session goals - osspeac goals • discuss “grief ... • review erikson’s model of psychosocial...

Understanding Psychosocial Development of Children

with Hearing Loss

Eileen Rall, Au.D. October 20, 2014

Session Goals

• Discuss “grief” and the emotions that often accompany the diagnosis of HL

• Review Erikson’s model of psychosocial development

• Describe the development of self-concept through self-esteem and social skills

• Discuss ways that growing up with hearing loss may impact development

Pediatric Counseling Guidelines

• Impact of diagnosis on a family • Psycho-Social development

– Erik Erikson’s model of development – Development of self-concept (15 mos+) – Development of social skills



– Erik Erikson’s model of development – Development of self-concept (15 mos+) – Development of social skills

Impact of Diagnosis

• Recognizing emotional reactions

• Promoting healthy attachment

• Positively impacting family systems

Impact of Diagnosis

• Recognizing emotional reactions

• Promoting healthy attachment

• Positively impacting family systems

“I don’t remember anything you said that day after you told me that my daughter

has a hearing loss.”

InformationGuilt

Anger

Denial

Grief

Shock

Support Sadness

Recognizing Emotional ReactionsFeelings Involved with Grief

• Shock/Denial/ Numbness

• Anger/Fear/Panic • Sadness/Hopeless • Guilt/Bargaining • Healthy acceptance

• Good grief: Core pain can’t be taken away. – It must be acknowledged, expressed in a safe,

caring environment. – Some emotions have an important purpose in

helping parents adjust to the diagnosis • Strong feelings of inadequacy

– Many parents happy to turn over their child to “the experts”

– Professionals eager to rescue Luterman, (1999)

Grief

Healthy AttachmentBetween Parents and Children

• Deep enduring connections established between child and caregiver

• Occurs between birth and age 3 • Learned ability • Result of ongoing reciprocal

interactions characterized by protection, need fulfillment, limits, love and trust

Levy (2000)

Healthy AttachmentCan Lead to Development of:

• Basic trust and reciprocity • Self-regulation of affect and behavior • Healthy identity = healthy self-worth + autonomy • Morality based upon empathy, compassion and

conscience • Resourcefulness and resilience for response to future

stress • Stimulating experiences required for healthy brain

development

Levy, (2000)

Potential Consequences of Insecure Attachment:

Self-regulation deficits: – Impulse control – Self-soothing – Initiative – Perseverance – Inhibition – Patience

Levy (2000)

Potential Consequences of Insecure Attachment:

Development of problem behaviors: – Impulsiveness – Hyperactivity – Inattention – Seeking stimulation – Poor self-image – No friends – Oppositional and defiant – Disruptive – Manipulative – Blames others (internalized helplessness)

Levy (2000)

What can you do?

• Inform parents that: – Teach parents about the importance of healthy

attachment – Support them through the feelings associated

with grief – Help them understand the impact hearing

impairment has on communication – avoid misunderstanding communication difficulties

Healthy Family System

• Feels empowered • High self-esteem (especially for the

mother) • Feeling that burdens are shared • Achieved healthy acceptance of the

diagnosis

Luterman (2001)

What can you do?

• Inform parents • Be a sounding board

• Listen • Coach • Acknowledge • Brainstorm • Support • Model strategies

• Refer to professionals when needed

What can you do?

Help families understand: • The etiology, emphasizing that cause was not

parents’ intention • Their child is not fragile • Their child can do anything, but, may have to do

some things differently • That taking good care of themselves and their

marriage = taking good care of their child

Luterman (1999)

What can you do?

Inform parents that: – Children with congenital and pre-lingual onset of

hearing loss do not experience grief until sometime between 7 – 9 years of age

– Parents need to keep their grief away from child. Child will misunderstand and misattribute parents’ grief

– Child has best chance of resolving their initial grief if parents have positively resolved their initial grief

Developmental Guidelines

Birth to Three

Three to Six

Six to Eleven



– Erik Erikson’s model of development – Development of self-concept (15 mos+) – Development of social skills – Development of auditory milestones

Erikson’s Stages of Psycho-Social Development

• Trust vs. Mistrust (birth – 18 months) • Autonomy vs. Shame and Doubt (18 mos – 2 years) • Initiative vs. Guilt (3 – 6 years) • Industry vs. Inferiority (7 – 11 years) • Identity vs. Role Confusion (11 – 21 years)

Trust

Autonomy

Initiative

Industry

IdentityPsycho-Social Development

Social Skills

• Healthy Attachment • Basic • Intermediate • Advanced

Self-Concept

An individual’s understanding of who they are • No self • Self-awareness • Factual self-concept • Egocentric view of self-concept

– Self-confidence and self-esteem emerging • Comparative • Peer-pressure • Individuation

Developmental Index of Audition and Listening (DIAL)

!

• Functional auditory milestones

Palmer and Mormer (1999)

Counseling Guidelines

• Birth to three !

• Three to six !

• Six to Eleven !

• Eleven through Adolescence

Psycho-Social Development

Erikson’s Stages

Trust versus Mistrust (birth – 18 months)

Babies learn to: • Trust their world if they are kept well-fed, warm,

dry, and receive regular human touch • Mistrust their world if they are left hungry, cold,

wet, and unattended

?

?Autonomy versus Shame and Doubt

(18 months – 2 years) Toddlers want to rule their own actions and bodies

With success develop Autonomy

! With failure develop Shame and

Doubt in their own abilities

Psycho-Social Development Erikson’s Stages

Self-Concept

• Birth through 14 months – no sense of self – Child views themselves as extension of their

parent/caregiver • 15 months to 2 years

– Self awareness emerges – Recognize self in a mirror

Self-Concept2 - 3 years

• Self concept emerges • Child identifies themselves as:

– A “girl” or a “boy” – A “baby” or “big boy/girl” – A “brother” or “sister” or only child – By religious affiliation – By ability



• Three to six !

• Six to Eleven !


Initiative versus Guilt (3 – 6 years)

Initiative: • Increased awareness of self and world outside of home • Eagerly attempts new tasks and play activities • Successful attempts at new tasks help children learn

and master many things, which becomes self-reinforcing (proud of themselves) and self-controlling to gain the approval of adults

Psycho-Social Development

Erikson’s Stages


!Initiative versus Guilt

(3 – 6 years) !Guilt: • When attempts result in failure or criticism, the

child feels: Guilty Incompetent Helpless


• Ego-centric thinking • “I am the world and the world is just like me!” • As they develop new skills:

– Repetition/Practice Mastery – Mastery Competence – Competence Self-confidence – Self-confidence Self-esteem

Professional as Coach

Professional Parent Child

Parents teach their child. Professionals support and

coach parents as they teach their child.

Development of Social Skills/Interaction

Provide information to parents on: • Lack of incidental learning due to hearing loss • Often deaf/hard of hearing children need specific training

on basic and more advanced social skills • Use of social skills books • Discriminating between “Can’t Do” or “Won’t Do” behavior

problems (Gresham, 1995)

Frequent Teaching of Social Skills

• For “Can’t do” behavior problems: Use Modeling, coaching, practice !

• For “Won’t do” behavior problems: Use behavior charts, positive reinforcement, effective praise, and noticing (and describing) good behavior

!(Gresham, 1995)

Examples of Basic Social Skills

• Eye contact • Smiling • Listening (for friendship) • Introducing yourself • Meeting new people • Joining a group • Giving compliments



• Three to six !

• Six to Eleven !


Psycho-Social Development Erikson’s StagesIndustry vs. Inferiority

(6 – 11 Years) • Child is ready to learn formal skills needed for

adulthood • Successful learners develop positive self-image,

competence and self-esteem • Children who struggle with learning develop

feelings of inadequacy, incompetence and poor self-esteem


• Comparative period: 7 – 9 years – “I’m not like the rest of the world (or my

parents, siblings, friends). I’m unique. I’m different. I’m a freak.”

• Peer pressure years: 9 – 13 years – “I want to be, dress, look, sound exactly like

my friends. I want to fit in (blend in).”

• Starts to emerge between ages 7 and 9

• Child understands: – he/she is different from her family and peers – their hearing loss is permanent

• Child feels inferior, embarrassed. Attributes problems to themselves personally, not their hearing loss

Development of Self-Conceptfor Deaf and Hard of Hearing Children

Development of Self-Conceptfor Deaf and Hard of Hearing Children (continued)

• Child may try to emulate hearing children minimizing their need for accommodations for effective communication

• Child often experiences grief over hearing loss for the first time

• Parents can help their child cope and resolve their grief only if they themselves have come to a healthy acceptance of the child’s hearing loss


• Teaching and practicing intermediate to advanced social skills, including: – Asking for clarification – Interrupting appropriately – Asking for help – Giving complements – Showing interest in others

• Review with parents need to discriminate between “Can’t do”/”Won’t do” problems, and fatigue (Is child getting enough sleep?)

Areas to Probe• How many close friends does Taylor have? • How often is Taylor playing with friends at home? At

school? • How often is Taylor invited to play with or parties of

friends? • How does Taylor’s hearing loss impact the family? • How do Taylor’s parents (siblings, grandparents) make

adjustments to enhance communication at home? • Does Taylor participate in family conversations? • Does Taylor know what his/her sibling’s favorite interests

are? Friends are?



• Three to six !

• Six to Eleven !



Identity versus Role Confusion (11 years – Adolescence)

• Teen becomes independent from family and establishes role in society

• Teen uses parents as first role model • Conflict often directed towards same sex parent • Teen’s identity

– can be influenced by adults outside the family – is developed through life experience

• Self-image becomes more well-rounded or inadequacies become magnified

Self-Concept 14 years - Adolescence

Individuation Period: Time for teens to discover who they are, what they want to be – “Who I am?” – “I am unique and different (or at least I

wanna be).” – “Where do I fit into society?” – “What will I be as an adult?”

Development of Self-Conceptfor Deaf and Hard of Hearing Children

11 years – Adolescence

• Settings that teens go into can significantly increase communication challenges

• For some teens this can create the first time in their life when they have to confront their hearing loss

• Teen may completely change their method of communication several times during adolescence

– BENEFIT: Allows teens to broaden their range and depth of communication skills and allows teen to achieve their developmental task of separation from parents and figuring out who they are (individuation)

Development of Self-Conceptfor Deaf and Hard of Hearing Children11 years – Adolescence (continued)


11 years – Adolescence

• Continue refining and practicing intermediate to advanced social skills, including: – Assertiveness skills – Dealing with being left out – Coping with change – Self-advocacy – Dating behavior

session goals - osspeac goals • discuss “grief ... • review erikson’s model of psychosocial...

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