Nicoletta Gentili Consultant Child & Adolescent Psychiatrist

1. The Mental Health of Deaf Children The limits of my language means the limits of my worldL. Wittgestein Nicoletta Gentili Consultant Child & Adolescent Psychiatrist National Deaf Child and Family Services Corner House Inpatient Unit

2. Background • 60, 000 “hearing disabled” children in UK • 20,160 in England • 90-95% of deaf children are born to hearing parents • 3.4% require specialist service every year • 10,000 Sign language users in school • 50-70,000 BSL users in Deaf community • 42% are severely/profoundly deaf

3. Mental health problems in deaf children • 1.5-2x more common than in hearing children • Increased rate of emotional and behavioural problems • Increased rate of autism? True increase, misdiagnosed speech and language disorder, or developmental delay linked to early language deprivation (incidental learning)?

4. Emotional understanding in Deaf children • Greater proportion of deaf children with delays in recognising, understanding and using emotional experience (Gray et al 2002) • Greater proportion of deaf children with delays in developing Theory of Mind (Remmel et al 2002)

5. Impact of parenting • Significant number of parents with minimal or no sign language deaf children with significant delay in signed or spoken language • Deaf children of Deaf parents have same incidence of Mental Health Problems as their hearing peers • Finland Study (Sinkkonen, 1994)

6. Language & Thinking • Significant language delay associated with delays in developing abstract thinking • Language delay and reading delay compounds reduced access to incidental learning

7. Consequences of impact of deafness on emotional development Deafness can lead to: • Isolation • Lack of defined identity • Low self-esteem • Poor attachment 40% of D, vs 25% of H, have a mental health problem at some point in their life (NHS Health Advisory Review)

8. “Deaf Culture” • 90% of deaf children are born into hearing families so vertical transmission is not possible • Residential school was historical milieu of transmission (Dolnick 1993) • As a result much of cultural acquisition child-child rather than adult-child (Moores 1987) • Mainstreaming and cochlear implantation impact?

9. Cause of mental health problems in Deafness • Organic cause of the deafness such as prematurity/CMV/Rubella • Poor intersubjective relationship • Early language deprivation • Abuse

10. Intersubjectivity Trevarthen C, Aitken P, 2001; Trevarthen C, 2004 Active involvement in communication Imitation & Companionship Attachment relationshipEmotional development Language Development

11. Emotional Development FEELING TONES CONTENTMENT DISTRESS INTEREST (familiarity established)SURPRISE(6th/12) JOY*(3rd/12)DISGUST*(3rd/12) SADNESS*(3rd /12) ANGER(4th/12) (“Pursuing a Goal” – 4th /12) FEAR(6th/9th month) CURIOSITY * SUBTLE EMOTIONS Michael Lewis, The Emergence of Human Emotions, Handbook of Emotions, 2000

12. Exposed Emotions or Self-Conscious Evaluative Emotions (Follow the development of the awareness of “Self” and “Other”) ENVY EMBARRASSMENT EMPATHY (second half of second year) Self-Conscious Emotions (from 30 to 36 months) PRIDE SHAME GUILT (These emotions complete their development by the 6th/9th year of age) M Lewis, 2000

13. Why deafness affects emotional development Deaf children are at greater risk of: • parental distress • lack of access to language and developmental experience • additional learning difficulties • abuse

14. Emotional Response to Deafness Parents Parents remember “when, where, how, who” (Hindley 93) “Relief” or “Panic” what about attachment? Shock, denial, grief, anger, guilt and…resolution (Webster 94) Parents react unpredictably, possibly influenced by manner of the telling (Beazley & Moore 95) Children Child may show anxiety, fear, anger, or behavioural disturbance if sudden and late hearing loss

15. Abuse • 72% of sexual abuse is extra familial • Deaf and HH with behavioural problems are at greater risk of physical abuse • Children with disabilities are at greater risk of intrafamilial abuse than hearing children • Children with disabilities 1.8x more likely to be neglected, 1.6x to be physically abused and 2.2x likely to be victim of sexual abuse than their non disabled counterpart • Mothers of children with profound hearing loss more likely to use physical discipline than mothers of hearing children(Knutson 2004)

16. Abuse • Children with sensory disabilities are more at risk (Sobsey & Varnhagen, 1988) • Children with behavioural problems are more at risk (Salomons, 1979) • Children with parental history of abuse, highly deprived (Friedrich & Boriskin, 1978; Frodi, 1981) • Mostly occurring in residential settings(Sullivan, Vernon & Scanlan, 1987) • Hearing parents of Deaf children more likely to use physical coercion(Schlesinger & Meadow, 1972) • Highest incidence of sexual abuse or a combination of sexual and physical abuse(Sullivan, 1991; Willging, Bower & Cotton, 1992) • Males with disabilities more at risk than hearing counterpart • No gender differences within the abused children

17. Language acquisition & development:from “impossible to miracle” • St Augustine (354-430) – Behaviourism: “empiricist associationism” (Skinner, 1959) • Chomsky: “nativism” – LAD (1975) • Bruner: LAD + LASS (1985)

18. Language Acquisition • Before child’s utters first lexicogrammatical speech • Within intersubjective relationship “input” the child masters: - Grammar - How to refer and mean - How to realise his/her intention communicatively

19. Language Acquisition Processes Children grammatical skills are extremely variable over the first 2.5 years of their life 2 reasons: Some children are more efficient learner • Girls are better language learner • children with larger working memory seem to learn and process language more efficiently (Adam & Gathercole, 2000)

20. Language Acquisition Processes Importance of language learning environment • Providing young children with extra exemplars of complex syntactic constructions facilitates their acquisition of such constructions(Nelson, 1977) • Children’s mastery of complex constructions is strongly related to the frequency with which both their parents and teachers use them(Huttenlocher et al., 2003) • Children acquisition of some particular grammatical English morphemes were facilitated when mothers used these morphemes as immediate recast(Farrar, 1990; 1992)

21. Effects of parental style of interaction on language development in very young severe and profound deaf children Fatima Janjua a, Bencie Woll b, Jim Kyle c a Child Development Centre, Addenbrookes’ University Hospital, Hills Road, Cambridge CB2 2QQ, UK b Department of Language and Communication Sciences, City University, Northampton Square, London EC1V OHB, UK c Centre for Deaf Studies, University of Bristol, 8 Woodland Rd, Bristol BS8 1TN, UK Received 7 July 2001; received in revised form 27 February 2002; accepted 6 March 2002

22. Conclusions Exposure to language in early childhood is essential to establish a first language(Mayberry 2002), to develop EF, to articulate emotions and to socialise No evidence that signing interferes with acquisition of spoken language(Marschark 1993) Incidental Learning; Deaf children in hearing families miss out on adult talk & social communication