Deaf And Hard-of-hearing Children Research Articles

Rates of socio-emotional difficulties among deaf and hard of hearing children in Ireland

ABSTRACT Higher rates of socio-emotional difficulties for deaf and hard of hearing (DHH) children have been reported compared with their typical hearing (TH) peers. Nonetheless, there has to date been limited examination on this issue internationally and no such examination in the Republic of Ireland. In this study, data was collected from parents using an online survey which included the Strengths and Difficulties Questionnaire to examine the socio-emotional development of 113 DHH children aged 5–16 in the Republic of Ireland. The results were compared with data from typically hearing (TH) children obtained from a large longitudinal study of childhood in Ireland – the Growing Up in Ireland study. The findings demonstrate that the prevalence of socio-emotional difficulties among this cohort of children is over three times that of the general population of children in Ireland, with 42% of the sample demonstrating clinically significant problem scores. Furthermore, DHH children had elevated subscale scores for the four problem scales in the SDQ when compared against the TH sample. These differences were statistically significant and had a range of effect sizes from small to large. The subscale of most concern was the peer problems subscale where the DHH sample had mean scores that were roughly double those of the TH sample, with a large effect size found. Finally, bivariate analysis revealed that several background variables were associated with elevated difficulty scores for DHH children, namely male gender, poorer communicative competency, and presence of an additional educational need.

A longitudinal study on moral emotions and psychosocial functioning among preschool children with and without hearing loss.

Moral emotions such as shame, guilt and pride are crucial to young children's social-emotional development. Due to the restrictions caused by hearing loss in accessing the social world, deaf and hard of hearing (DHH) children may encounter extra difficulties in their development of moral emotions. However, little research so far has investigated the development trajectory of moral emotions during preschool years in DHH children. The present study used a longitudinal design to explore the development trajectories of shame, guilt, and pride, in a sample of 259 Chinese DHH and typically hearing (TH) preschoolers aged 2 to 6 years old. The results indicated that according to parent reports, DHH children manifested lower levels of guilt and pride compared to their TH peers, yet the manifested levels of shame, guilt, and pride increased throughout the preschool time at a similar pace in all children. Moreover, whilst guilt and pride contributed to increasing levels of psychosocial functioning over the preschool years, shame contributed to lower social competence and more externalizing behaviors in DHH and TH preschoolers. The outcomes imply that early interventions and adjustment to hearing loss could be useful to safeguard the social development of children with severe hearing loss, and cultural variances shall be taken into consideration when studying moral emotions in a Chinese cultural background.

Parental self-efficacy and early language development in deaf and hard-of-hearing children.

This study examined the relationship between parental self-efficacy in parents of young deaf and hard-of-hearing (DHH) children and children's spoken language skills. A retrospective within-subjects study design was used that included 24 mother-child dyads with DHH children. Parental self-efficacy was assessed using the Scale of Parental Involvement and Self-Efficacy-Revised. Children's language abilities were assessed using the Preschool Language Scale-5th edition. Our data revealed no significant associations between global measures of parental self-efficacy and children's auditory comprehension, expressive communication, and total language scores. However, positive correlations were found between child language skills and specific parents' beliefs about their ability to support their child's spoken language development, their ability to use strategies to help their child communicate, and their active involvement in intervention. Findings highlight the importance of examining discrete aspects of parental self-efficacy as it specifically relates to parents supporting their DHH child's spoken language development. Future directions and implications are provided.

Factors associated with nonword repetition skills in 4-to 6-year-old deaf and hard-of-hearing and typically hearing children

ABSTRACT Children identified as deaf and hard of hearing (DHH) exhibit an increased risk of speech and language difficulties. Nonword repetition (NWR) is a potential tool for identifying language difficulties in children with limited experience with the target language. In this study, we explored associations between auditory, linguistic, demographic and cognitive factors and NWR performance in DHH children and their typically hearing (TH) peers. We also examined the effect of the group on NWR outcomes when different factors were statistically controlled for. Our study included 68 4- to 6-year-old children: 18 with bilateral hearing aids (BiHAs), 18 with bilateral cochlear implants (BiCIs) and 32 with TH. The participants completed the Finnish Nonword Repetition Test comprising 24 test items with varying syllable lengths. The assessment methods also included tests of phonological, lexical, language comprehension and sentence repetition skills, along with a measure of nonverbal intelligence. The results showed that none of the auditory, linguistic, demographic and cognitive factors examined in the present study were correlated with NWR performance in the BiHA group, while significant correlations between NWR skills and linguistic abilities were observed in the BiCI group. The DHH children showed extraordinary difficulties in NWR compared to their TH peers, and these group differences remained after controlling for linguistic and demographic variables. The NWR task may be a potential clinical tool for identifying DHH children at risk for poor language outcomes and in need of speech and language intervention.

Effectiveness of Group-Play Training on Emotion Recognition for Young Children Who Are Deaf or Hard of Hearing

Abstract: Deaf and hard of hearing (DHH) children are developmentally delayed in facial emotion recognition (FER). This study aimed to explore the possibility of enhancing the FER ability of DHH preschoolers through a group-play intervention. Nineteen children with a cochlear implant or hearing aid were enrolled in a 4-week intervention; six DHH children were assigned to a control group. The training program included a learning procedure for four basic emotions: happiness, sadness, anger, and fear. A pretest/posttest design was used to measure the DHH children's FER performance. The results indicated that although the two groups performed comparably on the FER task before the training (pretest), the performance of the intervention group was significantly better than that of the control group in the posttest. Moreover, the DHH children in the intervention group showed the greatest improvement in FER of happiness.

UX Design for Deaf Children: How is it Done Now? Should it Change?

The process by which user experiences (UX) for children are created is uncertain, especially for deaf and hard of hearing (DHH) children. This paper seeks to (I) describe the origins of UX and child–computer interaction and to describe what is being taught to designers today; (II) use the example of digital assessment to extract insights from practitioners about UX design for DHH children; and (III) describe opportunities for amending today's UX design curricula to foster more equitably designed products for children. Interviewing 13 practitioners revealed the following findings. (1) Allowing non-designer participants to self-identify their profession makes them more likely to discuss design concepts. (2) The challenge of working with children is more about legal/risk assessment than any gaps in design education. (3) Practitioners who design products for children follow similar processes to designers who design for adults; age-specific language is the main difference child and adult UX.

Orthographic Learning in French-Speaking Deaf and Hard of Hearing Children.

Children are assumed to acquire orthographic representations during autonomous reading by decoding new written words. The present study investigates how deaf and hard of hearing (DHH) children build new orthographic representations compared to typically hearing (TH) children. Twenty-nine DHH children, from 7.8 to 13.5 years old, with moderate-to-profound hearing loss, matched for reading level and chronological age to TH controls, were exposed to 10 pseudowords (novel words) in written stories. Then, they performed a spelling task and an orthographic recognition task on these new words. In the spelling task, we found no difference in accuracy, but a difference in errors emerged between the two groups: Phonologically plausible errors were less common in DHH children than in TH children. In the recognition task, DHH children were better than TH children at recognizing target pseudowords. Phonological strategies seemed to be used less by DHH than by TH children who very often chose phonological distractors. Both groups created sufficiently detailed orthographic representations to complete the tasks, which support the self-teaching hypothesis. DHH children used phonological information in both tasks but could use more orthographic cues than TH children to build up orthographic representations. Using the combination of a spelling task and a recognition task, as well as analyzing the nature of errors, in this study, provides a methodological implication for further understanding of underlying cognitive processes.

The effect of retrieval practice on vocabulary learning for DHH children.

On average, deaf and hard-of-hearing (DHH) children have difficulty developing expressive spoken vocabulary comparable to hearing peers. Yet, there are no evidence-based practices to guide classroom instruction for teachers of the deaf. Retrieval practice-a robust learning strategy-has been shown to improve children's retention of vocabulary, but it has not been investigated with DHH children who use listening and spoken language. The present study examined whether DHH children benefit from using retrieval practice to learn new vocabulary. Sixteen DHH children (in the age range of 5.0-8.11years) were taught a set of new vocabulary words using retrieval practice or repeated exposure. A recall test was administered two days later. Results showed that DHH children were twice as likely to recall a word taught through retrieval practice than exposure (OR = 2.01, p = .02). Presence of an additional diagnosis and number of practice trials were also significant predicting factors of vocabulary learning.

Implementing co-enrollment in preschool education in China: A case study

ABSTRACT This study aims to document the implementation of sign bilingualism and co-enrollment education in a kindergarten in Quzhou, Zhejiang Province, China, to identify the major characteristics of the programme, and to report findings of children’s language in terms of vocabulary and surveys on the views and attitudes of the stakeholders of the programme, including deaf and hard-of-hearing (DHH) as well as hearing children and teachers. The results indicate that (a) both deaf and hearing teachers enjoy working in the Sign Bilingualism and Co-enrollment (SLCO) class and believe it is beneficial for their professional development; (b) parents of both DHH children and hearing children are happy to send their children to the SLCO class; (c) the teachers and parents agree that the SLCO programme is helpful for the overall development of not only the DHH children but also the hearing children. They believe that such an environment benefits the children's language and communication skills and the development of self-confidence and social cognition; (d) both the teachers and parents believe that the DHH children and their hearing peers get along well with each other in the SLCO class and also enjoy learning sign language. Furthermore, they all agree that the SLCO programme is promising and should be continued in the current school and implemented in more schools.

Broadening understanding of executive function in children with different hearing histories: The roles of fathers and coparenting

Fathers and family-level characteristics are understudied but potentially impactful contributors to at-risk outcomes for deaf and hard-of-hearing (DHH) children who use spoken language. We investigated associations between paternal parenting stress, paternal self-efficacy for supporting language, and executive function (EF) development in DHH children and children with typical hearing (TH). Main and moderating effects of the coparenting relationship were also investigated. TH fathers of DHH children (n = 44) and TH children (n = 46) completed the Parenting Stress Index-4-Short Form, the Scale of Parental Involvement and Self-Efficacy, and the Coparenting Relationship Scale. Child EF was assessed via the Behavior Rating Index of Executive Function. Regression analyses revealed that paternal parenting stress was significantly associated with child EF difficulties regardless of child hearing status. Coparenting undermining moderated relations between paternal parenting stress and child difficulties with inhibition in the full sample. Coparenting undermining was associated with greater child difficulties with set-shifting for DHH children only. Paternal parenting stress represents a possible risk factor for child EF development, particularly in families with higher levels of coparenting undermining. DHH children might also be susceptible to adverse coparenting relations. Fathers of DHH children have previously been shown to be less involved and integrated during intervention, and a better understanding of the important contributions fathers have to child development could lead to novel, father-embedded intervention models.

Instruments for evaluating the parental emotional status and ecological support systems among parents who considered cochlear implantation for their children with hearing loss: A scoping review.

Parents of children diagnosed with severe-to-profound sensorineural hearing loss may experience a range of emotions owing to a lack of knowledge and experience in dealing with such children. However, most audiology clinics only attend to children with deaf and hard of hearing (DHH) and not their parents. Thus, parents' emotional and support needs are frequently excluded from the intervention sessions, making their own needs invisible. This study aimed to identify academic and clinical instruments used for assessing parental emotional status (PES) and ecological support systems (ESS) in early intervention and determine the factors affecting PES and ESS among parents of DHH children undergoing cochlear implantation. This scoping review followed the rigorous methodological framework; searched Medline (via OVID and EMBSCO), Scopus, and Web of Science; and selected studies relevant to validated instruments used to evaluate the PES and ESS among parents of DHH children below 6 years old. Before selecting and reviewing relevant articles, two reviewers independently assessed article titles and abstracts from the data sources. Two reviewers verified half of the first reviewer's extracted data. Overall, 3060 articles were retrieved from the database search, and 139 were selected for full-text review following title and abstract reviews. Ultimately, this study included 22 articles. Among them, 23 and 12 validated instruments, most of which are generic measures, were used for assessing PES and ESS, respectively. Three condition-specific instruments were identified and designed to be administered following cochlear implantation surgery. This study revealed that healthcare professionals who interact with parents of DHH children lack the necessary instruments, particularly for parents of children undergoing cochlear implantation surgery. Therefore, it is necessary to develop condition-specific instruments for parents who consider cochlear implantation for their children.

Early access to language supports number mapping skills in deaf children.

The ability to associate different types of number representations referring to the same quantity (symbolic Arabic numerals, signed/spoken number words, and nonsymbolic quantities), is an important predictor of overall mathematical success. This foundational skill-mapping-has not been examined in deaf and hard-of-hearing (DHH) children. To address this gap, we studied 188 4 1/2 to 9-year-old DHH and hearing children and systematically examined the relationship between their language experiences and mapping skills. We asked whether the timing of children's language exposure (early vs. later), the modality of their language (signed vs. spoken), and their rote counting abilities related to mapping performance. We found that language modality did not significantly relate to mapping performance, but timing of language exposure and counting skills did. These findings suggest that early access to language, whether spoken or signed, supports the development of age-typical mapping skills and that knowledge of number words is critical for this development.

Language experience matters for the emergence of early numerical concepts

Research has shown a link between the acquisition of numerical concepts and language, but exactly how linguistic input matters for numerical development remains unclear. Here, we examine both symbolic (number word knowledge) and non-symbolic (numerical discrimination) numerical abilities in a population in which access to language is limited early in development—oral deaf and hard of hearing (DHH) preschoolers born to hearing parents who do not know a sign language. The oral DHH children demonstrated lower numerical discrimination skills, verbal number knowledge, conceptual understanding of the word “more”, and vocabulary relative to their hearing peers. Importantly, however, analyses revealed that group differences in the numerical tasks, but not vocabulary, disappeared when differences in the amount of time children had had auditory access to spoken language input via hearing technology were taken into account. Results offer insights regarding the role language plays in emerging number concepts.

Applying the reference values of real-ear-to-coupler-difference for deaf and hard-of-hearing children in Taiwan: Cautions and considerations.

Measurement of real-ear-to-coupler differentials (RECDs) is a critical part of the hearing aid (HA) verification process. This study examines the validity of reference RECD values preset by the HA analyzer, Audioscan RM500, for deaf-and-hard-of-hearing (DHH) children in Taiwan. RECD measurements were performed on 658 ears of DHH children. A linear mixed model was used to analyze the reference and measured RECD values. The findings revealed slight disparities between normative RECD values from North America and those observed in Taiwanese DHH children. While generally small (less than 5 dB), these differences imply potential challenges in achieving optimal HA fitting in specific scenarios. Therefore, we recommend individualized RECD/REM measurements for cases of poor auditory performance, certain frequency ranges, or notable variations in ear canal volume. From a clinical perspective, while broadly applicable, the use of North American RECD normative data in Taiwan requires cautious consideration of potential minor variations. This study contributes to current knowledge by affirming the use of a Western RECD database for Taiwanese DHH children. However, we underscore the ongoing importance of individualized HA fitting strategies, particularly for cases with stagnant intervention progress. While built-in RECD reference values can offer preliminary fitting guidance, especially in busy clinical settings, our study sheds light on the circumstances where caution is essential. Audiologists can efficiently allocate their time and effort by focusing on personalized RECD measurements for cases exhibiting suboptimal intervention outcomes, thereby effectively optimizing HA gain settings.

Longitudinal relations between theory of mind and academic achievement among deaf and hard-of-hearing school-aged children

This 2-year longitudinal study investigated the bidirectional relations between the development of theory of mind (ToM) and academic competences in a sample of 270 deaf and hard-of-hearing (DHH) children (Mage at Wave 1 = 7.52 years, SD = 0.99; 58.5% boys and 41.5% girls). Across three waves (10 months apart), children were assessed for their ToM abilities, using the ToM scale and a second-order false belief task, as well as for their language and mathematics skills. Cross-lagged correlational analysis revealed significant bidirectional associations between ToM and academic achievement (language and mathematics). That is, ToM predicted academic achievement with similar strength as ToM development itself was predicted by academic achievement. Our results highlight the bidirectional nature of the association between ToM and academic achievement, and they show that ToM development plays a crucial role in DHH children’s school functioning.

71 Profiles of Parent Ratings on the Behavior Assessment System for Children-Third Edition in Children with Autism Spectrum Disorder who are Deaf and Hard of Hearing

Objective:Standardized assessment measures can provide data to inform a diagnosis of Autism Spectrum Disorder (ASD). Most measures assessing ASD characteristics rely on some degree of behavioral response to sound (e.g., responding to name, demonstrating listening response), and are often not appropriate for use with children who are Deaf and Hard of Hearing (DHH), especially with individuals who use signed languages. Few studies have reported on the Behavioral Assessment System for Children, Third Edition (BASC-3) for DHH children, and we aim to describe BASC-3 profiles in children with ASD who are DHH.Participants and Methods:Participants include eight DHH patients diagnosed with ASD through interdisciplinary team evaluations by developmental-behavioral pediatricians, speech-language pathologists, and neuropsychologists with expertise in DHH child development. Demographics include a mean age of 6.17 years, and 62.5% were Male. Self-reported racial distribution was 75% White, 12.5% Black and 12.5% declined to answer. Average Area Deprivation Index (marker of socioeconomic status) was 32.13%tile. As a part of the evaluation, parents rated their children using the BASC-3. Languages include spoken English (75%) and American Sign Language (25%). Relevant co-occurringneurodevelopmental/psychological diagnoses include Global Developmental Delay (n=1), Moderate Intellectual Disability (n=1), and Depression (n=1). Types of hearing loss include sensorineural (75%), conductive (12.5%), and mixed (12.5%). Three participants had different degrees of bilateral hearing loss in each ear: mild sloping-severe, moderate rising-mild (n=1), profound, moderate rising-normal level (n=1), and profound, moderate (n=1). Four participants had the same level of hearing loss in both ears: moderate-moderately severe (n=1), moderately severe-severe (n=1), severe-profound (n=1), and profound (n=1). One child had a unilateral moderate hearing loss. Technology utilized: unilateral hearing aid (n=2), bilateral hearing aids (n=2), unilateral cochlear implant (n=1), bilateral cochlear implants (n=2), and bimodal technology (n=1). BASC-3 scales of interest in this study were the developmental social disorders scale (DSD), Autism probability index (AUI), clinical scales, and adaptive scales. BASC-3 scores were standardized using General Combined norms and means were plotted.Results:BASC-3 mean scores on clinical scales were elevated (T>60) on Atypicality (M=71), Hyperactivity (M=63), Withdrawal (M=63), and Attention Problems (M=65) in children with ASD who are DHH in this sample. BASC-3 mean scores on adaptive scales were below threshold (T<40) on Social Skills (M=37), Functional Communication (M=39), and overall Adaptive Skills (M=39). DSD scores were in the at-risk (T>60<70) range for 2 out of 8 cases and clinically significant (T>70) for 5 out of 8 cases.The AUI was clinically significant for 2 out of the 3 cases within the age range for reporting AUI data.Conclusions:In this preliminary sample of DHH children with a confirmed diagnosis of ASD by comprehensive specialized interdisciplinary clinical evaluations, parent ratings on the BASC-3 were consistent with what is known about BASC-3 profiles in hearing children diagnosed with ASD. Our findings suggest it may be helpful to review the DSD, AUI, clinical scales, and adaptive skills scales profiles when assessing DHH children at risk for ASD. Further research, including a larger sample size and assessment of language differences among participants, is necessary.

Emotional behavioral outcomes of children with unilateral and mild hearing loss.

Deaf and hard-of hearing (DHH) children often experience emotional/behavioral difficulties. The impact of unilateral/mild hearing loss (HL) on children's emotion and behavior are unclear. We aimed to describe emotional/behavioral, health related quality-of-life (HRQoL) and parent psychological distress outcomes of school-age children with unilateral/mild HL, compared to children with moderate to profound HL, and in relation to population norms; and identify predictive factors of emotional/behavioral difficulties. Data of 339 DHH children, 5-12 years, enrolled in the Victorian Childhood Hearing Longitudinal Databank (VicCHILD), which include demographics, early development, medical/audiological characteristics and parent rated questionnaires of emotion/behavior, HRQoL and parental psychological distress collected at various stages of child's life were analyzed. We used Cohen's d to investigate the outcomes by measuring the mean score differences of both groups with published norms and logistic regression to analyze the factors predictive of emotional/behavioral difficulties. The proportion of children with unilateral/mild HL and moderate to profound HL who experienced emotional/behavioral difficulties was similar (18.3% vs. 20.6%), with hyperactivity and poor prosocial behavior reported as the predominant symptoms in both groups. Mean emotional/behavioral scores of both groups were comparable and substantially higher than normative population scores. This was also the case for HRQoL and levels of parent distress. Among children with unilateral/mild HL, additional health needs were the strongest predictive factor, demonstrating an approximately 1.7-fold increase in odds of emotional/behavioral difficulties (OR = 1.67; 95% CI 1.29-2.17, p < 0.001) with every additional health need. Early developmental concerns, other than communication milestone and attending mainstream schoolshowed weaker evidence of association. Children with unilateral/mild HL were just as likely as those with moderate to profound HL to experience more emotional/behavioral difficulties, poorer HRQoL and higher parental distress scores compared to population norms. Our findings justify the provision of early intervention, support and medical services for all DHH children to identify those at risk of poorer outcomes.

Identifying Developmental Language Disorder in Deaf Children with Cochlear Implants: A Case Study of Three Children.

(1) Background: While spoken language learning delays are assumed for deaf and hard of hearing (DHH) children after cochlear implant (CI), many catch up with their hearing peers. Some DHH children with CIs, however, show persistent delays in language, despite protective factors being in place. This suggests a developmental language disorder (DLD). However, at present there is little consensus on how to diagnose DLD in DHH children. (2) Methods: Given the lack of consensus in this area, a set of case studies provides an appropriate first step. The goal of this paper is to show the plausibility of a DLD diagnosis, following careful analysis of protective and risk factors. A retrospective case study review was conducted for three children. Their long-term language outcomes up to four years after CI were considered in the context of access to sound, speech sound discrimination, social skills and non-verbal cognition. (3) Results: It was possible to posit DLD in one child who had experienced good access to sound, alongside good speech discrimination abilities and social development, and normal non-verbal cognition, but who presented with severe language learning difficulties. (4) Conclusions: Finding markers for DLD in DHH children is important for diagnosis and intervention. The implications for clinical practice are discussed.

Deaf and Hearing American Sign Language-English Bilinguals: Typical Bilingual Language Development.

Some studies have concluded that sign language hinders spoken language development for deaf and hard-of-hearing (DHH) children even though sign language exposure could protect DHH children from experiencing language deprivation. Furthermore, this research has rarely considered the bilingualism of children learning a signed and a spoken language. Here we compare spoken English development in 2-6-year-old deaf and hearing American Sign Language-English bilingual children to each other and to monolingual English speakers in a comparison database. Age predicted bilinguals' language scores on all measures, whereas hearing status was only significant for one measure. Both bilingual groups tended to score below monolinguals. Deaf bilinguals' scores differed more from monolinguals, potentially because of later age of and less total exposure to English, and/or to hearing through a cochlear implant. Overall, these results are consistent with typical early bilingual language development. Research and practice must treat signing-speaking children as bilinguals and consider the bilingual language development literature.

Evaluation devices in the narratives of deaf/hard of hearing and hearing Arabic-speaking adolescents.

Pragmatic language use in general and the use of evaluation devices (EDs) are very important components in everyday communication and expressing thoughts and feelings in narrative production. However, very little is known about the use of evaluative devices in the narratives of Arabic-speaking adolescents, especially those who are deaf and hard of hearing (DHH). The present study investigated the use of EDs in personal oral narratives elicited from 124 hearing and DHH Arabic-speaking adolescents. Each participant was asked to tell a personal story about a time he or she was in a dangerous situation. Narratives were transcribed and coded for nine different types of evaluation. A three-way interaction of group (hearing/DHH) by gender (Female/Male) by evaluation type emerged such that female hearing adolescents' narratives contained significantly more frames of mind than the narratives of DHH females and hearing males and more hedges than DHH females. In addition, hearing males' narratives contained more hedges than those of DHH males and more negative comments than the narratives of both hearing females and DHH males. The present research identifies factors that facilitate narrative abilities by DHH. Discussion centres on explanations for group and gender differences in terms of exposure and language socialization. What is already known on this subject Although narratives have been researched extensively in comparisons of hearing and deaf and hard of hearing (DHH) children, only a few studies have examined pragmatic language use in general and evaluation devices in particular. These studies show that the narratives of DHH children and adolescents contain fewer figurative expressions, frames of mind and hedges and that children who are DHH have difficulty comprehending and producing metaphors. Very little is known about the use of evaluative devices in the narratives of Arabic-speaking adolescents, especially those who are DHH. What this study adds The present study found that hearing participants produced significantly more evaluation devices (Eds) than their DHH peers, and female participants produced significantly more EDs than their male peers. Moreover, hearing females' narratives contained more frames of mind and more hedges than did the narratives of DHH females; also, hearing females' narratives contained more frames of mind than those of hearing males. In addition, hearing males' narratives contained more hedges than those of DHH males. Finally, hearing males' narratives had more negative comments than both the narratives of hearing females and those of DHH males. Clinical implications The one evaluation device produced in large numbers (hedges) by adolescents who are DHH was expressed in only one of two ways. One important clinical implication of this finding is that pragmatic language in general and use of EDs in particular should be part of any speech and language evaluation. Another takeaway is that intervention should attempt to provide rich exposure to social communicative language, providing many ways to convey each function, enabling adolescents to communicate in different contexts.