Keep This Theory in Mind Children who are deaf or hard of hearing often struggle with pragmatic skills, specifically the “theory of mind,” an expert says. All Ears on Audiology
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All Ears on Audiology  |   April 01, 2017
Keep This Theory in Mind
Author Notes
  • Carol Westby, PhD, CCC-SLP, is an educational consultant who has written and presented workshops nationally and internationally on language-literacy development and disabilities; theory-of-mind and social-communication impairments; and multicultural issues in assessment and intervention. Westby is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; 14, Cultural and Linguistic Diversity; 16, School-Based Issues; and 17, Global Issues in Communication Sciences and Related Disorders. mocha@unm.edu
    Carol Westby, PhD, CCC-SLP, is an educational consultant who has written and presented workshops nationally and internationally on language-literacy development and disabilities; theory-of-mind and social-communication impairments; and multicultural issues in assessment and intervention. Westby is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; 14, Cultural and Linguistic Diversity; 16, School-Based Issues; and 17, Global Issues in Communication Sciences and Related Disorders. mocha@unm.edu×
Article Information
Hearing Disorders / All Ears on Audiology
All Ears on Audiology   |   April 01, 2017
Keep This Theory in Mind
The ASHA Leader, April 2017, Vol. 22, 18-20. doi:10.1044/leader.AEA.22042017.18
The ASHA Leader, April 2017, Vol. 22, 18-20. doi:10.1044/leader.AEA.22042017.18
Cochlear implants, bone-anchored hearing aids, digital hearing aids, personal-worn FM amplification systems, classroom amplification systems—all of these aid students who are deaf or hard of hearing.
And although improved sound access does not ensure a child will develop spoken-language abilities within normal limits, a number of students, particularly those with cochlear implants, do develop highly intelligible speech and enter general education elementary classrooms with some vocabulary and structural language skills in the average range.
However, pragmatic skills in children and adolescents who are deaf or hard of hearing may lag behind other language systems (see sources below). School-age children and adolescents with hearing loss demonstrate a range of pragmatic behaviors that may differ from their hearing peers, with significant implications for social interactions and peer relationships.
Audiologists’ awareness of the potential long-term effects of hearing loss on academic and social performance can help them offer guidance to students with hearing loss, as well as their parents and teachers.

Pragmatic skills in children and adolescents who are deaf or hard of hearing may lag behind other language systems.

Theory of mind
Deficits in theory of mind (ToM)—the ability to attribute mental states to yourself and others, and to understand that others have beliefs, desires, intentions, emotions and perspectives that are different from your own—likely account for some of these pragmatic and social-cognitive difficulties.
Children who are deaf or hard of hearing sometimes exhibit ToM deficits similar to those seen in children with autism spectrum disorder, but likely for different reasons (see sources below). ToM is a multidimensional construct and each dimension likely has different neurophysiological and neuroanatomical foundations.
ToM can be differentiated into cognitive and affective dimensions (see sources below). Cognitive ToM involves the ability to attribute mental states to yourself and others, and to understand that others have mental states that are different from your own; affective ToM involves the ability to recognize emotions in yourself and others, to reflect on your own emotions, to regulate your emotions, and to empathize with others.
Cognitive and affective ToM can be further differentiated into interpersonal and intrapersonal ToM. Through interpersonal ToM, we infer mental states and emotions of others; we use intrapersonal ToM to reflect on our own mental states and emotions.
People can have differing patterns of strengths and weaknesses in each of their ToM dimensions.

Children who are deaf or hard of hearing sometimes exhibit theory-of-mind deficits similar to those seen in children with autism spectrum disorder, but likely for different reasons.

ToM and hearing loss
Research has shown that students who are deaf or hard of hearing are at risk for ToM deficits in all dimensions.
Cognitive interpersonal ToM deficits
Researchers have investigated cognitive interpersonal ToM in children with hearing loss by evaluating their performance on false-belief tasks. For example, children are told or shown a story of a boy who leaves chocolate on a shelf and then leaves the room. His mother puts it in the fridge. To pass the task, the child must understand that the boy, upon returning, holds the false belief that his chocolate is still on the shelf.
Many studies have documented that children with hearing loss, particularly those of hearing parents, tend to be markedly delayed in passing false-belief tasks compared to hearing children. Deaf children of deaf parents reportedly perform similarly to hearing children on these false-belief tasks, but there is evidence that deaf children of deaf parents may exhibit delays in developing higher-order theory of mind, which includes understanding figurative language, lies, sarcasm and multiple embeddings (see sources below). An example of multiple embeddings: Ben thinks that Anna believes that he knows that Mom wants perfume for her birthday.
Cognitive intrapersonal ToM deficits
Cognitive intrapersonal ToM involves self-awareness or metacognition, comprising awareness of what you know and don’t know about a topic, awareness of the strategies for doing tasks, knowledge of when to use the strategies, and how to plan, monitor and evaluate your learning.
Compared to hearing students, students who are deaf or hard of hearing tend to exhibit poorer metacognition. They may be less aware of when they comprehend and do not comprehend while listening or reading, and they use fewer strategies to construct meaning and to monitor and evaluate comprehension (see sources below).
Affective interpersonal ToM deficits
Compared with normally hearing children, children and adolescents with hearing loss tend to be less proficient at sorting faces that express emotion or at labeling emotional expressions. They also show greater difficulty in matching emotional expressions to pictures of situations that might trigger that emotion, and they tend to give different rationales for the emergence of emotions than their hearing peers.
Students who are deaf or hard of hearing also tend to misinterpret the types and causes of emotions of characters in stories, and score lower in empathy than their hearing peers. On self-rating measures, they report lower levels of empathy and less supportive behaviors to their peers than hearing children, regardless of their type of hearing device, and teachers tend to rate them as less empathic (see sources below).
Affective intrapersonal ToM
Children with hearing loss are likely to have more difficulties identifying emotions in themselves than hearing children, display fewer moral emotions, and exhibit fewer adequate strategies to regulate their emotions. They also tend to have less detailed autobiographical memories, which are largely dependent on emotional reflections on experience (see sources below).

Even when children with hearing loss have the vocabulary and syntactic skills necessary to pass traditional theory-of-mind tasks, they are likely to continue to have theory of mind deficits in social and academic contexts.

Understanding ToM in children with hearing loss
Performance on many ToM tasks is highly correlated with language. But even when children with hearing loss have the vocabulary and syntactic skills necessary to pass traditional ToM tasks, they are likely to continue to have ToM deficits in social and academic contexts.
Aspects of affective ToM are not dependent on language, yet students who are deaf or hard of hearing may not perform like hearing students on these tasks. Although they may gain access to sound by a variety of devices, they are not like hearing children whose hearing is temporarily obstructed. They may process visual and auditory stimuli differently from hearing children (see sources below), exerting an effort to listen, particularly in noisy environments or when interacting with several people at a time. Stress and fatigue that arise from increased listening effort likely reduce the capacity to process the multiple environmental cues essential for effective social interactions.
As a consequence, children who are deaf or hard of hearing experience reduced incidental learning—they are likely to miss feedback directed to them, and they are likely to miss many cues that are important for interpreting the thoughts and feelings of others (see sources below).
Many students with hearing loss are not eligible for services from speech-language pathologists. Therefore, the audiologist may be the only professional who monitors these students’ behavior and social and academic performance. By being aware of ToM deficits, audiologists can better inform parents and teachers of ways hearing loss may influence social skill development in children and adolescents with hearing loss.
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April 2017
Volume 22, Issue 4