Introduction

Bilateral permanent childhood hearing impairment affects approximately 1 to 1.3 of every 1000 live births [1-3]. This physical handicap influences communication and cognitive functioning but can also result in an increase in psychopathological symptoms [4-6]. Children with hearing loss are at risk of developing psychopathology, which has detrimental consequences for academic and psychosocial functioning later in life. People with hearing loss encounter practical and social problems beyond those experienced by people who have their hearing. This may increase the risk of people with hearing loss developing mental health problems [7]. People who lose their hearing may give up interests and activities and this can impact on psychological well being [7]. Hearing loss can have an impact on quality of life and can lead to isolation, anxiety and depression [8] Losing one’s hearing due to illness or age may also lead to sadness about the loss of hearing and impact on one’s mental health and wellbeing [9,10]. Poor communication plays a large part in increasing the risk of anxiety and depression in deaf and hard of hearing people. Some deaf people are proactive in finding ways to communicate, such as pen and paper, etc. Other deaf people become shy and withdrawn. Adolescence is the stage of development between childhood and adulthood. During adolescence, peer relationships deepen [11]. The onset of adolescence is concurrent with early sexual maturation which may occur in school ages [12]. Adolescence is characterized with physical and psychosocial changes associated with intense emotions [13]. Moreover, depression, anxiety, and low selfconfidence are some of the most prevalent psychiatric disorders among adolescents [14]. Ear impairment refers to defect in or damage to auditory mechanism and its severity ranges between mild to severe deafness. People with hearing impairment may suffer from partial to complete inability to hear [15]. Adolescents with hearing loss, as with hearing adolescents, have been reported to have normal distribution of intelligence scores [16]. However, certain debilitating behavioural problems are prevalent in people with hearing impairment that cause many difficulties for these people and their families [17]. Generally, hearing impairments may be presented as various responses in individual, educational, and social arenas. Hearing impairment may lead to delayed speech, paranoia and isolation in individual arena, unreal laziness and false educational backwardness in educational arena, and antisocial disorders and reactions and even taking revenge in social arena. Social anxiety disorder (SAD) is one of the problems among children and adolescents with hearing impairment. Children and adolescents with hearing impairment have been found suffer from more behavioural and emotional problems, including social anxiety, than normal people do [18]. Anxiety is not a recently known disorder, and people at any stages of life and from any culture may experience it [19]. In the recent two decades, SAD has been recognized as one of the most prevalent chronic psychiatric disorders and the most common anxiety disorder. SAD refers to extreme or irrational fear of being evaluated or judged in social performance-based situations [20].

Recent epidemiological studies have reported the lifetime prevalence of SAD to be 2.4-16% in general population, and SAD is more prevalent in adolescent populations [21]. SAD affects mental health of affected people and health of both affected people and communities very adversely [22]. Reduced accountability [23] and absence from work [24]. Are two outcomes of social anxiety. Generally, children and adolescents with SAD suffer from severe emotional, academic, and social damage [25]. Studies have demonstrated that assertiveness training can affect the problems with cognitive and behavioral dimensions such as anxiety, depression, social phobia, and increased social interactions [26]. Assertiveness training is meant to help people change their attitudes toward life, improve their assertiveness, express their mood and thoughts rationally and therefore boost their self-confidence. Assertiveness training has been widely used for people at different ages and in different fields. It is believed that assertiveness group training has many advantages over individual training, as the members can practice assertive behaviors in the classroom and learn from each other. Besides that, there are more opportunities to persuade, encourage, and boost assertiveness in a group [27].

Many children and adolescents with hearing impairment suffer from many emotional, intellectual, and social disorders, most important of which are SAD and incidence of socially inappropriate behaviors. Moreover, most of these children and adolescents experience academic failure, school drop, avoidance, isolation, and depression. More clearly, children and adolescents with hearing impairment are shy and non-assertiveness, and their feelings of self-worth is gradually minimized. As a result, their motivations to do things are reduced and therefore experience failures consecutively. These failures cause them to develop this belief that they will never be successful at the community level. Facing bitter and unsuccessful experiences causes development of non-assertiveness in these people that is gradually boosted over time. Because these disorders and associated problems affect the process of growth in children and adolescents, especially those with hearing impairment, adversely, are considered the main barriers to rehabilitation, and causes certain limitations for then in social interactions, then it is vital to offer strategies and interventional programs that help decrease psychiatric and behavioral disorders and make training and rehabilitation efficient in these children and adolescents. To treat social anxiety, various theoretical points of view and, by extension, numerous approaches have been offered. Assertiveness training is an interventional programs that contributes to enhancement of self-esteem, relief of anxiety, stress, and depression, improvement of communication-social skills, rational expression of thoughts and emotions, observance of others’ rights yet gaining of one’s own rights, and ultimately improvement of life satisfaction and happiness. Assessment training has been found to help enhance assertiveness, selfesteem, interpersonal interactions, and communication skills as well as relieve SAD [27]. A study conducted on a group of students and university students suffering from high levels of anxiety and low assertiveness demonstrated that the effect of assertiveness training was more marked in the intervention groups than in control groups, and helped relieve anxiety and increase assertiveness [28,29].

Purpose of the study

Therefore, regarding the traits of non-assertiveness people with hearing impairment and the potential optimal effects of assertiveness training among these people, this study was conducted to investigate the effectiveness of assertiveness training on relief of SAD in non-assertiveness adolescents with hearing impairment. In other words, the main purpose of this study is to investigate whether assertiveness group training contributes to relief of SAD among adolescents with hearing impairments and whether the effectiveness of this type of assertiveness training on levels of SAD is different between adolescents with partial and complete inability to hear. Accordingly, four hypotheses are raised in this study:

1. The effectiveness of assertiveness group training on levels of SAD is different between adolescents with partial and complete inability to hear;

2. The effectiveness of assertiveness group training on levels of fear is different between adolescents with partial and complete inability to hear;

3. The effectiveness of assertiveness group training on levels of assertiveness is different between adolescents with partial and complete inability to hear;

4. The effectiveness of assertiveness group training on levels of Physiological discomfort is different between adolescents with partial and complete inability to hear;

Materials and Methods

Study design, study population, and sampling

In this semi-experimental, controlled study involving pretest-post-test, study population consisted of all deaf and hearing impaired students of schools of special education needs aged 12-16 years diagnosed with SAD in Shahrekord, southwest Iran. Forty eight, 24 deaf and 24 hearing impaired, adolescents were enrolled in the study by convenience sampling after they were diagnosed with SAD in the light of their scores (above 40) for Connor Social Phobia Inventory 2000 (SPIN) administered to them. Twelve deaf and 12 hearing impaired participants were randomly assigned to intervention group and the rest to control group. According to the findings, to interpret the scores, SPIN distinguishes people with SAD from those without SAD with cutoff point and diagnosis efficiency of 40 (50) and 80% (89%).

Study instruments

SPIN: In this study, SPIN, developed by Connor et al to investigate social anxiety, was used to gather data. This inventory is to investigate three clinical domains of social phobia, i.e. fear, avoidance, and physiological symptoms of social anxiety. SPIN is a self-assessment scale consisting of 17 items to investigate three subscales, fear (six items), avoidance (seven items), and physiological discomfort (four items).

The items are rated using a 5-point scale: 0 = not at all, 1 = a little bit, 2 = somewhat, 3 = very much, and 4 = extremely. Therefore, the total score for SPIN ranges from 0 to 68. This instrument has been reported to have high validity and reliability. Its reliability was derived 0.78-0.89 by test-retest for people with social phobia and its internal consistency (Cronbach’s alpha) obtained 0.94 for a normal population. Besides that, Cronbach’s alpha of the subscales fear, avoidance, and physiological discomfort was reported to be 0.89, 0.91, and 0.80 respectively. Construct validity was investigated by comparison of the scores of two groups of the respondents; one diagnosed with SAD and the other consisting of normal people diagnosed with no psychiatric disorders. The scores of the two groups were significantly different representing high validity of SPIN.

Program of assertiveness group training

In the program of assertiveness group training, certain skills were thought to boost assertiveness and improve assertive behavior in non-assertiveness people within 10-60 minute sessions by a trainer of children and adolescents with hearing impairment. For each session, certain purposes were set and the training and activities were aligned with and implemented according to these purposes. At completion of each session, the participants were asked to do a number of assignments to help learn the taught materials to them better. This program included certain subjects including rejecting a request, expressing one’s own limitations, requesting, initiating a social encounter, expressing positive feelings, dealing with and embracing criticism, accepting that one is different from others, and being assertive in situations in which one should help and receives negative feedback.

Procedure of the study

After the university provided approval for the protocol of the study and necessary coordinations were made with Education Organization and Special Education Office of Chaharmahal va Bakhtiari Province as well as the schools, SPIN was administered to all the students to select the samples, and then the samples were randomly assigned to two groups, intervention and control. First, some explanations about the research purposes and the instruments were given to the samples of both groups and SPIN was administered to them under similar conditions. This administration was considered pretest. After pretest, only intervention group attended ten sessions of assertiveness training (Table 1). Immediately after completion of the sessions of assertiveness training, SPIN was re-administered to both groups under similar conditions. Then, the data were analyzed.

Table 1. Summarizes the contents of each session.

Data analysis

To analyze the data, descriptive and inferential statistics were used. For descriptive statistics, frequency, central tendency indexes (mean, mode) and distribution indexes (variance, standard deviation, mean standard error) were used. For inferential statistics, ANCONA was used.

Results

As shown in Table 2, the mean scores of all subgroups in intervention and control group were not so much different. The standard deviation of all groups were also different. Then, ANCOVA was performed using SPSS to see whether the differences between the groups were significant or not. The results are presented in Table 3.

Table 2. Descriptive Statistics of the Deaf Participants’ Performance on Social anxiety disorder, Fear, Avoidance and Physiological discomfort in Pre and Posttest.

According to Table 3, the mean differences between the groups were not significant. The level of significance for all groups of Social anxiety disorder, Fear, Avoidance, and Physiological discomfort were respectively, 0.296, 0.239, 0.414 and 0.254 that are above 0.5.

Table 3. ANCOVA results on studied variables in intervention and control groups of deaf adolescents.

This shows that none of the studied variables are significantly different in both intervention and control groups of deaf adolescents between pretest and posttest. Therefore, it can be argued that assertiveness group training was not effective on SAD in deaf adolescents.

As Table 4 demonstrates, there are a lot of differences between mean scores of the all subgroups in intervention and control group. Then, ANCOVA was performed to determine whether the differences between the groups were significant or not. The results are presented in Table 3.

Table 4. Descriptive Statistics of the hearing- impaired Participants’ Performance on Social anxiety disorder, Fear, Avoidance and Physiological discomfort in Pre and Posttest.

As Table 5 demonstrates, except than the Physiological discomfort group mean differences between the groups were significant. The level of significance for Physiological discomfort group was 0.68 which is above 0.5 and is not significant. But, for other groups the level of significance were 0.000 which is less than 0.5 and is significant. SAD, fear, and avoidance are significantly different between the intervention and control groups of hearing impaired adolescents at both pretest and post-test. Therefore, it can be argued that assertiveness group training program was effective on SAD, fear, and avoidance in hearing impaired adolescents. However, physiological discomfort was not significantly different between the intervention and control groups at both pretest and post-test.

Table 5. ANCOVA results on studied variables in intervention and control groups of hearing impaired adolescents.

Discussion and Conclusion

The present study was conducted to compare the effectiveness of assertiveness group training SAD between deaf and hearing impaired adolescents. The findings of this study demonstrated that assertiveness group training was effective on SAD among the hearing impaired adolescents; in other words, assertiveness group training could improve SAD in the hearing impaired adolescents. Therefore, the first hypothesis of this research, i.e. the effectiveness of assertiveness group training on SAD is different between deaf and hearing impaired adolescents, is confirmed. As already mentioned, the program of assertiveness training is an interventional approach to enhance self-esteem, express thoughts and emotions rationally, relieve anxiety, stress, and depression, and improve communicationsocial skills, and various studies have been conducted using this interventional approach. Training assertive behaviors contributed to interpersonal relationships in critical situations among women [30]. Paterson et al study on a group of students and university students with high anxiety and non-assertiveness demonstrated that training assertiveness helped relieve stress and improve assertiveness28. Warland et al. found that university students’ scores for assertiveness generally improved after training assertiveness to them [31]. The findings of the present study confirmed the second hypothesis, i.e. the effectiveness of assertiveness group training on fear is different between deaf and hearing impaired adolescents. More clearly, hearing impaired adolescents’ fear can be reduced by assertiveness group training. To the best of our knowledge, no study was found to report consistent findings with the present study. A study found that training assertiveness skills caused coping behaviors to increase and non-coping behaviors to decrease among the students [32]. The third hypothesis of the study stating that the effectiveness of assertiveness group training on levels of avoidance is different between adolescents with partial and complete inability to hear was also confirmed. This means that assertiveness group training was effective on the levels of avoidance and caused improvement of avoidance in hearing impaired adolescents. The findings did not confirm the last hypothesis of this study, i.e. the effectiveness of assertiveness group training on levels of assertiveness is different between adolescents with partial and complete inability to hear. This means that assertiveness group training was not effective on the levels of physiological discomfort among deaf and hearing impaired adolescents. To the best of our knowledge, no study was found to report consistent findings with the present study. To explain the findings of the current study, it can be argued that the remaining hearing sense and language skills of hearing impaired children and adolescents are appropriately evolved in the structures of school and family, that leads to internalization of positive self-concept in them. As a result, an appropriate context is provided to train assertiveness to these children and adolescents. Therefore, equipping people with hearing impairment, especially hearing loss, with assertiveness skills depends on their remaining hearing sense such that SAD and its components such as fear and avoidance can be improved. For this reason, the remaining hearing sense persuades hearing impaired adolescents to exploit this amount of hearing as much as possible compared with deaf adolescents and therefore use assertiveness training programs to cope with SAD which is considered a main problem in these adolescents. To explain lack of confirmation of the fourth hypothesis, we can argue that physiological discomfort has a bodily basis and therefore has not been affected by hearing quantity and quality and assertiveness training program in this study. However, it can be argued that generally assertiveness group training has optimal effects on the levels of SAD in adolescents with hearing impairment, especially hearing loss. Therefore, it is recommended training of social skills, such as assertiveness, be incorporated into the curricula in the schools for hearing impaired students. Besides that, the parents with hearing impaired children are recommended to teach assertiveness skills to them. Similar studies can be conducted to comparatively investigate hearing impaired and hearing children.

Acknowledgment

Study has been funded by department of psychology and educational sciences, school of sychology, Allame Tabatabaei University, Tehran, Iran, as a Master of Science thesis.

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