Our clinical concerns for children who are deaf or hard of hearing center on providing audible and comfortable access to sound. Our counterparts in speech-language pathology focus on developing receptive and expressive communication skills. 

Although our field excels at helping children with hearing loss who use auditory technology (i.e., hearing aids and/or cochlear implants) acquire speech, language, and hearing skills, we do not necessarily shine in addressing how these children use their communication abilities in the real world. 

Can children and adolescents who are deaf or hard of hearing apply the communication skills evaluated in the clinic to everyday social life outside of the clinic?

Impressive improvements in speech perception, speech production, and language skills have been observed in children with hearing loss who have consistent listening experience with adequately and appropriately fit auditory technology (e.g., Dettman et al, 2016; Eisenberg et al, 2016; McCreery et al, 2015; Niparko et al, 2010; Tomblin et al, 2015). The communication skills of children with hearing loss, however, continue to lag behind peers with typical hearing, even over time (Dettman et al, 2016; Geers et al, 2017; Leigh et al, 2013; Niparko et al, 2010; Nittrouer and Caldwell-Tarr, 2016; Nittrouer et al, 2016; Poursoroush et al, 2015). 

Furthermore, adolescents with hearing loss exhibit challenges in social contexts, evidenced by pragmatic deficits and more peer problems than same-age-mates who have typical hearing. 

Historically, children and adolescents with hearing loss experience lower rates of peer acceptance and higher rates of peer victimization, social isolation, and loneliness compared to peers with typical hearing (Bauman and Pero, 2011; Huber et al, 2015; Kouwenberg et al, 2012; Percy-Smith et al, 2008; Punch and Hyde, 2011; Stinson and Lang, 1994; Warner-Czyz et al, 2018; Wiefferink et al, 2012). 

They also show less proficiency at making and maintaining friendships compared to hearing age-mates (Bauman and Pero, 2011; Percy-Smith et al, 2008). Lower levels of successful interactions with peers have cascading short-term and long-term effects on mental and social well-being (Coyne and DeLongis, 1986; Kohlberg et al, 1984).

This summary of social competence in children and adolescents who are deaf or hard of hearing has limitations. Some studies suggesting higher rates of social isolation and loneliness include participants who may or may not use auditory technology. In addition, most of these studies reflect older cohorts of children with hearing loss—not a contemporary group who benefited from earlier identification of hearing loss, implementation of auditory technology, enrollment in therapeutic intervention, and activation of cochlear implants. 

Early hearing detection and intervention yielded promising communication outcomes in most children with hearing loss, with positive effects on speech perception, speech production, speech intelligibility, and language. Improved communication outcomes—particularly speech intelligibility and spoken language—underlie the establishment of social relationships with peers, especially those with typical hearing (Most, 2007; Most et al, 2012).

Summary of Research

The paucity of studies exploring peer relationships in a contemporary group of children and adolescents with hearing loss led to a series of projects in my laboratory. Participants included 40 adolescents with cochlear implants (50 percent female) and 42 adolescents with typical hearing (48 percent female). Both groups had a mean age of 14.1 years. The cochlear implant users had a mean implantation age of 3.5 years and a mean implant experience of 10.8 years. 

Results Exploring Group Differences

Quantity of friendships. We initially asked participants how many friends they had on a five-point scale, ranging from I have no friends to I have lots of friends. Auditory status had no effect on self-reported number of friendships; three-fourths of adolescents in each group reported having several or lots of friends. However, parents and professionals question if peer relationships reported by the adolescents with hearing loss reflect mutual, high-quality friendships or mere acquaintances (Markides, 1989). 

Casual group of young kids posing for pictureQuality of friendships. Anecdotal and research-based evidence naturally lead to exploration of the effect of auditory status on friendship quality. Adolescents with cochlear implants and adolescents with typical hearing rated the quality of their best friendship across six domains through the Friendship Quality Questionnaire (Parker and Asher, 1987). The group with typical hearing rated overall friendship quality slightly more positively, but the two groups did not differ significantly. 

Feelings of loneliness. We also examined loneliness—a mismatch between the desire for, and the reality of, social interactions—to address the social isolation often attributed to children and adolescents with hearing loss. All participants completed the Loneliness and Social Dissatisfaction Questionnaire (Cassidy and Asher, 1992). Similar to self-ratings of the quantity and quality of friendship, the two groups did not differ significantly on their appraisal of loneliness. 

Considering Individual Differences

Our recent findings seem at odds with anecdotal reports and previous research. Has our field progressed so much as to eliminate social deficits that troubled children with hearing loss in the past? Perhaps the answer lies not in group comparisons, but in individual differences. 

For example, friendship-quality ratings by adolescents with cochlear implants covered a considerably broader range than the group with typical hearing (10–156 points versus 86–156 points, respectively), yielding nearly 50 percent more variability in ratings of friendship quality for the group with hearing loss. The variance seen in friendship quality mirrors the vast variability characteristic of children with hearing loss. 

What can account for the variability in outcomes? Previous studies linked communication competence and friendship status with feelings of loneliness (Ladd et al, 1997; Most, 2007; Most et al, 2012). Therefore, we compared self-reported speech perception, speech intelligibility, and friendship quality with self-ratings of loneliness. Significant inverse correlations emerged such that higher communication competence and higher friendship quality coincided with lower levels of loneliness in adolescents wearing cochlear implants. 

Other variables also could contribute to the variance in outcomes. For instance, traditional variables such as audiological characteristics (e.g., implantation age, speech recognition in noise) and language proficiency (e.g., supralinguistic and social-pragmatic skills) likely influence peer relationships. 

Non-conventional factors such as temperament (e.g., shyness, affiliation, depressive mood) also may affect social interactions with peers. Future studies should investigate separately the range of factors underlying the variance in outcomes in individuals with and without hearing loss, because explanatory factors may differ based on auditory status. 

Traditionally used group comparisons that suggest no effect of auditory status on social interactions with peers may not capture the nuances of individual differences, which may affect how efficiently children with hearing loss apply communication skills in the real world. Therefore, professionals should consider not only auditory status and communication skills, but also nontraditional factors to identify pediatric cochlear implant users at risk for social isolation and loneliness and make appropriate referrals to allied health professionals.

Conclusion

Social competence—especially in peer interactions—underlies psychological well-being and quality of life across the lifespan (Coyne and DeLongis, 1986; Kohlberg et al, 1984). Thus, parents and professionals should:

Stop assuming correspondence between clinical measures and real-life social interactions.

Pay closer attention to how children and adolescents with hearing loss interact with their peers. 

Every child represents a unique amalgamation of communication skills and temperament characteristics, highlighting the importance of explicitly asking individual children and adolescents with hearing loss about their social interactions to gauge the need for provision of referrals and resources.