Difficulties associated with aging are gaining interest in society as people are living longer and an elderly population is emerging with special needs. One group that has been identified but receives little attention is deaf people who have become elderly.
In the United States today, between 7 and 8 million elderly people have hearing impairments.1 By the year 2000, more than 11 million elderly Americans will have significant hearing loss. Approximately 3% of this number will have lost their hearing before the age of 3, or prelingually, and to such a degree that normal acquisition of spoken language will not have occurred. These people usually learn American Sign Language (ASL) as their primary language, and consider themselves to be members of the Deaf Community (also known as the Deaf Culture). On some occasions, deaf people with lesser degree losses or with postlingual impairments will also acquire ASL as their native language and function as members of the deaf population. *
The elderly deaf are discussed infrequently in the literature, perhaps because professionals without much exposure to the field of deafness assume that individuals who are born deaf confront relatively milder consequences to aging and hearing loss than do people who acquire a hearing loss in their senior years.3'4 The impact of deafness in later years is certainly significant, but the cumulative developmental effects of severe to profound hearing loss from an early age, compounded with the effects of aging, may create a more debilitating condition and a challenge to caregivers.5 The intent of this article is to identify some of the problems specific to the elderly deaf to raise awareness of their unique and urgent needs.
IMPACT OF DEAFNESS DURING CHILDHOOD
To understand some of the problems that the elderly deaf confront, their lifelong difficulties need to be understood. According to Levine, "... profound congenital deafness is the least traumatic [age of onset for hearing loss] emotionally but imposes the most severe and sweeping deprivations developmentally."6These problems start at an early age and have a continuing impact on the deaf person's life.
Because of their hearing loss, deaf people are impaired in developing normal communication methods with society at large.6 Complete auditory input facilitates the acquisition of spoken language in people who can hear. The loss of this input inhibits normal spoken language development and leads to the development of a visual sign language, most often ASL. Although ASL is a unique and complete language capable of conveying all the richness and subtlety of communication, it is not English (nor is it an inferior form or "broken" English) and is not widely known outside the Deaf Community. This creates an actual language barrier; deaf people are unable to easily communicate with the hearing society in which they live. In addition to this language barrier, other difficulties encountered by the elderly deaf individuals also originate during childhood.
Social Integration and Enculturation
Social integration, or "... the exceptional child's physical proximity, interactive behavior, assimilation, and acceptance by his or her normal-hearing classmates," is greatly affected for the hearing-impaired child.7 Some educators have proposed that placing deaf children in classrooms with hearing children promotes social interactions; however, Antia found that increasing the physical proximity of deaf and hearing children usually has little impact on the frequency of social interaction between the two groups. Also, deaf children do not tend to successfully initiate interactions with others.7
If certain skills are not developed as a child, they cannot be drawn upon in old age. Just as physical proximity between deaf and hearing children did not increase the frequency of interaction between the two groups, physical proximity between deaf and hearing elderly persons (eg, in nursing homes or senior citizen activity groups) will not automatically lead to successful interaction or integration. Hearing impaired children do not tend to successfully initiate interactions with others, and as older adults, because of early experiential deficits, the elderly deaf may also not be able to successfully initiate interactions with those in their environment.
A second problem that arises in deaf children is that their lack of hearing results in a lack of sounds that promote normal enculturation.6
Developmentally, the absence of meaningful sound since birth means the absence of sounds that bring language and information, that stir feelings, influence actions and attitudes, confirm identity, allow expressive release, impart aesthetic pleasure, and unite the individual to the company of humankind.6
Although deaf people are able to communicate fully by means of sign language, they are often not able to use the spoken language of the majority culture. This means that they will not be enculturated through audition like the hearing population, and thus may not relate well to their hearing peers. For example, hearing children grow up with an auditorily rich environment that includes music, which may be a strong component of the enculturation of a hearing child. A profoundly deaf child growing up in a residential setting will probably be aware of music but will not have that same strong component in his enculturation.
For an elderly deaf person who had been raised in a residential school and who is now in a geriatric facility, all of his peers likely will have been enculturated as hearing people, and this could result in the deaf person feeling like a foreigner, alone and unable to relate with those in his environment.
Impact of Being Raised by Hearing Parents
Feelings of powerlessness and frustration are common manifestations among some deaf children, most likely occurring when raised by hearing parents. Ninety percent of all deaf children in the United States are born to hearing parents. Hearing parents of deaf children are often frustrated that they cannot understand their child, especially if they are unable to make themselves understood by the child.8 The ramifications of having a deaf child are tremendous; it is a traumatic event for most parents, and a sense of grief and loss is not uncommon. The disruption of normal sibling relationships among their children is also common. The abrupt entrance into a new world filled with professionals, assistive devices, educational plans, specialized vocabulary, and modes of language choices creates confusion for parents. And as a result, hearing parents often feel powerless and may transfer these feelings onto the child.9
The deaf child of hearing parents may also develop feelings of doubt and distrust. This can begin when the parents' lack of communicative skills limits them to conversation of the present. When a situation arises in which the parent would normally explain a process to reassure a child of its outcome, such as the procedure of the child's first dental examination; or to explain predictions of circumstances such as the possibility of the death of a hospitalized loved one, the parent of a deaf child may not do so due to lack of skill in communicating these concepts. The child, because of the lack of this information, may doubt and distrust the parent and may generalize the doubt and distrust to all hearing people.8
If a deaf person felt frustrated and powerless in most of his interactions with the hearing world since childhood, these feelings will hamper the individual when old, especially if most interactions are necessarily with hearing peers or professionals. For example, a deaf person placed in a geriatric facility may feel frustrated and powerless if a staff person moves the resident to another room or escorts him to an activity without successful communication. The staff may have the deaf person's best interest at heart, but because of the communication barrier may not successfully discuss the situation.
The feelings of powerlessness, and the doubt and distrust of hearing people carried from childhood, would have a definite impact on the quality of life for the elderly deaf adult. A deaf person in a geriatric facility may doubt that he is being treated with equality compared with the hearing residents, who can more easily get information from the staff about important happenings. The deaf person may also distrust hearing nurses and doctors, based on a lifetime of experiences in which inadequate services were provided by medical professionals who did not understand the dea.
Social immaturity is another problem area for the deaf that originates during childhood. "The social immaturity seemingly characterizing deaf children and adults may result from the high proportion attending residential schools, where the development of independence and responsibility may be stifled."8 Residential schools serve as strict caretakers for deaf children with rigid schedules that do not allow for decision making, even about their activities for the day. Due to the liability concerns, the schools also impose unnatural limitations on social activities. The children are kept with same age, same sex students much of the time, whereas in a home situation they would be more likely to interact frequently with siblings and friends of different ages and of both genders. In the institutional setting, play activities are more structured and closely monitored than in a home environment. So the deaf child often does not develop social maturity to the extent that a noninstitutionalized child does.
This social and emotional immaturity noted in hearing impaired children is often still present in the deaf adult. According to noted researchers, social immaturity in the deaf actually seems to increase with age.10'11 Schlesinger also noted this characteristic when she stated, ". . . the most common psychological generalization about deaf adults is that they seem to be emotionally immature."9 In the elderly deaf population, the characteristic of social and emotional immaturity may appear to hearing peers or professionals as extreme dependency or irresponsibility.
Distorted Sense of Competency
Finally, the deaf have been characterized as having a distorted sense of self-competency, which, again, has roots in childhood. This sense of competency can either be impaired or exaggerated. According to Schlesinger, "... deaf children's sense of competency is frequently impaired since their [hearing] parents' expectations for competency so often lie in the area most crucially influenced by deafness: speech."9 Meadow, on the other hand, stated that, ". . . the deaf children's ideas about themselves are perhaps inaccurate; they have inflated ideas about their capabilities and the opinions others have of them."8
For an elderly deaf person whose hearing parents emphasized speech as a measure of competency, feelings of inadequacy and of needing to be cared for may be evident. Or the opposite might occur for the elderly deaf person with an inflated sense of competency, who might refuse needed services because he or she is unrealistic about his or her capabilities.
Those characteristics that are manifested in hearing impaired children combine to shape the personality of the deaf person throughout life. A composite psychological profile of deaf adults drawn from several studies included the following traits.12'17 Deaf adults tend to be immature; withdraw (especially from communication situations); be less flexible that a normal hearing adult; adhere rigidly to a set routine; demonstrate a negative selfimage (due in part to a general lack of information concerning the nature of hearing impairment); have a narrow range of interests; show a lack of social judgment; exhibit a lack of regard for the feelings of others; are more naive than the hearing adult; are more dependent than the hearing adult; are irresponsible; are impulsive; and are passive and overaccepting (especially if the loss occurred early).
The origins of these traits, however, are due to experiential deficits in relation to society's norms for behavior as well as differences in cultural expectations. The behavior should not be viewed as deficiencies in personality. This view is particularly important in that deaf people perceive negative attitudes from the hearing toward the deaf. According to Levine, deaf people feel more handicapped by hearing people's negative attitudes than by hearing loss itself.6 The elderly deaf person who perceives negative and discriminatory attitudes from hearing caregivers might be uncooperative or resentful. Care must be taken to understand his perspective and communicate fully with the elderly deaf person.
Because they cannot hear - and have not heard for all or almost all of their lives - deaf persons lace their later life with different needs from the general aged population.... When aging combines with deafness, the resulting disability can be massive, though it need not be.18
The handicaps of being deaf, such as impairment in communicating with the majority of society, lack of "normal" enculturation, inhibited psychosocial development resulting from a communication barrier with hearing parents, social and emotional immaturity, and distorted sense of competency, all have a disabling effect beyond the hearing impairment and compound the effects of aging. In the future, the quality of intervention that takes place in a family with a newly diagnosed deaf child needs to be improved, and better methods for facilitating English language acquisition for the deaf need to be developed. Although these improvements can lead to a better quality of life for the elderly deaf of the future, much needs to be done to enhance the lives of the elderly deaf now.
The following is a list of recommendations that caregivers, particularly in geriatric facilities, can implement to better serve deaf clientele.
Educate all staff (including medical professionals) who work with the elderly about the implications of deafness through all stages of life. This can dispel misconceptions and bring about improved communication between staff and deaf residents/clients.
Purchase the following assistive devices and educate staff about how to use them. (These devices will also greatly assist elderly persons who are deafened):
* Light signaling devices for fire alarms, smoke detectors, doorbells, telephones, and alarm clocks. A variety of signaling devices are available, and they can allow the deaf person to experience increased independence. The light signals on fire alarms and smoke detectors increase the safety of facilities and homes for deaf people; signals for doorbells (even in residents' rooms), telephones, and alarm clocks allow deaf persons to experience more privacy.
* Telecaption decoder. This device decodes a television frequency that provides subtitles of the conversation that is spoken on selected television programs. This allows deaf people to understand and enjoy more of their television viewing.
* Telecommunication device for the deaf (TDD). This is a machine that can be used in conjunction with a telephone that permits the conversation to be typed. To complete a call with a TDD, both the sender and receiver must have a TDD on their respective ends of the line. Many cities and states offer relay services for TDD users.
Advocate the establishment, or continuation, of quality relay services. A relay service is one in which a hearing or hearing unpaired person can call an operator who has both a voice phone and a TDD on two separate phone lines. The caller requests that the operator call a third party so that the person with a TDD can converse with another who does not have one. The operator acts as a go-between or interpreter.
Provide American Sign Language classes by a qualified instructor for facility staff and caregivers.
Follow basic rules to enhance communication:
* Take time to communicate. Do not assume the deaf person will understand what is happening around him.
* Look directly at the deaf person and establish eye contact before speaking, signing, or communicating.
* When speaking to a person who reads lips, make sure the speaker's mouth is clearly visible (no hands in front of mouth, do not turn head to the side) and speak clearly but do not exaggerate mouth movements.
* Make sure that lighting is adequate and that no outside light is shining from behind the speaker directly at the receiver.
* If the deaf person does not lip-read, write brief notes to inform him of upcoming activities or changes and to engage in informal conversation.
* If the deaf person best understands sign language, contact a professional interpreter to communicate serious information, such as medical reports or significant changes in the caregiving situation.
* Be certain that the deaf person is making his own choices and that you have not accepted the responsibility for making decisions that should be made by him.19
Because the elderly deaf may not know how to initiate interactions with others, actively encourage and include these individuals in situations in which they might have the opportunity to socialize with their peers.
Develop activities that do not depend on communicating in the English language for all residents to facilitate integration.
"Because they cannot hear - and have not heard for all of their lives" we, as professionals, need to be sensitive and encourage integration of these clients into their environments.
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