Article summary with The developmental trajectory of empathy and its association with early symptoms of psychopathology in children with and without hearing loss by Tsou a.o. - 2021

What is the background of this study?

Empathy is the ability to understand, share and show concern for the feelings of others, which is crucial for building and maintaining social relationships. For children with hearing loss, it may be less easy to acquire this ability. The influence of hearing on the development of empathy has not been examined yet.

During the preschool years, several abilities influence the development of empathy. Affective empathy: the emergence of emotional arousal when seeing someone else experiencing certain emotions. With age, children pay more attention to the feelings of others which enables them to understand how others feel. Responding to the emotions of others may result into showing concern through prosocial behavior (sharing, helping or comforting for instance).

Mastering empathic skills requires participation and social exposure, which explains why it is more difficult for young children with hearing loss to acquire those skills. They miss out on several learning opportunities, such as the sound of crying peers or listening to the conversations between others. Very little is known about the empathic development in children with hearing loss. A study concerning the overall empathy levels of 4-12 year olds with hearing loss found lower levels in comparison to typically hearing children. However, another study found that affective empathy levels did not differ.

Examining the development of empathy is also benificial for our knowledge of social-emotional development. A higher level of empathy is linked to fewer externalizing symptoms (conduct problems, aggression) and fewer internalizing behaviors (anxiety, depression). This negative link was found to be stable from preschool to the first years of primary school. Children who are capable of understanding others’ situation, sharing emotions and providing aid, build better friendships and are less likely to hurt others. It has not been examined yet whether this positive influence of empathy on psychopathology also goes for children with hearing loss. It is, however, an important question in the context of rehabilitation, since these children exhibit higher levels of externalizing and internalizing behaviors.

What are the goals of this study?

This study focuses on children in their preschool years, because they learn several emotional and social skills in this period.

Examined were the levels and development of the following empathic skills: attention to the feelings of others, prosocial behavior, acknowledging emotion and affective empathy in children with and without hearing loss aged between 1 and 5 years. The skills were measured at four moments with an interval of 12 months. Also was examined how empathic skills effect early symptoms of psychopathology in children with and without hearing loss.

What methods were used?

Who were the participants and what procedure was followed?

71 children with hearing loss using cochlear implants (CI) and 272 children without hearing loss (TH: typically hearing) aged between 1 and 5 years participated. Parents were asked to rate the empathic abilities of their children (attention to the feelings of others, prosocial behavior, acknowledging emotion and affective empathy) and psychopathological symptoms (externalizing and internalizing behaviors). Rating was done by filling in a questionnaire at four moments. The fine motor development of the children at moment 1 was used as an indicator for their cognitive development. At that moment, no gender, age, fine motor development, household income and parental education levels differences were found.

What materials were used?

The results of this study were based on parents reports. The Empathy Questionnaire was used to measure the empathic behaviors of the children in daily life. The Emotion Expression Questionnaire was used to measure the ability to acknowledge their parents’ emotions. The Early Childhood Inventory questionnaire was used for assessing the level of the externalizing and internalizing behaviors.

What were the results?

The CI-children exhibited less prosocial behaviors at moments 3 and 4 in comparison to the TH-children. Other group differences were not found.

Affective empathy decreased with age, no differences between the groups emerged. Attention to the emotions of others increased with age in CI-children, but was not associated with age in TH-children. Emotion acknowledgement and prosocial behaviors increased with age and stabilized around the time when children started primary school, but parents of CI-children reported less prosocial behaviors.

Children with a higher level of affective empathy and children with a greater increase in attention to emotions and affective empathy exhibited increased internalizing behaviors. Empathic effects in both groups had similar strength. Children with lower level of emotion acknowledgement and higher level of affective empathy exhibited increased externalizing behaviors. Empathic effects in both groups had similar strength.

What do these results mean?

This was one of the first studies regarding the development of empathy and its influence on early symptoms of psychopathology in children with and without hearing loss. Previous research targeted merely typically developing children.

Not many differences between both groups were observed. This indicates that the empathy development of CI-children is similar to that of TH-children.

No differences were observed between the groups on the level of affective empathy. The reports showed a decline with age and an association between higher levels of affective empathy and psychopathological (externalizing and internalizing) symptoms. This decrease in affective empathy with age is in accordance with Hoffman’s theory. Children whose levels of affective empathy remained high or even increased, were more likely of developing psychopathological behaviors.

The levels of attention to emotions were also similar in both groups, but they remained stable in TH-children over time while those of CI-children increased. The participating children in this study had a mean age of three years at the first measurements. The stable trend found in TH-children indicates that they get better at perceiving and understanding emotions from the age of three years. The increased level of attention to emotions of others observed in CI-children indicates that they are more sensitive or vigilance to emotions. Thus, paying too much attention could be a sign of issues with processing the others’ emotional display.

In both groups, children who became more aware of the emotions of others over time were more likely to develop internalizing symptoms. The increasing trend found in CI-children after the preschool years could be alarming. These findings show the importance of assessing the empathic development and psychopathological behaviors in older CI-children.

Prosocial behaviors were more frequently reported in TH-children. The lower rating in CI-children could be explained by their limited learning and Theory of Mind (ToM) ability. The ability of reacting prosocially to the emotions of others requires the ability to explain, understand and predict others’ situation. To obtain this ability, one needs to observe, overhear and participate in social interactions. This is more problematic for CI-children. In both groups, prosocial behaviors increased with age. They stabilized around the time children started primary school. No association was found with the development of psychopathology.

No group differences in the level of emotion acknowledgment were observed. Results show an increase with age, until children started primary school. Higher levels of emotion acknowledgement were linked to less externalizing symptoms. Since ToM problems are common in CI-children, they might find emotion acknowledgement challenging when the other is displaying more complex emotions. This emphasizes the relevance of giving CI-children an accessible social environment.

What are the limitations of this study?

Future research is essential in order to understand how much the findings of this study can be generalized to other children with hearing loss.

Another limitation regards the restricted number of children: a  larger clinical group needs to be recruited in order to assess the generalizability of the findings of this study.

Since only parent reports were used, future research should involve more research methods, such as in vivo experiments or real life observations. Also, the questionnaires used in this study were targeted at young children: only simple social interactions and basic emotions were involved. Future studies on the development of empathy in CI-children should therefore also involve more complex social situations and emotions.