Moreover, it is important to remember that a child with a CI is still Deaf, Dr Steinberg emphasized. “Once the implant is off, the child cannot hear. So even if these children are stellar users of the device and it is highly effective for them, when they take it off—let’s say they’re swimming or getting out of shower—or there’s a battery malfunction, they are still Deaf.”

These children, therefore, are living between two cultures and two worlds. “When the device is functioning, to some degree they are living in the hearing world. But there are times when they are experientially Deaf.”

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Parents considering a CI for their child should make the decision only after becoming thoroughly familiar with what it involves, Dr Egbert advised. For example, the implant destroys any residual hearing the child might have. There are some significant medical risks.10 Furthermore, having a CI presents challenges that go beyond the actual surgery and entail extensive rehabilitation.

Many parents also may have unrealistic expectations of the CI. “These devices do not guarantee that a child will be able to hear,” Dr Steinberg stated.

Compared with traditional hearing aids, a CI provides improved sound awareness to children with severe to profound hearing loss. “As is the case with hearing aids, intensive, appropriate follow-up therapy and ongoing monitoring of the device is essential to helping children make sense of the many sounds in their environment that are detected through the implant.”11

The sound detection that a child experiences may be at close-to-normal listening levels. However, that does not necessarily translate into a positive outcome in terms of understanding spoken language. Other factors that play a role include the presence of disabilities, the child’s nonspoken communication skills, and the family dynamic.12 So it is important for parents to bear in mind that a CI does not give a child normal hearing and does not guarantee spoken language development similar to that of hearing children.11

Working with parents who are struggling with this decision requires patience and profound respect, as well as recognition of the complexity of the issue. Parents are facing the dilemma of subjecting their child to surgery and its attendant risks with no guarantee of success. On the other hand, although learning sign language is critical for the child’s development, many parents are still coming to terms with the reality of having a Deaf child and may not be ready to undertake this and should not feel pressured or judged.8,13 It is not easy for parents and families to learn an entirely new language either. The availability of classes in sign language varies by community, and it may be difficult to fit this task into a complex family schedule.8 Parents need a safe environment in which they can gather information, process their decision-making, come to terms with their emotions, feel respected, and ultimately make decisions that are respectful of their child’s needs.13

Cultural Competency

As with other cultures, it is essential to develop cultural competency when working with Deaf children, Dr Egbert emphasized.

“Deaf people communicate differently from hearing people, not only because they are probably signing but because in our culture, we have a different communication style,” she said.

For example, “don’t be surprised if your Deaf client is very blunt and direct. We tend to be right up-front about everything and not to sugarcoat because we have been oppressed for so long by the oral community. If you do not understand this, you may think that the child is rude or oppositional but in the Deaf community, this is appropriate.”

Eye contact is extremely important during therapy, she advised. “Do not be shy when looking directly into the client’s eyes. In hearing circles, that might be interpreted as rude but in the deaf community, this is normal.”

Use an Interpreter

As with any client who cannot speak English, a Deaf client should be able to have an interpreter to maximize communication. “If the psychiatrist cannot have complete understanding and bidirectional communication with the child, then an interpreter is critical,” Dr Steinberg emphasized. She noted that a parent or family member should never be used as an interpreter for evaluation or therapy, nor should the interpreter be someone from the community or a colleague.

Dr Egbert agreed. “Psychiatrists and therapists should use only certified interpreters. There is a code of ethics and conduct that the interpreter must adhere to that ensures professionalism and client confidentiality.”

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When using an interpreter, be sure you talk directly to the child, rather than to the interpreter. “For example, don’t turn to the interpreter and say, ‘please tell or ask the child such-and-such.’ Instead, ask the child yourself and the interpreter will step in to interpret.”

Therapy is an intimate experience and typically, a child might feel the presence of a third party to be intrusive, but that is not usually the case here, Dr Egbert noted. “On the contrary, the interpreter can bridge the cultural gap and the child is more likely to be reassured that someone speaks his or her language.”

Encourage Families to Utilize Resources

The Americans with Disabilities Act (ADA) requires interpreters be made available in state agencies and similar settings. The Individuals with Disabilities Education Act (IDEA) ensures students with a disability are provided with Free Appropriate Public Education (FAPE) that is tailored to their individual needs.

“Many parents do not know that this is their child’s right by law and the educational facility is required to provide a free interpreter and even to pay for therapy,” Dr Egbert pointed out. “Legally, if something impacts the child’s education, and this would include psychological issues that are impeding the child’s academic or social progress at school, then the institution has to provide an interpreter, even for private therapy.”

She warned that obtaining this service is a “process that does not happen overnight.” But mental health professionals should make parents aware that there is an array of services and rights they might not be aware of and link parents to resources that can help them advocate.

Even if the practice might absorb the cost of an interpreter, Dr Steinberg feels that there is both a legal and an ethical duty to do so. “There are videoconferences and telephone relay services that are available in most cities or provided by the federal government,” she said.

“From my perspective, I think that it is the psychiatrist’s duty to provide equal access to his or her services. And if someone is coming to you for help, you cannot provide that help if you don’t have effective communication.”

She added that having an interpreter “models effective communication for the family by emphasizing that you centralize the importance of communication as the essence of everything we do.” If you are unable to provide this, then “you have failed the patient.”


Working with Deaf and Hard-of-Hearing patients can be challenging for a psychiatrist who is hearing but can also be very rewarding. “It is time for truly sensitive, culturally competent psychiatrists and mental health professionals to begin addressing the needs of this underserved population,” Dr Egbert said.


  1. National Institute on Deafness and Other Communication Disorders (NIDCD). Quick statistics about hearing. Available at: Accessed: November 16, 2017.
  2. Mitchell RE, Karchmer MA. Chasing the mythical ten percent: Parental hearing status of deaf and hard of hearing students in the United StatesSign Language Studies. 2004;4(2):138-163.
  3. Centers for Disease Control and Prevention (CDC). Hearing loss in children. Available at: Accessed: November 16, 2017.
  4. Shah RK, Lotke M. Hearing impairment. Medscape. July 14, 2017. Available at: Accessed: November 16, 2017.
  5. National Association of the Deaf. Community and culture—frequently asked questions. Available at: Accessed: November 16, 2017.
  6. Hall WC. What you don’t know can hurt you: the risk of language deprivation by impairing sign language development in deaf children. Matern Child Health J. 2017;21(5):961-965.
  7. Malloy TV. Sign language use for deaf, hard of hearing, and hearing babies: The evidence supports it. A presentation made at the American Society for Deaf Children Annual Conference, July 2003.
  8. Napoli DJ, Mellon NK, Niparko JK, et al. http:Should all deaf children learn sign language? Pediatrics. 2015;136(1):170-176.
  9. Theunissen SC, Rieffe C, Netten AP, et al. Psychopathology and its risk and protective factors in hearing-impaired children and adolescents: a systematic review. JAMA Pediatr. 2014;168(2):170-177.
  10. United States Food and Drug Administration (FDA). Benefits and risks of cochlear implants. Available at: Accessed: November 16, 2017.
  11. American Society for Deaf Children. Cochlear implants. Available at: Accessed: November 16, 2017.
  12. Cejas I, Hoffman MF, Quittner AL. Outcomes and benefits of pediatric cochlear implantation in children with additional disabilities: a review and report of family influences on outcomes. Pediatric Health, Medicine and Therapeutics. 2015;6:45-63.
  13. National Association of the Deaf (NAD). Position statement on cochlear implants. Available at: Accessed: November 16, 2017.