● Studies repeatedly demonstrate that children identified and receiving intervention before 6 months of age perform significantly better on measures of vocabulary, grammar, comprehension, and expressive language than those who begin later. PubMed+2PubMed+2
● Cochlear implantation before age one is associated with substantially better language outcomes—both receptive (understanding) and expressive (speaking)—compared to implantation later. Wiley Online Library+2PubMed+2

Social well‑being encompasses self‑esteem, peer relationships, experiences of inclusion,
psychological well‑being, and participation in activities. Multiple studies show that children
with HI can achieve social outcomes close to those of their hearing peers, especially when early
intervention is in place. BioMed Central+1
● For example, children identified early via newborn hearing screening, with early auditory access (via technology and therapy), report rates of bullying, victimization, social difficulties, and self‑reported distress that are similar to hearing peers. PubMed

November Article 2025

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Social Skills Products

Under this SOCIAL SKILLS section, refer to the website for more information on:

• 
  Addressing Self-Esteem and Issues of Fitting In
• Building Your Child’s Self-Confidence
• Self-Concept: How the Child Sees Himself
• Self-Concept: Infants, Toddlers, Preschoolers
• Self-Concept: School-Age Children
• 
  Self-Concept: Adolescents
• Self-Identity and Hearing Loss
• Social Needs and “I hate my hearing aids!”
• See below for Social Skills Area Assessment Considerations
• Also refer to:
  Social Communication- Pragmatics and
  Theory of Mind – Implications for Social Success

Look here for worksheets you can use to develop social cognition and recognizing emotions.

App for recognizing song lyrics so kids can be in tune with current music trends:

• 
  Shazam
  
• 
  List of Summer Camps for Children who are Deaf or Hard of Hearing
  

Social Skills Worksheets 
Source: MN Department of Education, 7/11/17
Sample worksheets to assist with determining needs or identifying concerns.

Social Skills include:

• Rules of conversation
• Responding to social cues
• Saying hello/goodbye
• Cooperating by taking turns
• Responding appropriately to questions
• Being sensitive to the feelings of others
• Making eye contact
• Smiling
• Being polite
• Problem solving
• Supporting others/helping
• Having interesting things to say
• Reinforcing and acknowledging other’s comments
• Controlling aggression and inappropriate behaviors

Rules of Conversation

• Don’t always wait for someone to talk to you. EVERYONE needs to take a turn at starting a conversation.
• Start talking to someone – it they want to talk about what you said, they will take a turn.
• Don’t talk, talk, talk – take turns as the talker and the listener
• Pay attention when another person talks to you. Listen so you know when you should take your turn.
• People build a conversation together. Listen to what the other person is saying and add to that topic.
• What you say should be about what the other person just said, unless you are both done with the topic.
• If you don’t understand what the other person said or meant, do not pretend that you did. Ask for clarification.
• Take your turn deciding what to talk about. It is your responsibility to hold up your end of the conversation!

How to be Cool

results of a study with a real group of teenagers tasked with defining COOL. Part of having self-confidence is knowing that you are ‘okay’ even when you receive some negative messages from peers. The How to Be Cool handout lists different aspects of ‘cool’ including speaking up for your self and not being afraid to be different.

Social Communication Styles quiz
setting the stage for developing self-advocacy by thinking about communication style

Making a Friendship Sandwich
 – activity to teach the rules of conversation

Social Skill Areas  
Definitions and criteria of the 4 social skill areas followed by specific social skill situations for elementary, junior high, and high school for home and school situations. Purpose: to provide a structure for goals and role-playing discussions to practice social skills.

SOCIAL SKILLS AREA ASSESSMENT CONSIDERATIONS

Evaluation needs to be tailored to assess specific areas of educational need (§300.304(c)(2)). Because we recognize that social/emotional development may be an area of need for students with hearing loss, the following section of IDEA is especially relevant:

Part
300 /
D /
300.304 /
c / 4
(4) The child is assessed in all areas related to the suspected disability, including, if appropriate, health, vision, hearing,
social and emotional status, general intelligence, academic performance, communicative status, and motor abilities.

Social Skills Checklists

  – Source:
MN Department of Education. 7/11/17
This checklist is a guide for all teachers of the D/HH and their districts to use with D/HH Children Birth-21. This checklist is a guide/tool for the Teacher of the Deaf/Hard of Hearing.

Less Effective Assessments for Children who are DHH in Inclusive Settings

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Why do kids reject their hearing aids – they help them so much!

It is ‘normal’ to want to ‘be normal’. All children struggle with this to some degree. Rejecting hearing aids is usually an emotional reaction to wanting to fit in. As children approach adolescence, how they view the acceptance of their peers is very powerful. Being an accepted member of the social group becomes increasingly important. Taking off the hearing aids, saying they don’t need hearing aids and pretending to ‘be normal’ are all emotional reactions to trying to ‘solve the problem of fitting in.’

To the child, not wearing hearing aids is a solution to an uncomfortable social/identity situation. Ironically, it is the students with mild and moderate hearing loss – those who can hear closest to ‘normal’ with amplification – who are at highest risk for rejecting their hearing aids because they can ‘hear’ and are willing to try to ‘get by’ with the hearing that they have.

Also refer to the webpage Addressing Self-Esteem and Issues of Fitting In and Why do so Many Students that Function with Mild Hearing Loss have Challenges Fitting In? at Mild Hearing Loss & Learning and to Being the Lone Student with a Hearing Loss at Relationship of Hearing Loss to Listening and Learning. The report Psychological Affects of Hearing Loss In Teens provides insights, especially for children who have recently lost their hearing.

Won’t it  help if I explain and ‘show’ the student how much better s/he does with hearing aids?

It is likely that the student realizes that communication is more difficult when the hearing aids are not worn or that they miss a lot more teacher information when they don’t wear the FM in the classroom. Providing them with the numbers will quantify this difference to the student, but it is unlikely to make him change his mind long term about wearing hearing aids since the uncomfortable reality of feeling as though he is ‘weird’ or ‘doesn’t fit in’ is still unresolved. Similarly, firm expectations and behavior contracts may work in the short-term, but are not likely to make a long term difference. That said, it is still important for the child as a consumer to be able to understand his hearing loss and what he can/cannot hear. The hearing loss will be with the child his whole life and he will be asked countless times about it. He needs the language to describe to others so they can understand what the hearing loss means in terms of the person’s communication needs and expectations for his/her communication partners.

Some students don’t seem to have these struggles while others start to reject their hearing aids by the 4th grade – what’s the difference?

To really ‘fit in’ to a group of typically hearing children the child with hearing loss needs to have age-appropriate social skills, be aware of subtle social cues and also have high self-esteem to admit they have a hearing loss (disclosure) and be willing to take the emotional risk of advocating for their communication needs. Underpinning these skills is a strong self-concept and identity as a person who is likeable and capable. Some children are raised with mixed messages that result in them internalizing that their hearing loss is a problem that separates them from being the child that their parents wanted (see Attitude is Caught, Not Taught). In this situation, rejecting the hearing loss (and hearing aids) is an attempt to make themselves more acceptable in the family setting. Emotional ‘loyalty’ to family attitudes can interfere with the child’s openness to recognize that hearing aids are necessary for learning and academic success. Alternately, some children come from families who have embraced them as ‘just kids who happen to need hearing aids’, treating use of the devices as matter of fact as needing to wear shoes, and as recognizing them as being special just for who they are. Coming from a ‘celebration and acceptance of differences’ value base from an early age goes far in providing a child with the resilience needed to answer the questions of curious peers and feel good about ‘cool technology.’ Of course there are some children who come from very supportive families who still reject their hearing aids, perhaps due to lack of resilience to negative peer comments or as a part of identity struggles due to other challenges unrelated to hearing loss that can cause a child to feel as though they do not fit in.

Early intervention services that include discussions of social development needs and connect families of children with hearing loss are an important contributors to the attitudes that develop children’s view of themselves. Once a child is in elementary school (by age 5) it is critical for them to have ongoing connections with other children who use hearing technology. Use of the hearing devices must become part of their identity and our identities are largely formed by our social groups. Children who are only surrounded by peers with typical hearing will be much more likely to reject hearing aids as a way to fit in. Identity is key!
Another thing to keep in mind is that adolescents are more likely to reject anything they felt ‘has been done to them.’ This is why it is so important to encourage the child to be involved in choosing hearing aid or earmold colors, asking the audiologist questions or and being responsible for their hearing devices as early as possible. If they’ve invested themselves and been recognized as being their own “Technology Specialist’ then they may be less likely to feel as though they were a bystander in the decision to wear hearing devices.

Viewpoints of tweens & teens

Adolescents are concerned with how they appear to others. They are trying to reconcile “the person I am” with “the person society expects me to become.” They establish this new sense of self by using past experiences to guide their anticipation of the future. When the adolescent finds a balance between “What have I got?” and “What am I going to do with it?” they will have established their identity. DHH professionals with long experience probably know of some students who rejected their hearing aids in middle school, only to return to using them in high school, whereas others never used amplification again. The difference is likely rooted in whether or not their developed identity included a central view of themselves as a person with hearing loss or a view of themselves without the hearing loss (but possibly a view of learning challenges, inadequacy, ‘can’t do school’).

Research by Elkayam and English (2003) identified that teens were experiencing the following themes:

3. Cosmetics and other hearing device issues: hate having to explain to people; seen as being different

The Effects of an Untreated Hearing Loss on Workplace Compensation

Possible prevention…

Part of these issues need to be prevented, by building strong self-concept and strong self-esteem from a young age. All of these issues need to be acknowledged and openly discussed by the time students are tweens to help the student become aware of “What have I got?” as a foundation for being able to positively visualize “What am I going to do with it?” as they move through adolescence.

In elementary school – certainly by the end of 4th grade – the early tweens are already aware of trying to reconcile “the person I am” with “the person society expects me to become.” If “the person I am” is the only child with hearing loss in the whole grade/school, then “the person society expects me to become” is likely to be internalized as someone without hearing loss. At this juncture it is important for students to be connected with peers who also have hearing loss and communicate/wear hearing devices like them. Being exposed to role models a few years older who willingly use hearing devices and advocate for themselves would tremendously increase the chance that the child would develop a positive feeling about being a member of the group of “successful/cool kids who wear hearing devices.” Discussing how the students feel about their hearing aids, tasking them with describing their hearing loss to one another, developing a sense of group by sharing ‘oh no, guess what happened to me’ stories and brainstorming ‘you could have done/said this’ in the group will strengthen the sense of valued membership
In addition, it is very important to also bring hearing peers into the discussion so that the student with hearing loss can understand, first hand, how peers view them in light of their hearing needs (SOAC-A checklist is suggested). Children need to reconcile themselves as part of the group that has hearing loss/wears hearing devices AND the group of age-peers in school who do not have hearing loss, rather than only the typically hearing group if they are to be emotionally as well as academically successful individuals. Also putting them in the important role of being their own ‘Technology Specialist’ can provide a source of pride and growing independence as they are better prepared to answer questions about their hearing technology – and kids really like technology, peers included.

Teen connections

Hearing Our Way      Hearinglikeme.com

Hearing Journey  (Advanced Bionics)

Are there resources available?

There are a variety of resources in Chapter 5 of Building Skills for Success in the Fast-Paced Classroom that have been developed or included to provide a format for conversations with children that will help them explore their feelings about being a person with hearing loss. The Peer Relationship Scale,
Self-Assessment of Communication – Adolescent (SAC-A), and
Significant Other Assessment of Communication – Adolescent (SOAC-A) are available for download from the Tests by Other Authors section of this website. Other resources from Building Skills are:

• You and Your Tricky Hearing Loss
• The Secondary School Survey (don’t wait until middle school – grade 5!!!)
• Various exercises related to feelings
• Teasing – It happens to everyone
• Hearing Technology and You: Your idea of the perfect hearing device
• Living in the World with Hearing Loss: What other people may think
• A Wizard’s Challenge game

Being able to consider themselves part of a group of other children with hearing loss and having the opportunity to talk about common issues can go a long way toward a more positive self-identity. Social group options through the school district or organized by the state may result in better test scores as more students keep their hearing aids on!

It is critical for early interventionists, preschool settings, schools and audiologists to connect families of children with hearing loss together so that kids can spend time with other kids who use hearing devices. It is every bit as important for the family members to encounter other families with ‘cool, successful kids’ who happen to have hearing loss. There are some handouts available for families regarding self-esteem building at the end of Chapter 5 in Building Skills that may be most useful for young students.

Rejection may also be due to problems with amplification!

In 2008 a study (Franks) investigated why students age 8-18 resist wearing FM amplification. Results indicated that there was no correlation between type of hearing loss (unilateral, bilateral) and resisting hearing aid wear. At least half (53%) believed that the primary reason for non-use was social. Students said:

• It makes you stand out.
• Students ask me “What is that?¨ I really dislike that.
• Mine used to always make weird loud noises that attracted attention to me
• It is annoying.
• If students didn’t grow up using the FM units, they don’t feel comfortable with them.
• Teacher forgets to use it.
• I don’t feel it makes a huge difference because I can just ask my friend if I think I missed something.
• I don’t like the fact that I have to give it to the teacher.
• I feel bad teachers have to use it.

Notice that some of these issues are due to poor functioning equipment, others to resistance from teachers and others from a lack of self-esteem on the part of the student to have the resilience to endure standing out when wearing the technology or self advocating. Results indicated reasons for resisting using FM equipment as: 15% mechanical issues, 10% comfort, 10% questioned benefit, 15% lack of support of teachers, 10% inconvenient to manage FM between classes/recharging.

Problems that are solvable with aggressive management (Johnson, 2011)

Technology

• Provides more flexibility to hear peers
• No bulk or less bulk to hearing technology
• Connectivity options
• Cool technology
• Must include aggressive troubleshooting

School/Teachers/Staff

• Hearing loss awareness: hearing vs. understanding
• Classroom support
• Orientation and training
• Enforcement: If in IEP or 504 use of hearing technology is not a teacher’s choice

If a student is resisting using their hearing devices, be sure that the devices are working properly, comfortable and that the student and staff clearly understands the benefit and use.

Making sure that these issues are aggressively and consistently addressed AND providing social/group support discussions of emotional issues seem to be an appropriate means to support students with hearing loss so they can perform as competitively as possible in the mainstream. Better student outcomes at graduation mean a better future!

Printable version – 4 pages: Social Needs & “I hate my hearing aids!”

These are the views of Karen Anderson, PhD who reserves the right to adapt them as she learns more from the literature and the many DHH professionals and parents who are helping students deal with these issues everyday.

Original post March, 2012 (c) Karen L. Anderson, PhD

Updated January 2016.

The post Social Needs & “I hate my hearing aids!” first appeared on Supporting Success For Children With Hearing Loss.

Some of the information below was derived from the Nov/Dec 2014 Volta Voices issue was devoted to self-concept, identity and self-esteem with hearing loss (look up
digital version).

Psychosocial Development

Erikson described the development of psychosocial skills as a series of developmental challenges, or stages. Because of reduced access to communication, progress through the stages of social development require more support if a child has a hearing loss. Refer to the chart found on page 325 of
Building Skills for Success in the Fast-Paced Classroom for more information
Only the stages for tweens and teens are discussed below. Note specifically:

• In grades 2-5 children want to show that they are competent. If they feel as though they are incapable, they may procrastinate in work because ‘it won’t be good enough anyway.’

• As they become tweens/teens (approximately ages 10-12) they are trying to reconcile “the person I am” with ” the person society/my group expects me to be.” For students who are the only person in their peer group, grade or school who had hearing devices, there is a subtle message that they should be like everyone else in their group. This often results in students who may try to ‘get by’ without their hearing devices.

What you can do:

Ellen Rhodes, in the Nov/Dec 2014 Volta Voices issue described her framework for working on psychosocial issues with tweens and teens:

• Help students to actively reframe situations in a positive light (the glass is half full rather than half empty)
• 
  
  In that same vein, take turns playing fortunately-unfortunately with one person being the optimist and the other being the pessimist in describing situations specifically from a positive and a negative perspective.
• Actively discuss how everyone can make mistakes, have failures, and experience embarrassing moments and that we can learn much from these experiences. Focus on generating a vivid positive mental image of how challenges can be handled well in the future.
• Discuss that self-identity (how you see yourself as part of the world) can change based on the situation. Under easy listening conditions they may view themselves as no different from a student with typical hearing. Under challenging listening conditions they may view themselves as hard of hearing, hearing-impaired or Deaf. It is important to help students explore their
  feelings about each of the labels and recognize the aspects that make them feel more/less “impaired” and that they can take action to deal with the challenges (self-advocacy).

• Each individual needs to feel as though they belong to one or more groups. Our identities are defined by the groups to which we belong. If a student never interacts meaningfully with other students with hearing loss, it is not surprising that he or she may reject the part of themselves that does not ‘fit in’ with the rest of the group. Whether it is face-to-face or through media, children with hearing loss need to connect!
• Encourage students who are feeling isolated to ‘take the extra step in kindness.’ By offering to help others, using their unique and positive attributes, they can realize that they are valued as group members. Often it is the students with the weakest social communication (pragmatics & theory of mind skills) who are at greatest risk for feeling isolated. These skills should always be a focus of services and skill building (see below).
  
  The Deafness Doesn’t Define You : How to Excel this School Year
  

  START EARLY

  
  
  An excellent article by Jay Luckner and Anne Molloy in the Nov/Dec 2014 Volta Voices addressed the challenge of overcoming group conversation issues. Some specific suggestions applied to what we can teach children, even starting from preschool:

  • Throughout early intervention and into early childhood, parents typically adjust their communication dynamics so that they face the child and stand close when communicating. The child with hearing loss may not realize that age-peers and other adults have no understanding of hearing loss and what they might need for successful communication.
  • Raise the child’s awareness that most people they meet will not understand that they have a hearing loss. The child, from a young age, needs to be able to simply explain to others that they have a hearing loss and may not always understand what is said.
  • The child needs to learn how to explain some strategies for successful communication such as, “Please look at me when you talk. I need to see your face when you talk so I can understand you.”
  • A strategy to learn in early elementary is to listen carefully and then summarize what people say. “You want me to get my coat and boots and meet you by the car.”  “Oh, you saw the movie Frozen and thought Olaf was funny too.”
  • A strategy to learn later in elementary is to practice ways to remind friends and classmates that  the student wants to be included in the conversation such as, “Did you just change topics? I really want to follow what you are saying and it’s kind of noisy here. Let me know when you change topics so I can follow along.”
  • The major theme to get across is to teach the child that people will be more likely to accommodate their needs if the child focuses on sharing how much they want to be able to understand what the other person is saying.
  • If these skills and strategies can be taught before the age of 10, then the child will have a way to deal with challenging conversation situations as a tween and teen.
  • 
    
    See Children’s Peer Relationship Scale
    
    

  ---

  I AM GREAT

  AG Bell’s Leadership Opportunities for Teens (LOFT) program has been a very successful means of fostering participant’s self-esteem. Ken Levinson, lead counselor of LOFT shared the I AM GREAT model in the Nov/Dec 2014 Volta Voices.

  
  I –
    Independence – it is through experience that we learn who we are and begin the journey to individualization

  A – Attitude – people are attracted to others with more positive attitudes.

  M – Mistakes are OK. We all make them and can learn from them.

  G – Groups – Teens need to find  groups that support who they are and the way they live. It is most important for tweens/teens with hearing loss to feel connected to role models and others their own age who have hearing loss.

  R – Respect – for ourselves and for others. Rather than responding to a comment about hearing loss or hearing devices negatively, take a more respectful approach to responding.

  E – Expectations – There is nothing a child who is deaf or hard of hearing should not try if it interests them. Don’t let other people reduce your respect for yourself or what you can achieve.

  A – Adults – who are important role models in the student’s life, including others with hearing loss?

  T – Tickle them. Have a good sense of humor and make fun of yourself. Poking fun at yourself is a universal teen thing to do.

Resources for Developing Self-Esteem & Exploring Feelings of Fitting In

WEIRD!
 shares the story of a girl who is picked on by a bully in her third-grade class. Luisa begins to feel bad about herself and stops doing things she likes to do. She comes to realize that she is okay just as she is and that the more that the bully thinks she doesn’t care, the more she will be left alone and not picked on anymore. It comes with teaching notes at the end.
WEIRD! is great to pair with conversations about what to say when peers ask about hearing devices or comment on having a hearing loss.

TJ really wrote this story!

I am very fortunate to travel across the US and Canada speaking to professionals who work with children with hearing loss. When I was in Kansas, I got into a discussion with a professional who described TJ and the challenges he went through with inconsistent hearing aid use and feelings of not fitting in. Her solution to helping him deal with these issues was for him to write a book about his experiences. She had it illustrated and the result is this meaningful booklet.

Available at the cost of printing, TJ’s Story is excellent to share with older elementary students, especially as a lead-in to completing the
SAC-A (Self Assessment of Communication – Adolescent) or the Secondary Survey (both of which can be done starting gr 4).

Self-Esteem Resources on the SSCHL Website

• Social Skills & “I hate my hearing aids!”
• Self Concept
• • Self-Concept for Infants, Toddlers, Preschoolers
  • Self-Concept for School-Age
  • Self-Concept for Adolescents
  • Building your Child’s Self-Confidence

Materials from the
https://successforkidswithhearingloss.com/tests webpage

• Children’s Peer Relationship Scale by Dr. Kris English
• SAC-A: Self-Assessment of Communication – Adolescent by Judy Elkayam
• SOAC-A: Significant Other Assessment of Communication: Adolescent by Judy Elkayam
• Checklist of Socio-Pragmatic Language Behaviors for Students with Sensory Impairment
  
• Various
  Social Skills Checklists
• Think About It Quiz – informal assessment of self-concept for adolescents
• The Secondary School Survey (Teacher Tools)

The post Addressing Self-Esteem and Issues of Fitting In first appeared on Supporting Success For Children With Hearing Loss.

• Pragmatic Language
  Pragmatics Checklist Ages 2.5 to 7 years
• Self-Concept
• Theory of Mind

What is Theory of Mind?

The ability to take someone else’s perspective. It includes the awareness that a situation may not look the same to another person AND the ability to view a scene from someone else’s viewpoint. It includes social cognition, or being able to ‘read’ what someone is thinking or feeling from their expressions and body language.

Theory of Mind includes:
(1) Recognizing other’s feelings
(2) Thinking about consequences of actions
(3) Recognizing that someone else may be thinking or feeling differently than you do

Enhance Theory of Mind via:

• Talking about misunderstandings
• Talking about why jokes are funny
• Engaging in rich pretend play
• Talking about people’s thoughts, wants, feelings and WHY they act the way they do
• Reading stories with surprises, mistakes, secrets; invite children to see things from a different point of view
• Vocabulary: Emotions! Thinking words (suppose, think, imagine…)

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Self-confidence is an essential ingredient for healthy development and school success. Confidence is a belief in your ability to master your body, behavior, and the challenges you encounter. Children who are confident are eager to face new challenges and expect adults to be helpful and supportive of their efforts.Self-confidence is crucial for getting along with others and making friends. Self-confident children see that other people like them and expect relationships to be satisfying and fun. Below are ways you can develop your child’s self-confidence:
First, really believe that your child can be successful. Most parents have never had contact with a child with hearing loss until their own child is diagnosed as deaf or hard of hearing. Yes, your family and child will need to work harder to make sure that language is truly accessible. The time you put in to these efforts is an investment in your child’s life long success.

No limits – Olympic athletes thriving with hearing loss
Read this inspiring article about athletes who were deaf or hard of hearing who didn’t let their hearing loss stop them from succeeding!

Establish routines with your baby or child.

When events are predictable your child will feel secure and in control of his world. The predictability of knowing what will happen next and helps him prepare for those changes. If day-to-day events are unpredictable, it may feel too scary to fully explore. When children know what to expect, they feel free to play, grow, and learn. Wearing hearing aids or cochlear implants for ALL waking hours is critical to your child with hearing loss learning that the world is predictable and safe.

Allow for and facilitate plenty of opportunity for play.

Through play, children learn how to solve problems and develop confidence. It is also through play that children try on new roles and work out complicated feelings. Let your child lead playtime—this will build his confidence, assertiveness, and leadership skills.

Help your child learn to be a problem-solver.

The goal is to guide and support your child in her problem-solving efforts but not do for her what she has the skills to accomplish herself. Sometimes, your child’s times of greatest frustration are opportunities for her to develop feelings of confidence, competence and mastery. She’ll learn that she can depend on you to encourage her. Meanwhile, she’s the one who finds the solution. Helping her learn to recognize that sound is important and a link to YOU and the experiences in her world is a key foundation to many of the problems she will solve in the future.

Practice with your child ways to respond to “What are those things?”

Hearing aids are uncommon, especially on children so it isn’t surprising that other children ask what they are. To the unprepared or self-conscious child it may feel like other children are being mean or picking on them rather than just asking for information. Your child’s health self-concept depends on being resilient to questions about hearing technology and confident in ways to answer. A child who has been raised to feel embarrassed of his hearing aids is likely to feel shame and that they have something wrong with them when they are asked about their hearing aids. Ultimately, most of these children stop wearing their hearing aids, even though their school success may be severely impacted. A child can learn many ways to respond to questions – some informative, some funny, some silly and some just matter-of-fact. Those who are raised recognizing that “ear computers” are cool technology and that most people KNOW NOTHING about them can develop a sense of pride in their knowledge. They are the ambassadors who help people who are ignorant of hearing loss and hearing devices learn about them.

Self-concept and self-confidence can be improved via the
Iron Man poster shown, or books like
I’m the Boss of My Hearing Loss.

Give your child responsibilities.

Feeling useful and needed makes children feel important and builds confidence. Jobs should be age-appropriate. Be specific about what is expected. Say, “Please put a napkin on each plate,” not “Help me set the table.” Even two-year-olds can learn expected to mommy or daddy for help if their hearing aids/cochlear implants are not working. They can also learn – by age 3! – to be responsible to put on their own hearing aids.

Celebrate your child’s successes.

Showing your child that you recognize how he is growing and learning helps to build his confidence. Hooray! You heard that! What a big boy – you are learning to put on your own hearing aids! What a big girl for telling mommy your hearing aid was not working!

Encourage your child to try to master tasks he is struggling with.

Children learn by doing. Break down difficult tasks into small steps to help him feel in control, confident, and safe. As you work on a task or skill that is tough for your child let him know you believe in him, but also communicate that you will not be disappointed if he isn’t yet ready. You are there to support him whenever he is ready to try again. Learning how to put on hearing aids takes much patience and praise!

Provide language for your child’s experience

Provide language that accurately reflects his experience, shows understanding and empathy, and instills confidence.

Be a role model yourself.

Children are always keenly watching their parents for clues about what to do or how to feel about different tasks or social interactions. When it comes to learning how to manageemotions like hurt, anger, or frustration,you are their “go-to” person. If you can model persistence and confidence in yourself, your child will learn this too. Try new things and

praise yourself aloud
. “I was really frustrated putting up that shelf. It was hard to do. When it fell, I was mad. I rested and tried again. Now I’m proud of myself for getting the job done and not giving up.”

For a HANDOUT of this page, go to
Helping Your Child Build Self-Confidence

This information was excerpted from the excellent information available at ZERO TO THREE
https://main.zerotothree.org/site/PageServer?pagename=ter_key_social_confidence&AddInterest=1157

Information included on
https://successforkidswithhearingloss.com/self-confidence

Supporting Success for Children with Hearing Loss; May, 2013.

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What is universal to children with hearing loss is that they have a reduced listening bubble, meaning that they are unable to overhear conversations going on around them beyond a few feet. Hearing aids have a very small microphone and pick up sound best in a quiet room when the speaker is within 3-6 feet. The distance between the ears of a child sitting on the floor near a standing parent is often further than 3-6 feet.

Along with fewer words learned, children with hearing loss are at high risk for not learning what typically hearing age mates know about social communication, or pragmatic language use.

Summary of the Need for Children with Hearing Loss to Develop Pragmatics

Pragmatic language skills are the most abstract and complex of all language skills. Even when the child has age-appropriate vocabulary and syntax (grammar) skills, she or he may not yet have learned how to use these skills in a socially appropriate manner for specific social purposes.

Young children with typical hearing acquire these skills rapidly between 3 and 4 years of age and are able to use these pragmatic language skills using complex language. Children with hearing loss acquire these skills much more slowly even when provided early intervention and preschool services. Even at the age of 7, typical children with hearing loss have the pragmatic language skills similar to a 3-year-old.

Without mastery of these skills, children will encounter significant challenges with literacy, written communication, and abstract conversational communication – all of which effects success in school and in getting along with peers. Being “socially awkward” and “not fitting in” all relate to pragmatic language skills and theory of mind.

The area of social cognition, or the ability to recognize emotional state in others, appears especially weak in children with hearing loss, with 7-year-olds having the ability to identify and explain feelings in a manner that is typical of a 3-year-old. This is why it is imperative to address social cognition specifically when a child has a hearing loss. (See intervention products below for intervention ideas).

How do we know this?

A 2012 study asked parents to complete a 45-item checklist about how their child uses social communication skills. It was completed by parents of 109 children with typical hearing  and parents of 126 children with hearing loss of all degrees between age 2-7 years. For each of the 45 items the parents had to decide if the child did not use any communication (not present), used no words (point, yank, other preverbal gestures), used 1-3 words to express the communication in the item or was able to use complex language.

Results for average number who were considered to have ‘mastered’ the item, meaning they used complex language (mastery = 75% of the age group being able to communicate using complex language)

• Average results for 109 children with typical hearing:
  • 3 years = 20 of the 45 items
  • 4 years = 43 of the 45 items
  • 5 years = 44 of the 45 items
  • 6 years = all of the items
• Average results for 126  children with hearing loss of all degrees:
  • 3 years = 6 of the 45 items
  • by 7 years = only 31 of the 45 items

Even children with “mild” degrees of hearing loss (26-40 dB) had substantial developmental delays in the area of social communication.

What should we do?

Assess specifically in the area of pragmatics.
 With 80% or more children with hearing loss being educated mainly in the mainstream, the ability to interact socially is crucial to their full participation in the classroom and acceptance by their peers.

In order to identify deficits in social communication we must expand the scope of a comprehensive oral language evaluation to include daily pragmatic language behaviors. Most standard instruments used to assess language do NOT provide a norm-referenced, valid or reliable measures of social communication and therefore substantially miss or underestimate this important area of development (i.e., TOLD, OWLS).

Although the CELF-4 contains a Pragmatic Profile, it provides no normative data or standard scores (CELF-5 does have a teacher-completed Pragmatic Profile). The extensive CASL does tap into pragmatics, but it measures a student’s knowledge of pragmatics rather than actual use in school and social situations. It is up to the parents and professionals who specialize in supporting students with hearing loss to advocate for appropriate measures of pragmatic language use.

What assessments should be used?

For a hierarchy of expectations for the development of pragmatic language and Theory of Mind skills for ages 6 months through 7 years access the Summary of Social Interaction (Pragmatic) Development / Theory of Mind handout.

We should use assessments that provide a valid, normative comparison between the student with hearing loss and his or her typically hearing age peers. An internet search can provide a list of assessment instruments for clinicians to review. An expansive list will not be included on this site. The assessments vary greatly in validity, administration time, practicality and expense. Below are recommendations:

 Early Intervention through Preschool 

The Language Use Inventory is completed by families for children ages 18-47 months. It has great norms and validity. The downside is the expense of the test and the length of the protocol that must be completed by families. If your agency will pay for it
and your families will complete all of the pages, you will end up with a clear trajectory of pragmatics language learning as children transition from early intervention and eligibility for specialized instruction is considered. The reality is that the expense and parent completion really can be very significant issues.

Most growth of pragmatic language skills occurs between 30-48 months. We really need a snapshot as to whether a child seems to be ‘on target’ at the time of eligibility from early intervention and for planning/monitoring during preschool.

The Pragmatics Checklist, used in the study described above

has been included free for use
by teachers/clinicians in their work with families of young children with hearing loss.A computer fillable version of the Pragmatics Checklist is also available. It fits on one page and can be completed individually by the parents or as part of an interview dialogue with the early interventionist.
The majority (75%) of children will be able to use complex language (full expressions of more than 3 words) per the following: Age 3: 20 of 45 items; Age 4: 43 of 45 items; Age 5: 44 of 45 items; Age 6: 45 items. Therefore, at transition, a child should have mastered 20 of the items using complex language. By entry into kindergarten, all items can be expected using complex language. Based on the results of the study however, it is more likely that the child with hearing loss will exhibit challenges in some or most of the areas listed above as pragmatic skill areas of weakness.  To provide further specificity of expected attainment of each of the skills, refer to the Pragmatics Checklist Interpretation which provides the age of mastery in months (75% of the age group can perform using complex language) and when emergence using 1-3 words and using complex language can be expected.

RECOMMENDATION:  The Pragmatics Checklist will be completed by families at least annually for all children with hearing loss ages 3, 4, and as part of planning for kindergarten readiness.
Hierarchy of skill development for children ages 6 months to 8 years = Summary of Pragmatic Development + Theory of Mind (in Teacher Tools). Download the resource Teaching Your Child to Identify and Express Emotions and share it with families.

Kindergarten through grade 2

Because the normative results for The Pragmatics Checklist included children with hearing loss up to age 7, it is appropriate for use through grade 2 as a parent-completed checklist. For ages 5, 6, 7 it is desired for the parents to identify any of the items in which the child is able to only use a few words to express themselves, especially for the 17 items that mastery is achieved between 48-54 months and the 1 item of mastery between 54-60 months. If the checklist has been completed by the families before and they have already checked that the earlier skills were mastered, it would be appropriate to just circle the items of interest (non mastered and/or most age-appropriate). Interpretation guide shown is available
with the fillable version of the Pragmatics Checklist. .

For a norm-referenced diagnostic tool the Pragmatic Language Skills Inventory (PLSI) is for students age 5.0-12.11 years. This checklist has 45 items that can be completed by the teacher in 10-15 minutes. It has three subscales: Personal Interaction Skills, Classroom Interaction Skills and Social Interaction Skills
. The PLSI has strong psychometrics to be able to clearly identify issues, even for children as young as kindergarten.

Another, or additional option, that may be useful for monitoring development or program planning is Checklist of Socio-Pragmatic Language Behaviors for Students with Sensory Impairment.  This checklist was found on the internet authorless, and was reformatted to fit on one page. It

has been included free for use.
It includes many of the items from the Pragmatics Checklist in a manner more appropriate to school-age (K+) students. It is NOT normed or validated in any way but could be useful for planning or monitoring progress.  If you developed this material please contact me so your name can be specified as author.

An excellent norm-referenced test to use is the
Social Language Development Test, which can be administered starting at age 6. It has four subtests: making inferences; personal negotiations; multiple interpretations, and supporting peers. The test assesses students’ language-based responses to portrayed, peer-to-peer situations which is unlike other tests which rely on observation forms, like the PLSI or PLOS.

There are tests specific to pragmatic language development that are appropriate starting at kindergarten age, however expense and time commitment to complete should be carefully considered. Regardless of the instrument, the person completing the checklist needs to be very, very familiar with the child’s behavior and what is typical for age peers.

RECOMMENDATION: 
Every student with hearing loss should be tested for pragmatic language deficits. The 18 older age (4-5 years) items of the Pragmatics Checklist can be completed as a screening measure by families for children with hearing loss ages 5, 6 and 7 (kindergarten through grade 2) prior to school entry or in the first couple of weeks of school. Once the classroom teacher has observed the student 6 weeks or longer, the PLSI can be given to determine pragmatic language behavior issues.  If a child is identified as having pragmatic language behavior issues in the classroom, the SLDT can be given to define the pragmatic language deficit.  In addition, the teacher of the deaf/hard of hearing can consider the social communication skills represented on the Checklist of Socio-Pragmatic Language Behaviors for Students with Sensory Impairment for student planning and monitoring of progress. Share Improving Your Child’s Social Skills with families.

Grades 3 – 12

Again, there are tests that tap into pragmatics skill development for this age group (refer to
list of assessment instruments). Most students with hearing loss are educated in the regular education mainstream classroom and have a classroom teacher who has observed their behavior over the course of many days and many situations. To initially explore pragmatic language skills, what seems most practical to obtain a snapshot as to whether a student seems to be ‘on target’ is a checklist that can be quickly completed by the classroom teacher and is also a valid measure of the student’s use of spoken language in school and social situations. The

Pragmatic Language Skills Inventory (PLSI)
has 45 items for the teacher to complete for students ages 5.0 – 12.11 years. Cut-off scores are provided for determining whether the student exhibits characteristics of a pragmatic language disorder. Guidelines are provided to assist the examiner in interpreting the results.

RECOMMENDATION:  That the classroom teacher annually complete the
Pragmatic Language Skills Inventory for children in grades 3-6. The
Social Language Development Test can be used to further diagnose the pragmatic language deficit that has been identified by these teacher checklists. An increasing number of students with hearing loss are not being identified as eligible upon school age, using a standard battery of language assessments. The results can also be used to support the referral of a student with hearing loss for educational assessment who was found to be previously ineligible. As part of that assessment an instrument specific to evaluating pragmatic language and valid comparison of results to normative performance can/should be performed.

Planning and Intervention

Planning: A pdf of a 2012 PowerPoint presentation on
Pragmatic Puzzle PPT_Practical Solutions for Evaluation and Treatment – Fleckenstein, Mary Michelle presents an overview of pragmatic language, choosing tests to determine pragmatic disorders, report writing for pragmatic disorders (includes detailed example), samples of goal writing, and a summary of intervention tools available.

Intervention: 

• 
  Teaching the Basics of Theory of Mind
  (much overlap with teaching pragmatics including social cognition, emotions, nonverbal language)
• 
  What’s Up? Game of Social Language
  (for teens gr 7-11)

One resource that suggests intervention for pragmatic language development, especially for young children, is available for consideration (
The Missing Link in Language Development of Deaf and Hard of Hearing Children: Pragmatic Language Development).

An interesting
British study researched the effectiveness of different interventions for children aged 6-10 years with pragmatic language deficits after 8 weeks of treatment (1 hour 3 times/week). Areas of intervention were:  a) pragmatic rules in discourse and conversation; b) turn-taking; c) meta-pragmatics; d) social understanding and social role-playing; e) formulation of conversation and narrative; and f) inferential understanding. All children showed positive change, some more than others.  Authors are careful to say that this intensive treatment schedule lacks evidence to show it is needed for every student, they do indicate addressing the above areas will result in improvement in student’s social communication behavior.
Use this link to refer to another study that provides information on successful intervention.

There are a wide variety of intervention materials available for pragmatic communication learning, especially with the rise of students on the Autism Spectrum (see suggested tools at the end of the
PowerPoint presentation mentioned under Planning).

Information compiled by Karen L. Anderson, PhD, September 2013 for
Supporting Success for Children with Hearing Loss.  Updated March 2017.

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