Journal of Deaf Studies and Deaf Education Advance Access originally published online on April 21, 2007
The Journal of Deaf Studies and Deaf Education 2007 12(3):335-349; doi:10.1093/deafed/enm006
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Intelligence, Parental Depression, and Behavior Adaptability in Deaf Children Being Considered for Cochlear Implantation
Department of Psychology, University of Houston
Learning Support Center, Texas Children's Hospital
School of Allied Health Sciences and Department of Pediatrics, Baylor College of Medicine
Department of Psychology, University of Houston
Department of Psychology, University of Houston
Learning Support Center, Texas Children's Hospital
School of Allied Health Sciences and Department of Pediatrics, Baylor College of Medicine
The Bobby R. Alford Department of Otolaryngology—Head and Neck Surgery, Baylor College of Medicine
Correspondence should be sent to Poorna Kushalnagar, Department of Psychology, 126 Heyne Building, University of Houston, Houston, TX 77204-5022. (e-mail: neuropsydeaf{at}gmail.com).
Received October 25, 2006; revised January 10, 2007; accepted February 26, 2007
Cognitive ability and behavioral adaptability are distinct, yet related, constructs that can impact childhood development. Both are often reduced in deaf children of hearing parents who do not provide sufficient language and communication access. Additionally, parental depression is commonly observed due to parent–child communication difficulties that can lead to parents' feelings of inadequacy and frustration. We sought to assess whether adaptive behavior in deaf children was associated with nonverbal intelligence and parental depression. Parents of precochlear implant patients seen for neuropsychological assessment were administered the Parenting Stress Index and Vineland Behavior Adaptive Scales to obtain measures of parental distress and child's behavioral adaptability. Precochlear implant patients' cognitive functioning was assessed via the Mullen Scales of Early Learning or the Leiter International Performance Scale-Revised, depending on the child's age at the time of testing. Regardless of age or neurological status, the deaf child's adaptive behavior consistently showed a strong relationship with intelligence. Moderate correlation between parental depression and the child's adaptive behavior was observed only in the younger group. The relationship between parental depression and communication subscale was moderated by intelligence for deaf children without neurological complications. The findings provide important implications for promoting family-centered interventions with early communication and language development.
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Introduction |
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Deaf and hearing children who have early access to a language prior to 36 months are comparable in their ability to learn a second language later in life (Newport, 1986
; Schlesinger & Meadow, 1972). Intellectual development of deaf children is typically similar to that of and hearing children (Zweibel, 1987). Deaf children whose hearing losses were diagnosed by 6 months of age and provided early intervention shortly after diagnosis showed typical development of language abilities as compared to those who were diagnosed later and subsequently, if at all, provided early intervention services (Yoshinaga-Itano, Sedey, Coulter, & Mehl, 1998). Normal language acquisition and intellectual development in these deaf children permit them to appropriately internalize social cues and self-regulate during interactions (Marschark & Spencer, 1997). For children who lack visual communication and language acquisition during their early years, delays in multiple areas of adaptive functioning were evident (Meadow-Orlans, Mertens, & Sass-Lehrer, 2003). This frequently occurs when hearing parents have limited routes of visual communication with their deaf infants. For example, in cases where hearing loss is still undetected, these hearing parents may use soothing sounds rather than touching and facial expressions to pacify crying deaf infants (Koester, 1994). The unawareness of the child's deafness and their associated visual communication needs (e.g., increased eye contact and gestures) can disrupt the caregiver–infant relationship during early infancy. The reduced caregiver–infant interaction can also contribute to the development of insecure attachment in the deaf child, independent of deafness (Lederberg, 1993).
Delayed identification of deafness in children, and thus delayed onset of early intervention services, is related to reduced language and communication fluency (Moeller, 2000; Yoshinaga-Itano & Apuzzo, 1998). The delays in language and socioemotional development are often attributed to delayed identification of deafness, limited provision of early intervention services, and reduced degree of family involvement (Magnuson, 2000; Moeller, 2000; Yoshinaga-Itano & Apuzzo, 1998; Yoshinaga-Itano et al., 1998). In a longitudinal study of 20 deaf infants and 20 hearing infants, adaptive behavior was found to be influenced by family and community support and by mother–infant behaviors (MacTurk, Meadow-Orlans, Koester, & Spencer, 1993). Parental reactions such as distress and denial can reduce the speed with which intervention services are initiated after identification of deafness. Reduced parental involvement due to poor emotional functioning can have an adverse effect on the deaf child's cognitive and socioemotional development (Koester & Meadow-Orlans, 1999). Thus, it is important to understand how parental depression interacts with the deaf child's cognitive development and the effect that this interaction has on the relationship between intelligence and the deaf child's adaptive behavior. A review of recent literature suggests relationships between communication, cognition, behavior, parental emotional functioning, and functional outcome in deaf children.
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Communication |
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In regions where access to resources on deafness is scarce, deaf children as well as their parents do not learn sign language or any other visual communication mode until they enroll in an educational program that employs one or more of these approaches. Children whose early years do not involve increased nonverbal communication (e.g., eye contact, visual cues) with their parents have demonstrated poor self-regulation and emotional development (Mundy & Willoughby, 1996
; Traci & Koester, 2003). Without communication reciprocity, deaf infants and toddlers do not learn to associate words with emotions and consequently are not able to express their needs and wants (Meadow-Orlans et al., 2003). When children do not incorporate internal self-regulation, which serves as a foundation for later development of executive functions, they begin to externalize their emotions and thoughts through behaviors (Barkley, DuPaul, & McMurray, 1990). This is consistent with the evidence indicating that deaf children who are language delayed present with a number of behavioral difficulties that are more frequent and severe than is typically observed in deaf children who have access to fluent communication in a language-rich home (Vaccari & Marschark, 1997). Moreover, early initiation and consistency in any communication modality employed by the parents (e.g., sign language, cued speech, or auditory verbal) has been found to contribute to better mental health status in deaf adolescents (Wallis, Musselman, & MacKay, 2004). |
Cognition and Behavior |
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A large body of literature evidenced a strong relationship between cognitive abilities and adaptability in hearing individuals. In a review of adaptive behavior research, Harrison (1987)
reported that the relationship between intelligence and adaptive behavior was moderate with correlations ranging from .40 to .60. This suggests that intelligence and adaptive behaviors are separate constructs but highly related. Adaptive behavior is in fact multidimensional and can be predictive of certain aspects of future performances such as socioemotional functioning and integration into the community. In a recent study on early adaptation to school in young children, McIntyre and colleagues (2006) found that children who had a higher degree of adaptability and intelligence at 36 months were less likely to exhibit behavior problems and more likely to have more positive student–teacher relationship at 60 months than children with lower intelligence and adaptive behavior scores.
Studies on deaf children have also examined relationships between cognition and behavior. A study involving 238 Dutch deaf children reported that higher intelligence was associated with better scores on social problems, thought problems, and attention problems of the child behavior checklist (van Eldik, Treffers, Veerman, & Verhulst, 2004). Academic achievement has been found to be associated with better psychosocial adjustment in a sample of 1,097 deaf students (Polat, 2003). In another study, a play assessment questionnaire (Calhoun, 1987) was filled out by parents to measure symbolic-cognitive play behavior, which was associated with prelinguistic development in early-identified and late-identified deaf children (Yoshinaga-Itano et al., 1998). Results from this study suggested that early identification of child's deafness and initiation of early intervention services predicted better language development, regardless of whether the deaf child had additional disabilities or not. Better language outcomes lead to better communication, which improves behavioral adaptability. Early childhood studies on deaf children like these suggest that the predictors of language development are independent of gender, socioeconomic status, ethnicity, communication modality, degree of hearing loss, age at identification, and parents' level of education (see Meadow-Orlans et al., 2003, for a review).
The aforementioned relationship between cognitive abilities and adaptive behavior leads to the question of whether this is affected by parental depression, particularly in children with language delay. The following discussion reviews studies of emotional functioning in parents and its relationship with language and behavioral developments in deaf children.
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Parental Emotional Functioning and Behavior |
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The difficulties that a hearing parent experiences when trying to raise a deaf child can lead to feelings of inadequacy and frustration (Koester & Meadow-Orlans, 1999
). As Meadow-Orlans and colleagues explained, these feelings contribute significantly to the primary caretaker's self-concept and feelings about their ability to communicate with the deaf child. A review of the literature provided evidence that parents of children with disabilities or illnesses are more likely than parents of healthy children to experience psychological distress and anxiety (Kazak, 1987). However, parents who have accepted their children's differences were more likely to adapt better than parents who experienced emotional struggles in accepting perceived disabilities in their children (Meadow-Orlans, Smith-Gray, & Dyssegaard, 1995; Watson, Henggeler, & Whelan, 1990).
Lederberg and Golbach (2002) found increased reports of parental stress and concerns about communication when deaf children were 22 months of age as compared to hearing parents of hearing children. When these deaf children were followed up at ages 3 and 4, their parents did not differ in their reports of general parenting stress compared to parents of hearing children. The lack of group differences in parental stress at follow-up may be related to the significant professional support the parents received when their deaf children initially participated in the study. In a study with 184 hearing mothers of deaf or hard of hearing children who received early interventions services before age 2, Pipp-Siegel, Sedey, and Yoshinaga-Itano (2002) found greater language delay to be associated with greater parental stress. Level of communication fluency between the deaf child and parents was also significantly related to parenting stress (Mapp & Hudson, 1997) as well as the child's emotional and behavioral regulation (van Eldik et al., 2004). A study exploring paternal–child characteristics indicated that the father's resistance to accepting deafness was associated with poor language outcomes in the deaf child (Hadadian & Rose, 1991).
Poor parental emotional functioning to this effect can contribute significantly to reduced communication effectiveness with the child. Communication breakdowns and misunderstandings can be especially frustrating for the deaf child who demonstrates high curiosity, a desire to learn, and a tendency to get "into everything" that is in discrepancy with their relatively lower receptive and expressive language skills. Without access to explanations and guidance from hearing parents, deaf children rely on behavioral observations of others to learn social skills and miss out on verbal cues exchanged by the hearing parties. Even if a deaf child with higher cognitive skills is able to tease out the subtlety in others' behavior, make the connection between outcomes, and adapt better to situations, this child is still faced with communication struggles and may exhibit even greater behavior problems. When parents are unable to control these children, they become distressed and may feel less motivated to come up with an alternate communication method. Indeed, research showed that hearing parents who had better problem-solving skills were more likely to resolve communication struggles with their deaf children than those who did not actively come up with solutions (Calderon & Greenberg, 1999; Calderon, Greenberg, & Kusche, 1991). According to results from self-report measures, those parents with better problem-solving skills also had higher personal adjustment, which was correlated with teachers' positive rating of the deaf children's problem-solving skills.
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Hypotheses |
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The preceding review suggests that adaptive behavior outcome in deaf children is likely to be associated primarily with intelligence or parental depression or a combination of these factors. Early intervention, as defined by age of enrollment in a parent–child intervention program, and neurological status can also contribute to adaptive behavior. This study was designed to investigate these issues in a specific subset of deaf children, precochlear implant candidates seen during the course of their comprehensive baseline evaluations. Adaptive behavior in precochlear implant candidates was predicted to correlate to intelligence and parental depression after controlling for early intervention and neurological status, (Hypothesis I). Consistent with Harrison's review (1987) of adaptive behavior in hearing children, intelligence was expected to have moderate correlation with adaptive behavior in this study.
Previous studies have shown that maternal depression has a negative effect on young hearing children, slowing their cognitive development and predicting behavioral problems. It has been suggested that when mothers are depressed, they are less likely to respond to their children's school performance, language difficulties, and problematic behaviors. The existing literature on deaf children suggests that there is a relationship between parental emotional functioning and child behavior adaptability. Both these variables have been found to be inversely related to provision of early intervention services and additional disabilities (Calderon & Greenberg, 1999; Meadow-Orlans et al., 1995; Traci & Koester, 2003). Despite early diagnosis and intervention, it is possible that better adaptive behavior due to higher intelligence level can deteriorate to some degree when the caregiver is clinically depressed and does not promote the deaf child's cognitive and behavioral development. Elevated parental depression was expected to reduce the intensity of the interaction between intelligence and adaptive behavior after controlling for early intervention and neurological status (Hypothesis II).
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Method |
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Participants
Data from 46 severely to profoundly deaf pediatric patients at the Texas Children's Hospital in Houston, Texas, were analyzed. These children, all with hearing parents, were referred by their otolaryngologist for neuropsychological assessment as part of the cochlear implant candidacy procedure. Information on age of identification (measured by month), enrollment in early interventions program, ethnicity, parents' education level, and status of hearing loss (moderate–severe, severe–profound, or profound) were obtained from the cochlear implant database.
Additional information on etiology and medical conditions were obtained from neurological reports in each patient's medical record. Where necessary for purposes of analyses, participants who became deaf due to neurological conditions or evidenced neurodevelopmental disorder were grouped as neurologically at-risk (NAR). Participants identified as NAR include those with attention disorders (n = 2), brain anomaly (n = 2), fetal distress (n = 3), microcephaly (n = 3), lung disease (n = 2), and respiratory syncytial virus (n = 1). Those who did not have a significant medical or neurological history were assigned to non-NAR group.
Clinical child neuropsychologists, postdoctoral fellows, and a deaf neuropsychology trainee under the neuropsychologist's supervision participated in the collection of demographic data. Data included parents' marital status, occupation, and years of education, as well as age at identification and status of hearing loss, age of enrollment in an early intervention program, developmental milestones, medical and psychological history on paternal and maternal sides, and the child's medical and psychological history. Missing early intervention data for three participants younger than 36 months was substituted with the sum of age at identification and the average of time elapsed between age at identification and initiation of early intervention services. Demographic and other pertinent information about the children and their parents are given in Table 1 and discussed below.
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Demographic information.
The ratio of male to female deaf children was about 5/4. Almost half were Caucasian and a third were Hispanic; about 9% were African American and less than 10% identified themselves as biracial or Asian. The figures appear to be representative of deaf and hard of hearing children population in Texas (Gallaudet Research Institute, 2004).
In this study, all parents were hearing and had either no or little experience with deafness. The parents who signed with their deaf children learned sign language after discovering that their children were deaf. The children's age at the time of enrollment in the cochlear implant program ranged from 3 to 35 months, with a mean of 18 months (SD = 10.94). Their mean age at time of testing was 38.9 months (SD = 26.97).
Education among parents averaged 1 year of college with 41% of mothers and 66.7% of fathers having attended college. However, 69% of the mothers and 45% of the fathers had 9–12 years of education. All the fathers were working, whereas only 45% of the mothers were working based on available information. Of the 45 families who reported marital status, 91% were married or living together and the remaining 9% were single.
Hearing loss, neurological condition, and etiology.
The overall mean age at identification of hearing loss among all participants in this study was 12 months, which was much later than expected according to a universal newborn hearing screening study (Connolly, Carron, & Roark, 2005). Connolly and colleagues reported that the mean age of hearing loss identification after the enactment of the universal newborn hearing screen program during 1997–2001 was 3.9 months. Within the younger group who were assessed with the Mullen Early Scales of Learning, the mean age of hearing diagnosis was 7 months. For the older group (Leiter-R), the mean age of diagnosis was 17 months (see Table 2).
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A profound hearing loss of greater than 90 dB was present in 61% of the children, whereas the remaining 39% had a severe–profound hearing loss ranging from 66 to 90 dB. Nearly one-third of the children had at-risk neurological conditions (e.g., brain anomaly, fetal distress, microcephalus, and respiratory syncytial virus). For 44% of the patients, etiology of hearing loss was unknown, and 33% were genetically deaf. Other etiologies included infection (12%), meningitis (5%), and other (7%).
Mode of communication.
Information was based on parental report and observation. Sixty-eight percent of these participants were exposed to signs either in their daily interactions at home or through early childhood intervention services. One participant used cued speech and the rest were limited to oral or auditory–verbal approach even though hearing aid benefit was not evident. Eighty-two percent of participants began early intervention services during the first 2 years of their lives.
Detailed information regarding the competence or quality of communication exchange between the parents and the deaf child was not commonly documented in reports, particularly in the earlier evaluations that occurred shortly after the establishment of the cochlear implant program within the hospital.
Procedure and Test Instruments Administered
Intelligence.
Either the Mullen Scales of Early Learning (Mullen, 1995) or the Leiter International Performance Scale-Revised (Roid & Miller, 1997) was selected and administered depending on the child's age and level of ability. The Mullen Scales of Early Learning is an individually administered measure designed for very young children to estimate functioning across areas thought to predict later intellectual development. This scale assesses a child's abilities in visual, linguistic, and motor domains and distinguishes between receptive and expressive processing. This measure can be given to children from 3 to 68 months of age. In this study, its use was limited to those under the age of 36 months and older children with severe developmental delays. Interrater reliability has been reported to be high (.91 to .99), which indicates that the directions for administration and scoring are clear and are interpreted similarly by different examiners. Test–retest reliabilities with a sample of 97 participants, aged 1–56 months, for visual reception, fine motor, and gross motor areas range from .75 to .96. It has been reported that this measure has potential for assessing early intellectual development in deaf children although this has not been empirically examined (Spragins, 1998). The language components of the Mullen Early Scales of Learning measure were taken out, and the composite scores were prorated as nonverbal scores.
The Leiter-R is an instrument developed to provide a nonverbal measure of intellectual ability in children (24 months and up), adolescents, and adults who cannot be reliably assessed with traditional intelligence tests. This test is uniquely designed to include no verbal instructions and therefore is appropriate for use with children with hearing and language deficits. Composite reliabilities have been found to range from .88 to .93 for the Visualization and Reasoning Battery. Test–retest reliability with a sample of 163 participants, aged 2–20, ranged from .83 to .96 (Assessment of children: Cognitive applications, 2001).
Intelligence scores from the Mullen (prorated) and Leiter-R (full) measures were transformed to z-scores based on the normative data given for each IQ test before they were combined in a data set. To date, there are no published studies that examined correlates of the Mullen and Leiter-R measures. These measures were selected as part of the precochlear implant assessment battery based on the reviews provided above.
Parental depression.
The Parenting Stress Index (PSI) (Abidin, 1995) was used to identify potentially dysfunctional parent–child systems. The PSI focuses intervention into high stress areas and predicts children's future psychosocial adjustment. The scale is composed of 101 items that represent six domains that are specific to child (e.g., distractibility/hyperactivity and adaptability) and seven domains that are specific to parents (e.g., attachment to child and depression). The measure has an alpha coefficient of .93 for the parent domain and an overall reliability index of .80. Although this has been used in several studies involving deaf children, no validity or reliability information was reported. Only the parental depression score from the PSI was drawn and entered as an independent variable. A score placing the individual at or above 90th percentile is indicative of high risk for the existence of psychopathology such as major depression.
Child's adaptive behavior.
The Vineland Adaptive Behavior Scales (Sparrow, Balla, & Cicchetti, 1984) assess parental perceptions of the child's personal and social functioning. The instrument yields four broad domains indicative of communication, daily living skills, socialization, and motor skills. The communication domain assesses receptive, expressive, and written skills according to age level. The daily living skills domain taps personal, domestic, and community skills. For the socialization domain, the child is rated on interpersonal relationship skills, socialization during play and leisure time, and coping skills. The motor skills domain includes development of gross and fine motor skills.
The Vineland measure was administered to a parent or caregiver in a semi-structured interview format. The total score was entered as the child adaptability outcome score, dependent variable. Reliability estimates, using split-half reliability coefficients, range from .83 to .97. Test–retest reliabilities are in the .80 to .90 range. Interrater reliability coefficients range from .62 to .75 (Assessment of children: Cognitive applications, 2001). All scales except for the communication domain, which contains items specific to auditory skills, are suitable for assessing those with hearing losses. The auditory-related items in the communication domain allowed for N/A scoring, thus not placing these deaf participants at a greater disadvantage.
Analyses
A power analysis was conducted for a sample size exceeding 20. A moderate effect with an R2 of .37 attributed to two independent variables using an F-test would be 80% likely to be detected at .05 levels. Initial analyses were conducted on the combined sample of 46 children, which should have provided adequate power. Bivariate correlations were computed to determine relationships of the dependent variable (adaptive behavior) with the aforementioned independent variables and possible demographic covariates based on the literature. Hierarchical regression procedures were used to determine interaction effects, that is, whether parental depression, intelligence, or the demographic covariates differed in the relationship with adaptive behavior. The demographic variables were first entered as a covariate followed by intelligence and parental depression and then the interactions were entered in the final predictive step.
Preliminary analyses using statistical analysis system (SAS Institute, Cary, NC) were carried out to detect any missing values or outliers with large influences on the regression lines. Regression models assume that the independent variable is measured without error and that the regression of the dependent variable on the independent variable is linear. Therefore, tests of normality and collinearity were performed to examine for distribution and correlation among variables. Frequencies for all the independent and dependent variables were examined to ensure normality in terms of skewedness and kurtosis. Skewness statistics for all variables fell within the expected range between 1.0836 and –1.0836 and were not indicative of significant skewness problems. All variables produced kurtosis statistics that fell within expected range, between 2.1669 and –2.1669. Parent and child variables were tested for outliers to examine their impact on the value of the regression coefficient before being entered into regression models. One outlier was found for the parental depression variable. Because the assumption of normality through analysis of the residuals was met with this outlier included (W = 0.98, p < .5613), the child was left in the analysis.
Correlational analyses were used to examine the degree to which demographic background, parental depression, and intelligence were related to the child's adaptive behavior. Correlation results did not indicate collinearity among parental depression and intelligence independent variables (r = –.10, p = .50). Demographic covariates in the analysis of Mullen data were neurological status and age at enrollment in an early intervention program. Demographic covariates were not needed in the analysis of Leiter-R data. In the combined data set, only the neurological status variable was found to be significantly associated with adaptive behavior and was entered as a covariate in subsequent regression analyses.
To test Hypothesis I, a regression analysis was conducted assessing the degree to which a child's intelligence and parental depression account for the child's adaptive behavior after controlling for demographic variables correlated with adaptive behavior. This analysis was carried out using a hierarchical multiple regression analysis to identify the child's intelligence and parental depression that contributed to child's adaptive behavior. To test Hypothesis II investigating the effects of parental depression variable on the strength of an association between intelligence and behavior adaptability, first-order interaction variables were created and entered along with demographic covariates in hierarchical regression analyses. To discern the effect of age on the relationship among the main variables, analyses by intelligence measure (Mullen and Leiter-R) was conducted, and findings were shown in separate tables for each group. The data sets were then combined and regrouped by neurological status to examine its effect on the intelligence-parental depression–adaptive behavior relationship.
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Results |
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Parent and Child Variables in Combined Data Set
As predicted in Hypothesis I and shown in Table 3, intelligence had a strong and distinct relationship with adaptive behavior (r = .65, p < .0001). The relationship of adaptive behavior with depression was also significant (r = .29, p < .05). Neurological status yielded significance in its relationship to adaptive behavior (r = –.34, p < .05), and this effect was therefore controlled for in subsequent analyses. As shown in Table 4, results from a hierarchical regression analysis revealed intelligence as the primary contributor for adaptive behavior (t = 4.91, p < .001). Parental depression, however, did not hold a significant contributory role in adaptive behavior (t = –1.87, p < .0681). After partialing out the effect of NAR status, intelligence explained 57% of the variance in adaptive behavior.
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Hypothesis II stated that there would be an interaction between intelligence and parental depression on adaptive behavior of precochlear implant candidates. In order to test this hypothesis, three first-order interaction terms involving two independent variables and neurological status were added to the above regression equation, and a multiple regression was conducted. According to Table 5, the overall model that included intelligence, parental depression, neurological status, and the interaction among these variables significantly contributed to adaptive behavior (F = 7.20, p < .0001). However, no significant interaction effect of intelligence and parental depression on adaptive behavior was observed. Hypothesis II of the study was thus not supported.
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Age at Evaluation
In order to determine whether differential effects of intelligence and parental depression are found across children at different ages, children were divided into those who were administered the Mullen and those who were administered the Leiter-R. This breakdown was employed as selection of test was determined by the child's age and level of ability. Table 2 compares demographic data and data related to their hearing conditions separately for the children tested with the Mullen and Leiter-R tests.
In the younger group, as shown in Table 6, the mean nonverbal intelligence score on Mullen Early Scales of Learning was 87.57 (SD = 18.11). NAR status and age at early intervention enrollment were found to be related to adaptive behavior (r = –.53, p < .05; r = –.59, p < .01, respectively), and these effects were therefore controlled in subsequent analyses. As expected in Hypothesis I, both intelligence and parental depression were positively related to adaptive behavior (r = .82, p < .001; r = –.45, p < .05, respectively). Results from a regression analysis in Table 7 indicated that the intelligence variable had a stronger relationship with adaptive behavior (t = 5.49, p < .001) as compared to that between parental depression and adaptive behavior (t = –2.69, p < .05). After partialing out the effects of age at early intervention and NAR status, intelligence and parental depression explained 63% and 28%, respectively, in their effects on adaptive behavior in deaf children. Hypothesis II stated that there would be an interaction between intelligence and parental depression on adaptive behavior of precochlear implant candidates. Specifically, it was predicted that higher parental depression would have an effect on the intensity of relationship between intelligence and adaptive behavior. The overall model that included intelligence, parental depression, and the interactions significantly accounted for adaptive behavior (F = 20.812, p < .0001). However, no significant interaction effect of intelligence and parental depression on adaptive behavior was observed, and Hypothesis II of the study was thus not supported.
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In the older group as shown in Table 8, the mean score on the Leiter-R intelligence measure was 102 (SD = 20). None of the demographic variables (early interventions, r = –.15; neurological conditions, r = –.12) yielded significance in its association with adaptive behavior dependent variable and therefore were not entered in the regression. As predicted, intelligence was found to be strongly associated with adaptive behavior (r = .47, p < .05). In contrast, results indicated no correlation between parental depression and adaptive behavior (r = –.0007). The overall model that included intelligence, parental depression, and the interaction between these two did not predict adaptive behavior (F = 1.85, p < .17). No significant interaction effect of intelligence and parental depression on adaptive behavior was observed, and Hypothesis II of the study was again not supported.
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Neurological Status
Intercorrelations were examined among the remaining variables for each neurological group, and these in addition to means and standard deviations are displayed in Tables 9 and 10. For parents in both NAR and non-NAR groups, child's intelligence was directly related to parents' rating of adaptive behavior in their children (r = .61, p < .01; r =.63, p < .05, respectively). Parental depression was significantly correlated with adaptive behavior only for deaf children who were not NAR (r = –.40, p < .05).
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The tendency for depressed parents to negatively rate non-NAR children's behaviors may be attributed to the mismatch between the parents' expectations and the deaf child's overall characteristics, particularly when the deaf child is perceived as having potential and is otherwise functioning normally. These parents may also be experiencing a communication struggle, which can be stressful. An alternative explanation may be that the parents who are clinically depressed display distorted perception of others' behavior and consequently underestimate their child's abilities or behaviors, resulting in lowered scores (Ritchers, 1992
). These explanations warranted further investigation on the relationship between parental depression and the domains within the Vineland Adaptive Behavior Scale. As shown in Table 11, for children without risk for neurological disorders, parental depression was significantly related to communication and daily living skills domains. When intelligence was partialed out, the relationship between parental depression variable and communication domain was reduced to nonsignificance.
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Discussion |
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The results of this study provide evidence consistent with previous work for a linear relationship between adaptive behavior and intellectual development after controlling for neurological status in deaf children. Deaf participants with lower intelligence scores were consistently rated worse on an adaptive behavior measure of daily functioning by their parents. All these children presented with language delays, making it difficult to understand commands or to effectively socialize (e.g., initiate or join conversations). This inability to successfully interact with peers can lead to frustration and externalizing behaviors. Clearly, early cognitive stimulation is of the essence to the development of socialization, language, and behavioral regulation in deaf children (Magnuson, 2000
; Moeller, 2000; Yoshinaga-Itano, 2003). When the combined data set was separated by intelligence measure, only the younger group (Mullen) displayed moderate correlation between parental depression and adaptive behavior, suggesting that the strength of a linear relationship between these two variables is much stronger in younger deaf children as compared to older deaf children. This is not surprising, as some of the younger participants were brought in for cochlear implantation soon after hearing loss diagnosis. The relatively short window time between hearing diagnosis and neuropsychological evaluation may not have provided some of these parents with sufficient time to fully process the feelings of shock and grief. Interestingly, data in this study did not yield an interaction effect of parental depression on the association between intelligence and adaptive behavior in the younger group. The lack of interaction effect may be due to a combination of early diagnosis of hearing loss, child's participation in an early intervention program, and the amount of professional support that the parents received prior to neuropsychological evaluation. Although some parents may be experiencing emotional difficulties around the time of child's evaluation, the severity of emotional functioning was not high enough to be considered clinically significant (above 90th percentile). The level of professional support is very likely to have had an ameliorative effect on the parents' emotional functioning. For instance, most parents in this study frequently met with the cochlear implant program coordinator and health care staff before the deaf child was brought in for the neuropsychological evaluation.
The lack of association between parental depression and adaptive behavior scores in the older group (Leiter-R) may be attributed to the time lag between the age of identification and the child's age at neuropsychological testing. By the time the older deaf child was evaluated, the parents may have already adjusted to the changes in the family dynamics following identification of their child's hearing loss and no longer display clinically elevated depression scores. A possible explanation for the lack of an interaction effect of parental depression with intelligence on overall adaptive behavior in the combined data set may be that the level of parental depression has little impact, if any, on the participants' intellectual development, which may have already been stabilized. Thus, for older children, intelligence becomes a more robust predictor for adaptive behavior with age as a function.
For children who do not present with a history or evidence of neurological disorders, parental depression was found to be associated with communication and daily living skills domains of the Vineland Adaptive Behavior Scale. The association between parental depression and communication domain was reduced to a nonsignificant level after intelligence was partialed out. This suggests that intelligence has some contributory role in reducing or increasing the effect of parental depression on communication interaction with the deaf child. Elevated level of parental depression can reduce the parent's interaction with the deaf child, which can result in placing this child at a greater risk for poor communication skills. Higher intelligence in the deaf child may either have an ameliorative effect on reducing parental depression through better coping mechanisms or exacerbating effect on elevating parental depression through increased frustration based on mismatch in the expectation between the deaf child and the hearing parent.
The lack of a significant relationship between parental depression and adaptive behavior in the NAR group may suggest that the effect of being NAR overshadows the mild impact of having a depressed parent. Alternatively, parents of children who are NAR may have gone through a more rapid adjustment and acceptance process, as these children are more clearly and readily recognized as disabled and thus typically receive substantial support from health care professionals (Meadow-Orlans et al., 1995).
Although children in this study with lower intelligence and higher parental depression appear to be at risk for behavioral and socialization difficulties, caution must be exercised when generalizing these results to certain populations. In this study, there was a trend of later identification of deafness among older participants who were delayed in language development. Younger participants, however, were more likely to be identified earlier with the newborn hearing screening test that was readily available and widely used. All participants had hearing parents who were provided with extensive information about cochlear implantation as an intervention option at the Texas Children's Hospital. Some parents were learning sign language or cued speech at the time of their children's evaluation. Other parents used exclusively spoken language as a communication method. This study is a retrospective study, based on a review of records in a clinical population consisting of primarily Caucasian and Hispanics. This methodology affects the demographic distribution and number of children included in this study, as well as the tests that were administered to these children. As a result, we see two types of deaf children being considered for cochlear implant candidacy: (a) young deaf infants and toddlers as part of early intervention plan promoting better language and behavioral development in deaf infants, and (b) older deaf children as the next alternate to other choices that have been attempted and did not satisfy family's expectation.
Future research regarding the relationship between intelligence, parental depression, and adaptive behavior would benefit from a prospective, rather than retrospective, design. This would allow the researcher to match subjects more carefully on demographic variables, including the quality of communication exchange between the parent and the deaf child. It may also provide a timeline that makes it possible to discern a more mediating pathway, rather than multiple correlations, between intelligence, parental depression, and adaptive behavior.
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No conflicts of interest were reported.
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