Eileen Rall, Au.D., CCC-A Louise A. Montoya, MA, LPC, CSC The Center for Childhood Communication Counseling Guidelines: Supporting Children with Hearing.

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)


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



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)


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


Healthy Family SystemHealthy Family System

Unhealthy Family SystemUnhealthy Family System


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


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


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


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


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


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

mailto:[email protected]



Eileen Rall, Au.D., CCC-A Louise A. Montoya, MA, LPC, CSC The Center for Childhood Communication Counseling Guidelines: Supporting Children with Hearing.

Documents

social development trust

hearing loss slide

adolescence slide

practice slide

years birth

school slide

diagnosis of hearing

years initiative