The goals of the current study were to (1) examine differences in pragmatic abilities and peer relationship behaviors among deaf and hard of hearing (DHH) adolescents who use spoken language, in comparison with their hearing peers; and (2) explore the contribution of pragmatic skills and speech (ie, articulation and intelligibility [AI]) to social aspects of school functioning among DHH and typically hearing adolescents.
Thirty-three DHH adolescents and 34 adolescents with typical hearing participated. All DHH adolescents attended mainstream school settings and used spoken language. Teacher reports were obtained on prosocial behaviors, peer problems, pragmatic abilities, and speech AI of the adolescents. Adolescents self-reported on the supportiveness of their peer relationships and their school emotional engagement.
Multiple hierarchical regression analyses revealed that DHH adolescents had greater difficulties with peers than their hearing counterparts. Increased pragmatic difficulties were related to more peer problems and decreased prosocial behaviors, regardless of adolescents’ hearing status. A significant positive correlation was found between pragmatic competence and adolescents’ perceptions of peers’ support. Finally, better speech AI were associated with higher levels of school emotional engagement.
The results emphasize the significant role of pragmatics for both DHH and typically hearing adolescents. Medical care providers and allied health professionals should be aware of possible difficulties that DHH adolescents may have in complex and nuanced pragmatic skills. Some adolescents may require a referral to specialized services to support the development of their pragmatic understanding and their skills.
Pragmatic behaviors refer to the social use of language in an appropriate and effective way.1 Many deaf and hard of hearing (DHH) children and adolescents who use spoken language experience pragmatic difficulties in their everyday interactions.2,3 They may find it difficult to follow rapid turn-taking and interruptions in group interactions,4 use repair strategies in response to communication breakdowns,5 or remain on topic.6 Many DHH adolescents demonstrate either a delayed or different trajectory of acquisition of pragmatic abilities in comparison with their typical hearing peers.7 For DHH children and adolescents, pragmatic difficulties may contribute to misunderstandings during social interactions with peers and can result in a lack of balance in conversations. Such a dynamic can reduce the quality of peer relationships, increasing the risk that DHH children and adolescents will experience social-emotional problems.8–11 Likewise, good speech intelligibility, which can be seen as a facet of pragmatic behavior in spoken language interactions, has been associated with good social integration and emotional adjustment within mainstream educational settings.12,13
Although the contribution of pragmatic abilities to peer relationships is documented among populations with other clinical conditions, such as specific language impairment,7 to our knowledge, there is scarce research in which investigators examined this issue in individuals who are DHH. In one study, a positive association was found between DHH adolescents’ pragmatic abilities and their popularity and acceptance by peers.14 Having reduced pragmatic abilities may lead to frustration and distress.15 Indeed, it has been reported that DHH adolescents with lower pragmatic abilities report increased levels of perceived stress regarding everyday peer interactions and school-related demands.3 It should be noted that behaviors related to peer interactions are extremely important because they are known to promote emotional adjustment. Specifically, difficulties with peer relationships are found to increase the risk for emotional difficulties,16 whereas positive behaviors, such as prosocial behaviors, promote emotional adjustment.17 Many DHH adolescents who present to clinical and psychological services for support manifest difficulties in peer relations. Yet their pragmatic abilities, which are fundamental to the initiation and maintenance of successful peer relationships, are often overlooked.
Currently, owing in part to advances in hearing assistive technology (such as digital hearing aids and cochlear implants), DHH children are often included in classes with hearing peers, where spoken language is the primary mode of communication.18 Studies have indicated that DHH children in mainstream educational settings experience difficulties with social participation (ie, taking part in social activities, peer integration, and involvement in the social dynamics of the group) and social interactions with hearing peers; they can experience feelings of loneliness at school.19–24 Overall, these experiences may also lead some children to have a reduced sense of belonging and engagement at school25,26 (eg, negative feelings and reactions toward school and their school-based peers).27 In addition, these negative experiences can reduce their motivation to engage in prosocial behaviors, such as being helpful, kind, and cooperative. Nevertheless, there is scant research examining the impact of DHH adolescents’ pragmatic abilities on their peer relationships and school engagement.
The goal with this study was to examine the contribution of adolescents’ hearing status, pragmatic skills, and speech (ie, articulation and intelligibility [AI]) to social school functioning (ie, peer relationship related problems, prosocial behaviors, and emotional school engagement) of DHH adolescents who use spoken language for communication and adolescents with typical hearing. It was hypothesized that hearing status, pragmatic abilities, and speech intelligibility would be associated with social school functioning. In addition, it was further hypothesized that the contribution of pragmatic abilities and speech intelligibility to school functioning will be moderated by adolescents’ hearing status (ie, having hearing loss versus having typical hearing).
Methods
Participants and Procedure
The study was approved by the Ministry of Education Research Ethics Board. Participants were recruited via teachers for the DHH working in individual mainstream high schools across Israel. Adolescents with typical hearing were recruited from the same classrooms to match the DHH adolescents’ sample.
Eligibility criteria included (1) attending a mainstream high school setting (grade 7 to grade 11), (2) having hearing parents, (3) using spoken language as the child’s primary communication mode, (4) having no known neurodevelopmental disabilities, and (5) possessing an IQ in the normal range.
Measures
Teachers completed 2 subscales from the Strengths and Difficulties Questionnaire,28 including prosocial behaviors (5 items, eg, “often offers to help others”) and peer relationship problems (5 items, eg, “picked on or bullied by other”). The psychometric properties of the Strengths and Difficulties Questionnaire are well established.29 Internal consistency (Cronbach’s α) was 0.78 for the prosocial behavior subscale and 0.82 for the peer problems subscale. Each subscale consists of 5 items rated on a Likert scale from 0 (“not true”) to 2 (“certainly true”). A higher score reflects more behaviors of the specific subscale.
The Children’s Communication Checklist–Second Edition (CCC-2).30 The CCC-2 is a checklist consisting of 70 items that has been predominantly designed to assess the social and pragmatic language of children aged 4 to 16. However, it is also used to assess other qualitative aspects of structural language, such as speech production and syntax. By using the CCC-2, teachers were asked to rate the frequency of each behavior, on a scale from 0 (never or less than once per week) to 3 (more than twice a day or always). The pragmatic composite score is calculated by summing 4 subscales, including inappropriate initiation, stereotyped language, use of context, and nonverbal communication. The coefficient α was α = .86. To assess speech AI we used the CCC-2 speech scale that is used to measure intelligibility and fluency (α = .76).
Two adolescent self-report measures were completed by each adolescent participant: (1) Classroom Life Measure31 (a 5-point Likert scale rating of peer supportive relationships; 4 items) and (2) MacArthur Health and Behavior Questionnaire (10 items).32 On the MacArthur Health and Behavior Questionnaire, the school engagement subscale was used, capturing adolescents’ emotional responses regarding school engagement (ie, how students feel about school); a higher score on this subtest indicates higher school emotional engagement (ie, higher school liking).
Parents reported on family demographic information (eg, age, sex, and education level) and children’s hearing loss (eg, degree of loss and use of sensory aids).
Data Analysis
Multiple hierarchal linear regression analyses were conducted for each school functioning dependent measure. In the first step of the regression models, we entered child hearing status (DHH versus typically hearing), pragmatic abilities, and speech AI. In the second step of the regression models, to determine the moderating role of child’s hearing status, the interaction terms between hearing status and pragmatic abilities and between hearing status and speech AI were entered. After model-testing recommendations, we mean-centered the continuous variables before creating interaction terms.33
Results
The sample was composed of 33 adolescents with a moderate to profound HL, (57% boys; mean age = 14.83 years; SD = 1.12), whose reduced hearing was identified at a mean age of 1.41 years (SD = 1.18). All of the children used hearing assistive aids (62% hearing aids; 38% cochlear implants); overall, 86.7% used bilateral assistive aids. The sample also included 34 adolescents with typical hearing (53% boys; mean age = 14.86 years; SD = 1.18). There were no significant group differences in terms of parental education levels or marital status. Overall, the majority of parents had postsecondary education (95%), and 76% were married.
Descriptive statistics for all variables are presented in Table 1. As expected, an independent t test analysis revealed that DHH adolescents demonstrated more pragmatic and speech difficulties than their hearing peers. In addition, they experienced higher levels of peer relationship problems and exhibited less prosocial behavior than their hearing peers.
Means and SDs of the Study Variables by Child Hearing Status
| Study Variables . | Total (N = 67) . | DHH (n = 33) . | Hearing (n = 34) . | P . | |||
|---|---|---|---|---|---|---|---|
| Mean . | SD . | Mean . | SD . | Mean . | SD . | ||
| Prosocial behaviors (teacher report) | 2.58 | 0.41 | 2.46 | 0.38 | 2.69 | 0.42 | .02 |
| Peer relationship problems (teacher report) | 1.29 | 0.42 | 1.44 | 0.51 | 1.14 | 0.23 | .002 |
| Peer supportive relationship (child report) | 4.00 | 0.81 | 4.08 | 0.92 | 3.91 | 0.70 | .40 |
| School engagement (child report) | 2.36 | 0.42 | 2.46 | 0.37 | 2.26 | 0.44 | .06 |
| Speech AI | 2.78 | 0.36 | 2.66 | 0.44 | 2.90 | 0.20 | .004 |
| Pragmatic | 2.68 | 0.29 | 2.56 | 0.33 | 2.80 | 0.19 | .005 |
| Study Variables . | Total (N = 67) . | DHH (n = 33) . | Hearing (n = 34) . | P . | |||
|---|---|---|---|---|---|---|---|
| Mean . | SD . | Mean . | SD . | Mean . | SD . | ||
| Prosocial behaviors (teacher report) | 2.58 | 0.41 | 2.46 | 0.38 | 2.69 | 0.42 | .02 |
| Peer relationship problems (teacher report) | 1.29 | 0.42 | 1.44 | 0.51 | 1.14 | 0.23 | .002 |
| Peer supportive relationship (child report) | 4.00 | 0.81 | 4.08 | 0.92 | 3.91 | 0.70 | .40 |
| School engagement (child report) | 2.36 | 0.42 | 2.46 | 0.37 | 2.26 | 0.44 | .06 |
| Speech AI | 2.78 | 0.36 | 2.66 | 0.44 | 2.90 | 0.20 | .004 |
| Pragmatic | 2.68 | 0.29 | 2.56 | 0.33 | 2.80 | 0.19 | .005 |
The results of multiple hierarchical regression models are presented in Table 2. Adolescents’ pragmatic abilities and hearing status had a significant main effect on their peer relationships (P < .01). Simply stated, DHH adolescents demonstrated more peer problems than their hearing peers. In addition, increased pragmatic difficulties were related to increased peer problems. In predicting prosocial behaviors, only pragmatic abilities had a significant main effect. Increased pragmatic difficulties were associated with decreased prosocial behaviors regardless of adolescents’ hearing status (P < .001). In addition, there was a significant positive relation between pragmatic abilities and adolescents’ report on their peer supportive relationships. Finally, in the regression model examining adolescents’ school emotional engagement as the dependent variable, only speech AI was a significant predictor (P < .05). Specifically, better speech AI was associated with increased levels of school emotional engagement. Across all regression models, the effect size of the significant pragmatic abilities and hearing status was low to medium.34 Finally, across all the regression models, no significant interaction effects were found (ie, interaction between pragmatic skills and children's hearing status and between speech AI and children’s hearing status).
Hierarchical Multiple Regression Results Predicting Peer Relationship, Prosocial Behaviors, and School Engagement
| . | Peer Relationship Problems (Teacher Report) . | Prosocial Behaviors (Teacher Report) . | Peer Supportive Relationship (Child Report) . | School Engagement (Child Report) . | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| B . | SE . | β . | R2 . | B . | SE . | β . | R2 . | B . | SE . | β . | R2 . | B . | SE . | β . | R2 . | |
| Final model | — | — | — | 0.23 | — | — | — | 0.29 | — | — | — | 0.10 | — | — | — | 0.13 |
| Hearing status | −0.22 | 0.10 | −.26* | — | 0.06 | 0.10 | .07 | — | −0.30 | 0.21 | −.18 | — | −0.21 | 0.11 | −.25 | — |
| Speech AI | 0.23 | 0.18 | −.19 | — | −0.03 | 0.17 | −.02 | — | −0.65 | 0.37 | −.29 | — | −0.42 | 0.19 | −.36* | — |
| Pragmatic | −0.59 | 0.23 | −.41* | — | 0.72 | 0.21 | .51** | — | 1.16 | 0.47 | .42* | — | 0.46 | 0.24 | .32 | — |
| . | Peer Relationship Problems (Teacher Report) . | Prosocial Behaviors (Teacher Report) . | Peer Supportive Relationship (Child Report) . | School Engagement (Child Report) . | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| B . | SE . | β . | R2 . | B . | SE . | β . | R2 . | B . | SE . | β . | R2 . | B . | SE . | β . | R2 . | |
| Final model | — | — | — | 0.23 | — | — | — | 0.29 | — | — | — | 0.10 | — | — | — | 0.13 |
| Hearing status | −0.22 | 0.10 | −.26* | — | 0.06 | 0.10 | .07 | — | −0.30 | 0.21 | −.18 | — | −0.21 | 0.11 | −.25 | — |
| Speech AI | 0.23 | 0.18 | −.19 | — | −0.03 | 0.17 | −.02 | — | −0.65 | 0.37 | −.29 | — | −0.42 | 0.19 | −.36* | — |
| Pragmatic | −0.59 | 0.23 | −.41* | — | 0.72 | 0.21 | .51** | — | 1.16 | 0.47 | .42* | — | 0.46 | 0.24 | .32 | — |
—, not applicable.
P <.05.
P <.01.
Discussion
The findings of the current study demonstrate that DHH adolescents who attend mainstream educational settings and use spoken language for communication, based on teacher report, experience more difficulties with peer relationships than their hearing peers. This is consistent with findings from previous studies.23,24,35 However, hearing status did not have a significant effect on perceptions of supportive peer relationships based on adolescents’ self-report. This finding reflects the common discrepancy between teachers’ and children’s reports of children’s social experiences. This discrepancy may suggest that students own subjective feelings regarding their social experiences and relationships are not always observed or perceived in the same way by teachers.36 This seems reasonable because teachers may be less able to interpret the idiosyncratic emotional expressions of their students. Making a judgment about whether a student may be liked by their peers may be an easier distinction to make than determining children's emotional inner experiences.37 Accordingly, future research should compile cross-informant findings to construct a more complete picture of children’s functioning.
No significant effect was found for adolescents’ hearing status on prosocial behaviors. This is consistent with previous studies that reported no differences in empathy, which is an ability that is related to prosocial behaviors, between young DHH children and typically hearing children.38 The findings highlighted the importance of both pragmatic abilities and speech AI for having positive peer relationships and prosocial behaviors, regardless of adolescents’ hearing status. Pragmatic language skills are required for initiating reciprocal and positive interactions, expressing needs, providing social support, and solving social problems resulting in successful peer interactions and enhancing social-emotional development, including prosocial behavior.39–41
Speech AI abilities were positively associated with children’s school engagement. This finding is consistent with previous findings, which indicated that speech AI abilities are important for DHH children’s and adolescents’ social and emotional feelings in educational settings13,21,42 as well as for social participation in social and school activities, as found among children with speech AI challenges.43 The level of speech intelligibility of DHH students who rely on spoken language can play a central role in the quality of communication between them and their teachers and classmates and, if poor, might discourage some DHH students from speaking in class.21,44 Children with speech AI difficulties may feel socially alienated and withdraw from classroom participation. This, in turn, might decrease their sense of emotional school engagement.
The results of the study emphasize the significant role of good pragmatic skills for all adolescents, whether typically hearing or DHH. The use of efficient pragmatic skills is related to many aspects of social interaction (eg, the context and the partner). Therefore, educators are encouraged to take advantage of the classroom environment and practice the use of pragmatic skills in various situations with the students. In addition, the current findings support previous studies that have indicated that better communication skills are important for children’s social relationships and for preventing mental health problems.24,45 The current study has some limitations. First, the correlational nature of the data precludes ascertaining the direction of the effects. Longitudinal studies would be advantageous to examine change over time in both pragmatic skills and social relationships during adolescence. Second, although common in DHH studies, the relatively small sample size limits the generalizability of the results. Third, although adolescents’ self-perceptions are the most significant information, additional corresponding data from independent informants, such as peers or direct observations, are important. It is recommended in future research to triangulate evidence from multiple informants.
Medical care providers need to be attuned to difficulties that DHH adolescents may encounter with social communication skills. Health care providers can play a critical role in identification of both pragmatic and speech difficulties and should refer for assessment and intervention services to support the development of those skills. Moreover, it is important that medical care providers establish collaborative relationships with school- and community-based allied health professionals, such as speech therapists and school counselors, to provide adequate referral for assessment and support services.
Drs Zaidman-Zait and Most collaborated on this research project and on the writing of the manuscript and approved the final manuscript as submitted.
FUNDING: No external funding.
References
Competing Interests
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
This article is licensed under the Creative Commons Attribution 4.0 International License (CC-BY 4.0). The named authors alone are responsible for the views expressed in this publication.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Comments