Considering parental hearing status as a social determinant of deaf population health: Insights from experiences of the "dinner table syndrome"

The influence of early language and communication experiences on lifelong health outcomes is receiving increased public health attention. Most deaf children have non-signing hearing parents, and are at risk for not experiencing fully accessible language environments, a possible factor underlying known deaf population health disparities. Childhood indirect family communication–such as spontaneous conversations and listening in the routine family environment (e.g. family meals, recreation, car rides)–is an important source of health-related contextual learning opportunities. The goal of this study was to assess the influence of parental hearing status on deaf people’s recalled access to childhood indirect family communication. We analyzed data from the Rochester Deaf Health Survey–2013 (n = 211 deaf adults) for associations between sociodemographic factors including parental hearing status, and recalled access to childhood indirect family communication. Parental hearing status predicted deaf adults’ recalled access to childhood indirect family communication (χ2 = 31.939, p < .001). The likelihood of deaf adults reporting “sometimes to never” for recalled comprehension of childhood family indirect communication increased by 17.6 times for those with hearing parents. No other sociodemographic or deaf-specific factors in this study predicted deaf adults’ access to childhood indirect family communication. This study finds that deaf people who have hearing parents were more likely to report limited access to contextual learning opportunities during childhood. Parental hearing status and early childhood language experiences, therefore, require further investigation as possible social determinants of health to develop interventions that improve lifelong health and social outcomes of the underserved deaf population.

The influence of early language and communication experiences on lifelong health outcomes is receiving increased public health attention. Most deaf children have non-signing hearing parents, and are at risk for not experiencing fully accessible language environments, a possible factor underlying known deaf population health disparities. Childhood indirect family communication-such as spontaneous conversations and listening in the routine family environment (e.g. family meals, recreation, car rides)-is an important source of health-related contextual learning opportunities. The goal of this study was to assess the influence of parental hearing status on deaf people's recalled access to childhood indirect family communication. We analyzed data from the Rochester Deaf Health Survey-2013 (n = 211 deaf adults) for associations between sociodemographic factors including parental hearing status, and recalled access to childhood indirect family communication. Parental hearing status predicted deaf adults' recalled access to childhood indirect family communication (χ 2 = 31.939, p < .001). The likelihood of deaf adults reporting "sometimes to never" for recalled comprehension of childhood family indirect communication increased by 17.6 times for those with hearing parents. No other sociodemographic or deaf-specific factors in this study predicted deaf adults' access to childhood indirect family communication. This study finds that deaf people who have hearing parents were more likely to report limited access to contextual learning opportunities during childhood. Parental hearing status and early childhood language experiences, therefore, require further investigation as possible social determinants of health to develop interventions that improve lifelong health and social outcomes of the underserved deaf population. PLOS

Introduction
Growing public health attention addresses underlying influences of early language acquisition and contextual learning experiences on lifelong health, such as the impact of the "30 million word gap" noted in children of low-income families [1]. One population for which early language experiences are particularly relevant is deaf children-the majority (more than 90%) of whom are born into hearing families [2] and cannot effortlessly access spoken language. Deaf children exposed to a natural sign language from birth are more likely to experience healthy, expected development than non-signing deaf children [3][4][5][6]. In contrast to deaf parents, hearing parents overwhelmingly do not sign with their deaf child [7][8][9]. The deaf population experiences significant health disparities-such as increased obesity, poorer mental health status (e.g., suicidal ideations, intimate partner violence, and interpersonal trauma), and increased use of the emergency departments, among others [10][11][12][13]. One possible underlying factor of these disparities and general deaf population health outcomes may be parental hearing status, moderated by parents' developmental language and communication choices for their deaf child. Chronic lack of accessible communication with hearing parents is a common childhood trauma reported by deaf adults [14]. Less than 8% of deaf children receive regular use of a natural sign language in fluent and bidirectional conversations [8]. Instead, common practice for deaf children's language development is often cochlear implants without natural sign language exposure. Cochlear implant research with non-signing children continues to demonstrate highly variable speech and language outcomes-with most not achieving comparable results to their hearing peers in large scale studies [15][16][17][18][19][20][21]. In contrast, implanted children who sign from birth can demonstrate desired speech and language outcomes [22,23].
These circumstances highlight that the majority of deaf children are at risk for not developing a native first-language foundation in either English or a natural sign language (i.e., American Sign Language). Delayed and/or absent exposure to an accessible first-language foundation is increasingly described as "language deprivation," which may create risk for various developmental consequences (such as a "language deprivation syndrome" in some extreme cases) across the lifespan [7,[24][25][26][27]. One such developmental consequence is adult brain structure differences based on timing and quality of childhood language access [28][29][30].
This context of language deprivation risks helps to inform what Deaf epistemology describes as the dinner table syndrome [31]-a catch-all phrase to explain a commonly experienced phenomenon in the Deaf community of observing indirect auditory conversations and being unable to understand what is said, such as family discussions at the dinner table. Recent studies indicate that indirect family communication during childhood, such as family medical histories and general family health discussions, is an important source of health knowledge and literacy-domains in which many deaf adolescents and adults have gaps [32,33].
Indirect family conversations include health-related contextual learning opportunities (e.g., "My mother has diabetes, her mother had a similar problem.") that children often internalize as part of their adult health knowledge. As a result of not accessing health-related contextual learning opportunities (also described as incidental learning opportunities) [33], many deaf adolescents struggle with health vocabulary and knowledge-such as misconceiving cholesterol as something that might be added "to food to make it taste better" or something that actually "makes the heart pump better" [32]. Unfortunately, this appears to be a common phenomenon as many deaf adults are unable to describe the typical signs and symptoms of heart attack and stroke [34]. As a result, ongoing research is now focusing on specific dimensions of deaf people's health knowledge and literacy (e.g., interactive health literacy) in order to identify some root causes for the relative poorer health of deaf people [33]. Access to indirect family communication is important for contextual learning opportunities, so it is not surprising that perceived ability to access parental communication is associated with deaf adolescents' quality-of-life outcomes [4]. The dinner table syndrome phenomenon, situated in context of the broader risks of language deprivation, likely has a significant impact on health outcomes of deaf people. Therefore, just as socioeconomic status serves as a useful indicator for a set of environmental influences on childhood development, parental hearing status might be a comparable marker for deaf children's lifelong health outcomes as partially represented here by access to contextual learning opportunities.
The aim of this study is to assess whether or not parental hearing status influences deaf adults' recalled access to indirect family communication during childhood. We hypothesize that deaf adults with at least one deaf parent will report greater access to indirect family communication during childhood than deaf adults from families with hearing parents. Combining subject responses about their mother and father's hearing status generated an "at least one deaf parent" variable. Recalled comprehension of indirect family communication responses were generated from a recoding of four responses ("most of the time," "sometimes," "a little," never") into a meaningful logical construct of two responses ("most of the time," "sometimes to never") for the following question: "The next question will ask you about your experience communicating with your family when you were growing up as a child. So please think back to when you were younger than 18 years old. Family means your mother, father, sister or brother. It can mean your real parents, step parents, adopted parents or anyone you live with most. How often did you understand what your family members said when they were talking to each other (not directly to you) such as at the dinner table or in the living room?" Analyses were performed in SPSS v23.0. Cochran's test of conditional independence and Mantel-Haenszel's test of common odds ratio estimate were performed to investigate possible sociodemographic and deaf-specific confounders. The resulting variables were entered into a logistic regression model to predict influence of parental hearing status on comprehension of indirect family communication. Possible confounders included in the analysis were common social and deaf-specific demographics (see Table 1) that were at least marginally (< .10) significant with both the predictor and outcome variables.

Results
Parental hearing status predicted recalled comprehension of indirect family communication (χ 2 = 31.939, p < .001 with df = 1). Prediction success overall was 80.6% (33.3% for "most of the time" and 97.2% for "sometimes to never"). As seen in Table 1, having hearing parents increases the likelihood of reporting "sometimes to never" for recalled comprehension of indirect family communication by 17.6 times (Odds Ratio = 17.6, 95% CI: 5.6-55.8). No other sociodemographic or deaf-specific factor-including having hearing aids or cochlear implants-predicted these deaf adults' recalled access to childhood indirect family communication, and were not included in the final regression model.

Discussion
Childhood indirect family communication is a central component of contextual learning opportunities that influences adult health outcomes. Consequently, it is important to understand the indicators and circumstance that influence and fosters contextual learning so we can identify those at risk for poor lifelong health outcomes. Respondents' recalled understanding of childhood indirect family communication was moderated by parental hearing status. This helps highlight the potential role parents of deaf children have in reducing current health disparities seen in the deaf population.
In particular, our findings exemplify the "dinner table syndrome" phenomenon that is a widespread experience for deaf people, but has yet to be studied analytically. From a public health standpoint, it is important to recognize that the sample reflects known proportions of parental hearing status and more than 90% of deaf children are born into hearing, typically non-signing households [9]; additionally, 80.1% of participants reported pre-lingual hearing loss onset at three years or younger. Consequently, it is possible the majority of deaf children are at risk for suboptimal access to contextual information beyond the current sample. Most importantly, parental hearing status and associated language developmental choices deserves more investigation as a useful predictive marker for both life outcomes of deaf people and as a critical target for future preventive interventions.
In this sample, having hearing aids and cochlear implants did not improve access to contextual learning opportunities for deaf adults who grew up in hearing families-although interpretation of this is limited because age of implantation and length of implant and hearing aid use was not asked. Regardless of whether adults in this sample may have gotten implants later in life, as only those under 30 would have been able to receive an implant in early childhood, this finding is similar to Smith and Samar (33) demonstrating the limited benefit of cochlear implants on deaf adolescents' health literacy. All in all, these findings align with growing recognition of the risks of language deprivation and current limitations of using auditory intervention technology as a standalone approach (i.e., the common approach of cochlear implants with no natural sign language exposure), and requires more investigation.
While deaf parents are three times more likely to use sign language regularly at home with their deaf child than hearing parents [9], the positive impact on development likely goes further than just language exposure. For instance, a deaf child may feel less "different" or "leftout," influencing their adult perceptions of inclusion and recalled access to indirect family communication. The known benefits of early sign language exposure do not have to be limited to a small percent of deaf children. Public health programs that incorporate deaf adult mentors can have positive outcomes for language and family well-being [36]. Further research on the role of having at least one deaf parent in a family and/or access to deaf adults would be useful for developing targeted strategies (such as a deaf mentor program) that holistically support hearing parents and family members in creating a healthy environment for the deaf child.
Overall attention to childhood language experiences should be a public health priority to improve the lifelong health outcomes of the deaf population. The findings of this study also highlight the important potential role of contextual learning for lifelong health outcomes in the public health literature. Other groups such as children from low SES families likely experience similar barriers, as represented by the "30 million word gap" phenomenon. Future public health research and interventions should include considerations of access to health-related contextual learning opportunities, especially for at-risk populations.
Our study is limited in that the RDHS-2013 recruitment methods mainly focused on outreach to deaf sign language users. No measure of childhood communication modalities (e.g., spoken language, sign language) was included and childhood experience was based on recall. Additionally, the variable of interest is one item from a cross-sectional survey. Future research should include additional items to assess a wider scope of contextual learning opportunities and elucidate more aspects of this complex phenomenon.

Conclusion
Deaf individuals' recalled access to indirect contextual learning opportunities is an important childhood experience moderated by their parents' hearing status. Parental hearing status and associated developmental language choices needs further investigation as a social determinant of deaf population health. Public health research should focus on early childhood language and communication experiences of deaf children at risk for language deprivation and other atrisk populations to improve their lifelong health and social outcomes.