The effect of hearing loss on the cognitive, linguistic, and educational development of children has been comprehensively researched in recent years. The sociocultural aspects of deafness have been more difficult to ascertain. Because the social consequences of hearing loss can far outweigh its purely medical effects, it has been suggested that, to best understand hearing loss, it should be seen as a social condition rather than a physical disability. Jamieson (1994). Hearing impaired children can still be seen, by their parents, their peer group and other adults as "outsiders in a hearing world" Higgins (1987).
Most hearing-impaired children are born into hearing families where the parents are shocked and even traumatised by the diagnosis of deafness. Often, long before these parents have begun to accept the ramifications of hearing loss, the child is issued with hearing aids. Although aware of the need for amplification on a logical, theoretical level, many parents find it very difficult to accept emotionally. The hearing aids are a very visual reminder that the child is not perfect. It may take many months or even years before some parents are prepared to advertise their child’s problem both to themselves and to others. Hodgson (1994).
Unlike spectacles, hearing aids would appear to carry a form of stigma for the wearer Goffman (1963) Danhauer et al. (1985). Tate (1994) sees them as an external sign of deafness which is still often confused with diminished mental capacity because of the associated communication problems. Ross (1996) points out that it is the aids that prevent hearing impaired children from looking the same as other children in the eyes of the public.
Although hearing impaired people are rarely recognised as a major group who are discriminated against in society, there is still a tendency, through ignorance rather than intolerance, one would hope, to confuse severe to profound deafness with limited intellectual capacity. The visible presence of a hearing aid should help to overcome this, proclaiming "deaf not daft" but it is still painfully obvious that the degree of success in hearing aid use is closely associated with the attitude of others to the aid.
Despite the fact that two ears is the physical norm and binaural hearing is regarded as the optimum, two hearing aids, even amongst many in the deaf community, are regarded as double the disability.
Goffman recognised that society finds it difficult to accept "an undesired differentness" and that a hearing aid wearer may possess "a trait that can obtrude itself upon attention and turn those of us whom he meets away from him."
Brooks (1989) maintained that the degree of success or failure of hearing aid use by adults correlates highly with their initial attitudes to hearing loss and hearing aids. Motivational factors are as important as audiological ones. It is accepted that the hearing impaired person must recognise the need for amplification before hearing aids can be successfully fitted. Dempsey (1994)
Despite the miniaturisation of hearing aids from body worn to post aural, a survey by Brooks and Johnson in 1981 of over 300 potential adult hearing aid users found that just over 25% regarded even the behind the ear aid as too obvious and "cosmetically unacceptable".
Dempsey (1994), also referring to adults, found that the successful use of a hearing aid depended on the preconceived notion on the part of the wearer of what type of instrument he or she required. This notion was almost always based on cosmetic considerations which played an important role in the motivation of the wearer.
Results of studies over the years have suggested that the more obvious the hearing aid, the more the wearer is stigmatised in areas other than his deafness. That these should include intelligence and personality or social skills may not be surprising but it is more disturbing that obvious hearing aid use leads to negative opinions of individual’s social, socio-economic status and achievement. Danhauer et al (1985).
Tate (1994) maintains that even when the need for amplification is understood, most people would prefer to use a hearing aid that is inconspicuous, while Brooks, as long ago as 1989, regarded the smaller behind the ear aid as more acceptable to others and hence less likely to stigmatise the wearer.
The striving for acceptability has run alongside the improvements in the acoustic qualities of hearing aids. The importance of miniaturisation has been recognised by many audiologists working with both adults and children. Danhauer et al. (1980),Brooks (1989), Smith (1997), Green (1999).
When dealing with children and their amplification requirements many additional factors must be taken into account. The age of the child will have great bearing on the size and style of aid prescribed, (Green, 1999) . A baby with a profound hearing loss may not have large enough ears or strong enough pinnas to support post aural aids which are powerful enough to reach his thresholds. An inquisitive toddler may spend much of his time taking out his post aural, dismantling the parts and hiding them so a body worn aid may be more appropriate at least until he begins to appreciate the benefits of amplification. School age children may wish to have less obvious ITEs but the need for direct input for radio systems may preclude this.
Traditionally there has tended to be a greater emphasis on the audiological requirements of amplification for children than on the motivational aspects. Dempsey (1994). Although Ross (1994) insists that it is not difficult to fit hearing aids to infants, "after all children are completely under the control of adults", he is aware of the need to address the psychosocial needs of children as much as adults.
Bess (1981) maintained that acceptability of any amplification by children should be an educational goal to the audiologist and that it was essential to include the cosmetic attributes of the system in any hearing aid assessment.
Madell (1990) went further when she suggested that when a child does not receive demonstrable auditory assistance from a hearing aid, or if there appears to be little difference between one type of aid and another, that a major factor in the child’s choice of aid will be the look of the instrument. This statement presupposes that the child has some say in the choice of the aid. Until quite recently this would not necessarily have been the case. Now, with an ever increasingly wide range of hearing instruments available, it is possible to find several different sized aids which may all cater for similar losses.
As children get older, their perception of their aids may change. As they reach adolescence they become more aware of their appearance and develop a desire to conform to their peer group. A child who has successfully worn hearing aids for many years may reject them at this stage. Hodgson (1994) stresses the importance of listening to the child’s concern and improving the cosmetic appearance of the aids where possible. Attitudes of hearing peers begin to have an effect, especially in the teenage years. It is at this age when peer pressure to conform can be at its greatest. The findings of studies in America in the 1980s, Dengerink and Porter, (1984); Silverman and Klees, (1989), indicate that children react negatively to peers who wear visible hearing aids and that the larger the aid the more negative the reaction. Danhauer, Blood, Blood and Gomez, (1980).
It was recognised that the more embarrassed the hearing aid wearer appeared, the more negative was the reaction of his peer group. In order to minimize this reaction it was suggested that children learn not to try to hide their hearing loss.
Conversely, at the same time, Silverman and Klees also recommended the use of the smallest visible aid possible. Later data collected by Silverman and Largin (1993) indicated that a negative reaction to the size of the aid was not always the case. In fact the peers of hearing aid wearers may have begun react more positively to them. As yet there seems to be no explanation for this change other than the suggestion that a heightened awareness of disability in school and the increasing inclusion of children with special educational needs in mainstream may have taught the children to be more accepting and tolerant.
In addition to the audiological concerns of the child, the audiologist must also be aware of the emotional needs of the parents. Sensitive handling of the initial hearing aid fitting must improve the chances of acceptance of the aids by both parents and child. As a young child cannot manage the everyday putting in and taking out of the aids the initial motivation to wear them must be supplied by parents. Hodgson (1994)
Ross (1996) discussed the dilemma of the audiologist who must insist that a child needs to wear aids and thus highlight the pain of the parents still in shock over the reality of their child’s hearing loss. He also maintained that, as part of the wider society, audiologists are similarly influenced by the feelings of stigma that hearing aids engender and so can find their selection of aids for children affected by issues other than audiology, often searching for the smallest aid rather than the one that best suits the hearing loss.
"Instead of viewing hearing aids as a technical miracle.......the devices become visible signs of the children’s impairment rather than tools for reducing its impact." (Ross, 1996).
Green (1999) recognises that most parents do not like the more visible and unwieldy body worn systems and much prefer the post aural aids. He goes on to accept that ITEs have enhanced cosmetic appeal due to their invisibility. He has addressed the question of coloured aids and how they are seen, by both parents and children. He suggests that many children see coloured aids as fashion accessories and that they enjoy being able to view the workings of translucent aids. He does recognise, however, the dilemma of parents, some of whom are content to follow their children’s whims and others who would still prefer to hide the aid, and by extension the disability, as much as possible.