. When this pressure exceeds a child s ability to cope, suicide may seem like an option. Parents, teachers and communities must be aware of these signs of stress in youth. The following links provide parents with more information on the topics of self-harm and suicide:

24 Section 6: Mental Health and Deafness A hearing loss is not a mental health issue and in itself does not predispose a child to having a mental health disorder. However, there are clearly a number of risk factors associated with deafness (described earlier in this Guide) which may affect the mental health of children who are Deaf/deaf or hard of hearing. As such, parents and educators need to educate themselves about and encourage the development of skills that will promote good mental health. Protective Factors A proactive approach that promotes well-being for children and youth shifts the focus from risk factors and deficits to the development of protective factors that build on the family s and the individual child s strengths. Protective factors are individual or environmental characteristics, conditions, or behaviours that reduce the effects of stressful life events ( Protective factors which promote positive mental health in children and youth include: Positive nurturing and attachment Knowledge of parenting and of child and youth development Resilience (parent, family and self) Social connections Concrete supports for parents 24

25 How will protective factors help? Protective factors encourage: Clear self-concept High self-esteem and confidence Self-efficacy Self-advocacy An ability to deal with change Skills and values that lead to efficient use of personal ability A good range of social problem solving skills Aspirations for the future The feeling of having options The feeling of being in control of one s life Parental reactions to the identification of hearing loss Parents hold dreams about their baby based on assumptions including the ability to communicate fully, effectively, and intuitively without barriers, just as their parents communicated with them. Parents emotional response and how they cope when they find out that their child is Deaf/deaf or hard of hearing will affect both family adjustment and child outcomes. Parents who can cope and adjust to the psychological stress precipitated by the identification can have a positive influence on their child s development. 25

26 Risk factors High parental stress is associated with: Child socio-emotional problems Child behaviour problems Child variables including: o children with disabilities in addition to being Deaf/deaf and hard of hearing o late language acquisition relative to their chronological age (communicative/language competence) o Inhibited parental involvement Protective factors Low parental stress is associated with: Parental access to personal and social support/resources support Sense of meaning in one s life Parental involvement Parents want information about accessing services, capacity-building informational resources, supports for parenting skills, and social supports. Top-ranked sources of support as indicated by parents include the following: individual professionals with expertise in the area other parents of children who are Deaf/deaf or hard of hearing family support organizations grandparents/extended-family members opportunities to connect with mentors and role models 26

27 service providers dedicated to children who are Deaf/deaf or hard of hearing, such as VOICE ( and CHS ( Parents have also shared that the following factors empower families to be resilient thereby promoting better outcomes for their children: family time and routines social support affirming communication attempts developing problem-solving skills having a religion and/or faith providing daily love and encouragement gathering many informational resources having high expectations actively searching for meaning and acceptance of the child s Deaf/deaf or hard of hearing status. Section 7: The Developing Child Developmental Milestones Child development generally refers to the time period between birth and the end of adolescence. This time period is markedly different from any other stage of human development for it encompasses tremendous biological, psychological, social and 27

28 emotional changes. These developmental changes represent a progression from dependency towards increasing independence, and are marked by the achievement of developmental milestones. Developmental milestones are functional skills or age-specific tasks that most children can do within a certain age range. Each milestone that a child reaches is like a building block or stepping-stone fostering the next phase of change. Child development typically progresses through four major skill areas, which are: Language: Expressing needs, wants and thoughts, using body language and gestures, understanding what others say/sign and expressing complex and abstract thought. Movement and muscle coordination: Using the body s large muscles (sitting, standing, walking, running, keeping balance, and changing positions) as well as small muscles (eating, drawing, playing, dressing, colouring) and developing hand-eye coordination. Play and social: Having relationships with others, cooperating, and responding to the feelings of others. Thinking and reasoning: Learning, understanding, problem-solving and remembering. Language Development Language is a very important key to success in the development of mental health of children who are Deaf/deaf or hard of hearing. 28

29 Early Language Development (0-3) The first three years of life are a period of incredible growth in all areas of a baby s development. Babies primary attachment is to their parents and these relationships are the foundation upon which babies build their knowledge of the world. All babies and toddlers need positive early learning experiences to foster their intellectual, language, social and emotional development and lay the foundation for later success. Early Screening Every year in Ontario, approximately four in 1,000 babies are born Deaf/deaf or hard of hearing. In addition, some infants or children will lose their hearing in the early years due to infections, high fevers, trauma, and genetic disorders. Many of these children may need to learn speech and language differently, so it is important to detect a hearing loss as early as possible. Early identification also provides parents with support and information which allows them to educate themselves regarding their child s needs. It is helpful for parents to meet with professionals, and other families with children who are Deaf/deaf or hard of hearing, who have travelled the same journey. One of the most crucial decisions parents will make at this time is how their children will develop language. Identifying a hearing loss early ensures that children can get the help they need and the chance to develop language skills comparable to typically hearing children. Babies born in Ontario are screened for hearing loss at birth and audiological and language intervention services are available to families though government funded programs. The following link provides more information about screening, child development, language stages and intervention services: 29

30 Family Reactions Some parents are prepared for the possibility that their baby will have a hearing loss. This may be because members of their family are Deaf/deaf or hard or hearing and/or the baby s parents are Deaf/deaf or hard of hearing themselves. These parents usually already have some knowledge, supports, and parenting experience. However, approximately 90% of children with a hearing loss are born to hearing parents and, for many, it may be a new experience. Some commonly expressed concerns are: How will we communicate? How do we parent her? How will his brother and sister play with him? How will he learn? What about her grandparents? Will she love us? Will he be normal? How will we know what to do? A baby who has been identified with a hearing loss is a baby like any other. Babies need love, care, and nurturing in order to develop secure attachments. A secure attachment between a baby and their parent leads to the healthy development of emotions, as well as a better understanding of relationships later in life. However, there are some important differences in parenting a baby who is Deaf/deaf or hard of hearing. It is not that parents need to do more or less for their child, but will need to do things differently. The following are some recommendations to consider in this early stage of getting to know your baby: 30

31 make effective language decisions communicate with your child play with your child ensure safety build a support team practice positive parenting have lots of patience take time with your spouse maximize strengths minimize weaknesses Communicating with their child is one of the most important things parents can do. This, however, can be one of the most difficult challenges facing children who are Deaf/deaf or hard of hearing. Whatever mode of communication parents decide for their baby, spoken or sign language, or what kind of amplification (hearing aids, cochlear implants) is decided, it is very important that the baby learns language from an early age. When a baby is born (and even while still in utero), a very specific area of the brain is ready to learn and use language. This highly specialized part of the brain does not particularly care which language is used - it just wants language. Early language milestones are found in the following link: chure_services.aspx Cognitive Development Cognition (or intelligence) is multi-faceted involving a combination of different language and non-language aspects: perception, memory, mental imagery, concept formation, problem solving, language learning, academic achievement, and navigating everyday life. Intelligence depends on the interaction between a child s innate capacity (i.e. what they are born with) and their environmental experiences. The human brain is remarkably flexible in that it works to capacity. It also tends to follow the maxim use it or lose it in terms of both structure and function. 31

32 Children who are Deaf/deaf and hard of hearing have the capacity to reach the same cognitive and developmental milestones as typically developing hearing children. As with hearing children, some Deaf/deaf and hard of hearing children may be intellectually gifted and some may be developmentally delayed. There is also the possibility that a Deaf/deaf or hard of hearing child may experience cognitive delays. Delays can be the result of something genetic that impacts the child s cognitive abilities (which may occur with certain etiologies, (i.e. causes of being deaf) or can be due to environmental conditions. It can be difficult to determine the intellectual level of Deaf/deaf and hard of hearing children in part because most intelligence tests used to measure cognitive abilities are not designed for children who are Deaf/deaf or hard of hearing. Professionals administering these tests with this population of children should have extensive experience with Deaf/deaf and hard of hearing students who use spoken language and/or signed language and are able to accommodate their needs. Social and Emotional Development Theorist Erik Erikson describes a framework for understanding psychosocial development in a child. Each critical phase in the sequence of a child s development is characterized by a specific task with the child hopefully achieving the goal on the left: Task Age Range Parents Role Basic trust vs. mistrust Infancy 0 1 yr. Providing most basic needs Autonomy vs. shame and doubt Early childhood 1 3 yrs. Respecting and developing child s independence Initiative vs. guilt Play age 3 6 yrs. Gentle, clear coaching of 32

33 boundaries Industry vs. inferiority School age 6 12 yrs. Teaching child to enjoy learning, productivity and striving for success Identity vs. confusion Adolescence yrs. Support and encourage adolescent s exploration and practice of being an adult Healthy social and emotional development will provide the child with a solid sense of self and strong inner security. Therefore, it is important for parents and educators to attend to this process of development to support a successful outcome. Reflection on Erikson s developmental tasks and the parents role in the child s achievements emphasizes again the importance of meaningful and clear communication between parent and child. Section 8: Tools and Strategies for Parents/Teachers One of the best ways to prepare all children and teens to deal with everyday challenges is to give them the emotional life tools they need to have successful connections with friends and adults in their social circles. Although childhood is thought to be a time of growth and development without the responsibilities of adulthood, it is a period that can carry concerns and anxiety related to social interactions, academics, and athletic accomplishments. Additional challenges, such as a hearing loss, other sensory or learning issues, may further impact the ease and confidence with which a child or teen navigates through life stages. A strong command of language forms the crucial foundation onto which children and teens build their knowledge of the world and interactions. Social language and skills are naturally learned by typically hearing children through overhearing, observations, and often with no direct teaching. These skills are naturally developed by children as they 33