stress and coping in families with deaf children - journal of deaf

Theoretical and Review Articles

Stress and Coping in Families with Deaf Children

Terri Feher-ProutUniversity of Pittsburgh

More than 90% of deaf children are born to hearing parentswho experience stress, not only in response to the initial diag-nosis, but also in adapting to the unique needs of their deafchild. This article is a selective literature review summarizinginformation from three fields in order to broaden our under-standing of family adaptation to deafness. Discussion in-cludes (1) psychology's model of individual stress and coping,

(2) family science's model of family stress management, and(3) literature on family adjustment to disability. The last partof the article traces the development of professionals' under-standing of the reciprocal influences between deaf childrenand their families and describes recent research indicatingthat the impact of deafness on families is complex and vari-able. The final conclusion is that adoption of a family stressand coping paradigm would inform discussion of current is-sues in deafness, such as cochlear implants and bilingual-ism/biculturalism.

"Oh, yes, hearing parents go through the stages ofgrief—shock, anger, denial and all that. I learned aboutit in one of my courses." Nowadays individuals trainingto be professionals in the field of deafness are routinelytaught the stages of mourning. That hearing familiesexperience grief in reaction to the diagnosis of deafnessseems obvious enough. Nonetheless, prior to the 1970s,very little was understood about a family's adjustmentto hearing loss in a child. In the last few decades, re-searchers and practitioners have made great strides in

The iuthor is now > teacher at Appahchia Intermediate Unit 8. Corre-spondence should be sent to Terri Feher-Prout, 128 Colgate Avenue,Johnstown, PA 15905.

Copyright © 1996 Oxford University Press. CCC 1081-W59

understanding the impact of a deaf child on a family,but professionals are only just beginning to appreciatethe diversity and complexity in families' responses todeafness.

More than 90% of children with severe to pro-found hearing losses are born to normally hearing fam-ilies (Moores, 1987). The realization that a child is deafcauses stress in families who have had little contactwith deaf persons and know little about the implica-tions of deafness. In addition to coping with the shockof the initial diagnosis, families must acquire an under-standing of a substantial and complex body of knowl-edge. Parents are often swamped with information onamplification devices, sign language, educational meth-ods, school placements, and legal issues, all of whichdemand comprehension to assure appropriate criticaldecisions about the deaf child's future (Meadow, 1980).

Professionals need to understand how families ad-just to a deaf child for two reasons. First, federal lawrequires that intervention with deaf infants and pre-schoolers be family-focused. Thus, planning and im-plementing educational programming for infants andpreschoolers demand an understanding of familyprocesses. Second, research indicates that competence,achievement, and adjustment in both preschool andschool-aged children are related to successful familyadjustment (Bodner-Johnson, 1986; Greenberg, 1983).

The purpose of this article is not to report new re-search, but rather to bring together three separatestrands of literature in order to broaden our under-

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156 Journal of Deaf Studies and Deaf Education 1:3 Summer 1996

standing of family adjustment to a deaf child. The firststrand includes information about individual stress andcoping from the field of psychology. The second strandinvolves literature from the field of family stress man-agement. The third strand includes information onfamily adjustment to a child with a disability as well asliterature on family adjustment to deafness, in particu-lar. In the final section of the article, I consider implica-tions for future research and practice in the field ofdeafness.

Stress and Coping: A Psychological Perspective

Psychologists' interest in how individuals cope withstress has grown significantly in the past 20 to 30 years.Currently, most psychologists use the cognitive modelof stress and coping that was developed by Folkman,Schaefer, and Lazarus (1979). Coping is defined as "thechanging thoughts and acts that an individual uses tomanage the external and/or internal demands of a spe-cific person-environment transaction that is appraisedas stressful" (Folkman, 1992, p. 34). Coping is con-ceptualized as an ongoing process that consists of aseries of appraisals and responses to the stressful event.There are three types of appraisal: (1) primary, inwhich the person evaluates the significance of the eventfor his or her well-being, (2) secondary, in which theperson evaluates the event with respect to available op-tions and resources, and (3) reappraisal, which occursas new information (from within and without) is re-ceived and processed.

Psychologists consider a person's appraisal of anevent as stressful to be essential to the coping process.Because individuals vary in their perception of events,what one person views as stressful, another may viewas inconsequential. The diagnosis of deafness presentsan illustrative example of how events can be interpre-ted differently. Hearing parents almost always appraisethe diagnosis of deafness in a child as highly stressful,whereas deaf parents typically accept or even welcomedeafness in their children (Moores, 1987). Moreover,appraisal of available options and resources varies ac-cording to the hearing status and experience of parents.Obviously, deaf parents have a lifetime of experiencecoping with hearing loss and consequently have accessto resources unfamiliar to hearing parents.

Once an event is evaluated as stressful, individualsrespond with coping processes. Coping processes con-sist of information search, direct action, inhibition ofaction, and intrapsychic (thought) processes, all ofwhich vary over time. Coping processes serve twofunctions or purposes: the regulation of emotion andthe adjustment of the person-environment relation-ship. Thus, coping behaviors are described in the liter-ature as primarily "emotion-focused" or "problem-focused." For example, parents of a newly identifieddeaf infant often seek out other parents with childrenwho are deaf in order to validate and manage their feel-ings toward their child's deafness. This is an example of"emotion-focused" coping. On the other hand, parentsalso request literature on hearing loss as well as ask nu-merous questions about communication and educa-tional options. This is an example of "problem-focused" coping. Obviously, a coping strategy can servea dual purpose. For instance, persons can read infor-mation both to find a solution and to lessen distress.But, most strategies are used primarily for one purposeor the other.

Coping behavior necessitates the use of four kindsof resources, according to Folkman et al. (1979): (1)health/energy/morale, (2) problem-solving skills, (3)utilitarian resources (economic status, educational pro-grams etc), and (4) general and specific beliefs (self-efficacy, belief in God, etc). With regard to deafness, afamily's resources might include past experience withdisability, access to parent support groups, familiaritywith legal and educational processes, and so on.

In summary, coping consists of, first, appraisingthe stressor (for example, hearing loss) and the avail-able resources (support groups, educational programs,etc) and, second, choosing behaviors to regulate emo-tions or solve problems. Folkman and her associatesstress that this process is always dynamic and some-times unconscious.

Folkman et al. (1979) suggest "goodness-of-fit" asa basis for evaluating the effectiveness of coping behav-iors. According to the "goodness-of-fit" model, copingeffectiveness depends on an appropriate fit between (1)reality and appraisal, (2) appraisal and coping, (3) cop-ing strategies and task demands and constraints, and(4) coping strategies and one's other agendas, (i.e.,goals, commitments, and beliefs). A "poor fit" can oc-

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Stress and Coping 157

cur at any one of these points and result in ineffectivecoping. For example, parents may demonstrate a poorfit between reality and appraisal if they believe that adeaf child's speech is intelligible to unfamiliar listenersin spite of much evidence that it is not. In addition,goodness-of-fit requires a match between coping strat-egies and task demands and constraints. For instance,denial and withdrawal may be effective strategies inregulating the intense emotions that occur in reactionto the initial diagnosis of deafness, but may prove tobe maladaptive strategies if maintained an extendedlength of time. Finally, there is sometimes a poor fit be-tween coping strategies and individuals' other agendas.For example, parents may commit to developing flu-ency in sign language and later find this commitmentdifficult to maintain as job and family responsibilitiescompete for time and attention.

As a final note about effective coping, the fact thathearing loss is a highly ambiguous stressor tends toexacerbate the stress experienced by hearing par-ents. Confusing information and contradictory opin-ions overwhelm parents who are attempting to appraisethe impact of deafness and the appropriateness of vari-ous coping strategies. Although parents may seek to di-minish this ambiguity by asking questions (informationsearch), professionals often have to answer parents' re-quests for a specific description of a child's future abili-ties with vague generalizations and a qualified "I don'tknow." Moreover, the expansion of choices in the lastfew decades with regard to communication options,educational placements, and technological devices hasserved to increase, rather than decrease, the ambiguityof the implications of hearing loss (Gregory, 1995).

In summary, because hearing loss in a child is expe-rienced as stress by hearing parents, the dynamics ofthe situation can be understood using the stress andcoping model proposed by Folkman et al. Althoughthere has been some disagreement over the specifics ofthe model suggested by Folkman et al., the model hasbeen used in numerous research studies and its generalaspects have been supported empirically. Additionaldistinctions have been made between emotion-focusedand problem-focused coping, and Folkman (1992) con-cedes that two categories are probably too few, but thateight or more are too many. In addition, researchershave attempted to clarify under what conditions coping

resources, such as social networks, are beneficial or det-rimental. Nevertheless, the cognitive model of copingproposed by Folkman et al. (1979) has stood the testof time and proved very useful in understanding howindividuals react to stressful events, such as the diagno-sis of hearing loss in a child.

Family Stress Management

While psychologists have been studying how individu-als react to stress, another group of researchers, familyscientists, has examined how families manage stress.Family stress theory and research began in the 1930swhen Reuben Hill developed his ABC-X model offamily stress management. Before describing Hill'sABC-X model, a definition of "family" and a descrip-tion of family processes are necessary. According toBoss (1988), a "family is a continuing system of inter-acting personalities bound together by shared rituals-and rules even more than biology" (p. 12).

Two important terms in this definition are "sys-tem" and "rules." Family theorists believe that the fam-ily is a system, a whole greater than the sum of its parts.In other words, one cannot predict the characteristicsand behavior of a system, in this case the family, simplyby looking at the characteristics and behavior of itscomponents, the family members. "Families have astructure, symbolic as well as real; they have bound-aries to maintain; instrumental and expressive func-tions must be performed to ensure the family's growthand survival" (Boss, 1988, p. 16). A family has "rules"to fulfill its functions and ensure its growth and sur-vival. Under normal stress-free conditions, a family'srules consist of implicit understandings about "whodoes what when." In addition, families share percep-tions and meanings about everyday events and aboutlarger issues such as the value of life, the efficacy orfutility of human action, and the justice or injustice ofthe world.

According to Burr and Klein (1994), families usu-ally interact with little difficulty, transforming inputs(energy, time) into outputs (meaning, affection) withease. "Family stress occurs when feedback indicatesthe family does not have the requisite variety of rulesto transform comfortably inputs into outputs that meetdesirable standards" (Burr & Klein, 1994, p. 34). For

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example, in the first months after parents learn thattheir child is deaf or hard of hearing, they may experi-ence stress because they lack "rules" about how tocommunicate effectively with a child who has a hearingloss. Furthermore, stress may lead to crisis if familymembers fail to perform roles, make decisions, andcare for each other. In crisis, the focus shifts from fam-ily to individual survival (Boss, 1988). According toReuben Hill's ABC-X model, the degree of familystress/crisis is the outcome (X) of a provoking event orstressor (A), the family's resources or strengths (B),and the meaning attached to the event by the family(C), thatis,A + B + C = X.

Family theorists have refined Hill's model in anumber of ways. Researchers have examined the stagesthat families experience as they attempt to cope withstress. The most common pattern is referred to as the"roller coaster" model in which the initial period ofstress or crisis is followed by a period of disorganizationand acute coping, which is followed by a recovery pe-riod and a new level or reorganization and normalfunctioning. Use of the roller coaster model led to theconcept of "stress pile-up," a situation in which fami-lies face additional stressors before reaching a level ofreorganization and normal functioning.

When faced with stress, families adopt strategiesin order to cope and reach a new level of functioning.Family coping strategies resemble individual copingstrategies in that they are defined as "the active pro-cesses and behaviors families actually try to do to helpthem manage, adapt, or deal with the stressful situa-tion" (Burr & Klein, 1994, p. 129). Additionally, familytheorists organize coping strategies into categoriessimilar to those employed by psychologists studying in-dividual coping (i.e., cognitive, emotional, community,etc). However, Burr and Klein (1994) add an interest-ing note to the study of coping strategies by suggestingthat families progress through a developmental se-quence in which level I coping strategies are adoptedinitially, followed by level II strategies if level I strate-gies fail, and finally level HI strategies in the event thatlevel II strategies are unsuccessful.

Level I strategies refer to attempts to change familyrules, for example, reassigning household responsibili-ties. Level II strategies refer to deeper changes, that is,rules about rules. An example of a level II change is

adjusting the intent and purpose of household routines.Finally, level HI strategies refer to changes in a family'sparadigm, its basic values and beliefs.

With regard to deafness, families often adopt levelI coping strategies. They adjust family rules as theyadapt to the demands of absorbing complex informa-tion about hearing loss, learning new communicationstrategies, and managing the educational and legal bu-reaucracy. Families use level II strategies as well. Anexample of the use of a level II strategy might be alter-ing the purpose of household routines from that ofmaintaining order to that of providing practice in com-munication skills. And finally, many families faced withadjusting to a deaf or hard-of-hearing child immedi-ately find themselves adopting level El strategies, asthey begin to question the meaning and purpose be-hind life's unexpected events.

Families and Children with Disabilities

Professionals who work with families who have chil-dren with disabilities have found it useful to conceptu-alize the family as a system attempting to manage thestress imposed by the child's disability. As Seligman(1991) points out, "A disability in one family memberaffects the entire system and in turn affects the disabledperson" (p. 27). Seligman describes the family in termsof its structure and function and makes a number ofpoints about how disability can influence the familysystem and vice versa. For instance, family structure isdefined by membership characteristics (single parent,extended family, etc); cultural style (beliefs, customs,etc); and ideological style, which is based on culturalstyle but is more specific to the individual family. Asan example, Seligman says that culturally based beliefsaffect the manner in which families adapt to a childwith a disability. Cultural beliefs can influence if andhow family members seek help, as well as the extent towhich members trust the advice of various profes-sionals.

Families are defined not only by their structure butalso by their interaction or function. Seligman positsfour components to interaction: subsystems (marital,parental, sibling, etc), cohesion and adaptability, com-munication, and other functions such as economic, do-mestic, recreational. Obviously, there are a number of

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ways in which a child's disability can affect a family'sinteraction. The quality of parents' marital relation-ship may influence how the child's disability is man-aged, and, conversely, the strain of dealing daily withdisability may affect the parents' marriage. In addition,a family's adaptability is a factor in how daily stressesare managed. As family members adjust to the needs ofa child with a disability, changes in roles may be neces-sary. For example, fathers and siblings may be asked toaccept greater caretaking responsibility.

As a final note, Seligman reminds us that familiesexist in a larger context both in terms of time andspace. Families have a life cycle—a beginning, middle,and end—that interacts with the changes imposed bydisability. Moreover, families live within a largercommunity and within a larger culture. Messages fromfriends, neighbors, health care workers, the mass me-dia, and the political system have a major impact on thefamily. In fact, an ecological view reminds us that, "Inunderstanding and helping famines with disabled chil-dren, one cannot only focus on the child, nor the childand the mother, nor the dynamics occurring within thefamily. Rather, it is becoming increasingly crucial toexamine the family within the context of larger social,economic, and political realities" (Seligman, 1991,p. 41).

Although Seligman's challenge to examine the fam-ily within the context of larger social, economic, andpolitical realities may seem overwhelming, Gallimore,Weisner, Kaufman, and Bernheimer (1989) have con-structed an ecocultural theory of family accommoda-tion to a child with developmental delay. Accordingto their scheme, families strive to create sustainableeveryday routines with their developmental^ delayedchildren. These daily routines or activity settings, asthe authors call them, not only accommodate broadereconomic and social forces, but also afford famines theopportunity to construct and communicate themes ormeanings associated with their own particular goalsand values. Thus, Gallimore et al. stress the impor-tance of both meaning and context in examining a fam-ily's efforts to cope with a child with a disability.

Seligman (1991) and others (e.g., Quittner, 1990;Wilder, 1986) who have sought to understand theimpact of disability on a family have noted that thestress experienced by families with disabled children is

chronic, rather than acute. Both the individual stressand coping paradigm developed by Folkman et al. andthe family stress model developed by Hill were firstused to explain reactions to acute stress. Nonetheless,Wilder (1986) points out that a number of researchershave used Hill's ABC-X model, either explicidy or im-plicidy, to study families of children widi mental retar-dation.

According to Wilder (1986), family stress meorycan be used to organize and understand a large numberof studies on families widi children with mental retar-dation. According to Hill's model, the stressor (mentalretardation) interacts with the family's resources (B)and the family's perceptions (C) to produce familystress/crisis (X). Thus, resources (B) and perceptions(C) are factors that mediate or buffer the stressful event(A) and die outcome (X). Wilder points out diat moststudies on families and mental retardation have ignoredmediating factors and simply reported on die impact of.a child with mental retardation on family functioning.

Nonedieless, a number of studies have focused onmediating factors (B and C) widiout using die concep-tual framework provided by Hill's model. According toWilder, die influence of family resources on the amountof family distress has been examined more often thandie relationship between family perceptions and dis-tress. And, of die large number of resources availableto families, social class and social support have been die-'two resources most studied. In general, higher socialclass and better social support have been shown to mit-igate the impact of mental retardation. However, thecomplex relationships among variables resist general-ization.

Wilder (1986) mentions two studies diat explicidyused Hill's ABC-X model to examine the impact ofmental retardation on family functioning. In die firststudy, the researcher found die stressor (A), rearing adevelopmentally delayed child, when interacting withfamily resources (B) and family perceptions (C), to besignificantly correlated widi amount of family distress(X). According to Wilder, when variables B and C wereremoved from die analysis, diere was no significantcorrelation between A and X. In the second study, theresearcher used the ABC-X model to explore whethermental retardation had a different impact on families atdifferent points across the life cycle. Transition periods

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(for example, the onset of puberty) were found more

stressful than nontransition periods.

Families and Deafness: Historical Perspectives

Although the above discussion is but a brief glance atthe literature dealing with families and disability, itsuggests that a family stress paradigm is useful in un-derstanding how families adapt to children with disa-bilities. While most professionals in the field of deaf-ness would agree that normally hearing parentsexperience great stress in rearing a deaf child, until the1970s, little notice was given to the interaction betweendeaf children and their families. Beforehand, writerstypically focused on the detrimental effects of deafnesson all aspects of development (Levine, 1967; Mykle-bust, 1964). Families were hardly mentioned, and whenthey were, writers usually noted that deafness had dev-astating effects on the family that only served to com-pound the deaf child's problems.

In the 1970s, writers began to pay attention to theimpact of a deaf child on the family and, conversely,the influence of the family on the child. Several writersconcentrated almost exclusively on the initial period ofmourning experienced by parents in reaction to the di-agnosis of deafness (Luterman, 1979; Mindel & Ver-non, 1974; Moses, 1985). In one of the earliest bookson the deaf child and his family, Mindel and Vernon(1974) discussed at length parents' reactions to the dis-covery of their child's deafness. These reactions in-cluded the stages of mourning human beings experi-ence in response to significant loss, that is, denial,rationalization, shock, guilt, anger, helplessness, andacceptance. According to the authors, "If the parentsfail to resolve their feelings of grief, anger, guilt, andhelplessness, they will be forced to remain arrested inthe earliest stages of their psychological reactions tothe child's deafness . . . . [T]he parents' early reactionsrelated to the discovery of deafness and their resolutionof these feelings toward the child influence all futuredecisions" (Mindel & Vernon, 1974, p. 22).

The realization that parents of children with disa-bilities experience grief and that mourning is a normalstage in parents' adjustment to a deaf child was an im-portant addition to our knowledge. But, because inter-actions between deaf children and their families are

necessarily complex and everchanging, writers' interestin family dynamics expanded beyond the initialmourning period experienced by parents. Two im-portant contributions to our understanding of familiesand deafness were made by Schlesinger and Meadow(1972) and Gregory (1976). Gregory interviewed 122mothers of young deaf children in Great Britain anddrew conclusions groundbreaking at the time. First,Gregory stressed the great diversity in parents' re-sponses to deafness. Second, she suggested that somecommonly held beliefs about deaf children and theirfamilies were simply not true. One was that motherswere unreasonably overprotective of deaf children, andanother was that parents allowed deaf children to un-necessarily restrict their social lives. Third, Gregoryconcluded that global prescriptions for deaf childrenand their families only created problems, and she ques-tioned whether integration into the hearing world wasa reasonable goal in all cases.

Also in the 1970s, Schlesinger and Meadow (1972)introduced the idea that deafness affected a child's de-velopment because it inhibited communication be-tween the child and the family. As evidence, the authorspointed to the superior performance of deaf childrenwith deaf parents (who generally communicated withtheir children from birth through Sign Language) ontasks requiring social maturity and independence. Al-diough the superior performance of deaf children withdeaf parents had been noted by researchers prior to the1970s, there had been little discussion of the factorsresponsible for this difference (see Altshuler, 1974).Schlesinger and Meadow pointed out that deaf parentsnot only communicated with their children from birth,but tended to take the diagnosis of deafness in stride.In addition, deaf children with deaf parents benefitedfrom their parents' personal knowledge of how to copewith being deaf in a hearing world. Thus, the authorssuggested that the quality of communication and inter-action between die deaf child and the family was a fac-tor that mediated the impact of deafness on the child.

At the end of the decade, Meadow (1980) articu-lated more fully her idea that communication operatedas an intervening variable between deafness and its de-velopmental outcomes. In addition, Meadow discussedat length how the presence of a deaf child put tremen-dous pressures on a hearing family. These pressures ei-

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ther created stress, acted as a focus for existing stress,or provided a rallying ground for increased family co-hesion. According to Meadow, how the possibilities forstress or growth emerged depended on a number offactors, including the quality of family resources.

In related work, Freeman, Mallcin, and Hastings(1975) agreed with Meadow that several factors inter-vened between deafness and its impact on both thechild and the family. Freeman et al. studied 120 deafchildren and their families in Greater Vancouver, Can-ada, and concluded that there were several factors, in-cluding delay in diagnosis and the influence of edu-cational controversies, that "make it difficult to sortout the inevitable primary consequences of childhooddeafness from the secondary social, medical and educa-tional factors" (p. 391).

As we approach the end of the twentieth century,professionals in the field of deafness seem to be arrivingat a consensus that the relationships between a familyand a deaf child are much more complex than pre-viously realized. In a discussion of the adaptation offamilies with school-aged deaf children, Calderon andGreenberg (1993) note that research has not supporteda stress-pathology model. In other words, it is not nec-essarily true that the stress involved in rearing a deafchild always results in negative outcomes for both childand family. According to the authors, a complex webof everchanging variables may interact to mitigate orexacerbate the impact of deafness on the family or, con-versely, of the family on the deaf child. Thus, whetherdeafness in a child results in positive or negative out-comes for a family may be impossible to predict at theoutset.

Families and Deafness: Research Perspectives

In review, the challenges faced by families adapting to

a deaf child fit the stress-coping paradigm suggested by

psychologists and family theorists. Individuals or fami-

lies in stressful situations must choose strategies to reg-

ulate emotions and to solve problems. Coping strate-

gies include intrapsychic mechanisms, information

search, direct action, and inhibition of action. In addi-

tion, the use of coping strategies necessitates accessing

coping resources, such as problem-solving skills, edu-

cational programs, social support, etc Parents of deaf

children must cope with the emotions associated withgrief, understand information on deafness and its im-plications, and make critical decisions regarding com-munication methods and educational interventions.These aspects of parents' coping processes have beenaddressed in a number of recent research studies.

Research on family stress and coping in responseto a deaf child can be organized into the following cate-gories: survey studies, comparative studies, correla-tional studies, and qualitative studies. These studiesexamine various aspects of the stress and coping pro-cess. According to both psychologists and family scien-tists, the outcome of the coping process depends uponthe family's or individual's appraisal of the situation aswell as on the evaluation and use of available resources.According to Hill's ABC-X model, A(stressor) + B(resources) + C (meaning or appraisal) = X (out-come). B and C can be seen as variables interveningbetween A, the stressor, and X, the outcome.

The first group of investigations, survey studies,depends upon self-report rather than direct observa-tion and thus, by design, focus on parents' appraisalsof the stressor, deafness, and the available resources,educational methods, and programs. The goal of sur-vey studies has been to examine parents' attitudes to-ward communication methods and educational pro-gramming. Kluwin and Gonter Gaustad (1991) sentquestionnaires to the families of 364 students in a lon-gitudinal study involving the schools of the NationalResearch and Development Network for Public SchoolPrograms for the Hearing Impaired. The purpose ofthe survey was to determine which factors influencedthe families' choice of communication method. The re-searchers found that mothers' mode of communicationpredicted both fathers' and siblings' mode of commu-nication. In addition, a greater degree of hearing loss,the use of manual communication in preschool, and ahigher level of maternal education were all correlatedwith maternal use of manual communication. Themain conclusion drawn from the study was that moth-ers are the primary decision-makers with regard tocommunication mode. From a stress and coping view-point, mothers' appraisal and choice of coping strate-gies strongly influence the behavior of other familymembers.

A survey study undertaken by Bernstein and Mar-

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tin (1992) examined another aspect of parents' copingprocess, that is, decision-making with regard to educa-tional placement. The researchers surveyed 357 hear-ing parents of hearing-impaired children to gather in-formation on factors that may have influenced parentsto place their children in residential settings. The re-searchers were also interested in assessing parents' sat-isfaction with both the placement information theyreceived and their child's placement. The survey re-sponses indicated that, although a large percentage ofthe parents were satisfied with their child's schoolplacement, only 36% of the parents were satisfied withinformation they had received. Interestingly, althoughthe greatest number of parents stated "better educa-tion" was presented to them as a primary advantage ofresidential schooling, the ability to communicateturned out to be the primary advantage based on theirexperiences. Thus, parents' appraisals of available re-sources indicated satisfaction with educational pro-gramming, but dissatisfaction with information onprogramming.

In another survey study, Bernstein and Barta (1988)compared and contrasted parents' and professionals'views on educational programming for parents. Ques-tionnaires were sent to parents and professionals inTexas. Results indicated that parents and professionalsagreed that communication and education were themost important topics in programming for parentsof hearing-impaired children. However, there weredifferences of opinion with regard to the importance oftopics across the child's age span. Parents rated almostall topics as important across the child's age span,whereas professionals viewed audiology and speech asimportant in the early years and discussion of thechild's future as important only in the later years. Inother words, parents and professionals differed in theirevaluation of the importance of various coping re-sources.

In summary, although survey studies permit gen-eral conclusions regarding the knowledge and attitudesof the parents who participate, they reveal little detailabout how families adapt to a deaf child. A second typeof study is the comparative study in which familieswith hearing-impaired children are compared to fami-lies without hearing impaired children. According toa stress and c6ping paradigm, the goal of comparative

studies is to find a connection between stressor (hear-ing loss) and outcome (family distress or well-being).Some comparative studies address mediating variables,such as family perceptions and family resources, whileothers do not. In a study evaluating the emotionaland marital adjustment of hearing parents of hearing-impaired youths, the investigators found that the par-ents of hearing-impaired youths reported fewer symp-toms of distress than did parents of hearing youths, andthat there were no differences in the marital satisfactionof parents in intact families (Henggeler, Watson,Whelan, & Malone, 1990). Interestingly, family cohe-sion was the most consistent predictor of parental ad-aptation and was associated with less distress, in moth-ers and greater marital satisfaction for both spouses. Asthe authors point out, this result meshes with the re-search in the field of family studies indicating that fam-ily cohesion is related to positive outcomes in reactionto stress.

Attempts to find the correlates of successful familyadjustment to deafness represent a third category ofstudies. In general, the goal of these investigations isto determine which factors (resources or perceptions)mediate the impact of the stressor (hearing loss) on theoutcome (family functioning). Calderon (1988) as-sessed 36 hearing families with school-aged profoundlydeaf children who were being educated in self-con-tained, total communication classrooms in publicschool programs. She evaluated the general personaladjustment of both parents as well as their specific ad-justment to the deaf child. The child's adjustment wasalso measured. Calderon's analysis was based on theFolkman et al. model of stress and coping. Thus, shereasoned that parental adjustment was a function of theuse of coping resources, specifically, social support,problem-solving skills, utilitarian resources, beliefs,and health/energy/morale. Calderon found that moth-ers who experienced fewer life stressors in the past orreported greater satisfaction with social support hadbetter personal adjustment. In addition, mothers' spe-cific adjustment to the deaf child was most relatedto satisfaction with social support. Interestingly, theamount of utilitarian resources available was not relatedto parental adjustment.

In examining paternal adjustment, Calderon foundno relationship between coping resources and adjust-

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ment. In fact, fathers' adjustment was found to be de-pendent on maternal adjustment and maternal use ofcoping resources. The impact of maternal adjustmenton paternal adjustment meshes with Kluwin andGonter Gaustad's (1991) finding that mothers play akey role in determining communication mode not onlyfor themselves but for the family as well. When Calde-ron examined child adjustment, she found that it washighly associated with maternal and paternal personaladjustment.

In a related study, Calderon, Greenberg, andKusche (1989) examined the influence of family copingon the cognitive and social skills of deaf children.Again, the Folkman et al. model of stress and copingwas used. According to die authors, the purpose of thestudy was to examine how five factors of coping re-sources (health/energy/morale, beliefs, social support,problem-solving skills, utilitarian resources) aflfect thefamily's adaptation and influence the child's develop-ment. Study participants included the 36 families ofCalderon's (1988) earlier study. Numerous instrumentswere used to assess parental use of coping resourcesand child outcomes. Results indicated the following re-lationships: maternal problem-solving skills were posi-tively related to the child's emotional understanding,reading achievement, and cognitive problem-solvingskills; maternal belief in chance was negatively relatedto the child's social problem-solving skill; utilitarian re-sources were correlated with reading achievement; and,finally, positive maternal adjustment to the child wasrelated to lower child impulsivity, greater cognitiveflexibility, and higher social understanding. Conversely,the investigators found no relationship between childoutcomes and maternal life stress, social support, andreligiosity. There was also no relationship between ma-ternal assessment of her own personal adjustment andchild outcomes.

The failure to find a relationship between the twomaternal factors, personal adjustment and experienceof social support, and the child outcomes, cognitiveand social skills, contrasts with Calderon's (1988) priorfinding that child adjustment was most related to pa-rental personal adjustment and maternal experience ofsocial support. In addition, in her earlier analysis, Cal-deron found no relationship between child adjustmentand utilitarian resources, whereas a significant relation-

ship was found between reading achievement and utili-tarian resources in the Calderon et al. analysis. It seemsthat child adjustment and achievement are differen-tially related to parental coping factors, with child ad-justment being related to parental adjustment andsocial support, and child achievement being relatedto parental problem-solving ability and utilitarian re-sources.

In addition to Calderon, a number of other re-searchers have suggested that access to social supportmoderates or buffers the stress involved in rearing achild with a hearing loss (Koester & Meadow-Orlans,1990; MacTurk, Meadow-Orlans, Koester, & Spencer,1993). In fact, MacTurk et al. (1993) found that thefamilies of deaf infants had social support networksequivalent to those of the families of hearing infants,and for both groups "the amount of support mothersreceived from family, friends, and professionals con-tributed significandy to the quality of later mother-child interaction" (p. 22).

Nonetheless, Quittner, Glueckauf, and Jackson(1990) have advised caution in the face of "widely heldnotions about the role of social support, and prematurerecommendations that increased support will be bene-ficial to those under high levels of stress" (p. 1266).Quittner et al. assessed parenting stress in 96 mothersof deaf children and 118 matched controls. The investi-gators also examined social support and distress symp^toms, such as depression and anxiety. They found nomoderating effects for social support. In contrast, par-enting stress was associated with lowered perceptionsof emotional support and greater symptoms of depres-sion and anxiety. The authors concluded that socialsupport mediated die relationship between stressorsand outcomes. In odier words, when mothers were ex-periencing stress, social support did not protect themfrom depression and anxiety. On die contrary, modiersexperiencing stress tended to experience their relation-ships as less supportive and less helpful.Quittner et al.interpret their results to mean that social support mayfunction as a buffer in situations of acute stress, but failin chronic stress situations, such as parenting a deafchild. But Gallimore et al. (1989) demonstrate evengreater caution and suggest that coping resources, suchas social support and income, are not good or bad inthemselves, but radier acquire their positive or nega-

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tive value in the context of the family's particular cir-cumstances and family-constructed themes or mean-ings. Thus, Gallimore et al. reiterate a feature of bothpsychologists' and family scientists' stress and copingmodels, that the meaning ascribed to both the stressorand various resources is critical to outcomes.

A final category of studies on family adaptation todeafness is qualitative research. The majority of quali-tative research consists of personal interviews and thusfocuses on family perceptions of the stressor and avail-able resources. In other words, qualitative research ex-amines how perception or appraisal mediates the im-pact of a deaf child on family functioning. Morgan-Redshaw, Wilgosh, and Bibby (1990) interviewed fivehearing mothers of hearing-impaired adolescents ontheir experiences in rearing a hearing-impaired child.Mothers were also asked to keep journals for a periodof two to three weeks. Journal entries and a second in-terview were used to validate the information gatheredduring the first interview. Transcripts of the first inter-view were analyzed for recurrent themes, and the fol-lowing six topics emerged as significant: (1) the moth-ers' personal growth, (2) the mother-child relationship,(3) parent-professional relationships, (4) concernsabout educational programming, (5) the importance offluent communications, and (6) support systems avail-able to the mothers.

Interestingly, content analysis of the interviewssupported many of the conclusions drawn from quanti-tative research. First, the mothers often expressed dis-satisfaction with professionals and with educationalprogramming. Second, mothers stressed the impor-tance of access to social support and of developing flu-ent communication with their children. And finally,the mothers assessed their child-rearing experience aschallenging, but personally satisfying.

In a similar study, Israelite (1985) interviewed 14female adolescent siblings of younger children with se-vere to profound hearing losses. Results indicated amixed pattern of sibling reaction to a hearing-impairedchild. In general, positive reactions were associatedwith positive family relationships and negative reac-tions with negative family relationships. Variabilityin sibling response seemed to be related to variabilityin parent attitudes and behavior. Israelite concludedthat the presence of a hearing-impaired child strength-

ens relationships in some families and exacerbates ten-uous situations in others.

As a final note on qualitative research, Gregory(1995) followed up her initial study of 122 deaf childrenand their families by reinterviewing the families 20years later. According to Gregory, many of the parentsremained concerned about their children, although thefocus of their concerns had shifted somewhat. Manyparents were concerned with their children's relation-ships with persons beyond the family and with the sta-bility of their employment.

In summary, it seems that writers and researchershave made progress in their understanding of the im-pact of a deaf child on a normally hearing family, butthat much remains to be learned. Traditionally, writersfocused on the negative effects of a deaf child on ahearing family. While it is true that hearing parentsexperience grief in reaction to the diagnosis of theirchild's deafness, the pattern of family response follow-ing the initial mourning period appears to be variable.Much of the research on family adjustment to a deafchild provides only general insights into the adjust-ment process. For example, surveys indicate that par-ents are not completely satisfied with the resourcesavailable (i.e., information delivery and educationalprogramming. In addition, surveys indicate that moth-ers play a key role in family adjustment. Comparativestudies as well as qualitative research suggest that hav-ing a deaf child in the family may not be as detrimentalas professionals once believed. In one study, measuresof marital satisfaction and family cohesion showed nodifference in families with a hearing-impaired member.'In other studies, personal reports suggested that ad-justment to a deaf child can result in personal growthand enhanced family relationships. Correlational stud-ies indicate that the presence of coping resources, suchas problem-solving skills and social support networks,contributes to successful adaptation to a deaf child. In-deed, the use of a stress and coping paradigm adaptedfrom the field of psychology has increased our under-standing of families and deafness.

Implications for Research and Practice

It is notable that, although investigators in the field ofdeafness have adopted the conceptual framework pro-

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vided by the literature on individual stress and coping,they have neglected the significant body of research inthe field of family stress management. Family research-ers are interested in how stress affects family roles andrelationships, in how families use coping strategies tosurvive and reach a new level of functioning, and inhow family coping behavior changes over time. Adopt-ing a family systems perspective suggests new ques-tions about how families adjust to a deaf child. Howdo family roles and relationships change when familieslearn of their child's deafness and attempt to adopt newcommunication modes? How does the search for ap-propriate educational placement affect family function-ing? What coping strategies do families use in responseto changing demands throughout the deaf child's de-velopment? Do families vary significantly in their useof coping strategies and in their pattern of ad justment?

Wikler's (1986) analysis of research on families ofchildren with mental retardation suggests that a stressmanagement paradigm is useful in understanding fam-ily response to a child with a disability. According toa stress management viewpoint, family resources andfamily perceptions operate as intervening variablesaffecting the impact of the stressor on outcomes. Fur-thermore, as Wilder points out, the use of a stress man-agement model reveals that, while many studies haveexamined the coping resources available to families, fewhave examined family perceptions of stressor or re-sources. With regard to the disability of deafness, itseems obvious that a hearing family's perception of thehearing loss itself, of its implications for the child andfamily, and of the resources available to the family is acritical factor affecting the family's adaptation. Indeed,qualitative studies involving in-depth interviews offamily members have demonstrated the importance offamily perceptions (Gregory, 1976; Israelite, 1985).

Currently, a number of debates in the field of deaf-ness would be better informed if a family stressmanagement view were adopted. Two issues underdiscussion are cochlear implants and bilingualism/ bi-culturalism. A cochlear implant is a device that is sur-gically implanted to stimulate the auditory nerve of thedeaf patient. Cochlear implants do not restore fullhearing and are only appropriate for a small number ofdeaf children. Nonetheless, the issue of medical treat-ment for deafness presents an example of how percep-

tions of available resources vary. Many hearing parentsof recently identified deaf infants react to informationabout cochlear implants positively, whereas deaf par-ents often react negatively. Although a complete dis-cussion of the dynamics underlying the different evalu-ations of cochlear implants is beyond the scope of thisarticle, the important point is that family (and commu-nity) dynamics should be considered in discussion ofcochlear implants.

In addition, the pros and cons of a bilingual/bicul-tural approach to the education of deaf children havebeen debated without reference to the response ofhearing families to such an approach (Stuckless, 1991).Again, a full discussion of this issue is beyond the scopeof this article, but professionals in the field of deafnessneed to remind themselves that educational trends aswell as medical treatments need to be examined in thecontext of family dynamics. Indeed, several writerspoint out that even larger social, economic, and politi-cal contexts need to be considered as well as the familycontext (Seligman, 1991; Gallimore et al., 1989).

In conclusion, psychologists' stress and copingparadigm and family researchers' stress managementmodel have proved useful in furthering our under-standing of family adjustment to deafness. Examiningthe reciprocal influences between deaf children andtheir families will not only further our understandingof the complex processes involved in family adaptation^but, ultimately, lead to more effective intervention fordeaf children and their families.

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Boss, P. (1988). Family stress management. Newbury Park, CA:Sage.

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