Review of peer bullying in children with hearing loss

Peer bullying is when one or more children systematically engage in aggressive behavior towards another child whom they consider weak. Children with hearing loss face many challenges due to the limitations of their hearing. In addition to these difficulties, the problems become even worse if they are exposed to peer bullying. Children with hearing loss may have more difficulty with social communication and interaction. This can increase the risk of being bullied by peers because bullying is often based on perception or the balance of power against differences. Peer bullying against children with hearing loss can have serious short-and long-term consequences. In the short term, it can increase a child’s stress level, damage their self-confidence and self-esteem, and negatively impact their mental health. Problems such as depression, anxiety, and social isolation may occur in children who are exposed to peer bullying in the long term. Therefore, it is extremely important to protect children with hearing loss against peer bullying and to carry out preventive studies. Strengthening the sense of confidence of children with hearing loss and integrating them into society is of critical importance for their healthy development.


Background
Social interactions play a huge role in human development.Humans inherently need social interactions to survive.Babies need the care of their parents or other adults to survive for a long time.This process allows people to develop patterns of behavior and thinking, but at the same time makes them vulnerable to the positive or negative behaviors of the people around them during sensitive and vulnerable developmental periods.Social interactions in early childhood focus primarily on parents or caregivers, shifting towards peers in late childhood and adolescence [1].
Social relationships are defined as the ability to interact with peers, make friends, and be accepted by peers [2].According to research, children with hearing loss often have few friends at school, interact less with their hearing peers, and are rejected more often than their hearing peers.They also feel isolated and lonely [3,4].
Children need relationships and friendships to develop their social skills.These skills are needed to improve social relationships later in life.It has been found that children with different degrees of social competence and friendship relationships show differences in their behavioral development [5,6].Popular children often exhibit positive social behaviors, while rejected children often show aggressive behaviors and may face negative developmental consequences.Children who have friends are usually more sociable and self-confident.However, children who have both friends and bullies may have slightly lower social competence and often have a rejected status.Children who are only bullies show a high degree of antisocial behavior and are often rejected.Children who do not have friendships or bullies, on the other hand, may be socially withdrawn and neglected [6][7][8].
This review examines the exposure of children with hearing loss to peer bullying and the effects of this situation on children's emotional, social, and language development.The basic concepts of peer bullying, different types such as physical, verbal, and emotional bullying, how often children with hearing loss are exposed to this bullying, and which types of bullying they are exposed to more are emphasized.Finally, the preventive and interventionist roles of parents and educators are emphasized, and suggestions are made to support children with hearing loss against peer bullying.The aim of this study is to raise awareness about the bullying experiences of children with hearing loss and to offer ideas on how to prevent bullying.

What is peer bullying?
The word bullying is a concept that has recently found a place in the literature and has been emphasized in many researches.Bullying is "behavior by an individual or group, repeated over time, which intentionally hurts another individual or group either physically or emotionally" [9][10][11][12][13].It can be defined as a problem that can affect the person in one or more time periods in all environments independent of factors such as age, gender, socioeconomic, and status [14].
In order for attitudes to be expressed in the form of peer bullying, they must contain an aggressive purpose aimed at deliberately harming them, they must be continuous, and there must be inequality of power [9].

Types of peer bullying
Types of bullying are processed in various ways, but they are grouped under two main terms as direct or indirect bullying.Direct bullying is all of the bullying behaviors that are physical and verbal because they are observable.In this sense, behaviors such as pushing, hitting, biting, kicking, stealing, or taking something from the bully victim are physical bullying [15]; offending, humiliating, threatening, insulting, and sarcastic behaviors are included under the heading of verbal bullying.In direct bullying, the individual who is the victim of the bully knows who made the public taunts or attacks on him [16].
Indirect bullying is defined as the creation of social manipulation or the spread of rumors in a way that harms the individual's relationships, where there is no direct attack on individuals.In indirect bullying, it is very unlikely that the bullied individual will know who is the bully.There are also behaviors such as addressing the victim with different nicknames, making fun of them, and excluding them.The basis of direct and indirect bullying lies in the continuous emergence of physical or psychological violence against the victim with attitudes such as constant harassment, intimidation, and mistreatment [6].
Bullying and victimization are among the most common behavioral problems at school [17].Bullying occurs as a result of academic competition or the behavior and attitudes of the bullying individual, regardless of whether the class size is large or not.Bullying in the school environment not only affects students psychosocially, emotionally, or physically, but also affects students' academic performance and studies.There are studies in the literature revealing that there is a relationship between bullying and school success [18][19][20].
The fact that there is a relationship between peer bullying and academic failure prevents students who are constantly victimized from being involved in activities or studies in the classroom environment.This situation results in individuals who are bullied experiencing negative emotional and psychological consequences that will affect their academic performance.The effects of bullying behaviors such as depression, anxiety, stress, and decreased self-perception are factors in the emergence of academic failure.Students who are exposed to peer bullying are unable to focus on their lessons and show poor performance in lessons [21].
Students who engage in bullying behavior are more self-confident than their peers, who do not feel happy in school, who are accepted among their peers who approve of bullying behavior [9,22], psychologically unstable behaviors, energetic, attention-seeking, depressionprone, personality disorder, and suicidal ideation [23].Unlike their peers, bullied individuals are defined as students who are physically weak, cry frequently, are sensitive, angry, quiet, introverted, and have high grades in school [24].
Peer bullying, which has increased in schools recently, negatively disrupts education in schools and students' adaptation and development to school.It has been revealed that there is a significant, negative relationship between defining the school as egalitarian and reliable and bullying.When students are exposed to violence and bullying at school, they result in academic failure and negative school experiences.According to Pişkin [25], students who experience peer bullying experience a sense of dislike of school.In addition, students who bully at school are prone to crime in their lives after school.
In a study, teachers frequently reported that students in inclusive education were often subjected to emotional or verbal bullying, while physical bullying was observed less frequently.According to the teachers, bullying of students in inclusive education is related to issues such as introversion, difficulty socializing, shyness, and trouble expressing themselves.Bully students, on the other hand, are described as those who try to assert themselves.Teachers state that bullying occurs in schoolyards, classrooms, and places where the child is left alone outside of school [26].
Identifying the reasons for being subjected to bullying, the causes of bullying behavior, and the locations where bullying occurs will contribute to developing strategies for inclusion students to cope with peer bullying.It is essential to prevent inclusion students who are victims of bullying from distancing themselves from the school environment.Facilitating the social integration of these students is of great importance.There needs to be an increase in research on bullying incidents in schools [27].
Whether students go to school willingly or do not want to go to school is directly related to what they experience at school.Although schools are safe, comfortable, and happy places for students, it is seen that bullying behaviors have increased in schools recently.In order to prevent bullying in schools, school administration, teachers, students, and staff should be informed about bullying, and awareness should be raised.In order to cope with peer bullying, which is usually interpersonal and in some cases can be interpreted as a process in which different people are involved, it is necessary to clarify the concept of bullying.In this way, an attempt will be made to create intervention programs to prevent peer bullying.In the researches conducted in this field, it is aimed to examine the studies on peer bullying and to guide the studies to be carried out to prevent bullying by determining the current situation.

Emotional and social development of children with hearing loss
Peers have a great importance in the development of the individual.By establishing a relationship with the child with hearing loss, the child can learn social rules, to react logically when faced with different situations, and to socialize with the individuals around him.However, if communication with the child with hearing loss cannot be achieved or the communication is not sufficient, there may be problems in the child's feeling of belonging to the social environment he is in and creating a healthy self-perception.Children may feel bad in this situation and as a result, their self-esteem may be damaged.Often, they find it difficult to adapt to society and feel isolated.Since the hearing-impaired individual in this situation has difficulty in expressing his feelings and demands, he may show problems of social isolation and maladjustment [28,29].This lack of communication can lead hearing-impaired individuals to isolate themselves from society over time.As a result, there may be problems in the development of social skills [30].
Research has shown that hearing loss increases the risk of emotional and behavioral problems in individuals showing that delay in language development causes behavioral problems [23].In a study, it has been revealed that behavioral problems are seen in people with hearing loss, but the problem of adaptation to school and peer bullying accompanies this situation.It has been observed that behavioral and attention problems are more common in children with moderate hearing loss than in children with mild hearing loss [31].
Individuals with hearing loss are more likely to have autism, attention, and behavioral problems than individuals with normal hearing [32].In addition to learning difficulties, children with hearing loss also have problems with distraction.This process negatively affects the development of children [33,34].
There are also studies in the literature stating that individuals with hearing loss do not encounter any psychological negativity and do not have any problems [32,35].In his research, Gent [35] revealed that children with hearing loss socialize quickly with their peers.In another study, it was determined that children with hearing loss had the same level of psychological problems compared to their hearing peers [32].
It is stated that the incidence of psychological problems in individuals with hearing loss varies between 0 and 77%, and not all individuals with hearing loss experience psychological problems [30].Studies emphasize that mental problems may be common among psychological problems in individuals with hearing loss [30,36,37].It has been shown that children who develop hearing loss due to brain damage such as intrauterine viral infections, complications of prematurity, and neonatal meningitis are more prone to experience mental problems [32,38].It is emphasized that it is possible to detect psychological and social problems earlier with early diagnosis in individuals with hearing loss [39].
It is emphasized that the school where the child with hearing loss is educated has an effect on the psychology.In a study, it was determined that psychology and body perception were more positive in adolescents with hearing loss who studied in normal schools than in deaf schools [40].Not being able to benefit from health services is another factor that can adversely affect the health status of hearing-impaired individuals.The inability of the individual to express himself adequately verbally is an obstacle to receiving an effective health service.Because a child with hearing loss has limited communication skills, the healthcare worker often experiences anxiety and uses excessive body language to communicate with the child.This process can cause the individual with hearing loss to experience stress and have difficulty expressing their feelings clearly.This situation leads to some methodological problems in the examination of psychological problems in children with hearing loss and delays in the diagnostic process [32].
In conclusion, most of the studies emphasize that hearing loss is a factor that increases the incidence of psychological problems.Most of these problems can be prevented by establishing effective communication with the family.It is of great importance for healthcare professionals, whose patient population includes children with hearing loss, to be aware of the communication needs of children with hearing loss and the developmental consequences caused by hearing loss [32].It is of great importance to treat children with hearing loss in the same way as hearing children, starting from an early age.In order for these children to become active members of society despite their hearing loss, educators, healthcare professionals, and families must cooperate, and the most appropriate environment must be provided for the child [28].

Frequency of peer bullying
Peer bullying can cause many problems in children with hearing loss.These children are twice as likely to be bullied by peers as their peers with normal development [41,42].Similarly, in a study, it was determined that children with hearing loss (50% or more) were bullied more than children with normal development (20-30%) [43].
The study by Weiner et al. [44] focused on 812 deaf and hard-of-hearing students from 11 U.S. schools and collected data using the Olweus Bullying Questionnaire.The results show that deaf and hard-of-hearing students are 2-3 times more likely to be bullied compared to hearing students, and that school staff are less helpful in intervention situations than hearing students.These findings highlight the need for more protection and support in the school environment for deaf and hard-of-hearing students.Therefore, it is important for educators and researchers to strive to provide a fair and safe learning environment for all students [44].

Factors influencing peer bullying Gender
In the literature, it is stated that boys bully more than girls [45].However, it has been shown that boys are more likely to be bullied by verbal and physical contact than girls, but girls are victims of verbal or indirect bullying that is harmful [46].On the other hand, there are studies that show that there is no difference between male and female students in terms of experiencing peer bullying [45].

Age
Peer bullying is more common among children at an early age [24].It has been found that peer bullying is very common, especially among primary school students.It is known that verbal and psychological bullying is common as age increases, but physical bullying decreases [45,47].

Communication and language skills
More than 90-95% of deaf children are born to hearing parents, and many of these parents have little or no experience of the deaf community's norms, values, or language development of the deaf child [36].This situation may result in language development retardation if the child is not supported in special education.
It has been reported that primary school students with language and speech retardation experience peer bullying more than their peers with normal development [48].Studies on bullying of deaf children to date reveal that language development retardation caused by hearing loss is a factor that increases bullying [49].
Communication skills depend on language development and the presence of good communication patterns in the developing individual's environment [50].Compared to their hearing peers, deaf children who use speech or both spoken and sign language are less likely to be chosen as friends by a hearing child [51].
According to a study, adolescents with hearing loss who communicate only through sign language are more likely to encounter peer problems when they are educated in a school based on verbal communication, as opposed to non-verbal communication [52].

Hearing status of friends of individuals with hearing loss
Hearing loss of any degree can interrupt the normal development of communication, social-emotional health, and academic performance [53].One of the basic instincts of the individual with hearing loss is the desire to be accepted.Research indicates that individuals with hearing loss who receive education in schools for the hearing impaired are more likely to have peers with hearing loss, whereas those educated as inclusion students in mainstream schools are more likely to have hearing peers [54].
In his study, Warick [55] found that hearing-impaired students had difficulty understanding their teachers and classmates.It has been revealed that lip-reading behaviors increase especially when new or substitute teachers enter their classes.It can be predicted that as the sound insulation of the classroom decreases, hearing-impaired children will have serious difficulty in understanding speech and, accordingly, both their academic success and friendship relations will be affected.
Additionally, a systematic review on the impact of educational environments on social processes has revealed that deaf children perceive their interactions with hearing peers as less satisfactory compared to their interactions with other deaf peers.This review emphasizes that deaf students constitute a minority compared to the general school population and highlights that their interactions and experiences with non-deaf peers can significantly vary depending on the level of support provided [3].While interactions and experiences with hearing peers vary based on the support offered by their environments, experiences in schools providing specialized support for the deaf show positive differences [56,57].

Conclusions
Research reveals that children with hearing loss experience more peer bullying compared to their peers with normal hearing, which has negative effects on their psychological state and academic performance.
Peer bullying creates negative effects such as anxiety, low self-esteem, and depression, preventing victims from integrating into the school environment.In this context, the necessity of preventing and intervening in peer bullying, especially for children with hearing loss, comes to the fore.

In-service training seminars
In-service training seminars for school administrators and educators can increase awareness about bullying.These seminars may also include strategies for students with hearing loss.

Bullying prevention and intervention programs
Training programs for bullying prevention and intervention can be organized for school administration, educators, parents, and school personnel.These programs can strengthen skills in recognizing bullying, intervening in bullying, and providing support to victims of bullying.

Family education programs
It is known that the family factor has an impact on students becoming bullies or victims of bullies.For this reason, training can be organized for teachers and parents to improve their communication skills and contribute to the solution of family problems.

Social activities and events
The social integration of students with hearing loss and bullying can be supported by organizing sports, artistic, and cultural events that will bring students closer to school.It is important that children who are bullied are directed to specially designed activities to increase their self-confidence.

Awareness training
Educational strategies can be developed to increase the awareness of children with hearing loss in the school environment and to encourage empathy towards them.Children who are bullied and bullied can be given training on topics such as social skills, anger management, self-expression, and communication.
Research in the literature has revealed the relationship between hearing loss and peer bullying.However, there are few studies on whether bullying experienced by children with special needs differs according to factors such as gender, age, and class.More studies are needed on peer bullying experienced by children with hearing loss.