Children with hearing or visual impairment are also at increased risk of psychiatric disorder. This is compounded by developmental delay in many cases. Children with fluctuating hearing impairments (often due to otitis media with effusions) are at greater risk of behavioural problems as well as language and reading delays. (28) The risk of developmental delay differs between deaf children of deaf as compared with hearing parents. In the former, parents are more able to attune themselves to the child's developmental needs using the modalities of vision and touch, allowing these children to develop attachments, symbolic play and (sign) language at the same rate as hearing children of hearing parents.(28) Early development in blind infants is facilitated by mothers who are attuned to and can respond to their infant's often subtle cues and give a continual sense of their presence using voice and touch. (28)
Social development is also affected in children with sensory impairment. This is particularly so for the visually impaired. Blind preschoolers may appear isolated from their peers. This continues into middle, late childhood, and adolescence with reports of a proportion (15 per cent) having no friends. (2 29)
Sensory impairment can be mistaken for mental retardation and a careful and thorough assessment is therefore of paramount importance. This is unlikely to be carried out adequately in the child with a hearing impairment without the involvement of a sign-language interpreter. In addition, in the absence of an interview with the child, internalizing disorder may be missed.(30)
Acquired causes of hearing impairment, such as congenital rubella, are frequently associated with other brain pathology in contrast to hereditary deafness. As for chronic physical illnesses affecting the brain, the former group of children and adolescents are at greater psychiatric risk, especially for behavioural disorders such as attention deficit disorder.(30) Children with rubella encephalopathy are at particular risk for autistic spectrum disorder. (28)
Whilst the degree of deafness alone is not an important aetiological factor for psychiatric disorder, other features related to deafness are ( T.a.ble 4.). They include impaired communication, intelligence (which is inversely related to psychiatric disorder), and the type of school attended. (28) The effects of schooling are somewhat contradictory, with some evidence that deaf children at deaf schools are at lower risk than those in mainstream schools where they are more frequently bullied, have fewer friends, and a poorer self-image.(30) However, other evidence, which does not include direct interviews with the children, suggests that children in deaf schools are at greater psychiatric risk.(28)
Comoftotd disorder eipetiallp affrcting the train Impaired conniiuiiicaii&ii
Table 4 Risk factors for psychiatric disorder associated with hearing impairment
The nature of psychiatric disorders in the hearing impaired
Attention deficit disorder is more common in children with acquired deafness, but not in those with hereditary causes. This difference is most likely to be accounted for by generalized brain abnormalities associated with the causal agent such as congenital rubella, congenital cytomegalovirus, and bacterial meningitis. (39
Affective disorder is more prevalent in the hearing impaired. Higher rates of anxiety disorders, particularly social phobias, have been found amongst hard-of-hearing compared with deaf children/3!' Children and adolescents with hearing impairment are also at risk of depression, and communication problems are likely to be contributory factors. Children who are able to communicate orally with their mother perceive them as communicating with them more and this enhanced communication is negatively correlated with depression. (3°) The increased prevalence of depression and behavioural disorder in the hearing-impaired child persists into adulthood, but no increased prevalence of schizophrenia has been reported. (28>
Hearing impairment is often suspected in, and may occur more frequently among, children with autism than amongst non-autistic individuals. (32' It seems unlikely that hearing impairment is an aetiological factor for autism, but the associations may be mediated by conditions such as rubella encephalopathy which are linked to both. If the two conditions are present together, each can confound the diagnosis of the other and lead to a late diagnosis. (33'
Differences in communication between the visually impaired child and the sighted child may contribute to assessment difficulties. For example, reduced facial expression may lead to difficulties assessing affect and responsiveness. Specific abnormalities of language, such as echolalia and pronoun reversal, are more common in this group of children. It has been suggested that they represent attempts to maintain communication as sighted children might do by means of manual and vocal gestures. Uncertainty about the significance of these features may lead to difficulties in diagnosing pervasive developmental disorders. (28)
The nature of psychiatric disorders in the visually impaired
Rates of psychiatric disorder are increased in visually impaired children. Developmental disorders and adjustment reactions in addition to mental handicap are the most common.
The severity of the visual impairment is related to the risk of psychiatric disorder, with blind children more likely to show psychopathology than the partially sighted. School factors are also important, with children at residential schools showing more disturbance than those at day schools.
As with sighted children, the presence of central nervous system disorder, multiple impairments, maternal mental illness, and marital breakdown are all important aetiological factors for psychiatric disorder. (28
Psychiatric input for these children may be on an individual basis with a child and his or her family, but it often also involves consultation with staff in residential units or schools. Specific disorders are treated as indicated using a combination of pharmacological and psychological treatments (appropriate to the child's intellectual level) and utilizing a communication modality that takes the sensory impairment into account. This may include behavioural work such as social skills training for the visually impaired, parenting programmes, and, in some cases, psychodynamic work. Close collaboration and regular communication needs to take place within the professional network.
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