Fathers of Young Deaf or Hard-of-Hearing Children - A Sistematic Review

Journal of Deaf Studies and Deaf Education, 2021, 187–208
doi: 10.1093/deafed/enaa039
Advance Access Publication Date: 18 January 2021
Theory/Review Manuscript
T H E O RY / R E V I E W M A N U S C R I P T
Fathers of Young Deaf or Hard-of-Hearing Children:

A Systematic Review
Amy Szarkowski1,2,3 , and Evelien Dirks4,5,*
1 Children’sCenter for Communication/Beverly School for the Deaf (CCCBSD), 2 Division of Developmental
Medicine, Boston Children’s Hospital, 3 Department of Psychiatry, Harvard Medical School, 4 Dutch Foundation
for the Deaf and Hard of Hearing Child and 5 Department of Psychology, Utrecht University
*Correspondence should be sent to Evelien Dirks, Dutch Foundation for the Deaf and Hard of Hearing Child, Lutmastraat 167, Amsterdam 1073 GX,
The Netherlands (e-mail: [email protected])
Abstract
Much of the literature exploring the role of parents of children who are deaf or hard of hearing (DHH) has focused on
mothers; yet, the involvement and perspectives of fathers is valuable and warrants attention. Following the PRISMA
guidelines, this systematic literature review examined the peer-reviewed research that has differentially explored the
experiences of fathers and mothers of young DHH children. Utilizing three databases (Web of Science, PsychINFO, Scopus)
and spanning 50 years (1969–2019), 457 non-duplicated articles were identified that included the fathers of DHH children,
birth to six years. Independent review of the titles, abstracts, and keywords by the authors limited these to 119. Full
manuscripts were assessed for eligibility; 37 were deemed appropriate for inclusion in this systematic review. The papers
included have been organized into the following themes: perspectives on parenting, parental stress and coping, parent-child
interaction, involvement in early intervention, parental self-efficacy, and benefits of fathers’ inclusion. Recommendations
for future research include: (a) actively recruiting fathers in research, (b) differentially analyzing fathers’ and mothers’
experiences in research studies, (c) using information gleaned from research regarding father-child and mother-child
interactions to guide interventions/programming, (d) recognizing the bidirectional inf luences of fathers and their DHH
children, (e) moving beyond descriptive studies to explore fathers’ inf luences on child outcomes, and (f) recognizing diverse
family constellations.
In the mid-1970s, Michael Lamb, renowned child development that compelling research of father-infant attachment, father-
scholar, described how the contributions of fathers to child infant interaction, and differences in paternal and maternal
development had been largely overlooked and underestimated styles of interacting with young children.
(Lamb, 1975). Lamb argued for a new theory of child development Eighteen years later, the Committee on Psychosocial Aspects
that hypothesized that fathers play a vitally important role in of Child and Family Health of the American Academy of Pedi-
their child’s development, and in particular in their socialization, atrics, led by Yogman and Garfield (2016), published a Clinical
albeit a role that is qualitatively different from that of most Report on fathers’ roles in the care and development of their
mothers. children. This document highlighted a number of shifts that
In a 1998 Supplement on Early Emotional Development in had occurred with respect to fathers’ involvement, including
the journal Pediatrics, Pruett (1998) articulated that fathers make (but not limited to) the increased amount of time fathers spend
“definite contributions to infant development” (p. 1253), noting with children, the increased level of involvement of fathers with
Received August 7, 2020; revisions received October 21, 2020; accepted October 22, 2020
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188 Journal of Deaf Studies and Deaf Education, 2021, Vol. 26, No. 2
these children across the span of childhood, the increased role To date, no overarching recognition of the importance of
that fathers of children with disabilities play in their child’s fathers of children who are DHH has been written in the liter-
care (in the home and with medical professionals), and the ature, no guiding document arguing for the inclusion of fathers
increased understanding of the influence that fathers’ physical has been published, no meta-synthesis of the impact of fathers’
and mental well-being has on their children. involvement on their DHH children has produced, and no “call
Acknowledging the substantial impact of fathers’ involve- to action” to include fathers in research has been documented
ment on a variety of child outcomes—such as cognition, in the literature on fathers of children who are DHH.
improved mental health, and a number of physical health
conditions—Allport et al. (2018) argued for researchers and
clinicians caring for families to shift from a focus on the mother-
Rationale for the Present Study
child dyad to incorporating the mother–father-child triad in
their work. They proposed a behavioral model of factors the Given their research interests in understanding young children
influence fathers’ involvement that considers many factors, who are DHH and their families, the authors of the present
which they conceptualized as falling within three broad areas: review found themselves questioning whether, as Lamb (1975)
fathers’ attitude, the perceived norms pertaining to involvement, had suggested, the literature related to children who are DHH
and fathers’ sense of personal agency (p.749). had also reconceptualized the role of fathers and begun to
In a meta-synthesis that examined the experience of fathers value understanding fathers’ unique roles. The present study
raising children with Autism Spectrum Disorder, researchers sought to explore—in the existing literature on parents and
explored fathers’ experiences and perceptions of their experi- families that include young children who are DHH—the extent
ence in the role of fathers (Lashewicz, Shipton, & Lien, 2019). In to which fathers have been included in studies and whether
addition to the three main findings of the review (i.e., adaptation their responses were analyzed separately from mothers. To our
and concern for the future, the importance of cultural context, knowledge, a review of fathers’ experiences and perspectives
and reverence for child and new opportunities), the review high- within this context has not been previously undertaken.
lighted the need for father-oriented resources that recognize This review has been conducted to systematically analyze
fathers’ value in children’s lives (p. 117). the literature and identify existing gaps in knowledge on the
Although studies of fathers of children with disabilities do topic of fathers of DHH young children. The authors utilized
exist, it is important to consider the experiences and perceptions Best Practices guides for conducting systematic reviews (Pollock
of fathers of DHH, as these are likely to differ in important ways. & Berge, 2018; Siddaway, Wood, & Hedges, 2019) and used the
Yet, the literature exploring the topic of fathers of DHH children PRISMA Statement (Preferred Reporting Items for Systematic
is limited. Researchers have articulated the need to explore the Reviews and Meta-Analyses) by Moher et al. (2009) to ensure the
role of fathers of children who are deaf or hard of hearing (DHH): highest quality standards were employed for this study.
The paucity of research focusing solely on fathers con-

tinues to provide little understanding of how fathers Objectives
are influenced by their child with a disability, the The explicit questions asked by the authors, using PICOS guide-
impact fathers have on that child, or how fathers lines (Moher et al., 2009), were as follows:
influence other family members’ interactions or per-
ceptions of that child (Calderon & Low, 1998, p. 226). 1. Participants—How and to what extent have fathers been
included in studies of young children who are DHH?
Admittedly, the current systematic review is heavily weighted 2. Interventions/measures/instruments—What was being
toward the experiences of hearing fathers, as this is what is assessed, or what were the foci of the studies involving
currently documented in the literature. Yet, it is important to fathers (or fathers and mothers) of children who were DHH
examine the experiences of fathers of children who are DHH between birth-to-6 years of age?
should include both hearing fathers and deaf fathers as their 3. Comparisons—If fathers and mothers were both included in
experiences may differ. Given that the majority of studies of a study, were the results of each reported separately? Did
fathers of DHH children involve fathers with typical hearing, the researchers explicitly differentiate the contributions of
it can be important for readers to note that the majority of fathers and mothers in the study and comment on the simi-
findings described in this systematic review are informed by larities and/or differences in their findings? If fathers of DHH
that particular lens. Fathers who are deaf may have a different children were compared with fathers of children who had a
lens through which they see their experience. For example, DHH typical hearing or with fathers of children with disabilities,
infants with deaf parents who communicate via sign language what was unique to the experience of being a father to a child
show greater gaze-following in early adult-infant communica- who is DHH?
tion compared to hearing controls (Brooks, Singleton, & Melt- 4. Outcomes/main findings—Were the outcomes described in
zoff, 2020). Deaf parents—including those who did and did not terms of the fathers’ experiences or perceptions or on the
use sign language—have been described as employing effective perceived influence of the fathers on their children? Descrip-
communication strategies with their young DHH children, which tive studies that mentioned fathers, but not their experiences
has been linked to higher vocabulary scores for DHH infants or perceptions, were excluded (e.g., papers that documented
with deaf parents when compared to DHH infants with hearing paternal genetic contributions to a hearing loss).
parents (Yoshinaga-Itano, Sedey, Wiggin, & Chung, 2017). While 5. Study design—Did the study incorporate qualitative, quanti-
neither eye gaze nor DHH infant vocabulary is the foci of the tative, or mixed methods research approaches? All of these
present paper, these examples highlight the potential differen- were included for this systematic review; however, single
tial influences on the DHH child when their father is deaf. case studies were not.
Fathers of Young Deaf or Hard-of-Hearing Children 189
Methods <fathers> AND < children OR toddlers OR infants> AND <

hearing loss OR deaf OR hard-of-hearing OR hearing impairment
Inclusivity/Exclusivity Criteria
OR cochlear implant>.
Inclusivity criteria. The following criteria were established for Selection of studies for inclusion in the review. Both authors inde-
inclusion in the review. Included papers must: (a) be peer- pendently reviewed each abstract and rated them against the
reviewed papers published in English prior to the end of August inclusionary criteria. Manuscripts were independently rated red
2019, as this review commenced in September 2019; (b) mention (excluded), yellow (potentially included; discussion required), or
fathers—either alone or in addition to mothers—in the title, green (included). Through this process, the two raters agreed
abstract, or keywords; (c) describe fathers of DHH children on the inclusion of all of the manuscripts with the exception
birth to six years of age; and (d) utilize quantitative, qualitative of two papers (thus inter-rater reliability was 98.3%). These two
or mixed methods approaches to research. Papers that met manuscripts were then reviewed by both authors and the deci-
the inclusivity criteria are included in the descriptive table of sion regarding inclusion was jointly made.
studies (below). However, some manuscripts met the inclusivity Evidence synthesis. Both researchers reviewed all of the
criteria (e.g., mentioned fathers in the title or abstract), yet included articles and independently generated groupings of
combined the parental responses of mothers and fathers in similar papers. Then, together, the authors explored, discussed,
their results and discussion sections. As such, these were and shared their rationale for the groupings. The groupings that
not included in the analysis of the present review; they are, emerged from each author were compared; both authors had
however, identified and mentioned at the end of the Results identified the same concepts. With further discussion, labels
section. were generated, and the papers were organized using six major
This systematic review is broad and inclusive in its concep- themes.
tualization of fathers. For the purposes of this review, fathers Documenting results. The authors utilized the PICOS format to
could include stepfathers, adoptive fathers, single-parent guide the investigation; however, a modified PICOS format has
fathers, fathers in relationships with other fathers, fathers been used to present the findings from the systematic review.
in relationships with persons other than the child’s mother, This was done to align with standardized reporting formats,
fathers who reside with the child or who reside elsewhere, or yet also to capture the unique nature of the data obtained. For
men who are not a child’s biological father but are actively example, published research in this area has not yet included
serving in that role. The authors have accepted the definitions large scale studies of fathers’ perceptions or experiences, nor
of “fathers” employed by each of the studies in the review. have there been documented investigations of interventions.
Individual authors/author teams have defined “fathers” using The original PICOS model suggests that researchers explore
their own parameters. All studies that expressly state that they interventions; however, the authors have expanded that cat-
are exploring fathers’ experiences or perceptions were included. egory by identifying the measures and instruments used by
Exclusivity criteria. Because the intent of this study was to scholars to assess the construct they were investigating. Sim-
explore the experiences and perceptions of fathers of young DHH ilarly, the authors have broadened reporting of outcomes to
children, studies whose foci were genetic, biological, or physi- include the main findings of the studies reviewed. In Study
ological in nature were excluded. Further, fathers’ perceptions Design, studies are described as using qualitative, quantitative,
of their involvement early in the child’s life are believed to be or mixed methods research approaches. Additional information
of particular significance, setting the stage for later involve- has been provided that can be useful to readers about the study
ment as the child grows. Studies of parents of DHH children design, where applicable, such as identifying whether studies
typically involve those that examine children by age groups: were cross-sectional or longitudinal (Figure 1).
infants, toddlers, early childhood, middle or late childhood, and
adolescence. Given the importance of the early years of a child’s
life in terms of their development and their connections with
caregivers, the researchers were most interested in the experi- Results
ences and perceptions of younger children. By limiting the age The first peer-reviewed work that included fathers of DHH chil-
of the children to birth-to-6 years, the researchers sought to dren, based on the results of this systematic literature review,
understand the experience of fathers of DHH young children was published in 1969. In the 50 years (1969–2019) covered by
following the identification of hearing status, through the years this systematic review, just 37 published articles were found that
of early intervention and preschool. explore the experiences and perceptions of fathers of young DHH
children. Most of the studies included in this review compared
responses of mothers and fathers (86.5%); few studies focused
solely on fathers (13.5%).
Procedure
Since the initial publication that included fathers of DHH
Search strategy for identifying relevant studies. Three separate elec- children, research and publishing requirements have become
tronic databases were searched: Web of Science, PsychINFO, more stringent. Some of the early work on this topic, by objective
and Scopus. These databases, respectively, cover a vast, broad standards, is not highly rigorous. In this systematic review, the
range of science; behavioral and psychological studies; and the authors do not comment on the strength of the arguments put
life, social, physical, and health sciences. The authors selected forth in the papers nor on the quality or depth of the research;
these databases in an effort to locate all of the relevant research readers are free to make their own judgements.
since studies involving DHH children can be found in medicine Further, given the diversity of methodologies employed in the
and health journals, deaf-specific publications, and general aca- studies involving fathers, the different theoretical conceptual-
demic journals that address psychological, social, and behavioral izations that researchers have used to explore fathers’ experi-
issues. ences, and the variety of constructs measured across the studies
Three variables were combined for each search: fathers, chil- that have included this population, no overarching synopsis of
dren, and DHH. The terms used were as follows: the literature in this area is (or can be) provided. This review
Figure 1 PRISMA recommended a flow diagram for a systematic review of the experiences and perceptions of fathers of young children (0–6 years of age) who are deaf
or hard of hearing.
will make no attempt to arrive at the statistical meaning of the with the child, and their perceptions of health-related quality
findings presented nor will it provide a meta-analysis of the of life (HRQoL). Studies have also explored fathers’ connections
manuscripts reviewed. Rather, the authors have undertaken a with their children, their knowledge of hearing-related topics,
narrative systematic review (Siddaway et al., 2019). This nar- the experiences that have shaped their understanding of what it
rative systematic review will serve as a historical account of means to be a father of a child who is DHH, and the relationship
the research of fathers’ perceptions and experiences in the first between having a child who is DHH and marital satisfaction.
6 years of raising a child who is DHH. In the earliest study found in this systematic review, by
The authors have categorized the information contained in Neuhaus (1969), it was reported that parental attitudes toward
the published papers into overarching themes: (a) perspectives children, both by fathers and mothers, had a direct association
on parenting, (b) parental stress and coping, (c) parent-child with the DHH child’s emotional adjustment. The study did not
interaction, (d) involvement in early intervention, (e) parental find a significant relationship between fathers’ or mothers’ atti-
self-efficacy, and (f) benefits of fathers’ inclusion. tudes toward disability and the child’s emotional adjustment.
However, the author acknowledged that by the time children
were old enough to be enrolled in the study (age 3), parental
Perspectives on Parenting attitudes toward both the child and toward disability are largely
Parents’ perspectives on parenting children who are DHH have set. Although the rationale for the following statement did not
been explored in several ways across the globe. Studies have seem to be substantiated by the evidence provided in the study,
examined parents’ attitudes toward their children, their atti- the article did state that, it was the “ . . . author’s opinion that
tudes toward disability, their perceived benefits of involvement the maternal attitude, either positive or negative, out-weighs the
paternal attitude in its effect upon the deaf child’s emotional differentiate the percentage of the fathers and mothers who
adjustment.” (p.724). mentioned critical incidents within each category. A review of
McNeil and Chabassol (1981) hypothesized that fathers are the table within that paper reveals that mothers were more
less involved with their deaf children. Their exploration of moth- inclined to mention intervention services, guidance from profes-
ers’ and fathers’ level and perception of involvement, however, sionals, and having a supportive childcare setting as being crit-
found that both parents believed fathers involvement to be ical to parenting a DHH child. Fathers were more inclined than
important and that both reported fathers to be as involved as mothers to describe taking action, utilizing personal resources,
mothers. Fathers were described as gaining most of the informa- and having a supportive workplace as being critical. Additionally,
tion that they knew about their child’s hearing status from the 50% of fathers compared to 20% of mothers mentioned the
mothers, who were more likely to make and bring the child to importance of the marital partnership.
audiologic and medical appointments. The majority of parents, In India, researchers examined the attitudes of parents of
80%, reported that the involvement of fathers is different from DHH children using a questionnaire developed in English for
the involvement of mothers. Whereas questions in this study the purpose of the study and then translated into “the local
framed “involvement” in terms of engagement with clinical care, language” (Kumar & Rao, 2008). Fathers exhibited more favorable
on interview both fathers and mothers suggested that fathers attitudes toward their DHH children than did mothers. Both
are active participants in their child’s care in different ways. mothers and fathers showed more positive attitudes toward
Fathers reported becoming closer to their DHH child than with their DHH sons than their DHH daughters. The authors specu-
their other children who had a typical hearing, attributing this to lated that the difference in favorability scores between fathers
the additional time spent with the child and the unique traits of and mothers may be attributable to the extensive care mothers
DHH child such as the child’s willingness to “try anything” and provide in the Indian cultural context, which could contribute to
“never give up” (p.124). maternal burn-out or fatigue. The investigators further posit that
A study of parental attitudes toward deafness and DHH chil- Indian mothers’ level of “emotional dependence” on the child is
dren’s communication skills was conducted in the United States greater than that of fathers, which may result in mothers’ greater
(Hadadian & Rose, 1991). Investigators reported that mothers and disappointment with having a “disabled child.” Parents of both
fathers of young children (18–60 months of age) held “relatively genders with higher levels of education also showed a higher
similar attitudes toward deafness.” (p.276). However, a relation- rate of acceptability of their DHH child.
ship between fathers’ attitudes and their children’s language In Turkey, investigators explored the understanding of “fam-
scores was noted. The more negative a father’s attitude toward ily roles” among fathers of DHH children (Sahli, 2011). Fathers of
deafness, as assessed by responses to the Attitudes Toward DHH children were self-reported to be more protective of their
Deafness Scale, the lower the language comprehension scores of children than fathers of children with typical hearing. Fathers of
the children. Because expressive language scores for the children DHH children also acknowledged being less democratic and dis-
were well below average, with just one exception, the authors ciplined with their children than fathers of children with typical
speculated that it was not possible to accurately determine an hearing. Overall, the researchers suggested that fathers of DHH
impact of fathers’ attitudes toward their child’s hearing status had adequate support for themselves and their families. They
on expressive language abilities. stated that the fathers who would do best would have “enough
In Malaysia, a study examining the knowledge of parents information” would be best equipped to “feel like themselves”
included Malay, Chinese, and Indian participants (Mukari, Van- (p.684).
dort, Ahmad, Saim, & Mohamed, 1999). Most parents (68.6%)— In order to better understand the impact of parenting
both mothers and fathers—indicated that they were unaware children who are DHH and children with speech impair-
and/or unsuspecting that their child had hearing loss until the ments, researchers in Croatia administered a health status
child reached an age at which they believed the child should questionnaire (Aras et al., 2014). Their assessment of HRQoL
have begun to speak. Parents were described as having a lack differentially assessed mothers’ and fathers’ responses across
of adequate information about hearing loss and hearing aid five scales: physical functioning, role-physical, bodily pain,
(HA) management [e.g., among children who wore HAs, half social functioning, and role-emotional. Overall, mothers of DHH
(50.2%) of the HAs had never been serviced, at least in part children and mothers of children with speech impairments
related to parents’ lack of awareness of how to care for them]. in the Croatia study rated HRQoL lower than did fathers of
All children in the study attended schools that utilize a form of both groups of children across nearly all health dimensions
signs in combination with a speech known as Bahasa Malaysia including physical, emotional, and social domains. While
Kod Tangan (BMKT). However, nearly half of the parents (4 l.3% of mothers in the control group also scored lower than the fathers
mothers; 48.5% of fathers) reportedly did not know BMKT. Finan- in the same group, the extent of the differences between
cial barriers to obtaining HAs in Malaysia influenced whether a mothers and fathers of children with hearing impairment was
child owned HAs; often the socioeconomic level of the family described as “substantial.” Fathers of children with speech
was determined by the extent of the father’s education. impairments scored lower on HRQoL than fathers of DHH
A study conducted in Canada explored parents’ mention of children. The researchers surmise that by preschool age, many
critical incidents that have shaped their experiences of par- of the challenging decisions parents make regarding their child
enting a DHH child (Zaidman-Zait, 2007). Interviewing moth- with hearing loss (e.g., regarding use of HAs or cochlear implants,
ers and fathers separately and analyzing their responses led CIs) have already occurred, while the challenges of children with
the researcher to 20 themes which could be broadly grouped speech impairments may be becoming more readily apparent in
into five categories: contextual sources of support, parents’ per- the preschool years.
sonal and psychological resources, child’s characteristics, and Fathers’ and mothers’ knowledge and experiences related to
perceived positive outcomes of existing coping resources. In hearing loss and HA use were compared in a study that explored
the presentation of the themes and in the discussion section, parent-reported challenges related to HA use in the U.S. context
the researcher did not distinguish between the responses pro- (Munoz et al., 2015). Munoz et al. found that most mothers
vided by the mothers and fathers. Zaidman-Zait did, however, receive information about their child’s hearing loss from
audiologists and prefer having information repeated often. In an additional study by Meadow-Orlans (1995), the subscale
Fathers are more likely to learn from mothers and are less scores of the parental stress questionnaire used in the 1994 sam-
inclined to desire a repetition of information. Mothers and ple were examined in more detail. These findings showed that
fathers reported similar levels of comfort with HA management, fathers of DHH infants rated themselves “less accepting” and
although fathers perceived that their child was receiving “more demanding” compared to fathers of infants with typical
greater benefit from the HAs, while mothers expressed greater hearing. Mothers of DHH infants and fathers of DHH infants
challenges with the HAs than did fathers. The researchers high- both rated their children more distractible/hyperactive than did
lighted recommendations for how professionals—audiologists parents of either gender with typically hearing infants. Com-
in this case—can use the information about fathers’ and parisons between fathers and mothers of DHH infants revealed
mothers’ experiences to better meet their different needs and, that fathers reported being less attached to their child; mothers
by extension, those of their children. reported being more depressed than their spouse. These findings
Researchers in Greece compared fathers of children who were, however, “marginally significant.” Mothers also endorsed
were DHH, fathers of children who had an intellectual disability, greater stress related to work, money, role restriction, and rela-
fathers of children diagnosed with an autism spectrum disor- tionships with their spouse than did fathers.
der, and fathers of children without disabilities (Mavrogianni & In a series of studies from Turkey, Spahn, Richter, Zschocke,
Lampropoulou, 2018). Across the four groups of fathers, investi- Löhle, and Wirsching (2001) and Spahn, Burger, Löschmann, and
gators measured the level of involvement with childcare, beliefs Richter (2004) examined general stress in fathers and mothers
regarding the parenting role, parental stress, marital satisfaction, of deaf children with CIs (age between 2–16 years). In their 2001
and social support. Collectively, fathers of children who were work, they found that 26% of mothers and 25% of fathers suffered
DHH or had a disability described similar experiences, which from “high psychic stress” (Spahn et al., 2001). Most of the fathers
differed from fathers of children without disabilities. Fathers of and mothers expressed a strong interest in receiving support,
DHH children and fathers of children with disabilities reported both in terms of further information about their child’s hearing
more stress, as well as greater support from their environment status and functioning, and through parent groups.
than fathers of typically developing children. Holding positive To explore psychic stress among parents of children who use
beliefs about their role as parents was associated with increased HAs and children who use CIs, Spahn, Richter, Burger, Löhle,
involvement. Fathers with higher levels of marital satisfaction and Wirsching (2003) retrospectively asked parents about their
and more positive beliefs about their roles as parents were also feelings of well-being during the various phases of auditory
more involved in the care of their children. The authors suggest (re)habilitation. In comparing the experiences of parents of chil-
that helping fathers to feel more empowered in their roles as dren with HAs versus the experience of parents of children with
parents to children who are DHH may facilitate positive effects CIs, more overall “psychic distress” was found in parents of
in their interactions with their children and their spouses. children with CIs than in parents of children using HAs. The
cochlear implantation process (including the operation and the
fitting/mapping of the device) were described as more stress-
ful for parents than the period of rehabilitation for HAs. The
Parental Stress and Coping fathers of the children with CIs reported having to take more
Compared to the number of studies that have explored other unpaid time away from work than the fathers of the children
themes that emerged in this review, parental stress of parents with HAs. The authors surmised that the process of cochlear
of DHH children has been examined relatively frequently in implantation might be more demanding for fathers, given the
the literature in several countries across the globe. Researchers need for multiple audiologic and medical appointments. Both
have assessed parental stress and explored relationships fathers and mothers endorsed feeling highly distressed at the
between stress and: social supports; parental coping and start of the (re)habilitation process, yet these feelings decreased
coping resources; acceptance of and reactions toward the child over the course of their child’s treatment, eventually stabilizing
and his/her hearing status; and child social-emotional and in the “medium range” of distress.
attachment outcomes. Spahn et al. (2004) asked parents of deaf children with CIs
Brand and Coetzer (1994) explored parents’ emotional expe- about their perceived general stress as well as their quality of life.
riences (e.g., shock, worry, anger) at the time hearing loss was Again, elevated “psychic stress levels” were reported by 23.1% of
identified and found no differences between fathers’ and moth- fathers and 20% of mothers (Spahn et al., 2004). Both mothers
ers’ emotional reactions. No differences in the amount of gen- and fathers of the children with CIs perceived themselves to
eral stress were found between parents. Mothers perceived the have a “moderately reduced” quality of life.
amount of free time they had for themselves and the extent A large German study involving 213 fathers and 213 moth-
of the emotional support they received from their spouse as ers of DHH children (age 4–13 years) examined the associa-
inadequate; fathers did not endorse these same views. tions between parental stress and coping resources (Hintermair,
Fathers of DHH infants reported parenting stress levels simi- 2006). Parental stress was found to be influenced by parents’
lar to U.S. population norms, yet marginally higher than a control resources; higher levels of personal and social resources were
group of fathers of infants with typical hearing. No differences in related to lower stress levels. Although these associations are
parenting stress or general stress between fathers and mothers found in both fathers and mothers, the strength of the associ-
of DHH infants were found (Meadow-Orlans, 1994). Meadow- ations was slightly different. Fathers who reported lower stress
Orlans also explored the availability of social support from oth- levels had greater social support from family, friends, and pro-
ers, which was conceptualized as a buffer to stress. Fathers and fessionals. Mothers with lower stress levels reported an elevated
mothers of DHH infants and parents of infants with typical sense of coherence for coping with hearing loss. For both par-
hearing experienced the same amount of social support from ent groups, levels of parental stress were related to children’s
their networks. The association between parenting stress and social-emotional functioning. Both fathers and mothers who
socials support was “marginally significant” for fathers of DHH experienced lower stress had children with more positive social-
infants and significant for mothers. emotional development.
Using the same large database of responses from 213 fathers mothers. Mothers who perceived more support reported lower
and 213 mothers of DHH children in Germany, Hintermair (2006) stress levels.
examined fathers’ and mothers’ responses on the Strengths
and Difficulties Questionnaire (SDQ). The purpose of this study
was to examine whether the German version of the SDQ could
Parent-Child Interaction
be used as an effective screening tool for the challenges and
strengths shown by DHH children and to provide information Researchers in the United States and Belgium have explored
about the prevalence of socioemotional programs in German- parent-child interaction and parent-child attachment. Across
speaking children who are DHH. This study examined the differ- four studies, the researchers explored whether mothers and
ential reports of both parents. Minor differences in the parents’ fathers utilize different communication approaches when inter-
ratings were noted and described in the tables (e.g., mothers’ acting with their infants. The United States and Belgian investi-
rating of the “total problem score” for children with additional gators also explored whether attitudes toward a child being DHH
disabilities was higher than fathers’ rating). Overall, however, the has an impact on attachment.
study showed no significant differences in fathers’ and mothers’ The nature of attachment relationships between deaf tod-
reporting of socioemotional problems in German DHH children. dlers and preschoolers and their hearing parents in the United
Importantly for this study, both fathers and mothers identified States were examined by Hadadian (1995). Negative parental
significant socioemotional challenges in DHH children, prompt- attitudes toward deafness, held by both fathers and mothers,
ing the author to argue for increased socioemotional support for were negatively related to their children’s scores on measures
this population. of security of attachment. No differences were found between
The emotional responses to having a child with a hearing loss child-father and child-mother security of attachment scores.
sometimes differs between fathers and mothers. A study in the DHH children were equally likely to attach and bond with both
United Kingdom asked parents retrospectively about their emo- caregivers.
tions related to having a child identified with hearing loss and A Belgian study revealed greater use of visual-tactile commu-
receiving a CI (Anagnostou, Graham, & Crocker, 2007). Fathers of nication strategies by deaf fathers than by hearing fathers, deaf
children with CIs reportedly used “denial” more frequently as a mothers, or hearing mothers of DHH children (Loots, Devisé, &
defense mechanism than mothers. From the time of identifica- Sermijn, 2003). In this study, deaf fathers allowed more wait time
tion of the child’s hearing status through 2 years postimplanta- to gain the child’s visual engagement than deaf mothers and
tion, both fathers and mothers identified “grief” as the strongest hearing mothers.
emotion that they experienced. Deaf parents-deaf infants were compared with hearing
In a study examining the perspectives of parents in Malaysia, parents-deaf infant dyads (18–24 months) in a study that
fathers and mothers were found to utilize different coping explored communication modalities and intersubjectivity
strategies in response to having a DHH child (Daud, Noor, conducted in Brussels (Loots, Devisé, & Jacquet, 2005). This work
Yusoff, Rahman, & Zakaria, 2013). Parents of both genders focused on the different ways that deaf parents interact with
highly endorsed religion, active coping, and acceptance as their infants using sign language in comparison to hearing
necessary means of dealing with their children’s hearing loss. parents who communicate using aural/oral methods and
However, mothers reported seeking more emotional support hearing parents using total communication to engage with their
and obtaining greater instrumental support than did fathers. toddlers. Most of the findings of this study were framed in terms
Mothers were also more likely to turn to religion to aid their of parent groups rather than differences between fathers and
coping, whereas fathers were reportedly more inclined to seek mothers (e.g., deaf parents were found to utilize different and
problem-focused solutions. Daud et al. surmised that, because more frequent attention-gaining strategies, which the author
most mothers in their study were not employed outside of the suggest allows deaf parents to involve their deaf toddlers in
home, much of the caregiving responsibilities fell to them. Thus, “symbolic intersubjectivity”). No significant differences were
it may be less that mothers were inclined to “seek solutions” found between hearing parents (i.e., fathers + mothers) using
in ways different from fathers. The researchers concluded that total communication and deaf parents employing Flemish Sign
fathers may exhibit less concern about factors impacting their Language with respect to the degree of involvement in moments
DHH children and may benefit from encouragement to become of intersubjectivity; both groups showed more involvement than
more involved with their children. hearing parents using spoken Dutch. Analyses specific to fathers
Other research has also found that CI surgery might be specif- revealed that fathers using auditory/oral communication were
ically stressful for parents. In a study conducted in Turkey on “less easily involved in intersubjectivity” than hearing fathers
parental emotions pre- and post-cochlear implantation, mothers using total communication or deaf fathers using Flemish Sign
were described as more “anxious” and “neurotic” (using psychi- Language.
atric measures) than fathers (Gurbuz et al., 2013). In both fathers In a study involving ten Belgian parent-child dyads, the extent
and mothers, anxiety decreased after cochlear implantation. to which deaf parents and hearing parents use visual com-
Israeli fathers and mothers of DHH children (3–8 years old) munications strategies during interaction with their 2-year-old
reported moderate levels of parental stress, as well as similar deaf children was examined (Wille, Allen, Van Lierde, & Van
levels of acceptance of their DHH child (Zaidman-Zait, Most, Herreweghe, 2019). Deaf fathers used more implicit strategies,
Tarrasch, Haddad-eid, & Brand, 2016). In general, across both such as waiting for a child to look to them for communication,
mothers and fathers, higher reported levels of child acceptance compared to deaf mothers. The deaf fathers in this study tended
were associated with lower reported levels of parental stress. to have the most successful back-and-forth interactions with
Social support was described as a potential mechanism to boost their deaf children compared to deaf mothers, hearing mothers,
parental coping. While fathers and mothers did not differ in or hearing fathers. Wille et al. did not find differences in hearing
the amount of support they perceived, an association between mothers and hearing fathers with respect to their use of visual-
stress and social support was only found to be significant for tactile communication or waiting strategies.
Involvement in EI of hours the fathers worked and their involvement in services;

some of the most involved fathers also tended to work more
Researchers have explored the extent to which fathers are
hours. However, the scheduling of the EI services during hours
involved with early intervention and explored the relationships
when fathers must work, and heavy work demands that
between this involvement and a number of other factors, includ-
left fathers with “little left to give” were said to influence
ing the fathers’ ability to communicate with the child, fathers’
their involvement. Additionally, approximately half of the
perceived benefit of participation, child preschool-readiness,
fathers reported that their partners made and managed the
coordination of care and appointments, and acceptance of the
appointments and did not include them.
child.
In Finland, parents were asked to describe their involvement
in a sign language training program. They were asked to rate
Parental Self-Efficacy
their own use of sign language, the extent to which their
child used sign language, and their perceived benefit from The existing literature pertaining to fathers of DHH children
sign language intervention (Takala, Kuusela, & Takala, 2000). has examined the relationship between fathers’ parental self-
Mothers reported higher involvement with the intervention efficacy and their involvement and engagement with their child.
and greater contact with the Finnish Deaf community than Researchers have also explored whether factors such as religios-
did fathers. Fathers had fewer contacts in the Deaf community, ity and cultural background of the families influence fathers’
endorsed having greater difficulty learning sign language, and sense of parental self-efficacy.
reported less satisfaction with the sign language intervention. Research from Israel suggests that fathers’ sense of self-
The researchers found a correlation between the father’s efficacy seems to be tied to the level of their involvement in daily
communication abilities and the child’s self-esteem, that is, as activities with their child; fathers who were more highly involved
fathers’ communication abilities increased, so did the reported with their DHH preschool children report higher levels of self-
self-esteem of their children. efficacy (Ingber & Most, 2012). Father involvement was positively
Fathers who were more highly involved in the early interven- associated with family cohesion. Fathers’ self-reported level of
tion had lower needs in supporting the transition of their DHH involvement mirrored their wives’ reports of their involvement
child through intervention to educational settings in a study as well. In this cultural context, fathers’ work experiences did
conducted in Turkey (Bayguzina, Yucel, & Atas, 2012). Higher lev- seem to influence their involvement; fathers with higher occu-
els of family socioeconomic resources and maternal education pational status and fathers who worked longer hours tended to
were also found to help young children with CIs be ready for be less involved.
school. The gender of the child was the remaining factor; overall, One study focused on Israeli-Arab parents of children who
boys were perceived as less “preschool ready” than girls. are DHH (Zaidman-Zait et al., 2016). These researchers noted
In their study of parents of DHH children in Israel, researchers that while 20% of the Israeli population is from the Arab sector,
found that the coordination of care and intervention appoint- 30% of DHH children in that country have families who could be
ments to support DHH children often falls to mothers, given described as Israeli-Arab. For this subset of caregivers, mothers
the “manager-helper dynamic” frequently found in that cultural reported higher levels of parental self-efficacy than fathers.
context (Zaidman-Zait, Most, Tarrasch, & Haddad, 2018). The Mothers were also more highly involved with their children than
authors described the cultural context as having a majority of fathers. Mothers were less inclined to work outside of the home;
mothers not employed outside of the home (73%); proposing the caregiving tasks largely fell to mothers. Fathers reported low
that, while fathers were inclined to assist with specific tasks levels of involvement, initiation, attendance, communication,
related to child-rearing, mothers often serve as the orchestrators and interactions with professionals. For fathers alone, parental
of family life and the intervention supports for DHH children. self-efficacy was positively associated with involvement. In this
However, in the presence of higher levels of support from family study, no associations were found between stress and parental
and friends, fathers’ involvement increased. Fathers could adjust involvement.
their work/routines in order to increase their involvement in the In a comparison of Jewish parents in Israel, for both moth-
DHH child’s intervention programming. ers and fathers, parental involvement was positively associ-
Additional studies in Israel have found a positive correla- ated with (a) child acceptance, (b) parental self-efficacy, and
tion between fathers’ acceptance of their child and their lev- (c) perceived social support (Brand et al., 2018). No interaction
els of involvement in early intervention (Brand, Zaidman-Zait, effects were identified between self-efficacy and levels of reli-
& Most, 2018). For mothers, involvement was not associated giosity in the family, nor between self-efficacy and the gender
with acceptance. Perceived social support was associated with of the parent. However, parents with higher levels of religios-
increases in fathers’ involvement. The researchers hypothesized ity tended to be less involved in the interventions for their
that perhaps fathers’ acceptance of the DHH child may motivate DHH child. Among fathers, higher rates of child acceptance and
them to be more involved, whereas mothers’ perceptions of more social support were negatively associated with mothers’
their roles as caregivers, rather than acceptance of the child involvement. The authors speculated that the more involved a
per se, may provide greater motivation. As the involvement of father, the less involved the mother was required to be; involved
fathers increased, the level of involvement reported by mothers fathers may contribute to more balanced involvement of both
decreased. The researchers suggested that as the involvement of parents.
either parent increases, the necessary involvement of the other In an additional study from Israel, a positive relationship was
parent decreases. found between parental self-efficacy and involvement; that is,
A German study involving fathers of young DHH children fathers who self-rated their parental self-efficacy as high tended
(Hintermair & Sarimski, 2018) found that most fathers (76.1%) to feel more encouraged to engage in their child’s intervention
never or rarely participated in their child’s early intervention (Zaidman-Zait et al., 2018). Fathers of DHH children who rate
programming, while a minority (23.9%) reported often or always themselves as more competent in their parenting role also tend
participating. No relationship was found between the number to be rated as more involved by the mothers of their children.
A study of fathers of very young children in Germany found such as turn-taking and looking to the communication partner
most fathers to be ready to “face the challenge” of raising a DHH for information.
child and described them as coping well (Hintermair & Sarimski,
2018). However, 20% of fathers who did not report coping well,
indicating that they were struggling to live in a household with Not Included in Analysis
a child who was DHH. The impact of the child’s hearing loss
Some studies that met the inclusivity/exclusivity criteria for the
was less when fathers felt more competent in educating their
systematic review did not, upon more critical analysis, truly
DHH child and in their role as a parent. Fathers’ parental self-
capture fathers’ unique experiences or perceptions. These stud-
efficacy was also found to be positively correlated with other
ies, included in Table 1, are briefly described below. They were
aspects of involvement including increased engagement in the
not utilized in the analysis of themes, given that they were
care of the child (e.g., daily routines) and the child’s early inter-
determined by the authors to be outside the intended scope of
vention programming. Marital satisfaction was also reported to
this review.
be higher among those fathers who had stronger parental self-
One study explored the experiences of 59 mother-infant
efficacy.
dyads and just one father-infant interaction (Crittenden &
Bonvillian, 1984). Although this study did include a deaf father,
this was just one participant; the comparison groups included
Benefits of Fathers’ Inclusion
neglecting mothers, abusing mothers, mentally retarded [sic]
Four studies were conducted in the United States during mothers, low-income families, and a “low risk” group. This study
the 1980s–1990s that examined the influence of fathers on was not deemed to provide useful information about fathers of
their DHH children. Collectively, these explored how the DHH children.
presence and inclusion of fathers may contribute to child Comparing the reported stress of fathers and mothers of
outcomes. DHH children, Hagborg (1989) focused on school-age children.
When fathers have been included in programs intended to Although the youngest was age 6, and thus met the inclusion cri-
support parents of DHH children, they and their children seem teria, the mean age of the children whose parents were involved
to benefit (Crowley, Keane, & Needham, 1982). Participation in in the study was 15.06 years. Given that this study focused
a fathers-only support group for fathers of children in the early on parents of children attending residential deaf programs, the
intervention was associated with fathers’ increased involvement types of experiences described differed substantially from the
with their child and greater awareness of the responsibilities and focus of the present review, children from 0–6 years of age.
joys associated with being involved. One study explored hearing parents’ appraisals of raising a
Researchers in the 1980s (McNeil & Chabassol, 1984), child who is DHH (Szarkowski & Brice, 2016). Of the 11 respon-
proposed that fathers’ roles as “breadwinners” with strong dents in their qualitative study, three were fathers; yet the find-
commitments to their jobs meant that fathers could not be ings from this research did not differentiate parental responses
involved in the lives of their young DHH children. However, based on the gender of the parent and thus could not contribute
using an “exploratory and descriptive design,” the researchers to this analysis.
asked questions of both fathers and mothers regarding their
involvement. Fathers indicated a recognition that DHH children
need more support from both parents. Fathers reported being
more involved with—and closer to—their DHH child than their
Discussion
other children. Both mothers and fathers reported a need for In the 50 years since the initial published investigation of fathers’
programming that is for both parents, rather than programming experiences and perceptions in raising a young DHH child, the
aimed at only mothers. field has only “scratched the surface” in understanding the influ-
Positive attitudes toward deafness were found to be higher ence of fathers, the strengths that fathers bring to the parent-
among fathers involved in the early intervention programming child interactions, and the impact that fathers have on their
for their young children than among fathers not involved family. Exploration of the literature reveals a lack of information
in their children’s early intervention programming (Hada- about the experiences and perceptions of fathers of children
dian & Rose, 1991). Positive attitudes toward deafness, in who are DHH. Despite a relatively long history of exploring
turn, were significantly correlated with better language out- parents/parenting experiences of DHH children in the field of
comes in children with severe to profound levels of hearing deaf-related research, the research on fathers of DHH children is
loss. in its infancy with respect to the understanding in the DHH fields
DHH children without a father present in their lives were about fathers’ experiences and perceptions. With few exceptions
compared to DHH children who had fathers involved in their (e.g., Hintermair & Sarimski, 2018; Mavrogianni & Lampropoulou,
lives at the time of completion of their early intervention 2018), studies have not actively sought to explore fathers’ expe-
programs. Children whose fathers were present in their lives riences independent of mothers’ experiences. Existing studies
were found to have higher academic and language outcomes have rarely explored unique aspects of being a father to a DHH
(Calderon & Low, 1998). No differences were found in the child and offered recommendations based on findings to suggest
two groups of children on non-verbal IQ or social-emotional altering programming or interventions to support the unique
outcomes. Fathers’ signing skills were not as strong as those needs of fathers.
of the mothers, per self-report and observational ratings by Returning again to the report from the American Academy
the researchers. Fathers were described as promoting play of Pediatrics Committee that explored child and family health
interactions that, although not “building language” per se, did (Yogman et al., 2016), it is clear that in many families, fathers’
seem to have a positive and substantial effect on fostering levels of involvement and time spent with their children has
children’s non-verbal yet essential communication behaviors, increased in the last generation. It has been established that the
Table 1 Description of studies including fathers of deaf or hard of hearing young children utilizing the PICOS-guided questions
First author Year Country Participants Measures/instruments Main results Design
F/M Na Age Child hearing

196
status
Anagnostou 2007 UK F/M 27 F NA CI-users Parental emotions following CI questionnaire (NS) F used defense mechanism of denial QUAN
et al. 26 M more than M CS
Aras et al. 2014 Croatia F/M 60 F Preschool Severe HL HRQOL SF-26 F scored better than M on physical, QUAN
71 M (Croatian version)1 emotional and social aspects of life CS
182 MTH 167 FTH F scored worse than FTH on social
functioning, pain and general health
perception
Bayguzina 2012 Turkey F/M 130 M 3–6 yr CI users Demographic information form (NS) F who participated in EI had lower QUAN
et al. 129 F Scale of Parental Information needs in transition needs than F who did not CS
to Kindergarten2 Younger F had more needs than
older F
Family SES influenced pre-school
readiness
Brand and 1994 South F/M 30 C 11 Mild-profound Biological questionnaire (NS) No differences F/M general stress QUAN
Coetzer Africa mo–11 yr HL Questionnaire on Resources and Stress and emotional response on diagnosis CS
QRS-F—short form of the (QRS)3 M more stress concerning parent and
Individual interview (NS) family problems than F
M perceived amount of free time as
inadequate
M receive less emotional support
than F
Brand et al. 2018 Israël F/M 70 C 5.2 yr Mild-profound Parental Involvement Questionnaire4 F reported lower involvement than M QUAN
Journal of Deaf Studies and Deaf Education, 2021, Vol. 26, No. 2
(mean) HL Child Acceptance Questionnaire5 F involvement related to child CS

Early Intervention Parental Self Efficacy Scale acceptance, self-efficacy, support
(EIPSES)6 F acceptance and support negatively
Support System Questionnaire7 related to M involvement
Family report of Jewish religiosity (NS) The higher the level of self-efficacy
and the higher the support, the more
involved the parent
Calderon 1998 United F 17 F present 43–83 mo. Moderate- Child demographics (NS) F present in family—better academic QUAN
and Low States presen- 5 not present 36 mo profound SKI∗HI Language Development Scale8 & language outcomes CS
t/not (mean) HL Percentage of visits each parent was present F present in family—no impact on
present Perceived parent involvement (based on parent social-emotional outcomes
trainers’ narrative notes)
Family stress (# major life events documented in
parent trainer narrative notes)
Preschool Language Scale 3 (PLS-3)9
Test of Early Reading Ability-Deaf/Hard of
Hearing (TERA-DHH)10
Geometric Design of the Wechsler Preschool and
Primary Scale of Intelligence-Revised (WPPSI-R)11
Language Proficiency Profile (LPP)12
Social-Emotional Assessment Inventory (SEAI)-
Preschool version13
Child Behavior Checklist (CBCL); Child Behavior
Profile14
(Continued)
Table 1 Continued

status
Crittenden 1984 United M/F 59 M Infant Severe HL Three-minute videotape, assessing for No analysis on F QUAN
and States 1F maternal sensitivity displayed during CS
Bonvillian parent-child play interaction. Scored using
standardized coding15
Crowley 1982 United F 8F Early Severe- No formal measures used. Paper describes F more involved with deaf child QUAL
et al. States inter- profound reported benefits of involvement in parent F reported increased awareness of
vention HL training the responsibilities & joys
involvement brings
Daud et al. 2013 Malaysia F/M 36 F NA Moderate- Brief COPE Scale questionnaire—Malay F sought less emotional and QUAN
36 M profound HL version16 instrumental support than M CS
Sociodemographic questionnaire (NS) F used less problem-focused coping
strategies than M
Gurbuz 2013 Turkey F/M 25 F 1–16 yr CI users Beck Anxiety Inventory (BAI)17 -Turkish F less anxious and neurotic than M QUAN
et al. 25 M 5.2 yr version18 Parental anxiety decreased after CI CS
(mean) Assessment of Coping Attenuations (COPE)
Inventory19
Problem-Solving Inventory20
Penn State Worry Questionnaire (PSWQ)21
Revised Eysenck Personality
Questionnaire-Abbreviated (EPQR-A)22
Hadadian & 1991 United F/M 30 C 18–60 Severe- Attitude toward Deafness Scale23 F attitude toward deafness QUAN
Rose States mo. profound Minnesota Child Development Inventory associated with child language CS
HL (MCDI)24 comprehension measures
Parent interview form (NS) No differences F/M in attitude
toward deafness
Hadadian 1995 United F/M 30 C 20–60 Severe- Attachment Q-Set25 No differences F/M in security of QUAN
States mo. profound Attitude to Deafness Scale23 attachment CS
HL Parental Interview form (NS) Parental attitude to deafness was
negatively related to security of
attachment
Hagborg 1989 United F/M 42 C 15.6 yr Severe- Parent Sign Language Rating (self-report; NS) No differences F/M in perceived QUAN
States (mean) profound Student rating of Parent Sign Language (child stress and resources CS
(included HL report; NS) F perceived stress negatively related
6 yr) Questionnaire on Resources and Stress – to child’s lipreading skills
Short Form (QRS-SF)3
Problem Behavior Checklist (PBD)26
Oral Communication Skills: Intelligible
Speech and Lipreading27
Fathers of Young Deaf or Hard-of-Hearing Children
How I Feel Toward Others (HIFTO)28

Stanford Achievement Test—Hearing
Impaired29
197
Sociometric status (self-report; NS)
(Continued)
Table 1 Continued

198

status
Hintermair 2006 Germany F/M 213 F 4–13 yr Mild-profound Parenting stress index30 No differences F/M in perceived QUAN
213 M 9.9 yr HL Strengths and Difficulties stress and personal resources or CS
(mean) Questionnaire—German Parent Version reported social-emotional problems
(SDQ-D)31 child
Sociodemographic questionnaire (NS) Parental stress related to
Sense of Coherence questionnaire—German social-emotional problems, child
short version (SOC-K-3)32 communication, competence,
Parents’ subjective view of parenting parental resources and sense of
competence (single question; NS) coherence
Social Support Questionnaire (F-SozU-K-14)33 Difference F/M in associations sense
Child’s Communication Competence of coherence and specific support
(self-constructed scale; NS)
Hintermair 2007 Germany F/M 213 F 4–13 yr Mild- profound Strengths and Difficulties No differences F/M in reporting QUAN
213 M 9.9 yr HL Questionnaire—German Parent Version social-emotional problems child CS
(mean) (SDQ-D)31
Sociodemographic questionnaire (NS)
Hintermair 2018 Germany F 92 F 9–36 Mild- profound Fathers of Children with Developmental 76% of F never or rarely participated QUAN
and mo. HL Challenges 34 in EI CS
Sarimski Daily Caregiving Scale35 40% of F noted that EI is mainly
Child-Related Tasks Scale35 negotiated between EI and M
Informal scale—quality of fathers’ Positive associations between
experiences with early intervention self-efficacy, involvement in EI and
services36 perceived support from EI

Generalized Self-Efficacy Scale37
Ingber and 2012 Israël F/M 38 F 3–6 yr Moderate- Demographic questionnaire (NS) No differences F/M and F/FTH in QUAN
Most 36 FTH profound HL Inventory of Father Involvement38 (Hebrew self-efficacy and involvement CS
38 M Adaptation)39 F Number of hours working
36 MTH Parenting Self-Efficacy Questionnaire40 (in negatively related to F involvement
Soref et al.)41 Higher involvement of F contributed
Family Adaptability & Cohesion Evaluation to F feeling stronger, more
(FACES-III)42 – Hebrew adaptation43 self-confident and resilient
Kumar and 2008 India F/M 30 F 0–12 yr NA Questionnaire developed and distributed F exhibit more favorable attitudes QUAN
Rao 30 M (referred to as the Parental Attitude Scale; NS) toward DHH child than M CS
F exhibit more favorable attitudes
towards their DHH sons than
daughters
Loots et al. 2003 Belgium F/M 16 C 18–29 Moderate- Videotaped parent-child interactions for Deaf F used more communication QUAN
1 M (included 5 mo. profound 24 min of free play strategies (tapping, use of space, and CS
deaf couples) HL Computer Acquisition of Multiple waiting until child looks) than
Ethnological Records and Analysis (CAMERA) hearing F
coding system44 Deaf F waited longer to gain DHH
child attention than deaf M and
hearing F or M before starting
interaction
(Continued)
Table 1 Continued

status
Loots et al. 2005 Belgium F/M 15 C 18–29 Moderate- Videotaped parent-child interactions for Hearing F communicating in an QUAN
1M mo. profound 24 min of free play auditory/oral way were less easily CS
(included four deaf HL Computer Acquisition of Multiple involved in intersubjectivity than
couples) Ethnological Records and Analysis (CAMERA) hearing F communicating in signed
coding system44 Dutch or deaf F communicating in
Flemish sign language
Mavrogianni 2018 Greece F 25 F 4.52 yr Deaf Parental Involvement on Child Care Index No differences F/FTH in involvement QUAN
and Lam- 94 FTH (mean) (PICCI)45 or beliefs concerning parental role CS
propoulou 30 fathers of children The Clarke Modification of the Holroyd and marital satisfaction
with autism Questionnaire on Resources and Stress F reported more stress than FTH
23 fathers of children (Clarke QRS)46 F reported less stress than fathers of
with intellectual Family Support Scale (FSS)47 children with autism and intellectual
disability Beliefs Concerning the Parental Role (BCPR)48 disability
Kansas Marital Satisfaction Scale (KMS)49 F reported more support from their
environment than FTH
No differences F and fathers of
children with autism or intellectual
disability in support
F positive beliefs about their role was
positively associated with their
involvement
McNeil and 1984 Canada F/M 20 C 10.7 yr NA Interviews with M and F (NS) Neither M nor F rated mother’s role MIX
Chabassol (mean) 10-item questionnaire (NS) as more important
F involved in different ways than M
(per M and F report)
Meadow- 1994 United F/M 17 F 9 mo. Mild-Profound Parenting Stress Index30 F/M no difference in social support & QUAN
Orlans States 20 M HL Stress of Life Events50 life stress CS
17 FTH The Family Support Scale7 F marginally higher stress scores
20 MTH than FTH.
Stress in F marginally significant
related to support
Meadow- 1995 United F/M 16 F 9 mo. range Parenting Stress Index30 F marginally higher stress scores QUAN
Orlans States 20 M Scale to Measure the Stress of Life Events than FTH CS
20 MTH (SLE)50 F significantly less “Acceptable” and
17 FTH Interviews (F not included, M only) more “Demanding” than FTH
F less stress concerning life events
than M
F less stress related to “Restriction of
Role” and to “Relations with Spouse”

than M
F marginally less attached to their
199
child than M
(Continued)
Table 1 Continued
200

status
Mukari et al. 1999 Malaysia F/M 787 F/M NA 4–15 yr Mild-profound Questionnaire about awareness and No analyses specific on fathers QUAN
HL knowledge about special needs of parents’
children, designed for this study (NS)
Munoz et al. 2015 United F/M 20 F 0–3 yr HA users Family Demographic form (NS) M more likely to learn about HA from QUAN
States 35 M 22 mo. Parent Hearing Aid Management Inventory audiologists (81%); F more likely to CS
(mean) (PHAMI) (designed for this study) learn from M—Just 43% reported
Acceptance and Action Questionnaire learning from audiologist
(AAQ-II)51 No difference F/M in their confidence
Patient Health Questionnaire (PHQ-9)52 of dealing with HA
F reported less challenges in HA use
and believed that their child
benefited more from HA use than did
M
F and M both reported a solid ability
to manage emotions regarding HA
use and child’s HL
Neuhaus 1969 United F/M 84 3–19 yr Deaf Parent Attitude Survey53 F of deaf children between 3–12 years QUAN
States Attitude Toward Disabled Persons Scale accepted the disability more than F CS
(ATDP)54 of 13–19 years old
Haggerty-Olson-Wickman Behavior Rating F/M showed no differences in
Schedules55 expressed attitudes towards their

children
Sahli 2011 Turkey F 20 F 36–112 CI users Demographic questionnaire (NS) F had more protective approach to QUAN
20 FTH mo Parental attitude research instrument (PARI)56 their child than FTH CS
76 mo F were less democratic and
(mean) disciplined with their children than
FTH
F who had “enough information and
support” could feel more like
themselves
Spahn et al. 2004 Germany F/M 42 F 8.4 yr CI users Symptom Checklist (SCL 90R)57 23.1% of F and 20% of M had elevated QUAN
52 M (mean) The Everyday Life Questionnaire (EDLQ)58 stress levels CS
Scales of early communication skills for F/M showed no differences in
hearing impaired children59 perceived quality of life
Spahn et al. 2001 Germany F/M 46 F 2–16 yr CI users Sociodemographic data questionnaire (NS) F/M showed no differences in QUAN
57 M 7 yr Symptom checklist (SCL90-R)60 – German motivation for CS
(mean) version57 treatment/psychosocial support; 60%
Questionnaire on psychosocial support61 F and 59% M motivated
F/M reported no differences in stress
levels
(Continued)
Table 1 Continued

status
Spahn et al. 2003 Germany F/M 119 F 2–16 yr HA-users Sociodemographic questionnaire (NS) Comparisons between parents of HA QUAN
138 M 7 yr CI-users Self-assessment of parental emotional state and CI users were made CS
73 F HA (mean) during the rehabilitation of the Family climate: F/M of CI children
81 M HA hearing-impaired child62 showed lower cohesion, less
46 F CI Questionnaire on initial information about openness and more control than F/M
57 M CI HA/CI63 of HA children.
Questionnaire on treatment expectations64 F of children with CI take more
Family Climate Scale65 unpaid vacation than F of children
with HA
Treatment expectations in the
medium range for both groups of
parents
Szarkowski 2016 United F/M 3F 1–14 yr Severe- Family demographic questionnaire (NS) No separate analyses on F/M QUAL
and Brice States 8M profound Interview
HL
Takala et al. 2000 Finland F/M 81 families 0–6 yr Deaf Questionnaire to assess benefit from F had greater difficulty learning to QUAN
participation in the program (NS) sign than M
F had fewer and less extensive
contacts in the deaf community than
M
M reported greater satisfaction with
the sign language intervention
F and M reported the child was the
best signer in the family, they
struggled to “keep up”
Wille et al. 2019 Belgium F/M 5F 24 mo. Deaf Naturalistic, in-home observations of F used more explicit strategies than QUAN
5M parent-child communication strategies M CS
Assessed based on “strategies of attention”66 F used more waving and displacing
objects in their interactions than M
Deaf F (n = 2) used more implicit
strategies than Deaf M (n = 2)
Deaf parents used more visual
communication and tactile strategies
than hearing parents
(Continued)
201
202
Table 1 Continued

status
Zaidman- 2007 Canada F/M 13 F 3.53 yr CI users Family Demographics questionnaire (NS) Table provides information about % MIX
Zait 15 M (mean) Retrospective self-report parent experience of M and F who endorsed particular
questionnaire (NS) critical themes
Critical Incidence Interview67 M – Greater % endorsed: intervention
services, professionals’ guidance,
supportive childcare settings
F—Greater % endorsed: taking action,
personal resources, supportive
workplace, martial partnership
Most results & the discussion
combine parents into one group
Zaidman- 2016 Israël F/M 30 C 3–8 yr Mild-profound Impact of Hearing Loss on the Family (family F lower self-efficacy than M QUAN
Zait 5.7 yr HL stress scale)68 F/M report no differences in stress, CS
et al. (mean) Parental Acceptance Questionnaire5 support and acceptance
Early Intervention Parental Self-Efficacy Scale F/M higher stress was related to
(EIPSES)6 lower self-efficacy and acceptance
Scale of Parental Involvement and
Self-Efficacy69
Support System Questionnaire7
Zaidman- 2018 Israël F/M 30 C 3–7 yr Mild-profound Parental Involvement Questionnaire70 F lower involvement, interest, QUAN
Zait 5.7 HL Impact of Hearing Loss on the Family68 attendance, communication and CS
et al. (mean) Early Intervention Parental Self-Efficacy Scale interaction with professionals than
(EIPSES)6 M
Family Support System Questionnaire7 F self-efficacy related to involvement
Parenting stress related to
involvement
a N = only the number of parent of children with HL are given.
C = Couples; CI = Cochlear implant; CS = Cross-Sectional; DHH = Deaf or hard of hearing; F = Fathers of DHH children; FTH Fathers of children with typical hearing; HA = Hearing aid; HL = Hearing loss; M = Mothers of DHH children;
MIX = Mixed; MTH Mothers of typically hearing children; Mo = Months; NA = Not applicable or information not provided; NS = Non-standardized; P = Parents; TH = Typical hearing; QUAL = Qualitative; QUAN = Quantitative; Yr = Yea.
Please see all footnotes for this table in Notes section.
involvement of fathers influences many important outcomes for (c) parent-child interaction, (d) involvement in early inter-
children, including their physical and mental health, as well as vention, (e) parental self-efficacy, and (f) benefits of fathers’
their cognition and achievement (Allport et al., 2018). Yet, collec- inclusion.
tively, the numerous potential impacts of fathers on their DHH 5. Comparisons—if fathers and mothers were both included in
children are not yet well understood. Across the studies exam- a study, were the results of each reported separately? Did
ined in the present systematic review, diverse research method- the researchers explicitly differentiate the contributions of
ologies were employed, divergent theoretical frameworks for fathers and mothers in the study and comment on the simi-
analysis were used, dissimilar populations were examined, dif- larities and/or differences in their findings? If fathers of DHH
ferent levels of rigor were implemented, and disparate con- children were compared with fathers of children who had a
structs were measured. On the basis of this review, it is not typical hearing or with fathers of children with disabilities,
possible to definitively state the influence(s) that have fathers what was unique to the experience of being a father to a child
have on their DHH children. who is DHH?
Few studies directly examined the impact of fathers on
Table 1 details whether fathers were the focus of the study, or
DHH children’s outcomes. The presence of a father in the lives
whether fathers and mothers were compared and their results
of DHH children has demonstrated a positive impact on the
reported separately. Some studies did include both fathers and
children’s academic and language outcomes (Calderon & Low,
mothers as participants, yet did not analyze their responses
1998). Parents experiencing lower levels of stress—both mothers
separately; these are included in the table because they met
and fathers—have been described as having DHH children
inclusivity criteria, yet they could not be included in the analysis
with more positive social-emotional development (Hintermair,
because insufficient information was available to ascertain the
2006). It might be expected that fathers’ involvement in
role or impact of fathers per se. Some studies did compare
early intervention would have beneficial effects on children’s
fathers of DHH children with fathers of children with typical
outcomes. However, it is not possible to declare this with
hearing or children with disabilities. The significant findings
certainty, as none of the studies reviewed examined this
from those studies are also captured in Table 1.
relationship. Rather, the influence on the fathers themselves
as a result of their involvement has been examined; fathers 1. Outcomes/main findings—Were the outcomes described in
who were more involved in early intervention, for example, terms of the fathers’ experiences or perceptions or on the
showed higher levels of self-efficacy and perceived more social perceived influence of the fathers on their children? Descrip-
support from their networks than did less involved fathers tive studies that mentioned fathers, but not their experiences
(Ingber & Most, 2012). Involved fathers are described as better or perceptions, were excluded (e.g., papers that documented
understanding their children and report finding joy in their paternal genetic contributions to a hearing loss).
involvement with their children (Crowley et al., 1982).
Drawing from the general literature on fathers, it is possible to Table 1 captures the main findings for each study reviewed.
identify the influence of fathers on child outcomes. For example, The six categories described above provide a conceptual frame-
a meta-analysis (including 21 studies, spanning from 1998– work for understanding the areas of study that have examined
2008) found associations between direct father involvement fathers’ experiences and perception of raising a child who is
and children’s social and cognitive early learning (McWayne, DHH.
Downer, Campos, & Harris, 2013). Another meta-analysis found 1. Study design—Did the study incorporate qualitative, quanti-
that fathers’ engagement with their children has been linked to tative, or mixed methods research approaches? All of these
positive social, behavioral, and psychological outcomes (Sarkadi, were included for this systematic review; however, single
Kristiansson, Oberklaid, & Bremberg, 2008). We suspect that case studies were not.
involvement and engagement of fathers of DHH children will,
likewise, have a positive influence on children’s development The majority of the studies utilized quantitative research
(and, recognizing the bidirectional nature of relationships, it designs. Information regarding the research design for each
follows that the fathers are likely influenced by their children study has been included in Table 1.
as well). Given the unique attributes as well as needs of children
who are DHH, and the diversity of what it can mean to “be DHH,”
Limitations
a better understanding of the role of fathers in the lives of their
children is needed. The authors have sought to demonstrate rigor and transparency
The PICOS questions that guided the authors’ review process with this systematic review. Yet, it is possible that some per-
were posted in the Introduction section. Based on the informa- tinent articles may have been omitted. As this review did not
tion gained through the review, we were able to answer the PICOS include unpublished materials nor information in the grey lit-
questions; responses have been provided below and in Table 1. erature regarding the experiences or perceptions of fathers of
young children who are DHH, some relevant information may
1. Participants—How and to what extent have fathers been have been missed.
included in studies of young children who are DHH? The quality of the research reviewed for this article was
2. Over a 50-year span, only 37 studies met the inclusivity variable. In some papers, the information about research
criteria of this study. methods and the data obtained were poorly described. The
3. Interventions/measures/instruments—What was being authors have opted to maintain researchers’ descriptions of
assessed, or what were the foci of the studies involving findings, even when these do not align with more standardized
fathers (or fathers and mothers) of children who were DHH reporting mechanisms; for example, some findings are reported
between birth-to-6 years of age? as “marginally significant” or one parent is described as having
4. The research involving fathers spanned six broad categories: “more” of a particular characteristic than the other parent,
(a) perspectives on parenting, (b) parental stress and coping, although information regarding statistical significance or
effect sizes are not provided. This systematic review captures understanding in the DHH field of the impact that mothers
researchers’ self-proclaimed results; these are neither supported AND fathers have on their children. Some investigators
nor denied by the authors of this review, they are simply have begun to encourage consideration be given to the
summarized. different perspectives and needs of mothers and fathers
The scope of the present study is focused on fathers of chil- (e.g., Brand et al., 2018; Zaidman-Zait et al., 2018). As one
dren who are DHH, birth to 6 years of age, as this time frame was example, increased understanding of, and accounting for,
of greatest interest to the investigators. However, some studies the facilitative and prohibitive factors that influence the
that included 6 years old also included older children; thus, the involvement of both mothers and fathers in the intervention
findings are inclusive of fathers of some DHH children who are and care of the DHH child is needed.
older than the intended scope. This review is limited in that it 4. The characteristics of father-child and mother-child interac-
does not intentionally explore the perspectives or experiences tions differ; explorations of these father-child and mother-
of fathers of DHH children over the age of 6 years. child dynamics can be useful. It may be possible that the
different results obtained from the two groups can guide
understanding and intervention in important ways. If exist-
Implications for Further Research
ing interventions and programs for supporting families are
Fathers’ experiences and perceptions are worthy of investiga- not addressing the needs of mothers AND fathers, this may,
tion. In the general literature, there is a growing body of evidence itself, contribute to reduced involvement of fathers.
regarding the importance of caregivers, the significant impact 5. There is a need for research that recognizes and explores the
parents have on children’s development, the potentially unique interactions of children who are DHH and their caregivers
contributions of fathers with their children and within families, as bidirectional. Fathers not only can have a positive impact
the importance of parent engagement, and the lasting impacts on their children; children can positively affect their fathers
of parent-infant attachment/parent-child bonding in the early as well. Studies that have begun to examine this (e.g., Brand
years of life. The literature has not yet sufficiently explored these et al., 2018; Daud et al., 2013) suggest that fathers who are
topics in the context of fathers of children who are DHH. Thus, more highly involved with their DHH children’s programming
the authors propose the following seven suggestions for future and who show greater acceptance of their children may have
research. children who exhibit better social-emotional functioning and
even language outcomes. A strong father-child relationship,
1. Research involving fathers will benefit from including a def-
in turn, can positively influence the family system.
inition of who is included in the sample. Existing research
6. Descriptive studies that explain whether and to what extend
involving fathers of DHH children rarely provides this specific
fathers are involved with their children are an important
information. However, depending on the type of study, it may
step, but only the initial stride toward understanding the
be relevant whether the father is biological, resides in the
impact of fathers on the children. Further research is needed
home with the child, how long the father figure has been in
to link fathers’ presence, involvement, beliefs, attitudes, and
the child’s life, or whether the father is actively coparenting
behaviors to specific child outcomes for DHH children.
the child. Clearly identifying whether fathers themselves are
7. Researchers are encouraged to be mindful that not all fam-
deaf or hearing is also encouraged; whether a fathers is deaf
ilies are composed of a mother, a father, and a child or
or hearing (and related other phenomenon, such as access
children. Father-child dyads and father–father-child triads,
to deaf role models, involvement in supportive communi-
and other family dynamics involving fathers also exist; the
ties) can influence the constructs being studied. Clarifying
influences and perspectives of these fathers, too, are also
the roles and contributions of the fathers participating in
worthy of consideration.
research will provide valuable information to this growing
field of inquiry.
2. Investigators are encouraged and challenged to actively
recruit fathers. Studies of “parents of DHH children” need to
Notes
be intentional and purposeful in capturing the perspectives
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Conf licts of Interest
stress among mothers and fathers of deaf school-
The authors have no conflicts of interest to disclose. age children. Journal of Community Psychology, 17(3),
220–224. doi: 10.1002/1520-6629(198907)17:3<220::AID-
JCOP2290170304>3.0.CO;2-N
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Journal of Deaf Studies and Deaf Education, 2021, 187–208

Fathers of Young Deaf or Hard-of-Hearing Children:

The paucity of research focusing solely on fathers con-

Methods <fathers> AND < children OR toddlers OR infants> AND <

Involvement in EI of hours the fathers worked and their involvement in services;

First author Year Country Participants Measures/instruments Main results Design

F/M Na Age Child hearing

(mean) HL Child Acceptance Questionnaire5 F involvement related to child CS

First author Year Country Participants Measures/instruments Main results Design

F/M Na Age Child hearing

How I Feel Toward Others (HIFTO)28

Sociometric status (self-report; NS)

First author Year Country Participants Measures/instruments Main results Design

F/M Na Age Child hearing

services36 perceived support from EI

First author Year Country Participants Measures/instruments Main results Design

F/M Na Age Child hearing

Role” and to “Relations with Spouse”

First author Year Country Participants Measures/instruments Main results Design

F/M Na Age Child hearing

Schedules55 expressed attitudes towards their

First author Year Country Participants Measures/instruments Main results Design

F/M Na Age Child hearing

First author Year Country Participants Measures/instruments Main results Design

F/M Na Age Child hearing

a N = only the number of parent of children with HL are given.

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