Abstract
Netten, A. P., Rieffe, C., Theunissen, S. C. P. M., Soede, W., Dirks, E., Briaire, J. J., & Frijns, J. H. M. (2015). Low empathy in deaf and hard of hearing (pre)adolescents compared to normal hearing controls. PLoS ONE, 10(4), Article e0124102. doi:10.1371/journal
Empathy is defined as the ability to perceive and understand another person’s emotional state and the competence to appropriately respond to others’ emotions. It is needed to induce prosocial behavior and is often referred to as the social glue in relationships. Little is known about the development of empathy in deaf and hard-of-hearing (DHH) children, but prerequisites for empathy, such as emotion recognition and regulation and development of a Theory of Mind (ToM), have been shown to be delayed in DHH children. Although, initially, children with cochlear implants (CI) were found to perform as well as normal hearing (NH) children, at an older age, they fell behind on more advanced ToM abilities such as false belief tasks (Bachara, Raphael, & Phelan, 1980; Ketelaar, Rieffe, Wiefferink, & Frijns, 2012; Rieffe, 2012)
The purpose of this study was to determine the differences in the levels of self-reported and observed empathy between DHH and NH children. To identify those factors that may be most influential for the levels of empathy in DHH children, the researchers also investigated the influence of several audiological factors on empathic abilities, such as language development, intelligence, degree of hearing loss, age at intervention of hearing loss, type of device, mode of communication, and educational setting.
The Study
Participants
The researchers recruited 122 DHH children and a control group consisting of 162 NH children from the Netherlands and the Dutch-speaking part of Belgium to participate in this study. All children were between 9 and 16 years of age at time of assessment. All children had an intelligence quotient (IQ) of 80 or higher and no other known disabilities besides their hearing loss. Of all DHH children, 52 were fitted with a CI, and 70 children wore conventional hearing aids (HAs). Hearing impairment was defined as experiencing a loss of greater than 40 dB in the best ear that was detected pre- or perilingually. Children with postlingual onset hearing loss were excluded. The NH group was matched with the DHH group on sex and mean age. The groups did not differ on gender, intelligence, socioeconomic status (SES), and age. The children with CIs had profound hearing losses, whereas the child with HAs had more moderate to severe losses.
Materials/Procedures
The following instruments were used in this study:
Self-reported empathy
The Empathy Questionnaire for Children and Adolescents (EmQue-CA) consists of a total number of 18 items, scored by children on a 3-point Likert-type scale (1 = not true, 2 = somewhat true, and 3 = true). The items measure three different levels of empathy:
The affective empathy scale defines the extent to which emotions in others cause similar feelings in the observer (e.g., “If a friend is sad, I also feel sad”).
The cognitive empathy scale defines the level to which children understand the emotions they observe in others (e.g., “When a friend is angry, I tend to know why”).
The prosocial motivation scale defines the tendency to support a distressed other (e.g., “If a friend is sad, I like to comfort him”).
From the Emotion Awareness Questionnaire (EAQ), the “attendance to others’ emotions”
scale was used (e.g., “If a friend is upset, I try to understand why”). Children rated how valuable they found other children’s emotions on a 3-point Likert-type scale (1 = not true, 2 = sometimes true, 3 = often true; Rieffe, Oosterveld, Miers, Terwogt, & Ly, 2008).
The “emotion recognition” scale from the Emotion Expression Questionnaire (EEQ) was scored by parents (e.g., “Does your child know when you are angry?”). The questions were rated on a 5-point Likert-type scale with 1 = (almost) never, 2 = rarely, 3 = sometimes, 4 = often, and 5 = (almost) always.
Observation of empathy
Children observed the experimenter acting out three different emotional situations and were observed to what extent they showed empathic reactions directed at the experimenter.
The experimenter pretended to receive text messages from a friend. The experimenter reached for her phone and pretended to read the first message, after which she shared with the participant that it contained an invitation from her friend to go to the movies that night. The experimenter had an excited, happy facial expression and said that she was looking forward to it. After that, she put away the phone and continued the test session. Approximately 30 min later, the experimenter pretended to have received another text message. This time, she shared with the participant that her friend had to cancel the appointment, meanwhile showing a disappointed, sad facial expression. After 5 s, the experimenter stored her phone and carried on with the session.
The experimenter pretended she could not find her pen. Earlier, the pen was placed outside the direct line of sight of the experimenter (i.e., behind a binder), but in full view of the child. For a duration of 10 s, the experimenter looked around and searched her bag, stating that she could not find her pen. Meanwhile, children’s responses were observed.
The experimenter collected testing materials and dropped one item on the floor. The experimenter looked at the item and said “oops,” but continued to gather the rest of the materials. Children’s behaviors in response to the situation were observed.
Children’s reactions across all three situations were scored on a checklist (1 = no, 2 = slightly, 3 = yes) and were grouped into “attention to emotions” (e.g., looking at the experimenter) and “supportive behavior” (e.g., returning the lost pencil).
Language skills and intelligence
Nonverbal intelligence was assessed using two components of the Wechsler Intelligence Scale for Children–Third Edition (WISC): block design (duplicating geometric designs with cubes) and picture concepts (arranging pictures to create logical stories).
Children using oral language as their preferred mode of communication completed the
Dutch version of the Clinical Evaluation of Language Fundamentals–Fourth Edition (CELF-IV). DHH children who preferred communicating by sign (supported) language completed subtests from the Assessment Instrument for Sign Language of The Netherlands.
Results
Self-Reported Empathy
DHH children overall scored lower on cognitive empathy and prosocial motivation than NH peers, regardless of their type of hearing amplification. This difference remained when corrected for language development and intelligence.
On affective empathy, children with CIs scored lower than the NH group. Scores on affective empathy by children with HAs did not differ from NH children.
Language development was significantly related to the levels of empathy but intelligence was not.
Girls scored higher than boys on affective empathy and prosocial motivation. Girls and boys were similar on cognitive empathy.
On attendance to others’ emotions, NH children reported higher scores than DHH children, and girls scored higher than boys. Language development was significantly related to the attendance toward others’ emotions.
DHH and NH children did not differ on emotion recognition (as scored by parents and corrected for language development and intelligence).
Observation of Empathy and Supportive Behavior
DHH students scored higher than their NH peers on emotion attention.
NH students showed more supportive behavior than DHH students.
Audiological and Socio-Demographic Factors Influencing Empathy
DHH children attending mainstream schools had higher levels of cognitive empathy than DHH children attending special schools.
No significant differences were found in observed empathic reactions nor in parent-reported emotion recognition or attendance to others’ emotions comparing DHH children in mainstream and special education schools.
DHH children using sign language scored lower on self-reported prosocial motivation and on observed attention to emotions than DHH children who preferred to use spoken language.
No relationships were found between empathy and several audiological variables (degree of hearing loss, age at detection, age at intervention, and age at implantation).
Implications
The U.S. Department of Education, Office of Special Education and Rehabilitative Services (OSEP) reported that approximately 87% of students who are DHH spend a portion or all of the school day in general education classrooms. Many states provide services for these students only when they are performing 1.5 to 2.0 standard deviations below the mean on measures of language and academic performance. With the technology of CIs and HAs, many students who are DHH manage to “get by” in general education classes. Yet, CIs and HAs are not like eyeglasses. They do not correct hearing loss, so DHH students do not have full access to classroom experiences. Speech-language pathologists need to be aware of factors that can put students who are DHH at risk for social and academic difficulties in the classroom.
Affective and cognitive empathy have different neurophysiological underpinnings. Affective empathy (i.e., feeling what the other person feels) is thought to be neurologically hard-wired via mirror neurons—it is present in children despite their social learning experiences. In contrast, cognitive empathy (i.e., understanding the other’s emotions) depends on the extent to which children can participate in a social environment. Children who are DHH are compromised in their ability to fully access the social environment. Although in this study DHH children reported affective empathy equal to that of their NH peers, DHH children reported lower levels of cognitive empathy and valued emotional information about other people as less important. Furthermore, both a self-report and an observation task show less supportive behavior in the DHH group compared with NH peers. In other words, DHH children might feel what the other person feels, and also attend to those emotions, but they have less understanding of their causes; they value others’ emotions as less important, and also react less adaptively to supporting the person in distress. Even when researchers controlled for language skills, DHH children were outperformed by their NH peers on cognitive empathy and prosocial motivation, which are more dependent on social learning.
Students who are DHH miss out on incidental learning that occurs in social situations because they fail to overhear conversations or they are working so hard to hear that they fail to see important visual cues. For adequate cognitive empathy to develop, a child needs to be able to recognize emotions in others. Lower levels of emotion recognition have been reported in DHH toddlers and school-aged children compared with NH peers (Dyck, Farrugia, Shochet, & Holmes-Brown, 2004; Wiefferink, Rieffe, Ketelaar, De Raeve, & Frijns, 2013). Deficits in recognizing emotions could explain impaired levels of cognitive empathy in persons who are DHH. But in this study, the DHH children were as capable as their NH peers in recognizing emotions in others. It appears that the difficulty in this study was the more complex interpretation of the whole emotion-evoking situation that causes confusion: why is my friend angry, what has happened? These deficits can affect students’ social interactions with their peers because there is a strong positive association between empathy and friendship quality in both NH and DHH children (Chow, Ruhl, & Buhrmester, 2013). Students also need to bring cognitive empathy to the task of comprehending narrative text. They must be able to recognize characters’ emotions, understand what triggered the emotions, and infer what the characters might do in response to these emotions.
For cooperative play with peers, children need to share one another’s goals, desires, and beliefs. Not being able to empathize with the other may result in less participation in play with others, causing isolation for the DHH child (Rieffe, Netten, Broekhof, & Veiga, 2015). Sufficient language skills are important but not sufficient for empathic abilities. The authors of this article advocate that professionals give greater attention to developing students’ empathic abilities.