Hearing loss affects the language and behavioral development of millions of children (WHO, 2018). The prevalence of behavioral disorders in children with hearing loss is over double than in children with normal hearing (J Child Psychol Psychiatry. 1994;35:917). Timely treatment of hearing loss with hearing aids or cochlear implants may mitigate oral communication deficits, but does not address co-existent behavioral problems (Pediatrics. 1998;102:1161; Dev Med Child Neurol. 2011;53:269). Untreated patterns of disruptive behavior that develop in early childhood can lead to negative social and educational outcomes later in life (Am Psychol. 1989 Feb;44(2):329). A recent systematic review evaluated the connections between behavioral problems and hearing loss in children, as well as the characteristics of the methods used to manage these issues in this population (DOI: 10.1177/0194599818797598).
PREVALENCE OF BEHAVIORAL ISSUES
The review identified 36 studies on behavioral problems in children with hearing loss. These studies described the use of a wide range of tools to assess behavior and included children of different age groups with widely varying degrees and types of hearing loss. The most frequently used validated behavioral assessment tools were the Child Behavior Checklist, Vineland Behavior Adaptive Scale, and Strengths and Difficulties Questionnaire. Nearly one-third of the studies assessed the behavior of children with permanent hearing loss treated with hearing aids or cochlear implants. They found strong evidence of internalizing behavioral disorders that can be characterized by emotional and social withdrawal, depressive symptoms, poor self-esteem, and anxious behavior. These behaviors were reported by parents and/or teachers, and negatively influenced conduct and educational engagement. Two studies found that cochlear implantation did not reduce internalized behaviors in children, but that it did help reduce externalized behavioral disorders, characterized by outwardly aggressive, defiant, destructive, and impulsive behavior (Otol Neurotol. 2012;33:751; Cochlear Implants Int. 2006;7:61). Thirteen studies assessed the behavior of children with permanent hearing loss who were not treated with hearing aids or cochlear implants. All but one study observed internalized behavioral problems among the children studied. Eight studies looked into the behavioral issues of children with otitis media, minimal hearing loss, or unilateral hearing, and reported conflicting evidence on the connections between behavior and hearing.
ASSESSMENT AND INTERVENTION
Like early intervention for hearing loss, early intervention for behavioral problems is critical to preventing life-long adverse outcomes. Evidence-based and effective behavioral interventions have been well studied in normal hearing children (J Abnorm Child Psychol. 2008;36:567). However, very little research has been done on the development and delivery of behavioral interventions for children with hearing loss. This review identified only two studies that evaluated behavioral interventions within this population. Play therapy, also known as filial therapy, was found to be effective in addressing behavioral problems in children with hearing loss; however, this therapy was only studied in a school setting with older children. This form of therapy was time- and effort-intensive for the children and their families. These limited studies suggest the need for the adaptation of evidence-based interventions to this vulnerable population.
Many parents and providers are aware of the challenges in the care of children with hearing loss and the wide range of behaviors that can affect consistent usage of hearing aid or cochlear implant or participation in speech therapy. However, assessment of behavioral disorders in children in the hearing clinic setting is not a common practice. While the interaction between hearing and spoken language development is quite familiar to hearing health care specialists, the connection between hearing loss and the development of early childhood behavior disorders is likely an unfamiliar territory—but this connection may influence care delivery and long-term outcomes.
AREAS OF INTEGRATION
Hearing-related challenges affecting early childhood communication may lead to maladaptive interactions with others, which could lead to disruptive behavioral disorders. Despite their apparent connection, hearing loss and behavioral disorders are treated very differently. According to Stevenson, et al., early treatment of hearing loss and speech delay does improve long-term language development outcomes; however, hearing loss treatment does not prevent or treat behavioral problems in young children with hearing loss (Dev Med Child Neurol. 2011). Compared with their normal-hearing peers, children with hearing loss who wear hearing aids or cochlear implants have shown a higher prevalence of disruptive behavioral disorders (e.g., oppositional defiant disorder). Yet, these children are less likely to obtain mental health services (Otol Neurotol. 2017;38(10):1456). Current standard behavioral interventions can require weeks of therapy. Families of children with hearing loss who already struggle with multiple audiology and speech therapy appointments may find it overwhelming to add behavioral therapy sessions to the list. While research on effective behavioral treatments for this population is limited, there is a great potential to integrate behavioral evaluation and intervention into hearing health care. Providers need to increase awareness of the relationship between behavioral disorders and hearing loss, expand the use of validated methods to assess behavior in children, and develop approaches and interventions to treat these problems.