Social inclusion for children with hearing loss in listening and spoken Language early intervention: an exploratory study

Despite the acknowledgment of social inclusion and its positive benefits, a common understanding of its conceptual underpinnings and approaches to measurement has not been reached [7, 8]. Social inclusion is measured using varying methods across the different fields of economics, education and health, which may contribute to this inconsistency. Discussion in these fields centre on two perspectives; a policy or a clinical perspective (specifically for individuals with disabilities). From a policy perspective, indicators of economic self-sufficiency and education are mainly used to measure social inclusion [9, 10]. In the clinical context, literature on the social inclusion of children with disabilities primarily focuses on social interactions, school participation and the way that children with disabilities are included in these contexts. Much of the literature examining the social inclusion of children with disabilities focuses on the type of school that the child attends. This views social inclusion as a state (e.g. that all students should attend mainstream schools) [11]. However, social inclusion can also be seen as a process by which participation is increased, or as a means to an end (e.g. academic outcomes are improved in mainstream schools), or more broadly as a value system concerned with human rights and based on citizenship and community membership [11, 12]. Through the lens of a value system, social inclusion is viewed as broader than the way that a child is accepted and included within an education setting by also incorporating community and all aspects of the child’s life [11, 12]. It is implied within a value system that the classroom and community need to change to accommodate the child with different needs, and it is not simply about the child being present in those environments [2, 13]. This is highlighted by Hyde who explains, “included students are mainstreamed but not all mainstreamed students may be included.” ([2], p93). For example, a child may be in an inclusive school or community environment but may not feel included if they are bullied by peers who do not understand how to support their needs [14‐17]. Therefore, experiencing a sense of belonging is increasingly seen to be a key element of social inclusion [18].

The policy and clinical perspectives of social inclusion have been captured within a framework depicting five facets (perspectives) of social inclusion: economic participation, health and access to services, education, personal independence and determination, and interacting with society and fulfilling social roles [19]. The five facets of social inclusion demonstrate that there is more to social inclusion than economic participation or participation in the school environment. They also demonstrate the complexity involved in measuring social inclusion. In this paper, social inclusion will be defined as the purposeful connection of the individual with their social setting rather than purely being present in the setting.

As previously mentioned, it is reported that children with hearing loss may experience lower levels of social inclusion than their typical hearing peers and communication skills may be an influential factor [1, 2]. The focus of these studies on adolescents [1] and the narrow view of social inclusion in only education settings [2] limits the applicability of their findings to understanding the social inclusion of children with hearing loss across the breadth of everyday life as outlined in the above framework.

There are studies, although not explicitly focused on social inclusion, that do provide some insight into the domains listed in the framework, particularly in relation to the facet of ‘interacting with society and fulfilling social roles’. For example, there is evidence to suggest that children with hearing loss under 10 years of age have difficulties with: attention [20]; behaviour [20‐22]; communication [20]; and relationships [23]. This literature indicates that children with hearing loss experience restricted levels of social inclusion on these domains of the ‘interacting with society and fulfilling social roles’ facet. In comparison, a study by Percy-Smith, Cayé-Thomasen, Gudman, Jensen & Thomsen [24] took a slightly broader view, investigating self-esteem and social well-being, which also fit within the proposed new facet of ‘interacting with society and fulfilling social roles’. This study included 164 children with cochlear implants (educating using listening and spoken language or sign language) and 2169 typical hearing children aged 2–17 years. The authors found only minor differences between the two groups, with children with cochlear implants scoring the same, if not better than the typical hearing children on aspects of self-esteem and social well-being [24].

A more recent study by Warner-Czyz and colleagues also reported similar findings for self-esteem, where the 50 children and adolescents with hearing loss in the study had significantly higher ratings of self-esteem to hearing peers [25]. The children with hearing loss were aged eight to 18 years, aided using hearing aids or cochlear implants and had received listening and spoken language early intervention. Additional factors to influence self-esteem in the study included personal behaviours such as attention, affiliation, temperament and mood. Communication skills (as rated by the participants), participant age, age of fitting of hearing aids or cochlear implants, duration of use and social engagement (e.g. participation in activities and friendships) were not found to be linked to self-esteem [25].

In a previous study, we investigated the impact of spoken language skills on social inclusion for 95 children with hearing loss aged 5 years [19]. Using the facets of ‘education’ and ‘interacting with society and fulfilling social roles’, it was found that speech skills and vocabulary impacted social inclusion. When looking at the facet of ‘education’, speech skills were predictive of conduct skills such as the children’s ability to regulate behaviour, and use of social resources such as computers. For the latter, it was suggested that children with better speech skills spent more time using technology rather than needing more structured time with parents to work on their speech. Vocabulary skills also predicted parent satisfaction with teacher support, where higher skills reflected higher satisfaction. On the facet of ‘interacting with society and fulfilling social roles’, vocabulary skills also predicted whether the children with hearing loss were invited to social activities such as birthday parties. Better skills were likely to reflect more meaningful interactions with peers and being invited to social events [19].

To contribute to the existing knowledge, this study aimed to investigate the social inclusion of children aged 4–5 years who are educated using listening and spoken language early intervention (a cohort for which literature on this area is particularly limited) and compare these outcomes to those of their typical hearing peers. The study focused on the two facets of social inclusion using the new framework which were most relevant at the clinical level for this age group and closely related to the goals of listening and spoken language early intervention:

Although the facet ‘personal independence and self-determination’ is relevant at the clinical level, its applicability is limited for children under 5 years where caregivers largely influence choice and independence and not included here. The ‘economic participation’ and ‘health and access to services’ facets were not included because they are more related to a policy rather than clinical perspective. The knowledge from this study will further contribute to the evidence-base in relation to social inclusion outcomes, which is currently lacking for children with hearing loss, particularly young children.

Cross-sectional data for typical hearing children from Wave 1 (2004) of the existing LSAC dataset were used as a comparison group. Data were included in this study for children who were: (1) aged 4–5 years; and (2) were not reported to have the following health conditions: hearing problems, vision problems, Attention Deficit Disorder, eczema, diarrhoea or colitis, frequent headaches, ear infections, other infections, food or other allergies, other illnesses and other physical disabilities. Applying these criteria to the data resulted in 3265 participants.

Children included in the LSAC cohorts are broadly representative of the Australian population [26]. Children from single-parent, non-English speaking families and those living in rental properties were slightly underrepresented, while children with more highly educated parents were slightly over-represented (by around 10 percentage points). LSAC data were collected from mothers, fathers, carers or teachers and direct observations of the children. However, primary caregivers (98% mothers) were the respondent for the items analysed in this paper.

To detect differences between the children with hearing loss and typical hearing children on the demographic variables, scale data were analysed using independent-samples t-tests and Levene’s test for equality of variances, and categorical data using Pearson chi-square analyses (with Yates continuity correction when both categorical variables only had two categories). Results were considered significant at p < .050. Logistic regression was used to compare the two groups on the two facets of social inclusion (‘education’ and ‘interacting with society and fulfilling social roles’), adjusting for the child’s age and primary caregiver’s highest level of education (both of which were found to be higher for the group of children with hearing loss). For the logistic regression, categorical items from the social inclusion survey were recoded as dichotomous variables (see Tables 2, 3, 4, 5 and 6). The adjusted odds ratios and 95% confidence intervals of these comparisons are reported in each table. The odds ratio indicates how likely it is that an individual who displayed a certain characteristic belongs to the group of children with hearing loss rather than the group of children with typical hearing. For example, the first item in Table 4 indicates that the parents of children with hearing loss are 8.31 times more likely than the parent of children with typical hearing to read to their child from a book 3 or more days a week. The p value (.003) indicates that this finding is statistically significant following Bonferroni adjustment. Bonferroni adjustments were used to reduce the risk of Type 1 error due to the multiple comparisons included in these analyses. The Bonferroni corrected significance level is listed below each table.

When comparing the two groups for gender, no differences were found (55.1% males for the children with hearing loss; 49.4% males for the typical hearing children). At the time of survey, the children with hearing loss were significantly older (t =−7.40; p < .001), with a mean age of 4.93 years (SD = 0.54 years) compared to a mean age of 4.74 years (SD = 0.22 years) for the children with typical hearing.

The type of education program attended by the children with hearing loss was primarily (39.7%) pre-year 1 program in a school. This is seen as the first year of formal schooling where typically the children would be 5 years of age or turning 5 during that year. The next highest attendance (23.0%) was pre-school, which is the year prior to formal schooling where typically the children would be 4 years of age or turning 4 during that year. The remaining children (17.9%) attended day/child care, which is the year prior to pre-school where typically the children would be 3 years of age or younger during that year. These results were somewhat different to the percentage of children with typical hearing who primarily attended a pre-year 1 program (16.8%) and pre-school program (55.7%), while similar for day/child care (18.4%) attendance. These differences may be reflective of the group with hearing loss being significantly older. For the type of care apart from school or pre-school, the hearing loss group was significantly more likely than the typical hearing group to also receive care from a day care where the child has a pre-school program (χ² = 11.41; p = .001); gym, leisure or community care (χ² = 6.20; p = .013); grandparent (χ² = 23.66; p < .001); or another relative (χ² = 10.99; p = .001).

There was a significant difference between the groups for primary caregiver’s level of education (χ² = 21.62; p < .001), with the hearing loss group more likely to have completed year 11–12 or equivalent (96.0% versus 71.7% for the typical hearing group). The typical hearing group was more likely than the hearing loss group to have only completed year 10 or below or equivalent (28.2% versus 4.0% for the hearing loss group), or to never have attended school (0.1% versus 0.0% for the hearing loss group). Due to the significant differences between the two groups for the child’s age and primary caregiver’s highest level of education, adjustments were made during analysis to account for this.

This paper focused on comparing the social inclusion of children aged 4–5 years who are educated using listening and spoken language early intervention to the outcomes of their typical hearing peers. The facets of social inclusion investigated in this study were ‘education’ and ‘interacting with society and fulfilling social roles’. The results related to these two facets are presented in the next sections.

On the ‘education’ facet of social inclusion, similarities were generally found between the education skills of the children with hearing loss and those with typical hearing. The interesting finding here is that although the children with hearing loss were significantly less likely to be able to read simple words than the typical hearing children, they were equally as likely to read complex words. These contrasting outcomes have highlighted the need for further research using in-depth questions or assessments relating to literacy to better determine any possible trends in performance for the groups and the extent to which there may be differences between them. Dornan and colleagues [38] did touch on some similarities in reading performance between seven children with hearing loss aged 8 years and seven typical hearing children in their study, where both groups demonstrated skills within the average range. However, further research is needed to add to the current limited knowledge in the area of literacy development for children educated using listening and spoken language early intervention.

Overall, the outcomes for language, vocabulary and speech assessments at the time of the study highlighted, on average, the age-appropriate spoken language development of the children with hearing loss. When comparing education participation, the differences identified may indicate that the children with hearing loss were spending more time within the home environment with their primary caregivers, grandparents or other relatives as noted in the results. The children with hearing loss were more likely to spend less time (specifically 6 h or less or irregularly) in an education program than typical hearing children. This finding is in keeping with the overall philosophy guiding listening and spoken language early intervention where the primary caregiver is seen as the facilitator of the child’s language enriched environment [39]. Meaningful time spent together is seen as optimizing the listening and spoken language development of the child.

When looking at this facet of social inclusion, the children with hearing loss were involved to a similar level as typical hearing children in activities relating to the domains of social participation and role functioning and engagement. These findings are similar to the Percy-Smith et al. [24] study of self-esteem and social well-being in children aged 2–17 years with cochlear implants. The outcomes in the present study may be related to the primary caregiver’s level of understanding and confidence to engage children in activities both at home and in the community to facilitate the child’s social development. It would be interesting in further studies to look at factors (e.g. parental factors or type of early intervention received) that may drive this comparable finding. This will help to identify areas where primary caregivers and their children can be supported to achieve optimal social inclusion outcomes.

As well as knowing about the child’s involvement in a range of activities, it is important to also know about the quality of their interactions so that a true representation of their social inclusion in these activities can be gained. In the present study it was promising to see that on the SDQ overall scale scores that reflect quality of interactions, most of the children with hearing loss had comparable behaviours, emotions and relationships to children with typical hearing, and further, were more likely to have appropriate conduct skills. These findings are similar to those noted by Wong and colleagues [40] in their population based study where on average, the children with hearing loss at 5 years had SDQ scores on all domains within the average range. The authors noted that factors such as no additional disabilities and higher language, functional communication and non-verbal cognitive skills predicted psychosocial functioning. Studies that consider additional factors noted clinically such as the presence and impact of bullying are also needed here. Together, the findings would assist in supporting children when transitioning to the education setting and encountering new experiences in which social inclusion occurs.

The study reported in this paper applied two of the facets of social inclusion to measure the social inclusion of children with hearing loss in listening and spoken language early intervention. This is the second study to investigate the social inclusion of this cohort of children. It is promising that most of the children with hearing loss had comparable levels of social inclusion to typical hearing children. This positive finding is a foundation for future studies to explore specific factors that contribute to these comparable levels of social inclusion. This knowledge will assist primary caregivers and early intervention providers to support children with hearing loss to achieve optimal social inclusion outcomes.

The study findings provide preliminary insights into the social inclusion of this cohort on the facets of ‘education’ and ‘interacting with society and fulfilling social roles’. It is acknowledged that the clinical nature of this research may limit the generalizability of the study findings. For example, this was a relatively small group comparison to a population based study, and participation was sought from an existing early intervention cohort where self selection of the primary caregivers to the type of early intervention needs to be recognised.

In future, by looking at social inclusion as part of a population based study of children with hearing loss such as the Longitudinal Outcomes of Children with Hearing Impairment study [41] may provide broader insights across the types of early intervention offered in Australia. Further population based studies are also needed worldwide to look at similarities and differences across regions. Clinically, these studies will give service providers the tools to identify areas where lower social inclusion is experienced for children with hearing loss, and the domains that could be integrated into goal setting to address their individual needs.

Additionally, a greater representation of social inclusion would be gained by including children with unilateral hearing losses and those with more complex needs in evaluations (i.e. those with physical and cognitive difficulties impacting on learning). These groups also represent the children with hearing loss seen clinically in Australia and overseas and it would be important to explore their social inclusion. The findings from these studies would help to identify clinical areas for supporting individual children in their social inclusion. Such an investigation was outside the scope of the present study.

Further longitudinal large-scale studies involving greater participant numbers (only 37% of primary caregivers responded to the current survey); all five facets of social inclusion; and with child rather than parental report (where applicable) are needed to add to the current knowledge from this study of the impact of listening and spoken language early intervention on the social inclusion of children with hearing loss. Such studies will provide a more comprehensive picture of the social inclusion across all five facets for children with hearing loss in relation to typical hearing children and from the perspective of the children themselves (where applicable at older ages).