There is no emotion that is so often regulated in early development as the expression of anger. When a child is three years old, he / she is already guided by social considerations. Socio-cultural norms, beliefs and expectations influence what is seen as a social expression and influence the socialization of emotions. Cross-cultural studies focus on the distinction between expressing and suppressing negative emotions, but it is still unclear whether cultural groups differ in response styles for anger.

Anger is one of the three significant emotions of children. The suppression of this can have negative consequences for health, but the expression of anger can lead to problems in interpersonal contact (for example, fewer friends). However, from a functionalistic point of view , anger is a response to a threat to personal goals. However, anger is only adaptive if it is considered justified and if the expression is socially appropriate. What is socially appropriate, however, depends on the cultural background.

In Asian cultures, group interest is more important than individual interest. This encourages emotions in Asian cultures that prevent negative consequences for the social relationship, while in Western cultures emotions are encouraged that support personal needs. Asian children and adults more often suppress negative emotions than Western people. Confrontation techniques , for example, are more often used by Western people, and distancing people is more common among Asians. Asians also less often share negative emotions with others because this can have a negative effect on the relationship.

This study investigates cultural differences in the expression of anger in children. The goals are 1) comparing self-reported use of a large number of angry behavioral responses between Chinese and Dutch children and 2) investigating the verbal manifestations of anger and the expected responses. Chinese children are expected to be more passive and subtle in their expressions of anger, to prevent negative consequences for relationships, while Dutch children are more active and confronting. This is measured with a questionnaire to measure various behavioral responses to anger after a conflict with a friend. Then the children get hypothetical anger-provoking situations where a friend is the aggressor. The children are asked questions related to their verbal measure reaction of anger, the expected reaction of the aggressor and the usefulness of their responses. Gender is also taken into account in the analyzes, because girls generally express their negative emotions less openly.

Method

68 Chinese and 73 Dutch children participated in the study. To measure the responses of anger , an adapted variant of the Behavioral Anger Response Questionnaire for Children (BARQ-C) was used. This describes specific situations of a conflict with a peer, and asks how the child would respond. The children of a number of assertions must then indicate to what extent they can agree with this on a three-point scale. In the modified version of the BARQ-C, two interpersonal response styles of anger are measured: Anger Verbalization (the verbal expression of anger in a controlled manner) and Anger Out (the expression of anger in an aggressive manner), and two intrapersonal response styles: Anger Reflection (reflecting on what happened internally or with another person) and Anger Diversion (cognitive or behavioral distraction from anger).

Furthermore, the verbal expressions of anger are measured with four vignettes. They are then asked: how angry would you feel? What would you say to your friend? How angry do you feel now? Their anger is coded in three categories: tolerant, open and confrontational. Expected responses from the aggressor could be positive or negative, and if they were positive it could be either an excuse or a solution.

Results

Anger Reflection and Anger Diversion were reported more than Anger Out and Anger Verbalization. Chinese children used Anger Reflection more often than Dutch children, and Dutch children used Anger diversion more often. Girls used Anger reflection more often and less often anger out than boys.

Chinese children were more often tolerant than Dutch children, and Dutch children more often confronting. Dutch children more often expected a negative reaction from the aggressor than Chinese children. With Chinese children, the anger decreased more often after the conversation with the aggressor than with Dutch children.

Discussion

The results show that both groups of children use intrapersonal rather than interpersonal responses. Chinese children worry and reflect more often about the situation, while Dutch children seek cognitive or behavioral distraction from anger more often.

Additional research into how the children would respond verbally shows that children usually respond in an open manner by emphasizing the negative consequences and by asking about the intentions of the aggressor. The more angry the children feel, the less tolerant they would react. Dutch children would more often confront the aggressor , while Chinese children would more often tolerate what happens without making a big deal of it. The Dutch response is less successful in terms of social interaction and emotional experience.

Although earlier research has shown that Asian expressions are more often passive and withdrawn than Western ones, this research shows that both groups show verbal responses just as often . It seems that Dutch children more often use an internally independent reaction style, in which nobody is involved and the situation is left for what it is, while Chinese children want to understand more often what has happened, to prevent a repeat. The reactions of Chinese children reflect acceptance of the situation, while Dutch children would more often confront the aggressor. These differences match the characteristics of the Dutch and Chinese cultural models. Verbal communication with the aggressor led to a greater decrease in anger in Chinese children than in Dutch children. Only with the Chinese children does the decrease in anger appear to be sensitive to the aggressor's response.

Dutch culture can be seen as more loose than tight. The degree of tightness of a culture is "the strength of social norms, or how clear and pervasive norms are within a society, and the strength of punishment, or how much tolerance there is for deviating from norms." Because of this, Dutch children have a larger repertoire of anger reactions. Being able to be yourself is considered important in Dutch culture .

Gender differences were only found in responses when using the questionnaire. Boys respond more aggressively, while girls worry more. In future research, a larger sample and more diverse social situations must be used with the vignettes.

The results of this study cannot simply be generalized due to 1) a small sample, 2) lack of information about the background of the children, 3) there are also cross-cultural differences between European countries and Asian countries.

What is the background of this study?

In the context of social cognitive development, it is considered a great achievement when a child comes to understand the display rules governing the expression of emotion. In order to be capable of gathering knowledge of display rules, a child must have the cognitive ability to understand the difference between apparent and real mental states. This also requires sociocultural knowledge. Display rule norms are subjected to cultural differences, but very limited research is done on the influence of culture on the development of display rule knowledge.  

Display rules: norms concerning the way people should express their mental state. There are two categories: 1) nonverbal display rules concerning the right way of expressing emotions through nonverbal behaviors. For example intensified (exaggerated), de-intensified, neutralized facial expressions or masking emotions. 2) verbal display rules concerning the expressing of emotions in a verbal way, for instance by telling a lie or giving a vaguely formulated answer.

Earlier research showed how cultural differences influence the display rule norms as conformed to by adults. For example, adults from Japan and the United States express disgust through the same facial expression when looking at disturbing images while being alone. However, the adults from Japan masked their expressions when in the company of others. These findings are in accordance with later research, which showed the importance of individuation and self-expression in the United States and the great contrast between the public and the private life of Japanese adults in order to maintain harmony.

Display rule knowledge develops from an early age: 4-year-olds are capable of understanding the difference between contexts in which expressing happiness or sadness is appropriate versus inappropriate. Children who attend preschool are capable of regulating their emotions by hiding their real emotions in an appropriate way, for example when they are gifted something that they do not actually like. Throughout childhood, display rule reasoning increases. Children become more capable of distinguishing apparent from real emotions. Six-year-olds understand that not only negative emotions can be masked, but also the positive emotions. 

What is the goal of this study?

The goal of this study is investigating the development of verbal display rule knowledge among adults, adolescents and elementary school children from two culturally different countries: Japan and the United States. This will be done by presenting two scenario’s: a welfare scenario (in which the expression of a true opinion will likely hurt the feelings of the other person) and a conflicting opinions scenario (in which two people have different opinions but it is not likely that someone’s feelings will get hurt).

Participants were asked to predict the response in both scenarios and to explain the reason behind that specific use of display rule.

Hypothesis: the welfare scenario will be similarly interpreted by the Japanese and Americans (masking the real feelings in order to prevent hurting the feelings of others). Cultural differences will come to light in the context of the conflicting opinions scenario. The Japanese were expected to favor greater regulation of emotional expression because they highly value maintaining harmonious relationship and abiding social norms. The Americans were expected to favor a more direct expression of feelings.

What method was used?

Who were the participants?

Participants from the United States: 34 adults (aged between 18 and 48), 25 adolescents (aged between 12 and 13 years) and 25 elementary school children (aged between 8 and 11 years). All were born in the United States.

Participants from Japan: 34 adults (aged between 19 and 22 years), 41 adolescents (aged between 12 and 13 years) and 25 elementary school children (aged between 6 and 11 years). All were born in Japan.

What materials were used and which procedure was followed?

The participants were asked to respond to two short stories portraying situations designed to evoke verbal display rules.

The welfare scenario: “One day, Rick goes to the house of his aunt for a visit. She cooked a special meal for him. The aunt asks Rick if he enjoys the meal. Rick strongly dislikes the meal.” In this situation, expressing the true opinion is highly likely to hurt the other’s feelings.

The conflicting scenario (adult version): “One day, Rick is at the office talking to a co-worker during a coffee break. The co-worker is talking about a new song he likes. The co-worker asks Rick what he thinks of that song. Rick strongly dislikes the song.”. The version presented to the children differed only in wordings (“school” and “classmates”). In this situation the characters have different opinions, but the chance of feelings being hurt is small.

Participants had to answer the following questions:

1. What do you think that the story’s protagonist will say in response to the question asked by the co-worker or classmate? (display rule endorsement)
2. Why do you think the protagonist answered in the way he did? (display rule motive)

What coding scheme was used to analyze responses to the question regarding display rule endorsement?

Responses to the first question were analyzed with the help of a coding scheme. This scheme used several display rule strategies, which included these possible responses:

• Unmodified (a true opinion is directly expressed, for instance: “I hate this meal” or “I don’t like the song”);
• Neutral (expressing an opinion is being avoided, for instance: “i dislike it”, “it’s alright”, “Why do you like it?”);
• Masked (the true emotion is hidden by expressing a different opinion, for instance answering that he likes the song or the meal).

What coding scheme was used to analyze the motives behind display rule usage?

The coding scheme included four categories of possible motives:

• Welfare: the participant referred to the protagonist being concerned with the feelings of the other person (“He said that because he does not want to hurt her feelings”).
• Instrumental: these motives consists of self-focused reasons for engaging in display rules, like trying to avoid a potential negative outcome (“If he says he dislikes the meal, his aunt will never give him a meal again”).
• Authenticity: the participant referred to honesty, truth or self-expression. Mention was made of the true feelings of the protagonist (“Because he does not like it”).
• Relational: the participant referred to general norms and a broader social context regarding social relationships, for instance: “If he expresses his dislike like that, it could damage their relationship” or “Because saying he hates the meal is very impolite”.

What were the results?

The responses of the participants were assessed by using the following measures:

• Degree of display rule usage;
• Types of display strategies (masking, neutral, unmodified) endorsed;
• Motives for display rule usage.

No differences were observed between both groups in display rule endorsement in response to the conflicting opinions scenario and the welfare scenario.

What were the results regarding the welfare scenario?

Age had a significant effect on the degree of display rule usage in response to the welfare scenario. As expected, adults endorsed a greater expression regulation in comparison to adolescents and children. The results show that age predicts the degree of display rule usage. No cultural differences were observed.

Regarding the types of display strategies, endorsement of unmodified responses decreased with age. No differences between the age groups were observed with regard to the endorsement of neutral responses. Endorsement of masking responses increased with age.

Age was no predictor of neutral responses, but it did positively predict the likelihood of endorsing masking responses and negatively the likelihood of endorsing unmodified responses.

Welfare motives were endorsed more often than the other motives. This is in accordance with the hypothesis that welfare concerns are the main motive in response to the welfare scenario. Among the cultural and age groups, the quality of the welfare responses was remarkably similar.

The endorsement of relational motives increased with age: adults mentioned them more often. This indicates that adults are more inclined to refer to the broader social context. For instance, one Japanese adult mentioned how aunts are older (of a higher status) so complaining is not done. An American adult mentioned how guests should appreciate and respect the effort.

The endorsement of authenticity motives decreased with age: adults mentioned fewer authenticity motives than children and adolescents. Children frequently mentioned the true feelings as the main motive for the display rules use.

Conflicting opinions scenario: what were the results regarding the degree of display rule endorsement?

Culture had a significant effect on degree of display use in response to the conflicting opinions scenario. Adults from Japan endorsed modifying their expressions to a greater extent than the adults from the United States. There were no differences between Japanese and American adolescents and children in their display rule endorsement. Japanese adults endorsed greater display use compared to the Japanese children. Among the Americans, no differences were observed.

Culture proved to moderate the relationship between degree of display rule endorsement and age. Among the Japanese only, age positively predicted the degree of display rule endorsement.

Conflicting opinions scenario: what were the results regarding the types of display strategies used?

Adults from the United States were more likely to endorse unregulated responses, while adults from Japan were more likely to endorse neutral strategies. Japanese adults had the tendency to avoid certain questions, for instance by counter-questioning, while the Americans expressed their responses very openly. With regard to masking strategies, no differences were observed.

Remarkably, Japanese adults tended to reply with the display rule of masking in the welfare scenario, while they displayed a more neutral attitude regarding the conflicting opinions scenario.

Conflicting opinions scenario: what were the results regarding the motives for display rule use?

A comparison within the age groups showed that adults from the United States endorsed more authenticity motives, while those from Japan endorsed more relational motives. The Americans’ motives referred to the character’s true feelings and were expressed in a factual manner (“That is how Rick feels about the song and his co-worker asked for his opinion about it”). The motives also demonstrated the importance of self-expression: being able to communicate one’s true feelings. The relational motives mentioned by the Japanese show how much they value etiquette and a respectful communication to maintain a good relationship. 

Least mentioned were instrumental motives. Those were endorsed less than authenticity motives (except for Japanese adults and American children) and less than welfare motives among American adults and adolescents.

What do the results show?

Americans and Japanese both try to protect the welfare of other people by endorsing the use of masking display rules, which increased with age. This finding is in accordance with earlier studies on display rules.

In the context of conflicting opinions, Americans and Japanese endorsed contrasting degrees of display rule usage. A gradual emergence of cultural differences was observed in the period between child- and adulthood. Regarding the adult groups, a greater emotion regulation was observed among the Japanese. The adolescents and children did not differ. Display rule behavior was viewed by Americans in terms of authenticity motives and by Japanese in terms of relational motives.

The results of this study demonstrate the influence of social norms on the development of display rule knowledge. The responses given by Japanese and American children to both scenarios were remarkably similar. Cultural differences emerged gradually in response to the conflicting opinions scenario: Japanese and American adults endorsed different display rule behaviors and different motives behind those behaviors.

Children in both groups had the tendency to endorse directly expressing their true feelings and mentioned similar motives. This finding could be indicative of a lack of sensitivity to display rule norms due to having little experience with these kind of situations. However, the children expressed welfare concerns in their responses to the welfare scenario, by referring to protecting others from emotional harm. This indicates that children have an early sensitivity to moral issues involving welfare, harm and the (emotional) needs of other people.

An increase with age regarding display rule knowledge and the endorsement of relational motives was observed in both groups. With time, children get better at estimating when it is socially expected to mask an opinion in order to spare the feelings of the other person.

In response to the conflicting opinions scenario, it was observed that Americans developed a greater expression of true feelings which reflected authenticity motives. With age, the Japanese tended to endorse less expression of true feelings which reflected relational harmony motives. The gradual emergency of cultural differences between the two groups demonstrates the progressive process of individuals gaining culture-specific display rule knowledge.

What is the conclusion of this study?

Display rule norms form an important component of social knowledge. This study is helpful in terms of acquiring a better understanding of display rules by adding a cultural dimension to the development of display rule knowledge. In a broader context, the research contributes to an better understanding of the relationship between socio-cognitive development and culture by showing how social knowledge may change over time in diverse cultures. 

What is the background of this study?

An important human quality is showing concern for other people in distress. However, there is a lack of knowledge regarding its early ontogeny. This study aims to provide new insights into the onset, development, consistency and predictive power of early displays of concern for other people.

What is ‘empathy’ and ‘concern’?

Naturally, people experience emotional arousal in response to the emotional state of another person, which can result into concern for other people. The three components of concern for someone else are: cognitive, behavioral and affective.

The cognitive component, also known as cognitive empathy, represents the capacity to understand others’ situation and feelings. In young children, this includes the ability of trying to understand the distress of someone else.

The behavioral component is prosocial behavior: acting to benefit or help others (supporting, sharing, comforting). Feeling concerned for someone else provides a strong motive for action. Empathic concern does not always result into prosocial behavior, for instance because the child does not know how to act or is psychically unable to take action.

The affective component is empathic concern (or ‘affective empathy’). This includes caring for or worrying about the needs or hurt of someone else. Young children exhibit this by orienting towards the other, stopping what they are doing in combination with a concerned facial expression and/or comforting communication.

What are the classic theories regarding the early development of concern for others?

There are several theories about empathy development. According to the theory of Piaget and psychoanalytic theories, young children are too immature to experience concern for someone else. Hoffman argued that concern for others emerges in a child’s second year. However, this theory also emphasized a stage conceptualization of development.

Many studies in the last decades proved that the theory of Piaget underestimates the cognitive capacities of young children. The theory of Hoffman paid no attention to concern and caring. According to Hoffman’s theory, a child’s first year consists of empathic arousal (self-distress or contagious crying). An infant under the age of one was not considered as capable of other-oriented empathy, because infants don’t comprehend the difference between their own and someone else’s distress. Once they are able to distinguish themselves from others, (e.g. by recognizing themselves in a mirror, during their second year), they are capable of experiencing and expressing a sincere concern for others. Therefore, most research is focused on children from the age of 2 years.

The theory of Hoffman was refuted by studies demonstrating young infants’ responding also included the distress of others. Those studies were, however, limited (small group of participants, not directly examining the concern for others). One study found cognitive empathy and affective concern among infants aged 8 and 10 months. They tried to explore and understand the distress of the other and showed concern through facial expressions, gestures and vocalizations. This is in accordance with Darwin’s finding: his 6 month old child’s empathic response to seeing someone else cry.

Dadidov et al. (2013) presented a new theory of early empathy development: concern for other people is already present in a child’s first year. This challenges the classic theory that self-distress emerges first and does not develop into empathic concern before the second year. The capacity of infants to experience concern is not dependent on emerging cognitive qualities and empathy does not develop in stages. Davidov et al. argue that concerning responses do not require the capacity of explicit self-knowledge, but the capacity of implicit self-other distinction. This alternative theory is limited by knowledge gaps, especially regarding the onset, development, consistency and predictive power of early cognitive and affective concern for other people. This study targets these knowledge gaps.

What are the research questions?

Question 1 regarding ‘onset’: How early are cognitive and affective empathy for other people in distress seen?

Question 2 regarding ‘consistency’: Are individuals differences in concern stable over time and across situations?

Question 3 regarding ‘development’: How do the various responses to distress change with age?

Question 4 regarding ‘prediction’: Do early markers of concern for other people predict later prosocial action?

What method was used?
Who were the participants?

Followed were approximately 150 infants from Israel at 6 months, 12 months and 18 months old. They came from a diverse group of families with regard to income, family size and religious beliefs.

What procedure was followed?

Data were collected through home visits. The infants were exposed to three distress stimuli: experimenter simulation, mother simulation and video of a crying peer, and two neutral stimuli: peer video and mother.

What measures were used?

Experimenter simulation: the experimenter pretended to be in physical pain and distress. Eye contact was avoided, until the fake crying was stopped, which was followed by a smile and telling the infant she was feeling okay now. The simulation carried out by the mother was similar. The infants watched a video of a peer crying for 50 seconds on a tablet placed in front of the infant.

The used coding system included five dimensions:

• Concerned affect (facial expressions of concern, vocal and gestural-postural markers of concern). Coding is based on intensity and duration of the responses. 
• Inquiry behavior (to assess the cognitive dimension of empathy: attempting to understand the other’s feelings by visual scanning or intense looking, social referencing: gazing from victim to other adult and vocalizations: questioning or labeling feelings). Coding is based on intensity, duration and complexity. 
• Self-distress.
• Prosocial behavior (attempting to comfort or help the distressed person). 
• Other dimensions (avoidance, communicative smiles, positive affect).

The neutral stimuli included being read to from a book by the mother and watching a video of a babbling peer. The project started with the first neutral episode (mother), followed by the distress episodes and ended with the second neutral episode (peer).

What were the results?

Only one gender difference was observed: 18-months-old girls exhibited greater exploration of someone else’s distress. No significant differences showed regarding other demographic statistics. The manifestations of empathy, inquiry behavior and concerned affect, were positively intercorrelated at all ages (3, 6, 12 and 18 months) and frequently negatively with self-distress.

Interestingly, empathic responses (inquiry and concern affect) were not higher toward the mother, at some ages they were even higher toward the experimenter. Other responses (prosocial behavior, communicative smiles, self-distress and positive affect) were higher toward the mother at 12 and 18 months.

Onset: how early is concern for others in distress evident?

Infants aged 3-6 months exhibited concern for others. Inquiry behavior and concerned affect were higher in response to others in distress in comparison to the response to neutral stimuli. The comparison between the responses to the distressed mother simulation and the crying infant video on the one hand and the neutral stimuli on the other hand led to similar results.

The levels of self-distress in response to the distress of someone else, however, were significantly lower at 3 and 6 months. These levels also did not differ much from the levels of self-distress as a response to neutral stimuli. Most infants at 3 and 6 months did not exhibit self-distress in all three episodes. Only few infants exhibited no concerned affect at all, while many exhibited weak or brief concern.

Infants aged 3 and 6 months typically show their empathy for the distress of others through concerned facial expressions and by trying to explore and understand the situation of the other. Smiling (positive affect) also emerged as a typical response. Some smiles were wide and repeated, while others were fleeting. Some were the result of unease or confusion, others were communicative. The latter were quite common: 39.5% of the infants aged 3 months and 39% aged 6 months exhibited those smiles in at least one simulation. The positive affect responses were positively related or unrelated to the degree of inquiry behavior and empathic concern.

How consistent was concern for others?

Also examined was the consistency of the concern for others across age and situation. Self-distress and inquiry behavior responses were consistent across all three situations, although not as strongly as empathic concern. There was only moderate evidence of continuity over time for inquiry behavior, while there was strong evidence of consistent empathic concern.

The findings regarding the stability of individual differences between infants aged 12 and 18 months in prosocial behavior showed no correlation. Prosocial behavior was not exhibited by younger infants.  

Development: what changes with age were found?

Empathic concern increases with age, but the increase became less strong over time. Surprisingly, the growth pattern of inquiry behavior did not differ from that of empathic concern.

In levels of self-distress, no change with age was observed. This finding is in contrary to the theory of Hoffman.

A substantial increase with age was observed with regard to prosocial behavior. Nearly 14% of the infants showed prosocial behavior toward the experimenter or mother at 12 months, in comparison to nearly 41% at 18 months. Prosocial behavior was not exhibited by 3- and 6-month-olds.

What links between subsequent prosocial behavior and early empathy were found?

The prosocial attempts by 18-month-old infants included three forms of prosocial behavior: recruiting help, offering an object and physical comforting. 

Inquiry behavior proved to be a significant predictor of prosociality at the age of 3 months. 3-month-olds who exhibited greater exploration of the distress of others were at least three times more likely to exhibit prosocial behavior towards distressed others at 18 months. No other response to distress at 3 months proved to be a predictor. The total empathy score at 3 months was nearly significance.

Total empathy was a significant predictor at the age of 6 months, with a stronger effect for empathic concern. Infants who exhibited greater concerned affect at 6 months were nearly three times more likely to exhibit prosocial behavior at 18 months.

At 12 months, none of the responses to distress proved to be predictors. At 18 months, the total empathy score was linked to prosocial behavior.

What are the conclusions?

The responses by infants show the early onset of their ability to response empathic to others’ distress (as early as 3 months). The findings of this study challenge the Hoffman-theory of infants only showing self-oriented distress during their first year. The findings support the notion of Davidov et all., that infants are capable of self-distress and empathic concern during their first year. In this study, those responses were negatively correlated or not related.

Individual differences in concern for others were modestly consistent across age and situations  Already during the first year of life, an empathic disposition seems evident. The findings of this study show that empathic responses are not linked to people they know, which indicates that concern is not a relationship-specific response. Prosocial behavior, however, was higher towards the mother. Some infants may feel more at ease with exhibiting their concern in a familiar context and children are likely to have gained experience in responding to their mother, which encourages prosocial behavior.

Consistency was greater for empathic concern compared to prosocial behavior and cognitive empathy. An explanation could be that some abilities emerge during the first year (motor development, social referencing, ability to shift attention, stranger anxiety), which influences infants’ ability to explore someone else’s situation. Prosocial behavior requires certain cognitive and motor abilities that most infants do not possess at 12-18 months.

The findings of this study show no gender differences. Those are likely to emerge later in life when children start to understand gender role expectations by society.

As expected, affective empathy increased moderately with age. However, inquiry behavior did not increase significantly with age. Earlier studies show that this response is likely to increase later in life.

Earlier research proved that empathy promotes prosocial behavior in adults and children. This study shows that the same goes for infants. The current findings support the early ontogeny of concern for other people as a motivator of prosocial action. While smiling was seen as a frequent response to the distress of others, communicative smiles were not predictive of greater prosociality. Neither were smiles linked to less exploration of the other’s distress and less empathic concern.

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.

Introduction

A moral and constructive life is the weighted sum of many individual, morally relevant behaviors that are performed daily. However, this behavior is not always in line with moral standards. There can be several explanations for this:

• Social psychological theory: there is no perfect link between intentions and behavior.

• Field theory: individual behavior varies per situation, interpersonal negotiations can undermine the link between intention and behavior, and the spread of responsibility can undermine the ability to act according to one's own (deep-rooted) beliefs.

• Ajzen's theory of planned behavior: attitudes, norms and perceived (emotional) control have an influence on behavioral intentions and subsequent behavior.

The link between moral standards and moral decisions and behavior is influenced by moral emotions. Moral standards are the knowledge and internalization of moral norms and conventions. These are determined by universal moral laws, but also by cultural regulations. Important in moral choices and behavior are the individual differences in anticipation and experience of moral emotions.

Moral emotions are used to understand why people follow moral standards in terms of behavior. Moral emotions are linked to the interests and well-being of society or other people. It provides motivation for doing good and avoiding evil.

Self-conscious emotions

Shame, guilt, embarrassment, and pride are called self-conscious emotions that arise through self-reflection and evaluation. Self-evaluation can be implicit or explicit and conscious or unconscious. In any case, the self (the person) is always the subject of self-conscious emotions. The emotions therefore provide direct reward or punishment as feedback on social and moral acceptability. Because of this, they have a strong influence on our moral choices and behavior. Emotion disposition is the tendency to experience a certain emotion. Shame susceptible individuals, for example, are more vulnerable to anticipatory and actual experiences of shame.

Shame and guilt

An attempt has been made to distinguish between shame and guilt in three ways:

• Type of provocative events

• Public versus private violations

• Failure of yourself or of behavior

Research shows that the type of event cannot properly distinguish between shame and guilt. Some researchers state that shame arises after moral and non-moral offenses, while guilt is primarily associated with moral offenses. There is a "Big Three" ethics of morality, namely autonomy, community and divinity. Shame is mainly linked to violations of ethics of community and divinity, although this does not translate one-on-one to certain situations.

In addition, shame is often seen as a more public emotion, caused by public exposure and disapproval. Guilt is more a private emotion, arising from self-generated thoughts. However, empirical research does not support this distinction. Then why do we think this distinction exists? It appears that people in shame-inducing situations are more concerned about other's evaluations about themselves. In guilt situations people are more worried about the effect of their actions on others. Shame would therefore lead to a focus on itself (egocentric) and guilt on a specific behavior (others-oriented). Empirical research does support this distinction.

Both shame and guilt can lead to feeling intrapsychic pain. However, shame is more painful because one's core of self is affected. It can lead to the feeling of being 'small' and feelings of worthlessness and powerlessness. Guilt brings about a less painful experience, because it is about a specific behavior and not about core characteristics of the self. People who feel guilty think about their behavior and the consequences of it and this thinking leads to regret about the 'bad' action. Research shows that internal, stable and uncontrollable attributions for failure are positively related to shame, and internal, unstable and controllable attributions for failure are positively related to guilt.

Adaptive versus non-adaptive

Guilt is an adaptive emotion that benefits the individual and his or her relationships. However, shame is not adaptive. Shame leads to attempts to deny or escape the shame-inducing situation. This leads to increased levels of pro-inflammatory cytokine and cortisol. Guilt leads to remedial actions, such as confessions, apologies and undoing consequences. Although guilt therefore leads to constructive and proactive behavior, shame leads to defensive behavior, interpersonal separation and distance.

Guilt is also related to other-oriented empathy, because an action has led to negative consequences for another, while shame disrupts emphatic connections with others. Because of shame, people actually focus on themselves, so that they cannot address themselves to the other. Shame is positively correlated with anger, hostility and the tendency to look for factors outside of themselves in case of setbacks. Designating others as the cause of the guilt helps to feel in control, but it has negative long-term consequences for relationships with others. Guilt-prone people are less likely to end up in aggression and take responsibility faster, resulting in positive long-term consequences.

Vulnerability to shame is related to low self-confidence, depression, anxiety, eating disorders, PTSD and suicidal thoughts. Guilt is only related to psychological symptoms if it occurs along with shame. Problems can arise if you have an exaggerated or disturbed sense of responsibility for events beyond control or where you have no personal involvement. Guilt can lead to psychological problems. In addition, there is a positive relationship between internalizing symptoms and vulnerability to guilt in situations where responsibility is ambiguous.

Vulnerability to experience guilt is negatively related to antisocial and risky behavior. The chance of arrests and the use of drugs and alcohol is lower and the chance of safe sex is higher. Guilt vulnerability therefore has a protective function. In addition, shame-vulnerability is positively correlated with externalizing symptoms and can lead to illegal behavior, early drug and alcohol use and higher chances of unsafe sex. However, this link does not apply to all populations and all behaviors.

New study

Shame vulnerability is described in three ways:

• The tendency to experience shame in different situations

• Frequent or continuous experience of global shame, not necessarily related to specific events

• Chronic feeling of shame about certain behaviors or traits

Little research has been conducted into how people deal with shame and guilt. However, various instruments have been developed to measure individual differences in coping with shame: Compass of Shame Scale (COSS-4), TOSCA and Self-Report Psychopathy Scale (SRPS).

People who have elevated levels of shame also appear to have elevated pro-inflammatory cytokine activity. Shame, but not guilt, is a predictor of immune-related response. In addition, it appears that there is more shame in situations of negative social evaluations and rejection, which increases activity in the cortisol and pro-inflammatory systems. Increased cardiovascular reactivity may also be associated with shame.

Victims of abuse or trauma often experience feelings of shame. This is especially present in child abuse, because this is often kept secret and hidden. Severe punitive parenting is also associated with helplessness and self-blame. Physical and sexual abuse in childhood is related to physical shame and shame about the traumatic event. Internalizing shame is related to unwanted sexual experiences. Vulnerability to shame is associated with a history of emotional abuse and shameful practices of parents. In addition, shame after sexual abuse can lead to depression and PTSD. Abuse-specific shame appears to be stable over time. People who have told about their abuse express their shame more verbally, while people who have not told about their abuse express their shame more non-verbally.

In addition to the self-aware emotions of guilt and shame, there is also 'substitute' or 'group-based' guilt and shame. These are feelings that are experienced in response to violations or failures of other people. Personal causality is therefore not a requirement for the experience of guilt or shame. Personal guilt and shame has many similarities with group-based guilt and shame. Group-based shame mainly occurs when there are concerns about maintaining the positive group identity. Substitute guilt is more common when someone has an interpersonal relationship with the perpetrator and when relationship-based concerns are increased by damage to another group or individual.

With ambiguous information about the violations of group members, people who identify with the group take advantage of this and report less substitute shame or group-based debt compared to people who identify less with the group because they themselves are less threatened. Just like personal guilt experiences, group-based guilt is also associated with empathy and motivation to restore relationships. In substitute group-based shame, there is a desire to remove oneself from the shame-inducing event. The link between anger and substitute shame also remains. 

Embarrassment

Embarrassment is less relevant to morality. It is an aversive state of mortification and sorrow after public social difficult situations. Possible causes are:

• Normative public deficiencies. These are situations in which a person behaves in an awkward, absent or unhappy way

• Uncomfortable social interaction

Situations that evoke embarrassment often indicate that something is wrong. This means that an aspect of yourself or your behavior must be carefully monitored, hidden or changed. Shy people behave in conciliatory ways to earn approval and inclusion. It can lead to the adoption of widely accepted moral standards or locally endorsed deviant acts. Embarrassment is associated with neuroticism, high levels of negative feelings, self-awareness and fear of negative evaluation from others. People who are susceptible to shyness are also more sensitive to peer pressure.

Moral pride

Pride is generated by the assessment that someone is responsible for a socially valued outcome or that someone is a socially valued person. It improves self-confidence and leads to more behavior in line with social standards. It has a motivating function and rewards engagement with the ethics of autonomy, community and divinity. There are two types of pride: alpha pride (pride in yourself) and beta pride (pride in your behavior). Being proud of yourself can be maladaptive, because it can lead to bending situations to your own advantage, which can lead to interpersonal problems.

Moral emotions focused on others

Examples of moral emotions directed at others are elevation and gratitude. Those emotions are experienced after observing admirable actions of others, which is a motivation to start exhibiting admirable actions themselves.

Anger, contempt and disgust

Anger is a negative emotion which is often aimed at others, but it is not necessarily a moral emotion. It occurs in many situations, but especially when an event is seen as personally relevant, an obstacle to achieving personal goals and when an event is caused by someone else. Justice anger arises when the behavior of a perpetrator is a violation of a moral standard. The damage does not have to be personally experienced. Justice anger occurs primarily in violations of the ethics of autonomy. It can motivate bystanders to take action to correct the injustice.

Disregard and disgust arise with negative evaluations of others, whereby disregard is primarily linked to violations of the ethics of community and disgust to violations of the ethics of divinity.

Elevation

Elevation is a positive emotion that is evoked when others behave in a virtuous and praiseworthy way. It can lead to a warm, pleasant and tingling sensation in the chest, where one is open to others and feels motivated to help others and become a better person.

Gratitude

Gratitude is a positive moral emotion. It is a reaction to the benevolence of others, which benefits one, especially if this is unexpected or detrimental to the person who gives it. It can lead to moral motivation in the recipient and stimulates helping behavior in the future. The people who get the most benefit from the experience and expression of gratitude are the grateful people themselves. People who feel gratitude have improved psychological resistance, physical health, quality of life and adaptive behavior.

Empathy

Empathy is an emotional process with implications for moral behavior. It is a shared emotional response between one person with another. It requires three skills:

• The cognitive capacity to take a different perspective (so, you need to be able for Theory of Mind)

• Cognitive ability to recognize and distinguish the feelings of others

• Affective ability to feel many emotions

Empathy can lead to the desire to help others. It is different from sympathy, which is about the emotional state of the other, but not the substitute or shared experience of other people's emotions. There is a distinction between others-oriented empathy and self-oriented personal needs. During other-oriented empathy, you take on the perspective of someone else and you feel the same emotions. So, people focus on the experiences and needs of the other person and not on their own empathetic response. This leads to altruistic behavior, such as helping others without expecting anything in return. With self-oriented personal need one focuses on one's own feelings, needs and experiences. This leads to interference with prosocial behavior.

The development of antisocial behavior is influenced by biological factors. However, these factors also influence how one responds to interventions aimed at reducing antisocial behavior.

Individuals who develop antisocial behavior at a young age are more likely to engage in criminal behavior later in life compared to later emerging antisocial behavior. Various interventions are aimed at preventing the development of problematic behavior in youth. Unfortunately, these programs are limited by their complexity, high costs and modest effects. The programs are not equally beneficial to all participants.

For interventions to be successful, it has to be determined which youth are most in need of them. Some individuals outgrow their issues, while others’ behavior spirals. At some point, both may exhibit similar behaviors, but their development could differ. It is therefore important to determine which individuals are most likely to persist in their problematic behavior and are in need of more intensive interventions. Also, it needs to be determined which type of intervention is the most beneficial to a specific individual. Research indicates that different factors, such as difficulties with attention, self-regulation or emotional responding, lead to antisocial behavior in different individuals. In order for interventions to be more effective, it is necessary to understand the (biological) factors that influence the intervention outcome and use this knowledge in the selection of individuals for programs or to develop programs for particular individuals.

Research done by Albert et al. (2015) already showed the relevance of biological factors in relation to interventions. In that study, the effect of a certain gene on intervention responses was assessed. High risk children who carried this gene benefited most by the intervention program, while intervention had no effect for non-carriers.

While using biological information could improve the effectiveness of interventions, a number of ethical issues arises (for instance: privacy, discrimination, stigma).

Which biological factors are associated with antisocial behavior in youth?

Research has shown the existence of heterogeneity in the biological factor of youth with antisocial behavior. Different combinations of environmental and biological factor result into problematic behavior. How children will respond to an intervention depends partly on their hormone levels, genes, levels of neurotransmitters and brain functioning.

A child’s outcome is influenced by its environment, genetic factors that affect the character (IQ, temperament) and how it responds to its environment. Studies indicate that antisocial behavior is heritable at a rate of 40-50%. The effect of single genes on antisocial behavior is considered to be small, but acquiring genetic information could help predict one’s response to intervention. Several studies found a link between certain gene variants and levels of brain structure and functioning.

Also helpful could be information concerning the stress response system. In youth with antisocial behavior, a significant heterogeneity in responding was observed. The stress response system includes the autonomic nervous system and the HPA axis. As a response to stress, the HPA axis releases cortisol. Both high and low levels of cortisol have been linked to antisocial behavior. The functioning of the autonomic nervous system is measured through monitoring heart rate and skin conductance. A low resting heart rate and reduced level of skin conductance have been linked to antisocial behavior in youth. However, environmental factors were also associated with a higher risk for antisocial behavior.

Some studies found an association between low levels of respiratory sinus arrhythmia (RSA) and aggression in young males, while others found a positive link between RSA and externalizing problems or did not find an association between aggression and RSA. Higher levels of RSA are considered to reflect to ability to adapt to environmental stressors and emotion regulation, so it could influence the response to intervention programs.

Functional and structural neuroimaging studies have shown divergent brain functioning and structure in youth exhibiting antisocial behavior. In youth with conduct disorder, reduced brain functioning and structure were found. However, other studies lead to various results regarding the brain functioning.

Although biological abnormalities will not be found in everyone with antisocial behavior and vice versa, several biological risk factor could underlie heterogeneity in how youth responds to interventions.

Which biological factors affect responding to the environment?

The relationship between environmental and biological factors has a reciprocal nature. While biological factors potentially influence one’s response to the environment, environmental factors can alter our biology. Being exposed to stress for a long time can modify the functioning of the stress response system and gene expression.

Research has shown that the combination of social risk factors and biological risk factors increases the risk for antisocial behavior. Biological factors could influence the response to various types of environments. For instance, cortisol levels can influence whether rejection by peers is related to antisocial behavior. The majority of studies concerned negative environmental factors, but biological factors can also influence the response to positive environments. A number of children is highly responsive to their environment, whether it is a positive or negative one.

How do biological factors affect the response to intervention?

Intervention during the early years is potentially successful in preventing youth to continue their problematic behavior. Some studies investigated how biological factors influence the response to intervention.

Studies indicate that genes linked to glucocorticoids and dopamine temper the response to interventions aimed at reducing antisocial behavior in youth. Research showed that a genetic factor tempers the responsiveness to the Coping Power intervention. Youth with one variant of the oxytocin receptor gene exhibited reduced externalizing behavior, regardless of the type of intervention. Youth with the other variant of the gene receiving intervention in group format, exhibited very limited improvement and even worse behavior in the following year. Youth who received one-on-one intervention exhibited reduced externalizing behavior. Genetic factors could be helpful regarding the choice of intervention format.

Physiological factors were also linked to the potential responses to intervention. Parent training and intensive day-care treatment were found to be the least successful in youth with lower resting heart rate. Risk factors such a attention issues, age, cognitive functioning and delinquency did not influence the success of the intervention. Biological factors can be helpful predictors of the most effective intervention for specific youth.

Hormones have also been the subject of studies on intervention responsiveness. In a study among participants with disruptive behavior disorders, those with elevated levels of cortisol exhibited more improvement when receiving a structured intervention aimed at reducing aggressive behavior. Youth with higher testosterone levels were several times more likely to not respond to multifaceted psychological treatment.

Research suggests that a biosocial approach could be helpful in predicting which youth may benefit the most from intervention and which youth will probably not respond to certain therapy.

How can biological information help in determining which youth are most in need of intervention?

Less than 50% of children who exhibit antisocial behavior continue this behavior into adulthood. Not all children are in need of intensive interventions. Biological factors are helpful in determining which youth are likely to engage in continuous anti-social behavior.

A study found that youth (aged 12-22 years) carrying a variant of the GABRA2 gene exhibited continuous externalizing behavior. Normalizing cortisol levels is considered to be predictive of a decrease in aggression. A better prediction of antisocial trajectories may positively influence interventions.

Which ethical issues arise regarding the use of biological information?

Various (ethical) issues could arise regarding the use of biological information in order to improve the outcomes of interventions, such as discrimination, equity of service provisions and stigma. However, biological information about children must be kept private and will not be used by others than the interventionists. It is up to society whether the potential benefits of using this information outweigh the possibility of harming one’s privacy.

Hard-hearing (HH) or deaf (D) children face various challenges when interacting with typically hearing children. Fortunately, social interaction in inclusive settings can be improved through adequate intervention programs. The reviewed literature suggests that deaf and hard-hearing children struggle with communication, initiating, entering and maintaining interactions in inclusive settings. Social skills training and co-enrollment programs are deemed effective interventions. Key aspects of social interactions are social skills, communicative skills, the responses of typically hearing children and environmental effects.

In the last 20 years, inclusive education (children with disabilities attending regular schools) has become increasingly popular. While the literature mentions several benefits of inclusive education, it is also argued that placing D- or HH-children in a classroom with TH-children does not necessarily result into more social interaction, positive inclusion, peer acceptance or better social communication skills. Research shows that children with hearing problems are at greater risk of being ignored by typically hearing children in regular schools in comparison to special schools. Even those with no speech impairments and hearing aids struggle in noisy environments and group situations.

What is the definition of interaction?

Interaction concerns the social exchange between at least two individuals, with their actions being interdependent.

What was the focus of previous reviews?

The number of literature reviews regarding this topic in inclusive settings is limited. One review was focused on the affective and social effects on D- or HH-children. Another also assessed the interactions between HH- or D-children and typically hearing children in segregated and inclusive settings, but this review was based on studies who were not up-to-date. A more recent review concerned the factors that affect the social interaction between both groups of children. How they interact and how their interaction can be improved needs to be further investigated.

What is the purpose of this study?

21 studies published between 2000-2013 were reviewed in order to provide more accessible information to researchers and teachers. Three research questions were formulated:

1. How do D- and HH-children interact with hearing peers in inclusive settings?
2. What challenges do D- and HH-children face regarding social interactions with hearing peers in inclusive educational settings?
3. What interventions improve social interactions between D- and HH-children and their hearing peers in inclusive education?

What method was used?

The themes of the papers were divided into two broad themes (processes and outcomes of interactions between D- and HH-children and their hearing peers) and several major themes (communication, entering, initiating and maintaining interactions).

What were the findings regarding communication?

Communication is essential for D- and HH-children in establishing and maintaining relationships and interactions with typically hearing children. One study found that there was no symbolic communication between deaf or hard-hearing children and hearing peers at preschool ages. A study concerning children that attended elementary school found that deaf or hard-hearing children tried to initiate interactions with their hearing peers, but were frequently ignored by them. When peers were responsive, most interactions were non-linguistic and had a short duration. The findings of this study demonstrates that D- or HH-children are at risk of social isolation in regular schools.

The results of another study regarding 42 to 65-month-olds who were observed during play sessions suggest that D- or HH-children procedure less verbal initiations compared to children with normal hearing. They had, however, a greater rate of play and verbal turns.

Studies concerning children with cochlear implants found that these implants are beneficial in terms of social communication with hearing peers in inclusive settings. The communication skills of those children progressed significantly. However, individual differences were observed: some children showed no improved communication skills. Other findings show that D- or HH-children found it easier to communicate with hearing peers in one-on-one interactions. Group conversations were challenging, even for children with implants and sufficient language skills.

In another study participants (aged 11-19 years) were asked to form pairs and describe sets of pictures. They could use requests for clarification. The D- or HH-participants requested more clarifications in comparison to hearing peers, but no differences were found in the production of nonspecific and specific requests nor with regard to the responses to the requests. This suggests that D- or HH-students have similar conversation skills in comparison to their hearing peers.

One study concerned children aged 7-12 years and their ability to receive, ask questions and to response. All children attended regular schools. They formed mixed pairs and were asked to play a trivia game. The results demonstrate D- or HH-children found it more challenging to repeat trivia questions verbatim, but they provided more right answers and requested a greater amount of general clarifications (‘Sorry?, ‘What?’).

Summarized, in comparison to the social interactions between children with normal hearing, it was found that fewer interactions occur between D- or HH-children and their hearing peers. With age and increased experience, some levels of communication skills became similar. D- or HH-children understand their hearing peers better in quiet environments, but found it challenging to express complex linguistic content.

What were the findings regarding entering and initiating interactions?

One study focused on the initiation of social interactions by 2-3 year old D- and HH-children. The results indicate that these children attempted to initiate interaction with hearing children more often than with other D- or HH-children. However, the attempts were less successful compared to the attempts to interact with other D- or HH-infants.

Other studies found no differences in response and initiation skills between D- or HH-children and hearing children aged 37-62 months. However, D- or HH-children received less responses over time. One study, concerning 49-63-month-olds, found that children from both groups were equally successful in engaging in play situations, but D- or HH-children had significantly less success with entering non-play activities.

A study regarding D- or HH-children with cochlear implants and hearing children (aged 6 -14 years) entering play situations, found that D- and HH-children took longer to enter into plays with others, had fewer continuous interactions, had more failed attempts at entering into play, were less cooperative and verbal. Children who used the cochlear implants longer than 2 years, exhibited no significant improvements compared to the children who used them for a shorter period.

What were the findings regarding maintaining interactions?

One study focused on social attention skills, social engagement and social competence of D- or HH-children and normal hearing children (aged 49-64 months). The findings showed no difference in their ability to acknowledge, notice, initiate, follow and respond to other children. However, the quality of the communicating skills of D- or HH-children was poorer. They were also more easily distracted and showed less focused and continuous attention during social interaction. This indicates that D- or HH-children are less capable of maintaining interactions with peers.

Another study found gender differences in D- or HH-children aged 5-11 years regarding the maintenance of relationships and interactions with hearing peers in inclusive educational settings. Girls used strategies like advocating needs, requesting repetition and assertiveness, while boys also used excelling in sports as an strategy to bond with peers.

What were the findings regarding intervention programs?

Several intervention programs are aimed at promoting interactions of D- and HH-children with hearing peers in inclusive educational settings. Examples are the social skills training program and the co-enrollment program.

In the co-enrollment program, D- and HH-students received education with normal hearing peers in the same classroom were special and general teachers worked together. The social interactions and educational performance were assessed through informal interviews and observations.  The findings demonstrated an increase in interactions between D- or HH-students and their hearing peers.

One study examined social behavior, participation and communication in a co-enrolled classroom program. The children were aged between 9 and 12 years. No differences emerged regarding classroom communication and social behavior. However, D- or HH-children with extra difficulties found it more challenging to engage in interactions.

Another study found that the co-enrollment program was not merely beneficial to deaf and hard hearing students, but had a positive influence on everyone involved in the program.

Social skills are necessary in order to interacts with other people and build friendships. One study examined the social skills training program. D- or HH-children and hearing children aged between 9 and 13 years participated. Part one of the program included interpersonal problem-solving training and was targeted at only the D- and HH-children. Part two of the program concerned a social skills training, taught to all children. This included negotiating, apologizing, avoiding issues, recognizing and dealing with group influence, sharing and cooperating in a group. The findings show that this program helps to improve the emotional and social adjustment, social problem-solving abilities and assertive behaviors in all participants.

What are the conclusions?

Regarding research question 1 and research question 2, it is found that D- and HH-children experience difficulties in communicating, initiating and entering in social group and in the maintenance of social interactions with hearing peers. Some studies show that children with hearing aids do well in inclusive settings, especially in one-on-one situations.

Regarding research question 3, the social skills training and co-enrollment programs have shown their value.

What should future research focus on?

Future research should focus on:

• Examining communication skills in more natural or informal settings,
• Interactions between D- and HH-children and hearing peers during different periods in school life,
• The improvement of social interactions between deaf or hard hearing children and hearing peers in inclusive educational settings;
• Examining classroom climate and its influence on the social development of students.