Summary of evidence

To the best of our knowledge, this is the first attempt to systematically identify and map the evidence on mental health support for children and adolescents with hearing loss. The scoping review identified 27 articles, two-thirds of which were conducted in the USA and two-thirds published before 2010. A number of interventions and support initiatives were described in the literature, including a broad range of therapy and counselling, and targeted training programmes, for both children and caregivers.

The interventions identified were, by and large, found to be effective at supporting the mental health and well-being of children with hearing loss. Although not all articles provided information on outcomes, nor all via quantitative assessment, those that did offered some encouraging signs as to the benefits of mental health support for children with hearing loss. Dance lessons, resilience training programmes and hearing aids demonstrate the diverse gamut of effective interventions that can be utilised to support children with hearing loss. Interventions provided treatment, prevention and promotion options in various settings, supporting recent advocacy for population- and community-level support for child mental health.^{Reference Petersen, Evans-Lacko, Semrau, Barry, Chisholm and Gronholm47} As the evidence suggests, an effective and sustainable approach to child mental health includes support from an early age, improving information and awareness, providing social and emotional learning activities, increasing detection and identification, and improving access to treatment and rehabilitation. The interventions in this review provide some examples of interventions that may be effective within such a system, although as we will go on to discuss, the strength of the current evidence is limited.

Most of the interventions identified in this review were provided in school, which follows evidence from among the general population as to the benefits of integrated mental health provision within education systems.^{Reference Fazel, Hoagwood, Stephan and Ford48} Interventions at school level provide a continuum of care that benefits a child's mental health, as well as their educational attainment. Only one identified intervention was conducted within a mainstream classroom, despite the recent global movement towards inclusive education.^{Reference Schuelka and Johnstone49} That said, a recent report outlines the limited transformations in education systems across the world, with most countries facing difficulties in inclusive provision, with understanding of what this means, and resources and evidence on good practice variable across regions.⁵⁰ As reform continues to spread, there will need to be evidence gathered on appropriate mental health interventions in inclusive classrooms, to ensure children with hearing loss are not excluded.

When considering interventions for children with hearing loss, it is important to note components and delivery methods unique to this group. Many of the interventions were initially developed for use in the general population, and more than half of the included articles described interventions that had been developed from evidence for children without hearing loss and adapted for the needs of children with hearing loss. Adaptations were most commonly focused on communication, and often sign language. Communication is often cited as a major barrier and facilitator to accessing healthcare for people with hearing loss, and it is appropriate to see this as the focus of many adaptations.^{Reference Kuenburg, Fellinger and Fellinger51} In some settings (typically high-income settings) such as the UK, and as seen in the included article from Wright et al (2012), specialist mental health services exist for children with hearing loss, where sign language and other accommodations are embedded in the service provided.^{Reference Wright, Walker, Holwell, Gentili, Barker and Rhys-Jones46} However, in other settings, provision of communication technologies and sign language interpretation may not always be possible, given restricted resources. Often, and especially in low- and middle-income countries, mental health interventions are adapted from one context to another, in order to meet the culture, needs and resources of a population. In low- and middle-income countries, this often includes adapting interventions developed in high-income settings, although there are good examples of adaptation in the other direction, in which we see novel and effective mental health interventions developed in low-resource settings and adapted to those in high-income settings (an example being the Friendship Bench, developed in Zimbabwe and adapted to New York City in the USA).^{Reference Rosenberg52} Adaptation is common and needed, and the well-evidenced stages of this process should be noted by those looking to adapt mental health interventions for children with hearing loss, in order to ensure appropriate intervention components and delivery mechanisms. This will include standard adaptations to the context, but also specific adaptation to the needs of children with hearing loss, such as those seen in this review. We did not find any studies that provided evidence of an adaptation process through formative research, theory of change workshop, feasibility study, or similar methods, and this would be a useful area of research going forwards, to promote interventions for children with hearing loss that are contextually and culturally appropriate, and hopefully then effective and sustainable. These approaches also promote the participation of stakeholders, including those with hearing loss and/or mental health conditions.

Evidence gap

Although 27 articles were identified, there is concern about the breadth, scope and strength of the evidence within the literature available. With two-thirds (67%) of articles published before 2010, and 41% pre-2000, it is evident that the published literature on this topic is not growing at a fast rate. Interest and research in disability has steadily increased since the United Nations Convention on the Rights of Persons with Disabilities (2008), and calls for further evidence on scalable mental health interventions have been delivered by leading figures for many years.^{Reference Patel and Sartorius53} Despite an increased focus on global mental health and disability rights, this review suggests that mental health support for children with hearing loss is not gaining sufficient interest in the research community. The Lancet Commission on Global Mental Health and Sustainable Development, published in 2018, may stimulate additional research in the future, calling as it does for a focus on culturally appropriate and participatory approaches to translating evidence for promotion and care in mental health across diverse populations.^{Reference Patel, Saxena, Lund, Thornicroft, Baingana and Bolton54} Our approach to classification using a continuum from well-being to mental health diagnosis draws on these ideas. Exploring the evidence among adult populations is also needed given the higher prevalence of hearing loss in this age group.

Furthermore, nearly all (81%) of the included articles come from high-income settings, with two-thirds (67%) conducted in the USA. Just one (4%) was conducted in a lower-middle or low-income setting. There are no articles from Latin America or Africa, and just one study from Asia. The geographical scope of study into appropriate interventions for children with hearing loss must increase. Given that 80% of the world's population and people with disabilities are living in low- and middle-income countries, there is an urgent need for evidence on contextualised interventions.⁵⁵ Relying on data from high-income settings has caused concern in the field of global mental health, as doing so reduces long-term effectiveness and sustainability of mental health interventions, especially when biomedical models of care are transferred to settings where they may not be culturally accepted, contextually feasible or appropriate.^{Reference Patel, Saxena, Lund, Thornicroft, Baingana and Bolton54} There is growing evidence on new and adapted mental health interventions for the general population in low- and middle-income settings, and as shown in this review, there is the possibility of adapting these to suit the needs of children with hearing loss (for example sign language provision). Evidence is needed on the process of adaptation and contextualisation, in order to inform delivery in the given country, and to provide a research framework for others.

Most of the studies were assessed to have medium or high risk of bias. Just six (22%) of the studies available and included are RCTs. The majority of included articles offer interesting case reports, but these provide the rationale for larger-scale trials, rather than high-quality evidence in and of themselves. Most of the studies included have also been conducted with very small sample sizes. Nearly half (48%) of studies contained a sample size smaller than 20, increasing to two-thirds (67%) when including those articles with no sample size available. To improve the evidence base with which to stimulate service provision and policy, there needs to be experimental research, with large samples, with which to build confident conclusions and inform scalable interventions. Potential sources of bias must be addressed, including appropriate statistical methods, including sample size calculations for sufficient power.

Limitations

There are several limitations to this review. First, we excluded articles that were not in the English language, and there may well be evidence missed that has been published in other languages. This is particularly important when considering the limited evidence from South America and East Asia. Our age range, 6–18 years, is broad and although not necessarily a limitation, it is important that readers of this review pay close attention to the targeted age range of interventions of interest. Younger children and older adolescents will respond differently to interventions, and will have different mental health needs, and not all interventions will be applicable across age groups. Second, we could not source 19 full-text articles, in which there may have been relevant and included studies. We contacted authors directly and utilised various institutional access agreements, but still could not find these for assessment. Third, we did not assess publication bias. When interpreting the results on effectiveness, readers should be conscious of the risk of positive publication bias and a potential lack of interest to publish results on ineffective interventions. Finally, in their framework for scoping reviews, Arksey & O'Malley recommend an optional sixth step; consultation with stakeholders.^{Reference Arksey and O'Malley18} Such consultation is time-consuming and costly, and was not feasible when undertaking this study, and may be an important area to address in any future and updated reviews.

Implications

This review has identified a number of articles and interventions, which generally showed positive results, but there are concerns over the breadth of the evidence available. There is evidence of some effective interventions, such as dance lessons and resilience training, but the applicability of the available evidence is limited by geographic location and publication date, and there is a need for more studies applying high-quality research methods. To improve the current evidence base, we must strengthen the quality of the research methods used and provide further research from low- and middle-income countries on adapting interventions to local contexts and on interventions tested at scale. Having a community of researchers set future research priorities, as informed by practitioners and people affected, will focus and strengthen research activities going forwards.

Recommendations on mental health support for children with hearing loss

Based on the findings of this review, we have listed below a number of considerations for delivering mental health support for children with hearing loss, including adaptations to existing mental health interventions.

1. (a) Consider the intervention models identified in this review, including the following.

   1. (i) Peer-support: children with hearing loss can benefit from interaction with peers, reducing isolation, while helping them learn more about themselves and their experience as a child with hearing loss. Peer-support can act as both a treatment and health promotion option.

   2. (ii) Resilience training: identified by a number of studies in this review, resilience training may be an effective way of preventing mental health conditions, especially if implemented at an early age. This type of training may be particularly appropriate to integrate into schools.

   3. (iii) Emotional and behavioural management training: this type of structured training programme can be provided for both parents and children. Helping parents learn the tools with which to support their child's emotional regulation and behaviour may help create a home environment that promotes well-being and positive coping strategies. Training children themselves, possibly in school, will further help children with hearing loss build the toolkit with which to understand and approach the challenges they face.

   4. (iv) Physical activity: physical activity is a simple way to build well-being and promote mental health. In this review, the physical interventions identified were specialist in nature – ice-skating and dance therapy are not necessarily available in all settings – but adapting these techniques and principles to a different context may prove effective.

2. (b) Consider the following when adapting or developing an intervention.

   1. (i) Knowledge and awareness: it is important that the delivery agent is given appropriate training and sensitisation on disability and hearing loss. There may also be cause to provide information to children without hearing loss in the same setting, in order to reduce any apparent stigma or discrimination; for example, to hearing children in a mainstream classroom.

   2. (ii) Communication methods: each child will have different communication needs, depending on their severity of hearing loss and personal preferences. Include appropriate training for delivery agents on communication methods, including clarity of speech and the language used. Where necessary, provide sign language interpretation, and where relevant provide training on hearing aid or cochlear implant use, as this knowledge will facilitate improved communication and reduce stigma.

   3. (iii) Physical environment: consider the environment in which the intervention is delivered. This may be a mainstream classroom, for instance, that is not set up to accommodate the needs of children with hearing loss. Considering the configuration of seating in a group is one example; children sitting in a circle may help improve visual contact and support those who lipread. Keeping the environment quiet and free from distractions will also help children with hearing loss, as might keeping the door closed and adding soft material to the underside of chairs.

   4. (iv) Intervention materials and techniques: where suitable, use visual aids and cues to support the intervention components. One example may include pictures matched to emotions, to aid the understanding and communication of feelings. Other techniques to reinforce behaviours and actions may include role-play, storytelling and peer-feedback.

3. (c) Consider the following during intervention development and implementation.

   1. (i) Interventions identified in this review benefitted from clear communication and coordination between different groups involved. For instance, interventions in schools were strengthened when teachers and parents worked together.

   2. (ii) Conduct feasibility studies and pilot studies, where possible, in order to make any necessary amendments early in the implementation process. This will also help inform others in the future.

   3. (iii) Providing a range of interventions within a service or facility (such as a school), where this is feasible, may provide the best model with which to support a personalised approach for each child.

4. (d) Consultation and coordination may help promote feasible, acceptable and sustainable intervention programmes.

   1. (i) Consult the children, their parents, mental health and hearing specialists, and the delivery agents (such as teachers). Understand their needs and context in the adaptation or development phase.

   2. (ii) In all, talk to the children who are the intended target of the intervention about their own needs and preferences for intervention components, including communication methods.