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Correlates of Psychosocial Adjustment among Deaf Adolescents with and without Cochlear Implants: A Preliminary Investigation


Drs. Deborah McCaw and Irene W. Leigh were available from 10/12/09 until 11/1/09 to answer questions and share ideas concerning their research and its implications for parents of children who are deaf/hard of hearing, their teachers and other professionals who work with them.

You are encouraged to read the research summary below and review the attached discussion.


The number of children who have received cochlear implants has increased dramatically in the past two decades. In view of publicized concerns about their psychosocial adjustment, our aim was to assess the effect of implants on the adolescents’ psychosocial functioning among a group of 57 deaf adolescents with and without cochlear implants (CI), using published and validated measures completed by the adolescents themselves, their parents and teachers. Adolescents with CI tended to be more hearing acculturated, whereas those without CI tended to be more Deaf acculturated. Despite some differences in background characteristics between the two groups, there were no differences between them on the psychosocial variables assessed in this study, regardless of the reporting sources. Rather than having a direct effect on the psychosocial outcomes assessed in this study, it is through the mediating effect of acculturation and school setting that CI status exerts an influence over many of this study’s outcomes. Recommendations for future research are made in light of our findings.

Introduction and Purpose

Today’s adolescents continue to experience rapid physiological, psychological, and social development. They are also experiencing a world that is rapidly changing in terms of technological advances and their access to that technology is sometimes limited. CIs represent a technology that has increasingly become the standard of care for young children who are identified as deaf.

Currently, there are approximately 160,000 who have obtained CIs worldwide (Nussbaum, 2009). We now have a significant cohort of children and adolescents with CIs. In industrialized countries, between 50% and 80% of children have CIs (Hyde & Power, 2006). Approximately 7,000 have bilateral implants, many under age 18 (Nussbaum, 2009). Increasing numbers are mainstreamed nowadays (Gallaudet Research Institute, 2008), approximately 80% depending on the source.

Deaf culture advocates have questioned the effectiveness of CIs for deaf children, and have expressed concerns regarding their psychosocial functioning with CIs. (e.g., Ladd, 2007). They express concerns about identity evolution as Deaf persons versus academic achievement. They view the efforts to create “hearing” deaf children as misguided considering that many enter the Deaf community and find a home there.

Regarding academics and quality of life, research results indicate increased auditory perception, speech, and spoken language development (e.g. Geers, 2004; Waltzman, 2006). Without a doubt, this necessitates intensive communication therapy utilizing listening and speaking. The expectation is that better academics will result. Thus far, research has supported this expectation in that children with CIs generally do better than those with hearing aids, but do not equal hearing peers academically (for reviews, see Fagan, Pisoni, Horn, & Dillon, 2007; Geers, 2006; Marschark, Rhoten, & Fabich, 2007). It is important to keep in mind that results have been quite varied, depending on sample characteristics.

Moving on to psychosocial aspects, research covering parent perspectives indicate that they perceive their children with CIs to have improved quality of life, greater self-esteem/confidence, and higher levels of outgoing behavior post-implantation (Bat-Chava & Deignan, 2001; Bat-Chava, Martin, & Kosciw, 2005; Chmiel, Sutton, & Jenkins, 2000; Christiansen & Leigh, 2005; Kluwin & Stewart, 2000; Nicholas & Geers, 2003). However, observational findings indicate that integration in social situations continue to be less than ideal (Boyd, Knutson, & Dahlstrom, 2000; Preisler, Tvingstedt, & Ahlstrom, 2005). Self-perceptions tended to be positive (Nicholas & Geers, 2003).

Regarding deaf identity development, the general trend is toward categorization as hearing acculturated, Deaf acculturated, Bicultural, or Marginal (not belonging to either) (Glickman, 1996; Maxwell-McCaw, 2001). Bat-Chava (1993) found that deaf adults with stronger culturally Deaf identities had higher self-esteem. How cultural identity impacts on those with CIs has received limited attention in the literature. In two studies that have been conducted, adolescents with CIs indicated they were socially flexible and wanted contact with both hearing and deaf peers. (Christiansen & Leigh, 2005; Wheeler, Archbold, Gregory, & Skipp, 2007).

The purpose of this study was to further explore the psychosocial effects of CIs on deaf adolescents and compare these with adolescents who did not have CIs, incorporating self-reports from the adolescents themselves in addition to reports from their parents and teachers. The focus was on exploring factors that contribute to psychosocial well-being for deaf youth with and without CIs.


Participants included 57 deaf high school students; 28 were CI-users and 29 were non-users. In terms of ethnicity, 84% were White, 26% other. Most (96%) had parents who were well-educated with 45% having 2-4 years of college and 42% had graduate degrees). For CI-users, the average age of implantation was 7 (quite late by today’s standards, but keep in mind the adolescents are an earlier cohort in terms of cochlear implant technology), and the average length of use was 8 years. The two groups were not significantly different in terms of age, ethnicity, gender, age of identification, parental SES, or reading ability.

Outcomes assessed utilized measures specifically covering acculturation (Deaf Acculturation Scale), self-esteem (Self-Perception Profile for Adolescents), satisfaction with life (Satisfaction with Life Scale), loneliness (Revised UCLA Loneliness Scale), and overall psychosocial functioning (ASEBA) (this one was filled out by parents and teachers as well).

We did group comparisons (CI-users and non-CI-users) and looked at the effects of school setting and degree of hearing loss because both groups differed on these variables. We also examined findings from the overall sample related to predictors of acculturation, self-esteem, satisfaction with life, negative behavioral outcomes, and positive behavioral outcomes. We also looked at findings related to CI users only.


Group comparisons between CI users and non-users (controlling for school environment and age of detection): The only finding was: that CI users showed higher hearing acculturation & non-users showed higher Deaf acculturation. All other factors were found not to be significant.

Effects of school setting and degree of hearing loss: Mainstreamed students showed lower
Deaf acculturation, higher hearing acculturation, and slightly higher self-esteem in the scholastic, friendship, and global areas. They demonstrated higher parent-reported social competence compared to those in schools for the deaf. Greater levels of hearing loss resulted in lower hearing acculturation, fewer attention problems/rule-breaking behaviors, and marginally significant higher Deaf acculturation.

Overall sample results for predictors of acculturation: Higher levels of satisfaction with home communication resulted in higher levels of hearing acculturation and lower levels of Deaf acculturation. Higher numbers of deaf peers resulted in higher levels of Deaf acculturation and lower levels of hearing acculturation. Higher grade levels were associated with higher levels of Deaf acculturation and lower levels of hearing acculturation.

Overall sample results for predictors of self-esteem & satisfaction with life: Higher satisfaction with home communication resulted in higher scholastic self-esteem and social competence self-esteem. The earlier the hearing loss was identified, the higher the scholastic self-esteem. As for satisfaction with life, higher levels of satisfaction with home communication resulted in higher levels of satisfaction with life.

Overall sample results for predictors of behavioral outcomes

Positive behavioral outcomes: Satisfaction with home communication is associated with parent-rated higher social competence. Earlier identification of hearing loss is associated with higher scholastic competence (parent-rated).

Negative behavioral outcomes: Later identification of hearing loss is associated with greater attention difficulties, rule-breaking behaviors, and aggression.

For CI-users only, factors contributing to psychosocial functioning as reported by adolescents: Having deaf peers resulted in greater Deaf acculturation, and having hearing peers resulted in greater hearing acculturation. Having more deaf peers resulted in lower levels of scholastic self-esteem. The greater the perceived teacher support, the lower the satisfaction with life was. Having more hearing peers was related to higher levels of loneliness.

For CI-users only, factors contributing to psychosocial functioning as reported by parents: There were no significant findings for negative psychosocial functioning. For positive psychosocial functioning, higher scholastic competence was related to socialization/acceptance with hearing peers.

For CI-users only, factors contributing to psychosocial functioning as reported by teachers: Withdrawn behaviors were related to higher levels of teacher support and higher levels of socialization with/acceptance by hearing peers.


It is not the CI or lack of that matters, but rather environmental factors, most notably home communication, early identification of hearing loss, school setting (though not conclusive), relationship between hearing status and environmental response, and the importance of peer groups. The findings generally bring up questions for discussion and we look forward to dialogue on this forum.

References based on above citations

Bat-Chava, Y. (1993). Antecedents of self-esteem in deaf people: A meta-analytic review. Rehabilitation Psychology, 38(4), 221-234.

Bat-Chava, Y. & Deignan, E. (2001).
Peer relationships of children with cochlear implants. Journal of Deaf Studies and Deaf Education, 6, 186-199.

Bat-Chava, Y., Martin, D., & Kosciw, J.G. (2005). Longitudinal improvements in communication and socialization of deaf children with cochlear implants and hearing aids: Evidence from parental reports. Journal of Child Psychology and Psychiatry, 46(12), 1287-1296.

Boyd, R., Knutson, J., & Dahlstrom, A. (2000). Social interaction of pediatric cochlear implant recipients with age-matched peers. Annals of Otology, Rhinology & Laryngology (Supp.. 185), 12(2), 105-109.

Chmiel, R., Sutton, L., & Jenkins, H. (2000). Quality of life in children with cochlear implants. Annals of Otology, Rhinology & Laryngology (Supp.. 185), 12(2), 103-105.

Christiansen, J.B. & Leigh, I.W. (2005). Cochlear implants in children: Ethics and
choices. Washington, D.C.: Gallaudet University Press.

Fagan, M., Pisoni,D., Horn, D., & Dillon, C. (2007). Neuropsychological correlates of
vocabulary, reading, and working memory in deaf children with cochlear
implants. Journal of Deaf Studies and Deaf Education, 12, 461-471.

Gallaudet Research Institute (November 2008). Regional and national summary report of

data from the 2007-2008 annual survey of deaf and hard of hearing children and
youth. Washington, DC: GRI, Gallaudet University.

Geers, A. E. (2004). Speech, language, and reading skills after early cochlear implantation. Archives of Otolaryngology -- Head & Neck Surgery, 130(5), 634-638.

Geers, A. (2006). Spoken language in children with cochlear implants. In P. Spencer & M. Marschark (Eds.). Advances in the spoken language development of deaf and hard-of-hearing children (pp. 244-270). New York: Oxford.

Glickman, N. (1996). The development of culturally deaf identities. In N. Glickman & M. Harvey (Eds.). Culturally affirmative psychotherapy with deaf persons (pp.115-153). Mahwah, N.J.: Lawrence Erlbaum.

Hyde, M. & Power, D. (2006). Some ethical dimensions of cochlear implantation for deaf
children and their families. Journal of Deaf Studies and Deaf Education, 11(1), 103-111.

Ladd, P. (2007). Cochlear implantation, colonialism, and Deaf rights. In L. Komesaroff
(Ed.). Surgical consent (pp. 1-29). Washington, DC: Gallaudet University Press.

Kluwin, T. & Stewart, D. (2000). Cochlear implants for younger children: A preliminary
description of the parental decision process and outcomes. American Annals of the Deaf, 145, 26-32.

Marschark, M., Rhoten, C., & Fabich, M. (2007). Effects of cochlear implants on children’s reading and academic achievement. Journal of Deaf Studies and Deaf Education, 12(3), 269-282.

Maxwell-McCaw, D. (2001). Acculturation and psychological well-being in deaf and hard-of-hearing people. Unpublished doctoral dissertation, The George Washington University, Washington, D.C.

Nicholas, J. & Geers, A. (2003). Personal, social, and family adjustment in school-aged
children with a cochlear implant. Ear & Hearing, 24, 69S-80S.

Nussbaum, D. (2009). Evolving trends and practices. Presentation, Cochlear Implants and Sign Language Conference, Clerc Center, Washington, D.C.

Preisler, G., Tvingstedt, A, & Ahlstrom, M. (2005). Interviews with deaf children about their experiences using cochlear implants. American Annals of the Deaf, 150, 260-267.

Waltzman, S.B. (2006). Cochlear Implants: Current status. Expert Review of Medical
Devices, 3 (5), 647-55.

Wheeler, A., Archbold, S., Gregory, S., & Skipp, A. (2007). Cochlear implants: The young people’s perspective. Journal of Deaf Studies and Deaf Education, 12(3), 303-316.

JDSDE Reference

Leigh, I.W., Maxwell-McCaw, D., Bat-Chava, Y., & Christiansen, J. (2009). Correlates of Psychosocial Adjustment among Deaf Adolescents with and without Cochlear Implants: A Preliminary Investigation. Journal of Deaf Studies & Deaf Education, 14(2), 244-259.