eileen rall, au.d., ccc-a louise a. montoya, ma, lpc, csc the center for childhood communication...
TRANSCRIPT
Eileen Rall, Au.D., CCC-AEileen Rall, Au.D., CCC-A
Louise A. Montoya, MA, LPC, CSCLouise A. Montoya, MA, LPC, CSC
The Center for Childhood The Center for Childhood CommunicationCommunication
Counseling Guidelines: Counseling Guidelines: Supporting Children with Hearing LossSupporting Children with Hearing Loss
Session ObjectivesSession Objectives
Understand the impact ofUnderstand the impact of
the diagnosis of hearing loss on a family the diagnosis of hearing loss on a family systemsystem
hearing loss on psycho-social development of hearing loss on psycho-social development of a childa child
Become familiar with a pediatric counseling Become familiar with a pediatric counseling guideline and understand how to integrate it guideline and understand how to integrate it into your practiceinto your practice
Child Developmental ModelChild Developmental Model
?
Audiologist,
Physician
Teacher, Speech
Language Pathologist
Pediatric Counseling Pediatric Counseling GuidelinesGuidelines
Birth through transition to Birth through transition to schoolschool
Pediatric Counseling GuidelinesPediatric Counseling Guidelines
Impact of diagnosisImpact of diagnosis Psycho-Social developmentPsycho-Social development
Erik Erikson’s model of Erik Erikson’s model of developmentdevelopment
Development of self-concept (15 Development of self-concept (15 mos+)mos+)
Development of social skillsDevelopment of social skills
Pediatric Counseling Pediatric Counseling GuidelinesGuidelines
DiagnosisDiagnosis
Birth to Three yearsBirth to Three years
Three to Six yearsThree to Six years
Six to Eleven yearsSix to Eleven years
Eleven through AdolescenceEleven through Adolescence
Erikson’s Stages Erikson’s Stages of Psycho-Social Developmentof Psycho-Social Development
Trust vs. Mistrust (birth – 18 months)Trust vs. Mistrust (birth – 18 months)
Autonomy vs. Shame and Doubt Autonomy vs. Shame and Doubt
(18 mos – 2 years)(18 mos – 2 years)
Initiative vs. Guilt (3 – 6 years)Initiative vs. Guilt (3 – 6 years)
Psycho-Social Psycho-Social DevelopmentDevelopment
Self-ConceptSelf-ConceptAn individual’s understanding of who they An individual’s understanding of who they
areare No selfNo self Self-awarenessSelf-awareness Factual self-concept Factual self-concept Egocentric view of self-conceptEgocentric view of self-concept
Self-confidence and self-esteem emergingSelf-confidence and self-esteem emerging ComparativeComparative Peer-pressurePeer-pressure IndividuationIndividuation
Psycho-Social Psycho-Social DevelopmentDevelopment
Social SkillsSocial Skills
Healthy Healthy AttachmentAttachment
BasicBasic
IntermediateIntermediate
AdvancedAdvanced
Developmental Developmental Index of Audition Index of Audition and Listening and Listening (DIAL)(DIAL)
• Functional auditory Functional auditory milestonesmilestones
Palmer and Mormer (1999)Palmer and Mormer (1999)
Impact of DiagnosisImpact of Diagnosis
Sharing informationSharing information
Recognizing emotional reactionsRecognizing emotional reactions
Promoting healthy attachmentPromoting healthy attachment
Positively impacting family Positively impacting family systemssystems
Sharing InformationSharing InformationMedical ModelMedical Model Family Centered Family Centered
ModelModel
What are the benefits of Family-What are the benefits of Family-Centered Care?Centered Care?
(not specific to hearing impairment)(not specific to hearing impairment)
Improved teaching skills of parentImproved teaching skills of parent Better behavior from child as a result of Better behavior from child as a result of
improved parental teaching skillsimproved parental teaching skills Decreased parental stressDecreased parental stress Improved satisfaction of servicesImproved satisfaction of services
Recognizing Emotional Recognizing Emotional
ReactionsReactionsFeelings Involved with Feelings Involved with GriefGrief
Shock/Denial/ Shock/Denial/ NumbnessNumbness
Anger/Fear/PanicAnger/Fear/Panic
Sadness/HopelessSadness/Hopeless
Guilt/BargainingGuilt/Bargaining
HealthyHealthy acceptance/adaptatioacceptance/adaptationn
GriefGriefCore pain Core pain can’tcan’t be taken away. be taken away. Feelings must be Feelings must be acknowledgedacknowledged, expressed in , expressed in
a safe, caring environment.a safe, caring environment. Some emotions have an important purpose in Some emotions have an important purpose in
helping parents adjust to the diagnosishelping parents adjust to the diagnosis
Potential Pitfall: Because parents may Potential Pitfall: Because parents may have strong feelings of inadequacy have strong feelings of inadequacy
Many parents happy to turn over their child to Many parents happy to turn over their child to “the experts”“the experts”
Professionals eager to rescueProfessionals eager to rescue
Luterman (1999)Luterman (1999)
Feelings Involved with Feelings Involved with GriefGrief
Shock/Denial/Numbness - Shock/Denial/Numbness - protects protects parents from deep pain and allows parents parents from deep pain and allows parents to build up energy for the work ahead of to build up energy for the work ahead of themthem
Anger - Anger - Parents feel cheated. Anger Parents feel cheated. Anger hides their fear. Many professionals are hides their fear. Many professionals are very afraid of the anger and respond very afraid of the anger and respond defensively. Need to help parents capture defensively. Need to help parents capture and direct their energy effectively.and direct their energy effectively.
Feelings Involved with Feelings Involved with GriefGrief
Sadness/Hopelessness – Sadness/Hopelessness – expressing expressing grief – moving forwardgrief – moving forward
GuiltGuilt:: Fathers for not protecting the familyFathers for not protecting the family Mothers because she secretly believes she’s at Mothers because she secretly believes she’s at
fault for the hearing lossfault for the hearing loss Comes between the marriage, family becomes Comes between the marriage, family becomes
unbalanced (Mother+child, father+work)unbalanced (Mother+child, father+work) Danger is overprotection of child. Conveys Danger is overprotection of child. Conveys
helplessness to the child.helplessness to the child.
A vicious cycle begins when parental helplessness A vicious cycle begins when parental helplessness and powerlessness intersects with professionals’ and powerlessness intersects with professionals’ need to help, save, assume the powerful, “expert” need to help, save, assume the powerful, “expert” role with familiesrole with families
Results in parents who are:Results in parents who are:
Over-controllingOver-controlling Lack self-confidence Lack self-confidence
Self-servingSelf-serving Don’t feel competence Don’t feel competence
PassivePassive
Children internalize this powerlessness, Children internalize this powerlessness, helplessness, and head down a path of life long helplessness, and head down a path of life long poor self-esteempoor self-esteem
The Hearing Healthcare ProfessionalThe Hearing Healthcare Professionala.k.a.a.k.a.
““The Healer”The Healer”
Parents with Unresolved Grief Can Parents with Unresolved Grief Can Be:Be:
Emotionally overwhelmedEmotionally overwhelmed
Stuck in angerStuck in anger
Frequently suppressing their emotionsFrequently suppressing their emotions
Depressed or passiveDepressed or passive
Unrealistic or stuck in denialUnrealistic or stuck in denial
Disorganized, confusedDisorganized, confused
Actively searching for the cause of the hearing Actively searching for the cause of the hearing lossloss
Yoshinaga-Itano (2001)Yoshinaga-Itano (2001)
What can you do?What can you do?
Provide immediate, appropriate supportProvide immediate, appropriate support Have appropriate counseling skillsHave appropriate counseling skills Have expert knowledge and experience Have expert knowledge and experience
with living with hearing losswith living with hearing loss Actively listeningActively listening No judging the familyNo judging the family Build parental self-esteem, self-confidenceBuild parental self-esteem, self-confidence
Yoshinaga-Itano (2001)Yoshinaga-Itano (2001)
What can you do?What can you do?
Help families understandHelp families understand
The etiology, emphasizing that cause was The etiology, emphasizing that cause was not parents’ intentionnot parents’ intention
Their child is not fragileTheir child is not fragile
Their child can do anything, but, may have Their child can do anything, but, may have to do some things differentlyto do some things differently
That taking good care of themselves and That taking good care of themselves and their marriage = taking good care of their their marriage = taking good care of their child child
Luterman (1999)Luterman (1999)
What can you do?What can you do?
Inform parents that:Inform parents that: Children with congenital and pre-lingual onset Children with congenital and pre-lingual onset
of hearing loss do not experience grief until of hearing loss do not experience grief until sometime between 7 – 9 years of agesometime between 7 – 9 years of age
Parents need to keep their grief away from Parents need to keep their grief away from child. Child will misunderstand and child. Child will misunderstand and misattribute parents’ griefmisattribute parents’ grief
Child has best chance of resolving their initial Child has best chance of resolving their initial grief if parents have positively resolved their grief if parents have positively resolved their initial griefinitial grief
Healthy Healthy Acceptance/AdaptationAcceptance/Adaptation
Acknowledge their preference Acknowledge their preference that their child not be deaf/hard that their child not be deaf/hard of hearingof hearing
Accept the permanence of the Accept the permanence of the hearing losshearing loss
Understand and have Understand and have entireentire family family take consistent actiontake consistent action to make necessary changes to make necessary changes create accessible/effective create accessible/effective communication environment for communication environment for deaf/hard of hearing childdeaf/hard of hearing child
Healthy AttachmentHealthy AttachmentBetween Parents and ChildrenBetween Parents and Children
Deep enduring connections established Deep enduring connections established between child and caregiverbetween child and caregiver
Occurs between birth and age 3Occurs between birth and age 3
Learned abilityLearned ability
Result ofResult of ongoing reciprocal ongoing reciprocal interactionsinteractions characterized by characterized by protection, need fulfillment, limits, protection, need fulfillment, limits, lovelove and and trusttrust
Levy (2000)Levy (2000)
Healthy AttachmentHealthy AttachmentCan Lead to Development of:Can Lead to Development of:
Basic trust and reciprocityBasic trust and reciprocity
Self-regulation of affect and behaviorSelf-regulation of affect and behavior
Healthy identity = healthy self-worth + autonomyHealthy identity = healthy self-worth + autonomy
Morality based upon empathy, compassion and Morality based upon empathy, compassion and conscienceconscience
Resourcefulness and resilience for response to Resourcefulness and resilience for response to future stressfuture stress
Stimulating experiences required for healthy Stimulating experiences required for healthy brain developmentbrain development
Levy, (2000)Levy, (2000)
Potential Consequences Potential Consequences of Insecure Attachment:of Insecure Attachment:
Self-regulation deficits:Self-regulation deficits: Impulse controlImpulse control Self-soothingSelf-soothing InitiativeInitiative PerseverancePerseverance InhibitionInhibition PatiencePatience
Levy (2000)Levy (2000)
Potential Consequences Potential Consequences of Insecure Attachment:of Insecure Attachment:
Development of problem behaviors:Development of problem behaviors: ImpulsivenessImpulsiveness HyperactivityHyperactivity InattentionInattention Seeking stimulationSeeking stimulation Poor self-imagePoor self-image No friendsNo friends Oppositional and defiantOppositional and defiant DisruptiveDisruptive ManipulativeManipulative Blames others (internalized helplessness)Blames others (internalized helplessness)
Levy (2000)Levy (2000)
What can you do?What can you do?
Inform parents that:Inform parents that: Teach parents about the importance of Teach parents about the importance of
healthy attachmenthealthy attachment Support them through the feelings Support them through the feelings
associated with griefassociated with grief Help them understand the impact Help them understand the impact
hearing impairment has on hearing impairment has on communication – avoid communication – avoid misunderstanding communication misunderstanding communication difficultiesdifficulties
Healthy Family SystemHealthy Family System
Feels empoweredFeels empowered
High self-esteem (especially for the High self-esteem (especially for the mother)mother)
Feeling that burdens are sharedFeeling that burdens are shared
Achieved healthy acceptance of the Achieved healthy acceptance of the diagnosisdiagnosis
Luterman (2001)Luterman (2001)
Healthy Family SystemHealthy Family System
Unhealthy Family SystemUnhealthy Family System
What can you do?What can you do?
Inform parentsInform parents Be a sounding board Be a sounding board
ListenListen CoachCoach AcknowledgeAcknowledge BrainstormBrainstorm SupportSupport Model strategiesModel strategies
Refer to professionals when neededRefer to professionals when needed
ChildChildDevelopmental ModelDevelopmental Model
Audiologist,
Physician
Teacher
Insert your Insert your picture herepicture here
YOU!!
Psycho-SocialPsycho-Social DevelopmentDevelopment
Erikson’s StagesErikson’s Stages Trust versus MistrustTrust versus Mistrust
(birth – 18 months)(birth – 18 months)
Babies learn to:Babies learn to: TrustTrust their world if they are kept well-fed, their world if they are kept well-fed,
warm, dry, and receive regular human warm, dry, and receive regular human touchtouch
Mistrust Mistrust their world if they are left their world if they are left hungry, cold, wet, and unattendedhungry, cold, wet, and unattended
Psycho-SocialPsycho-Social DevelopmentDevelopment
Erikson’s StagesErikson’s StagesAutonomy versus Shame and DoubtAutonomy versus Shame and Doubt
(18 months – 2 years)(18 months – 2 years)
Toddlers want to rule their own actions and Toddlers want to rule their own actions and
bodiesbodies
With success With success develop develop AutonomyAutonomy
With failureWith failure develop develop Shame and Shame and
DoubtDoubt in their own abilities in their own abilities
Self-ConceptSelf-ConceptBirth – 14 monthsBirth – 14 months
No sense of selfNo sense of self
Child views themselves as extension Child views themselves as extension of their parent/caregiverof their parent/caregiver
Classic testClassic test: red nose in the mirror; : red nose in the mirror; All children 12 months and younger All children 12 months and younger do not know they are seeing do not know they are seeing themselves in a mirrorthemselves in a mirror
Self-ConceptSelf-Concept15 months – 2 years15 months – 2 years
Self awareness emergesSelf awareness emerges
Recognize self in a mirrorRecognize self in a mirror
Classic test:Classic test: red nose in the mirror; red nose in the mirror; Most children 15 – 24 months will Most children 15 – 24 months will notice the red on their nose and be notice the red on their nose and be curious or embarrassedcurious or embarrassed
Self-ConceptSelf-Concept2 - 3 years2 - 3 years
Self concept emergesSelf concept emerges
Child identifies themselves as:Child identifies themselves as:
A “girl” or a “boy”A “girl” or a “boy”
A “baby” or “big boy/girl”A “baby” or “big boy/girl”
A “brother” or “sister” or only childA “brother” or “sister” or only child
By religious affiliationBy religious affiliation
By abilityBy ability
What can you do?What can you do?
Evaluate and support access to Evaluate and support access to alerting devicesalerting devices
Include the child in conversations Include the child in conversations about hearing loss - positiveabout hearing loss - positive
Support families in developing Support families in developing relationships with other families with relationships with other families with children with hearing loss and with children with hearing loss and with D/HoH adults and older childrenD/HoH adults and older children
Psycho-SocialPsycho-Social DevelopmentDevelopment
Erikson’s StagesErikson’s StagesInitiative versus GuiltInitiative versus Guilt(3 – 6 years)(3 – 6 years)
Initiative:Initiative: Increased awareness of self and world outside Increased awareness of self and world outside
of homeof home
Eagerly attempts new tasks and play activitiesEagerly attempts new tasks and play activities
Successful attempts at new tasks help children Successful attempts at new tasks help children
learn and master many things, which becomes learn and master many things, which becomes
self-reinforcing (proud of themselves) and self-self-reinforcing (proud of themselves) and self-
controlling to gain the approval of adultscontrolling to gain the approval of adults
Psycho-SocialPsycho-Social DevelopmentDevelopment
Erikson’s StagesErikson’s StagesInitiative versus GuiltInitiative versus Guilt(3 – 6 years)(3 – 6 years)
Guilt:Guilt: When attempts result in failure or When attempts result in failure or
criticism, the child feels:criticism, the child feels:
Guilty Guilty
IncompetentIncompetent
HelplessHelpless
Self-ConceptSelf-Concept3 - 6 years3 - 6 years
Ego-centric thinkingEgo-centric thinking
““I am the world and the world is just like I am the world and the world is just like me!”me!”
Repetition/PracticeRepetition/Practice MasteryMastery
Mastery Mastery CompetenceCompetence
CompetenceCompetence Self-confidenceSelf-confidence
Self-confidenceSelf-confidence Self-esteemSelf-esteem
Professional as Professional as CoachCoach
Professional Parent Child
Parents teach their child.
Professionals support and
coach parents as they teach their child.
Development of Development of Social Skills/InteractionSocial Skills/Interaction
Provide information to parents on:Provide information to parents on:
Lack of incidental learning due to hearing lossLack of incidental learning due to hearing loss
Often deaf/hard of hearing children need Often deaf/hard of hearing children need specific training on basic and more advanced specific training on basic and more advanced social skillssocial skills
Use of social skills booksUse of social skills books
Discriminating between “Can’t Do” or “Won’t Discriminating between “Can’t Do” or “Won’t Do” behavior problems Do” behavior problems
Gresham (1995)Gresham (1995)
Frequent Teaching of Social Frequent Teaching of Social SkillsSkills
For “Can’t do” behavior problems:For “Can’t do” behavior problems: Use Modeling, coaching, practiceUse Modeling, coaching, practice
For “Won’t do” behavior problems:For “Won’t do” behavior problems:Use behavior charts, positive Use behavior charts, positive
reinforcement, effective praise, and reinforcement, effective praise, and noticing (and describing) good noticing (and describing) good
behavior behavior
Gresham (1995)Gresham (1995)
Examples of Basic Social Examples of Basic Social SkillsSkills
Eye contactEye contact SmilingSmiling Listening (for friendship)Listening (for friendship) Introducing yourselfIntroducing yourself Meeting new peopleMeeting new people Joining a groupJoining a group Giving complimentsGiving compliments
What can you do?What can you do?
Promote effective communication Promote effective communication strategies - for all (including YOU!)strategies - for all (including YOU!)
Evaluate and support access to age-Evaluate and support access to age-appropriate activitiesappropriate activities
Talk to families about social skill Talk to families about social skill developmentdevelopment
Foster development of initiative Foster development of initiative
Thank you!Thank you!
Eileen Rall, Au.D., CCC-AEileen Rall, Au.D., CCC-A(215) 590-7612 or (215) 590-7612 or [email protected][email protected]
Center for Childhood CommunicationCenter for Childhood Communicationatat
The Children’s Hospital of PhiladelphiaThe Children’s Hospital of Philadelphia3434thth and Civic Boulevard, Room 112 and Civic Boulevard, Room 112
Philadelphia, PA 19104Philadelphia, PA 19104