Predictors of flourishing among children with hearing loss

Accepted Manuscript Predictors of Flourishing among Children with Hearing Loss Laura Nabors, PhD, ABPP, Cathleen Odar Stough, PhD, Ashley Merianos, PhD, CHES, James Peugh, PhD PII:

S0165-5876(16)30377-9

DOI:

10.1016/j.ijporl.2016.10.031

Reference:

PEDOT 8303

To appear in:

International Journal of Pediatric Otorhinolaryngology

Received Date: 19 August 2016 Revised Date:

20 October 2016

Accepted Date: 26 October 2016

Please cite this article as: L. Nabors, C.O. Stough, A. Merianos, J. Peugh, Predictors of Flourishing among Children with Hearing Loss, International Journal of Pediatric Otorhinolaryngology (2016), doi: 10.1016/j.ijporl.2016.10.031. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Predictors of Flourishing among Children with Hearing Loss Laura Nabors PhD, ABPPa**, Cathleen Odar Stough PhDb, Ashley Merianos PhD, CHESa, &

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James Peugh PhDb

University of Cincinnati, School of Human Services, PO Box 210068, Cincinnati, OH, 45221, USA, emails: [email protected]**; [email protected]

Cincinnati Children’s Hospital Medical Center, Division of Behavioral Medicine and Clinical

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b

Psychology, 3333 Burnet Avenue, MLC 3015, MLC 7039; Cincinnati, OH, 45229, USA, emails:

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[email protected]; [email protected]

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** Corresponding Author

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Predictors of Flourishing among Children with Hearing Loss

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Abstract Objectives: To examine parent report of flourishing in children with hearing impairments compared to children without hearing impairments, and to explore whether school engagement

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and bullying related to child flourishing.

Methods: Participants were 655 children with hearing impairments and 44, 618 children without hearing impairments who were 10 to 17 years of age. Caregivers completed telephone interviews

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about their child’s functioning for the National Survey of Children’s Health.

Results: Children without hearing loss had higher parent-reported flourishing compared to

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children with hearing loss when controlling for child demographics (i.e., race, age, sex). School engagement was positively related to flourishing of children with hearing loss. Bullying behaviors were not related to flourishing of children with hearing loss. Conclusion: Improving school engagement may increase flourishing of children with hearing

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loss, which is critical given that children with hearing loss experience lower flourishing than children without hearing loss. Examining the relationships among other risk and resilience factors and flourishing for children with hearing loss will provide information for interventions

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to enhance the adaptation of these children.

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Keywords: hearing loss, flourishing, resilience, school engagement, resilience, children

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1. Introduction

Hearing impairment is a common congenital abnormality in children, occurring in about 2 to 3 children per 1,000 in the United States [1]. Other estimates suggest about 2 to 3 children

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per 1,000 are considered clinically deaf, with approximately 1 to 6 per 1,000 having more mild levels of hearing loss [2]. Children with hearing impairments have reported lower levels of selfesteem and quality of life and higher levels of stress compared to children who do not experience

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hearing impairments [2, 3]. Keilmann et al. [4] assessed the resilience of children with hearing impairments and found that children’s self-perceptions declined as age increased. Children with

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hearing impairments are at risk for long-term problems with their behavioral and emotional functioning, which can negatively impact their development [5, 6]. Ching et al. [7] discovered that among younger children, the severity of hearing loss predicted poor outcomes, and resilient functioning needs to be examined in samples with older children with hearing loss.

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Although children with hearing impairments may experience gains in verbal language and performance on tests of cognitive abilities as they age, their academic performance may not keep pace with their changing abilities. Poor school performance may be related to not feeling

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engaged at school. For example, Dalton [8] reported that if children with mild or moderate

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hearing impairments feel disenfranchised at school, it may negatively impact their functioning. School may also be difficult for children with hearing loss due to peer interactions. Children with hearing loss may experience bullying by others [9]. No information is available on whether they engage in bullying of others, which also might negatively impact their functioning. The current study examined parent report of flourishing (i.e., resilience in child functioning) in children with hearing impairments compared to children without hearing impairments, between the ages of 10 to 17 years, enrolled in the National Survey of Children’s

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Health [NSCH 2011/2012; 10, 11]. It was hypothesized that parent report of child flourishing would be greater for children without hearing impairments than children with hearing impairments. Additionally, the relationships among bullying behavior and flourishing, and

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school engagement and flourishing among children with hearing impairments were explored. It was anticipated that severity of hearing loss, bullying or being cruel to others, and not being engaged in school would be related to lower flourishing.

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2. Methods

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2.1. Participants

Participants included in the present study from the 2011-2012 NSCH were 655 children with hearing impairments and 44,618 children without hearing impairments who were 10 to 17 years of age. Among children with hearing impairments, 354 (54%) had mild impairments, while 297 (45%) had moderate/severe impairments. Parents did not report on the severity of hearing

1.

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impairments for four children (< 1%). Additional demographic information is presented in Table

2.2. Data source

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Insert Table 1 here

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Parents were recruited using cross-sectional, list-assisted random digit dial samples of both landline and cellular telephone numbers from all 50 states in the U.S., the District of Columbia, and the U.S. Virgin Islands. The legal guardian or parent most knowledgeable about the child’s health completed the interview about one child. If there was more than one child in the home, then a child was randomly selected to be the subject of the interview. The NSCH 2011–2012 resulted in 95,677 interviews. Average interview length was about 33 minutes. The completion rate for interviews was approximately 54% for the landline sample and about 41%

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for the cellular telephone sample. Parents provided information about their health and their child’s health and mental health as well as providing information about their child’s functioning. A thorough description of the telephone interview procedures has been described by the Child

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and Adolescent Mental Health Measurement Initiative [10, 11]. The current study was approved by the primary authors’ university-based institutional review board and permission was received by the Data Resource Center for Child and Adolescent Health to analyze NSCH data.

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2.3. Study variables

A composite variable representing parent report of youth flourishing was the dependent

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variable. An expert panel developed questions to assess flourishing in the NSCH sample and three questions were selected to represent flourishing, a proxy for resilient functioning in children. For these questions, parents and guardians provided information about: (1) the child’s interest and curiosity in learning new things; (2) the child’s ability to remain calm and in control

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when faced with a challenge; and (3) whether the child followed through with what he or she said he or she would do. Interviewers recorded parent responses to the flourishing questions on a five-point scale (“never, rarely, sometimes, usually, or always”). A composite score from “0” (no

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flourishing items endorsed) to “3” was created from the three aforementioned questions. A score of “3,” indicating high flourishing, meant that the parent had provided a response of “usually” or

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“always” for all three flourishing questions and a score of “2” indicated the same responses were provided for two of the questions, and a score of “1” indicated a “usually” or “always” response was provided for one of the questions. Parent report of child engagement in school and bullying behavior were independent variables. Parents provided information about whether their child bullied on a five-point scale (never, rarely, sometimes, usually, or always). A school engagement variable was computed using two variables assessing how often children cared about doing well

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in school (“never, rarely, sometimes, usually, always”) and how often children did all required homework in the previous month (never, rarely, sometimes, usually, always). Both of these variables were then collapsed to have three response categories: “never/rarely/sometimes,”

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“usually,” or “always.” If children engaged in either caring about school or completing required homework “never,” “rarely, or “sometimes,” then they were categorized as

“never/rarely/sometimes” engaging in school. Children who engaged in both caring about school

other children were coded as “usually” engaging in school.

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and completing required homework “always” were coded as “always” engaging in school. All

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Children were classified as having a hearing impairment based on parent responses to the question “Does (child) have a hearing problem?” with the response coded as “does not have condition” or “currently has condition.” For children with hearing problems, severity was categorized based on parent report as “mild” or “moderate/severe.”

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2.4. Statistical analysis

A series of count regression models were conducted using Mplus statistical analysis software [12] using a subset of the NSCH database restricted to participants between ages 10-17.

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Information regarding the specification of subpopulation, sample weight, and clustering variables for all analyses have been published elsewhere [13, 14]. Preliminary analyses showed that

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negative binomial (without a zero-inflation assumption) was the appropriate distributional assumption for the flourishing count response variable whether analyses involved the full NSCH subsample (N = 45,290; M = 2.05; SD = 2.94), a subsample restricted to participants with any hearing loss (N = 655; M = 1.65; SD = 2.44), or a subsample further restricted to participants with severe hearing loss (N = 297; M = 1.54; SD = 3.34). Specifically, in the first analysis, flourishing counts were predicted by child hearing status (i.e., hearing loss, no hearing loss) and

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child demographics (i.e., age, sex, and race). In the second analysis, flourishing counts between children with mild hearing loss to children with moderate/severe hearing loss were compared in a model that included severity of hearing loss and child demographics as predictors. The third

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analysis explored possible predictors of flourishing in children with hearing loss with a count regression model that included school engagement, bullying, and child demographics as

predictors. All effect sizes are presented using odds ratios (ORs) that include 95% confidence

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intervals. To control for possible family-wise Type-I error inflation across multiple comparisons, a critical alpha of .01 was used for all significance tests. Missing data were very minimal (< .1%)

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and handled via the default maximum likelihood estimation algorithm (MLR) for count response variables. 3. Results

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Table 2 presents descriptive information about flourishing of children in each sample. Insert Table 2 here

Inspection of the descriptive data indicated that children with hearing loss and those without

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hearing loss engaged in low levels of bullying. Children with hearing loss were less engaged in

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school than children who did not have hearing loss. 3.1. Comparison of flourishing across children with and without hearing loss In the first analysis, children with any hearing loss (mild, moderate/severe) displayed

significantly lower flourishing scores than children without hearing loss (b = - .23, p < .001; OR = 1.26, 95% CI = 1.18, 1.33). Child age did not predict flourishing (b < - .01, p = .39, OR = 1.00, 95% CI = 1.00, 1.01). African American children (b = - .16, p < .001, OR = 1.17, 95% CI = 1.15, 1.20) displayed lower flourishing than Caucasian children. Children of other races (b = - .04, p =

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.02, OR = 1.04, 95% CI = 1.01-1.07) did not differ from Caucasian children in their flourishing. Females displayed greater flourishing than males (b = .08, p < .001, OR = 1.08, 95% CI = 1.06, 1.11). In the second analysis, flourishing scores of children with mild hearing loss did not differ

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3.2. Predictors of flourishing among children with hearing loss

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from children with moderate/severe hearing loss (b = < .01, p = .86, OR = 1.00, 95% CI = 1.00,

Child age (b = .03, p = .06, OR = 1.03, 95% CI = 1.00, 1.06) and sex (b = - .08, p = .27,

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OR = 1.08, 95% CI = 0.95, 1.21) were not significant predictors of flourishing. African American children displayed lower flourishing than Caucasian children (b = - .48, p = .01, OR = 1.62, 95% CI = 1.38, 1.85), but children of other races did not differ from Caucasian children on flourishing (b = - .13, p = .14, OR = 1.14, 95% CI = 0.99, 1.30). School engagement significantly

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predicted flourishing among children with hearing loss; higher school engagement was significantly associated with higher flourishing (b = .41, p < .001, OR = 1.51, 95% CI = 1.36, 1.66). However, whether the child bullied other children was not found to be a significant

4. Discussion

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predictor of flourishing (b = - .05, p = .20, OR = 1.06, 95% CI = 0.98, 1.13).

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Findings of this study indicated that flourishing was lower for children with hearing loss compared to those without hearing loss. Nationally and globally, children with hearing loss may experience lower quality of life and functioning, making interventions to improve resilience for these children important [4,6]. [Results of this study added to the literature by identifying school engagement as a protective factor, which was related to greater flourishing in children with hearing loss. Assessment of flourishing in a national sample showing that flourishing in children with hearing loss is more positive when they are engaged in school is consistent with the idea of

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inclusion and improving involvement for children with hearing loss to improve their social and academic development [7,8]. It was encouraging that being engaged in school was a resilience factor that was positively related to flourishing for youth, regardless of their age, sex, or race.

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Enhancing feelings of school connection may be one strategy for improving feelings of

involvement in school and may also lead to improved inclusion of children with hearing loss as they become engaged in more interactions and activities.

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Although engagement and full inclusion can be very beneficial for children who have hearing loss, many teachers may feel they are insufficiently prepared to teach students with

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hearing loss effectively [15]. Thus, teacher preparation programs and continuing education workshops should incorporate ideas for inclusion of children with hearing loss, and provide strategies for facilitating their engagement and academic development. Inclusion of children with hearing loss in cooperative or group projects and extracurricular activities may be methods to

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further improve their connections at school, and therefore, increase their sense of place in the school and feelings of engagement while reducing feelings of loneliness [16]. Continuing to focus on improving flourishing and inclusion of children with hearing loss remains important,

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because quality of life may be lower for children with hearing loss than their counterparts who do not experience hearing loss [4,6].

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Surprisingly, there was no difference in resilience between children with mild and

moderate hearing loss, which was contradictory to findings with young children, which have indicated that moderate to severe hearing loss may be more debilitating [8]. It may be that older children, such as those in this study, have received a cochlear implant or learned coping strategies which may enhance their functioning, irrespective of the severity of their hearing loss. Older children with more severe hearing loss may have learned compensatory strategies to

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communicate with peers and teachers or improved their spoken language skills, which allow them to overcome communication barriers. It is important to remember, however, that youth with moderate and severe hearing loss were combined into a single category and more research with a

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bigger sample size or more rigorous study design may be necessary to better understand if

flourishing and school engagement differ for children with moderate versus severe hearing loss. This study also contributed to the literature by examining the relationship between

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bullying and flourishing of hearing impaired youth. Rates of bullying behaviors appeared fairly consistent with those of non-hearing impaired children (see Table 2). It also was encouraging

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that bullying behaviors of children with hearing loss were low and were not related to their flourishing. As noted in previous research, children with hearing loss may be likely to experience bullying by others [9]. Unfortunately, being a victim of bullying was not examined in the national data set. Additional research exploring the relationship between victimization and

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concurrent bullying and victimization for hearing impaired youth, especially adolescents, may provide new insights for those working with this population. Several factors may have limited the generalizability of study findings. For example, this

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survey was based on parent report, and social desirability bias may have influenced parent

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responses. Moreover, the survey was cross-sectional and information on change over time for youth was not available. Additionally, ORs were small, and thus other variables at the child, family, and school level should be examined in future studies. The amount of non-response was a limitation. It may have been that parents of children who were not flourishing did not participate, and thus results may have appeared more positive than is actually the case. Conducting further interviews with caregivers of hearing impaired children will enhance knowledge of their flourishing. Nonetheless, results indicated that school engagement was a

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resilience factor and involving children in school, striving to maximize their academic performance may improve their flourishing in the long-term. 5. Conclusions

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Our findings provide information on flourishing of older youth, which is important, as much of the research focuses on younger children. Children with hearing impairments exhibited lower flourishing than children without hearing impairments. This indicated a continued need for

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interventions to improve their well-being and development. Results indicated that school

engagement was positively related to child flourishing, which contributes to literature supporting

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inclusion and involvement of children with hearing loss in school [16]. Given that resilience is critical to positive development [17, 18], further research should continue to identify protective and risk factors for children with hearing impairments. Improving inclusion and involvement in school may be one avenue for advancing flourishing among children who have hearing loss.

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Additionally, the relations among protective factors and risk factors, in terms of exploring possible mediating effects of protective factors on risk for children will improve knowledge about ways to minimize negative outcomes and maximize flourishing for children with hearing

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loss.

Conflict of Interest Statement

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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no conflicts of interest to report.

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Genomics guideline for the clinical evaluation and etiologic diagnosis of hearing loss, Genet. Med. 16 (2014) 347-355. 10.1038/gim.2014.2.

[2] K. Kuppler, M. Lewis, A. K. Evans, A review of unilateral hearing loss and academic

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performance: is it time to reassess traditional dogmata? Int. J. Pediatr. Otorhinolaryngol. 77 (2013) 617-622.

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[3] B. O. Olusanya, K. J. Neumann, J. E. Saunders, J. E. The global burden of disabling hearing impairment: a call to action, Bull. World Health Org. 92 (2014), 367-373. http://dx.doi.org/10.2471/BLT.13.128728.

[4] A. Keilmann, A. Limberger, W. J. Mann, Psychological and physical well-being in hearing-

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impaired children, Int. J. Pediatr. Otorhinolaryngol. 71 (2007) 1747-1752. 10.1016/j.ijporl.2007.07.103.

[5] A. Kirman, H. Yildirim Sari, Health status of hearing‐impaired children and adolescents, Int.

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J. Nurs. Pract. 19 (2013) 233-240. 10.1111/ijn.12071. [6] J. E. Lieu, N. Tye‐Murray, Q. Fu, Longitudinal study of children with unilateral hearing loss,

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Laryngoscope. 122 (2012) 2088-2095. 10.1002/lary.23454. [7] T. Y. Ching, H. Dillon, V. Marnane, S. Hou, J. Day, M. Seeto, et al. Outcomes of early-and late-identified children at 3 years of age: Findings from a prospective population-based study, Ear and Hear. 34 (2013) 535-552. 10.1097/AUD.0b013e3182857718. [8] C. J. Dalton, Lessons for inclusion: Classroom experiences of students with mild and moderate hearing loss, Canadian J. Educ. 36 (2013) 125-152.

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[9] M. T. Weiner, S. J. Day, D. Galvan, Deaf and hard of hearing students' perspectives on bullying and school climate, Am. Ann. Deaf 158 (2013) 334-343. 10.1353/aad.3013.0029.

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[10] Child and Adolescent Health Measurement Initiative: 2011–2012 National Survey of Children's Health Indicator Data Set. Data Resource Center for Child and Adolescent Health, 2013a. http://childhealthdata.org/learn/NSCH (accessed 08.15.2016).

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[11] Child and Adolescent Health Measurement Initiative: “What's New in the 2011/12 National Survey of Children's Health?” Data Resource Center, Supported by Cooperative Agreement 1-

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U59-MC06980-01 from the U.S. Department of Health and Human Services. Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB), 2013b. http://childhealthdata.org/docs/nsch-docs/2011-12-whats-new-in-the-nsch.pdf (accessed 08.15.2016).

Muthén (1998-2015).

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[12] L. K. Muthén, B. O. Muthén, Mplus user’s guide (7th ed.).Los Angeles, CA: Muthén &

[13] 2011-2012 NSCH: Child Health Indicator and Subgroups SPSS Codebook, Version 1.0.

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2011_2012_nsch_v1_all.pdf?sfvrsn=6 (accessed 08.15.2016). [14] C. Odar Stough, A. Merianos, L. Nabors, J. Peugh, Prevalence and predictors of bullying behavior among overweight and obese youth in a nationally representative sample, Child. Obes. 12 (2016) 263-271. 10.1089/chi.2015.0172. [15] A. Eriks-Brophy, J. Whittingham. Teachers' perceptions of the inclusion of children with hearing loss in general education settings. Am. Ann. Deaf. 158 (2013) 63-97. 10.1353/aad.2013.0009

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[16] M. Hyde, D. Power, D., Inclusion of deaf students: An examination of definitions of inclusion in relation to findings of a recent Australian study of deaf students in regular classes.

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Deafness Educ. Internat. 6 (2004) 82-99. 10.1179/146431504790560564 [17] A. S. Masten, Global perspectives on resilience in children and youth, Child Dev. 85 (2014) 6-20. 10.1111/cdev.12205.

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[18] A. S. Masten, Ordinary magic: Resilience processes in development, Am. Psychol. 56

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Table 1 Participant Characteristics

Youth without Hearing Loss

(n = 655)

(n = 44,618)

23,217 (52%)

Sex 23,573 (52%)

356 (54%)

Girl

21,646 (48%)

298 (46%)

Age

21,348 (48%)

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Boy

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Youth with Hearing Loss

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Total Sample (n = 45,273 )

5,393 (12%)

11 years

5,306 (12%)

12 years

5,790 (13%)

13 years

4,991 (11%)

14 years

5,365 (12%)

78 (12%)

5,287 (12%)

15 years

5,758 (13%)

81 (12%)

5,677 (13%)

16 years

6,261 (14%)

84 (13%)

6,177 (14%)

86 (13%)

6,323 (14%)

6,409 (14%)

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Race

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17 years

85 (13%)

5,308 (12%)

73 (11%)

5,233 (12%)

93 (14%)

5,697 (13%)

75 (12%)

4,916 (11%)

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10 years

Caucasian

33,481 (74%)

473 (72%)

33,008 (74%)

African American

4,485 (10%)

63 (10%)

4,422 (10%)

Other

6,231 (14%)

108 (17%)

6,123 (14%)

Missing values excluded.

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Table 2

Hearing Impairments

Flourishing*

Youth with Hearing Loss

Youth without Hearing Loss

(n = 655)

(n = 44,618)

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Total Sample (n = 45,273 )

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Flourishing, School Engagement, and Bullying Behavior across Children with and without

3,362 (7%)

109 (17%)

1

7,509 (17%)

169 (26%)

7,340 (17%)

2

11,502 (25%)

158 (24%)

11,344 (25%)

3

22,884 (51%)

218 (33%)

22,666 (51%)

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0

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Is Engaged in School

3,253 (7%)

9,740 (22%)

233 (36%)

9,507 (21%)

Usually

14,519 (32%)

178 (27%)

14,341 (32%)

Always

20,979 (46%)

243 (37%)

20,736 (47%)

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Never/rarely/ sometimes

Bullies/Cruel/Mean to

Never

30,094 (67%)

398 (61%)

29,696 (67%)

Rarely

10,399 (23%)

144 (22%)

10,255 (23%)

Sometimes

4,083 (9%)

91 (14%)

3,992 (9%)

Usually

364 (< 1 %)

8 (1%)

356 (< 1%)

Always

262 (< 1%)

14 (2%)

248 (< 1%)

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Others

*Count of Flourishing Items endorsed as “Usually” or “Always” (3 items total); missing values excluded.

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Table 3

1.03

Child Sex

1.08 1.62**

African American Race

1.14

“Other” Race

1.51**

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School Engagement

1.06

Bullying

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** Statistically Significant

95% CI Upper

1.00

1.06

0.95

1.21

1.38

1.85

0.99

1.30

1.36

1.66

0.98

1.13

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Child Age

95% CI Lower

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Odds Ratio

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Odds Ratios for Relationships between Predictors and Flourishing in Children with Hearing Loss