Behavioral problems in deaf pupils : perspectives from teachers and deaf pupils in the Gambia

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Faculty of Social and Behavioral Sciences Graduate School of Childhood Development and Education

Behavioral Problems in Deaf Pupils:

Perspectives from Teachers and Deaf Pupils in the Gambia

Research Master Child Development and Education Thesis II – I. (Iris) Nube

Supervised by: Prof. dr. S. (Sjoerd) Karsten

Reviewed by: dr. H.M.W. (Henny) Bos and prof. dr. M.L.L. (Monique) Volman

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Acknowledgments

First and foremost I would like to thank all the pupils and members of the staff at St. Johns School for the Deaf and Hard-of-Hearing in Serrekunda, the Gambia, for welcoming me into their primary, secondary and vocational school and into their lives for the fieldwork period of eleven weeks in the beginning of 2014. They have opened their hearts and minds to me from the start and thereby enabled me to write the thesis you are now reading. The children were always able to elevate my moods by signing ‘GOOD MORNING, HOW ARE YOU’ to me or pointing at my crazy shoes or other ‘toubab’ (= outsider/white person) elements of my life. I can not say or sign THANK YOU enough to all their pretty little bright faces.

A special thanks goes out to Binte, a deaf teacher of the highest two grades for supporting the photovoice part of this research, for being open and honest with me about any topic, for making me feel especially welcome. She is a great (deaf) role model and deserves the utmost respect and appreciation for the work she does with the deaf teenagers at the school. The school is a better place with her in it and I sincerely hope that she achieves her goals and dreams in live. THANK YOU, BINTE.

My gratitude goes out to my supervisor prof. dr. S. Karsten for guiding me through all different phases of the research proposal and fieldwork project and for his support during difficult decisions. His knowledge and comments have improved my skills and work greatly. Thank you sincerely for that, Sjoerd. I would also like to thank my reviewers dr. H.M.W. Bos and prof. dr. M.L.L. Volman for their time and devotion in improving my research and report.

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Furthermore, I would like to thank my loving partner Roel for supporting me in all steps involved in this thesis, my studies and for his visit to me during the fieldwork. Without our daily Skype-conversations, I do not know how I would have managed all the difficult patches in the research and the overall experience. Thank you so much for that, my love. My sincere gratitude also goes out to my mother Ria and her partner Hans for emotionally and financially supporting me in my dream of doing voluntary work in an African country. My friend Emma who dropped me of in the Gambia and saw me off to an awesome start of course also deserves all the ‘thank you’s’ I can manage. Finally, I’d like to thank Mariska van Zanten, who conducted a anthropological fieldwork study with deaf youth and their parents in the same period in Kenya. The exchange of experiences, theories, used methodology and cultural toe-stepping stories often elevated my mood.

The problem is not that the deaf students do not hear.

The problem is that the hearing world does not listen.

Rev. Jesse Jackson – Gallaudet University for the Deaf

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Abstract

Behavioral problems lead to academic, social and emotional hindrance in the development of children and are more prevalent in children with severe hearing loss. This research focused on the definitions, causes, consequences and possible addressing methods for behavioral problems of deaf pupils aged 4-24 in the Gambia, West-Africa, from the perspectives of the teachers and the deaf pupils themselves. Eleven weeks of participatory observations in all grades at two schools and informal interviews with teachers lead to interesting results. Problematic behavior was defined as stealing, fighting, teenage pregnancies, gambling, inattention in class, lack of concentration, and breaking (other) school rules. The most named causes were parental neglect, poverty and the resulting hunger, stubbornness, and low IQ. The observed causes were lack of school materials, lack of communication methods, violence from the teachers to the pupils, lack of school rules and absent teachers. The consequences ranged from drop-out, to criminality, to abandonment from the family and finally to punishment from God/Allah. The observed method of addressing problematic behavior was physical discipline, whilst the teachers mentioned building relationship with the students and general better behavior of the students as possible fixes for the problems. These results provide an interesting insight in the differences in perspectives on problematic behavior between and amongst teachers and students, between data gathered through observations and interviews, and between industrialized and developing countries.

Keywords: deaf, the Gambia, Sub-Saharan Africa, children, behavioral problems, CBCL, physical discipline

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1. Introduction

The United Nations Millennium Declaration of 2000 states eight goals that should be met by all countries of the world in 2015. One of these eight millennium goals is to ‘achieve universal primary education’ which prime target states: ‘to ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling’ (The Millennium Development Goals Report, 2012). For this goal, three indicators are given to measure progress: net enrolment ratio in primary education, proportion of pupils starting first grade and finishing their education, and finally literacy rate at ages 15-24 years old (The Gambia MDG Status Report, 2009).

In 2008, the Education for All Global Monitoring Report was published, stating that the universal access and enrolment to primary and secondary education has improved significantly and that there is more gender equality (UNSECO, 2011). However, the quality of education remains low. Moreover, the quality of the education will decline if more children gain access but have to share the same amount of resources. Moreover, the unequal access to education for different social groups, geographic groups and people with disabilities is still a critical issue that needs addressing.

The group of children with disabilities often fails to meet the three criteria of the primary education millennium goal: equal access, graduating from primary education and adequate literacy. Children with mental and/or physical disabilities often have unequal access to education due to their special needs. The nature of their physical, social and/or psychological problems increases their difficulty in finishing primary education. Obtaining literacy with these hindrances is often too big a challenge.

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To improve the position of people with disabilities, the United Nations adopted the Convention on the Rights of Persons with Disabilities, which is the first human rights instrument with an explicit social development dimension which focuses on creating equality for all people (Convention on the Rights of Persons with Disabilities and Optional Protocol, 2006). This document does not provide disabled people with more or new human rights, but instead strives to secure equal protection of the rights of people with disabilities.

Deafness is one of the disabilities that are covered in the Convention on the Rights of Persons with Disabilities. In 2012, 360 million people worldwide experienced disabling hearing loss (> 40 dB), 32 million of which are children (WHO, 2012). The prevalence of severe hearing loss is the greatest in South Asia, the Asia Pacific region and Sub-Saharan Africa. In Sub-Saharan Africa, disabling hearing loss affects 6.8 million children, which is 0.9% of the total child population. The Convention on the Rights of Persons with Disabilities (2006) includes the following on disabled individuals and the deaf in particular:

‘State Parties shall enable persons with disabilities to learn life and social development skills to facilitate their full and equal participation in education and as members of the community. To this end, State Parties shall take appropriate measures, including: […] Facilitating the learning of sign language and the promotion of the linguistic identity of the deaf community; ensuring that the education of persons, and in particular children, who are blind, deaf or deafblind, is delivered in the most appropriate languages and modes and means of communication for the individual, and in environments which maximize academic and social development’ (p. 17).

From this convention, different prerequisites can be deduced for deaf education with high quality: the use of an appropriate language, adequate modes and means of communication to the individual and, more general, environments that maximize academic and social development. Academic and social development can be disrupted by behavioral problems. Deaf children are at

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higher risk for behavioral problems than hearing children. Besides the known causes, they are also more likely to suffer from disruptions in linguistic, social, emotional and academic development.

This research aims to gain insight in behavioral problems of deaf children through a case study conducted in a school for primary, secondary and vocational education in Serrekunda, the Gambia. In order to increase the understanding of the causes, consequences and possible solutions to these problems, it is crucial to investigate the views of those involved: the pupils and their teachers. This deepens the understanding of the cultural notion of behavioral problems, the specific nature of behavioral problems in deaf children, the perceived causes and consequences, and the current way of dealing with behavioral problems, which is often through physical and mental violence. This will also lead to further insights in the Sub-Saharan African notion of behavior, child rearing, and education and possibly increased understanding of the high rates of disciplinary violence used with children in the Gambia.

Additionally, the insights gained from this research seek to inform policies and practices that aim to reduce behavioral problems in (deaf) children (in the Gambia). Knowledge of the perceived problems, their causes and their consequences is crucial for developing interventions for the home situation and formal education settings.

1.1 Research question

As described above, behavioral problems disrupt the social, emotional, and intellectual development of children. To date, no interventions are in place to aid children with behavioral problems in formal educational settings or at home in the Gambia. However, before the current

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situation of deaf children with behavioral problems can be improved, it is important to know what behavioral problems are in the Gambian cultural context, how they are experienced, and how teachers currently handle behavioral disruptions in the classrooms.

The main research question in this study is as follows:

How do deaf pupils and their teachers define, explain, judge and address behavioral problems of deaf pupils in Serrekunda and Basse, the Gambia?

Three sub-questions are formulated to answer the main research question:

1) How do deaf pupils and their teachers define behavioral problems of deaf pupils in Serrekunda and Basse, the Gambia?

2) How do deaf pupils and their teachers explain behavioral problems of deaf pupils in Serrekunda and Basse, the Gambia?

3) How do deaf pupils and their teachers judge behavioral problems of deaf pupils in Serrekunda and Basse, the Gambia?

4) How do deaf pupils and their teachers address behavioral problems of deaf children in Serrekunda and Basse, the Gambia?

1.2 Structure of the thesis

After this general introduction, a theoretical background with classic and contemporary academic publications will be given in the second chapter in which the afore-mentioned research questions can be placed. The third chapter is a contextual description of the Gambia, its population, its economic and developmental status, and its educational system. This chapter functions as a framework in which to place the results of the study. Next, the fourth chapter will focus on the used methods, participants, procedures, limitations and ethical considerations specific to this

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fieldwork study. Chapter five will discuss the results. The final chapter will combine the theoretical framework outlined in the second chapter with the results of the fifth chapter to answer the research questions central to this fieldwork study.

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2. Theoretical background

Even though a large percentage of contemporary and classic developmental and educational research is focused on behavioral problems in children, a clear definition of such problems is lacking. Moreover, little is known about behavioral problems in deaf children. Up to the DSM-III only a few, and ambiguous ones at that, categories of childhood disorders were defined, which is why researchers turned to analyzing the various child behavior checklists. Different researchers conducted multivariate statistics to empirically derive classifications of problematic behavior that are still used to date (Kovacs & Devlin, 1998). However, even today little is known about the specific nature of behavioral problems in deaf children.

It is important to place the development of a child within a framework of the relationships it has and environments it lives in. Therefore, the first paragraph of this chapter will describe the bio-ecological model with its different nested systems. This model is the most widely used model to describe the development of children in pedagogical sciences. Next, it will focus on the types of problem behavior, the instruments used to diagnose (deaf) children with behavioral problems, and the known causes, the possible consequences and treatments for (deaf) children with problematic behavior.

2.1 Bio-ecological model

The bio-ecological model adequately describes the development of an individual (child) in the context of the relationships it forms and the environment in which it is raised (Bronfenbrenner, 1979; Bronfenbrenner, 1994; Bronfenbrenner & Ceci, 1994). The model consists of five different nested layers: the microsystem, the mesosystem, the exosystem, the macrosystem, and the later added chronosystem (Bronfenbrenner, 1994).

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The microsystem includes settings such as family, school, peer group, religious belonging and work place and envelops ‘a pattern of activities, social roles, and interpersonal relations experienced by the developing person […] with particular physical, social, and symbolic features that invite or inhibit engagement in sustained, progressively more complex interaction with, and activity in, the immediate environment (Bronfenbrenner, 1994, p. 39)’. Different (possibly) strong relationships (dyads) are formed in the microsystem: the mother-child dyad, the father-child dyad, the teacher-father-child dyad and the relationships between siblings. Early father-childhood research often focuses on activities, social roles and interpersonal relations in the microsystem.

The mesosystem comprises all processes taking place between the various microsystems. Therefore, the mesosystem is a system of microsystems. Examples of a mesosystem are the interactions between parents and teachers and the influence of that on the education and upbringing of the child. The next system is the exosystem which comprises the linkages between situations and processes in those situations in which the developing individual is not present, but which have an indirect influence on their lives (Bronfenbrenner, 1994). The workplace of the parents, family social networks and neighborhood-community contexts are good examples of the exosystem.

The macrosystem is the ‘societal blueprint for a particular culture or subculture (Bronfenbrenner, 1994, p. 40)’ and holds all the (sub)cultural beliefs that influence the micro-, meso-, and exosystems of the developing individual. In multicultural settings, different blueprints are activated at the same time. The final system – the chronosystem – is not nested but describes the development of all other systems through time.

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Behavioral problems mainly take place in the microsystem settings: a child acts problematic in the home or school situation, gets into fights with parents or siblings, causes disruptions during instructions in the classroom. They also influence the mesosystem: parents might choose a different school because of the problems and have extra parent-teacher meetings. Parents in turn might experience extra stress due to the problematic behavior, which in turn might influence their performance in the work setting, which is in the exosystem of the child. The macrosystem also has a major impact on problematic behavior of children: culture can define what is appropriate and disruptive behavior, decides what the proper treatment of children with problems is and defines what the causes and consequences of the problematic behavior are. Finally, the development of all these different systems through time, in the chronosystem, influences the behavior of the child as well. The child might outgrow its problems, parents might have difficulty retaining their jobs, and children might have difficulty finding their place in society.

2.2 Externalizing and internalizing problem behavior

The context of the behavioral problems is outlined; therefore it is now important to describe what these problems might entail. There are two general types of problematic behavior: internalizing and externalizing behavioral problems. Internalizing behavioral problems refer to ‘conditions whose central feature is disordered mood or emotion (p. 47)’ whilst externalizing disorders have deregulated behavior as their central feature (Kovacs & Devlin, 1998). Internalizing problematic behaviors are often called emotional disorders, whilst externalizing behavioral problems are labeled behavioral disorders.

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The Child Behavior Check List (CBCL; Achenbach & Edelbrock, 1981; Achenbach, Howell, Quay, Conners & Bates, 1991; Achenbach & Rescorla, 2001) has been used to determine the extent of problem behavior in individual children worldwide for over thirty years. Currently, there are two versions: for 1.5-5 year old children and for 6-18 year old children. The 6-18 year old version of the check list was revised in 2001 and now contains 113 items. The CBCL/6-18 has eight syndrome scales: anxious/depressed, depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behavior and aggressive behavior. The first six syndrome scales together represent internalizing problem behavior, whereas the last two scales cover externalizing behavioral problems. The CBCL/6-18 also contains DSM-oriented scales: affective problems, anxiety problems, somatic problems, ADHD, oppositional defiant problems, obsessive compulsive disorder, posttraumatic stress disorder and conduct problems. Moreover, optional competence scales are added for skills, social relations and total competence.

The CBCL is part of the Achenbach System of Empirically Based Assessment (ASEBA), which assesses adaptive and maladaptive behavior from preschool age to elder adult age. Two other main instruments are also part of this system: the Youth Self Report (YSR) and the Teacher’s Report Form (TRF). The YSR contains items about social competence and 119 items regarding behavioral problems, including 16 specific items on social desirability (van Eldik, 2005). The TRF consists of 120 items for behavioral, emotional and social problems reported by the teachers of pupils aged 6-18 (Ivanova et al., 2007a). The cross-informant reliability of the CBCL, TRF and YSF is reported to be significant for almost all sub-scales of the questionnaires (Achenbach & Rescorla, 2001). Besides these quantitative instruments, the ASEBA for school aged children also includes the Semi-structured Clinical Interview for Children and Adolescents (SCICA), Test Observation Form (TOF), Direct Observation Form (DOF), and Brief Problem

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Monitor (BPM). A selection or all of these tests combined can be used to determine adaptive and maladaptive behavior in school aged children.

The CBCL/6-18 has been tested in 30 societies across the world from all continents by Ivanova et al. (2007b), who found support for the correlated eight syndrome structure in all participating societies. The sample had a strong emphasis on the European countries and the African continent was only represented by Ethiopia. Moreover, it is indicated that multicultural variations can not be abolished; the effect sizes of society, in a similar sample of 31 countries, were larger than the effect sizes for gender and age (Rescorla et al., 2007). Another study comparing the CBCL-preschool version in 24 societies found small to medium effect sizes for society but did not include any countries from the African continent (Rescorla et al., 2011). Similar results were obtained for the TRF in 20 societies not including any African countries and for the YSR in 23 societies including only Ethiopia from the African continent (respectively Ivanova et al., 2007a; Ivanova et al., 2007c). Whether the CBCL, the YSR and the TRF are valid instruments to be used in the context of the African continent and the Sub-Saharan Africa region is thus debatable. The SCICA, TOF, DOF and BPM have not been tested in multiple cultural and regional settings so whether their results can be compared amongst (Sub-Saharan African) countries remains unknown.

Deaf children generally show equal or more emotional and behavioral problems than their hearing peers according to CBCL guidelines. Vostanis, Hayes, Du Fue and Warren (1997) found that 40% of their sample of 84 deaf children in deaf schools fell into the clinical range of the CBCL, whilst a staggering 82% were socially dysfunctional in comparison with their hearing peers. A more recent Dutch study by van Eldik, Treffers, Veerman and Verhulst (2004) confirms

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these results for the Dutch population. They studied the emotional and behavioral problems of Dutch deaf children aged 4-18 through parental reports. Forty-one percent of their sample had emotional and/or behavioral problems according to CBCL total scores, which is 2.6 times higher than a normative Dutch hearing sample.

The consequences of behavioral problems can be serious and therefore it is important to look at their causes, so they can be addressed. According to Kovacs and Devlin (1998) there are several reasons to act quickly when behavioral problems are discovered. First of all, emotional disorders increase with age, so early addressing of the problems is advisable. Secondly, children with a behavioral or emotional disorder diagnosis often have multiple problems that need addressing and are impaired in multiple different areas of functioning. Finally, children with behavioral problems are often the offspring of parents who have psychiatric symptoms themselves and thus passing problems on should be attempted to be avoided. It can be observed here that multiple systems from the bio-ecological model intertwine: the chronosystem describes the influence of age and intergenerational transmission, whilst the continuation of problems could also be due to genetic or microsystem factors.

The remainder of this chapter will focus first on the causes of behavioral problems, which are described with regard to the different layers of the bio-ecological model. The chronosystem has no separate section but the development through time is apparent in all other systems. Section 2.4 describes the consequences of behavioral problems and the chapter closes with a section on the possible ways of addressing problematic behavior.

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2.3 Causes of behavioral problems 2.3.1 Biological causes

Genetic factors can be examined through twin-studies. A large longitudinal cross-informant study with Swedish twin pairs found both continuous genetic influences during the entire developmental period and new sources of genetic influence which emerged in early to late adolescence (Wichers, Gardner, Maes, Lichtenstein, Larsson & Kendler, 2013). The impact of shared environmental factors on externalizing behavior was minimal and insignificant, whilst the unique environmental factors’ impact at age 13-14 did have lasting significant effects on behavioral problems.

Another nature factor which is a good predictor of behavioral problems in deaf youth is the degree of hearing loss of the child (Calderon, 2000; Hintermair, 2006). The degree of hearing loss causes significant problems in establishing a mutual relationship between hearing parent(s) and their deaf child (Hintermair, 2006) and hampers the use of oral maternal communication skills (Calderon, 2000). This makes hearing loss, as a factor influencing behavioral problems, a combination of nurture and nature in cause.

There is a direct link between micronutrient deficiencies in pregnancy and early life and later behavioral problems (Benton, 2008). Iodine deficiency can cause both hearing problems and behavioral problems in young children (Benton, 2008), even though there is no research combining the two problems with regard to iodine status. Due to the poverty in the Gambia and the lack of nutrients, which will be elaborated upon in Chapter 3, it might be that there are more

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children with hearing problems and behavioral problems caused during and right after pregnancy.

Another factor combining both nature and nurture is IQ, in which a lower IQ has a significant effect on increased internalizing and social problematic behavior in deaf teenagers (van Eldik, Treffers, Veerman & Verhulst, 2004; van Eldik, 2005). Both educable children (IQ 60-90) and trainable children (IQ 30-60) show significantly higher scores on the CBCL and the TRF than a children with an IQ of above 90 (Dekker, Koot, van der Ende & Verhulst, 2002). Schools for the deaf in Sub-Saharan Africa often have children enrolled that are not only deaf, but also have a significant lower IQ, or sometimes even low-IQ children that are not deaf at all. Most schools lack appropriate audiology materials to test for the amount of hearing loss and therefore enroll all children that ‘do not speak’, thus including children with mental disabilities.

The temperament of the infant is another biological factor that is linked to internalizing and externalizing problematic behavior in adolescence (Caspi, Henry, McGee, Moffitt & Silva, 1995). Temperament can be defined as ‘constitutionally based individual differences in reactivity and self-regulation (Gartstein, Putnam & Rothbart, 2012)’. Temperament constructs have been made based on parent evaluations of child behavior, among which negative emotionality, positive affectivity, and effortful control. In general, it can be stated that children with an easy temperament exhibit lower internalizing and externalizing problem behaviors, and are less likely to develop behavioral problems in high risk environments (Derauf, et al. 2011). More specifically, high levels of negative emotionality and low levels of effortful control were associated with more internalizing and externalizing behavioral problems, whilst negative affectivity was associated with higher levels of all internalizing behavioral problems and with

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frustration, sadness and low reactivity for the externalizing problematic behaviors (Gartstein, Putnam & Rothbart, 2012).

2.3.2 Environmental causes 2.3.2.1 Microsystem causes

Genetics only account for approximately five to ten percent of the causes of deafness, although exact figures of the Sub-Saharan African region are unknown due to poor registration of medical conditions in most countries. Approximately ninety percent of deaf children are thus born into hearing families (Blume, 2002). They need alternative methods of communicating with their family such as lip reading, cued speech, sign language, or a mixture of these methods (Wilkens & Hehir, 2008). Parents, who choose an oral or written method for their child and succeed, grant their deaf child access to human, cultural and social capital in the spoken language-using community. In this case, the child is described as ‘deaf’, describing only the medical condition of hearing loss. Parents who choose a signed language as the visual method for raising their deaf child grant the child access to human, cultural and social capital in the Deaf community worldwide (Padden & Humphries, 2005). In this case, the capitalized Deaf is used, to symbolize the cultural identity of some deaf individuals who share a language and cultural heritage. Some parents choose both options combined and some parents lack sufficient information about the last option to even consider choosing a Deaf environment for their child. Most Sub-Saharan African countries lack a system to diagnose childhood deafness and to provide parents of deaf children with information about signed languages, and the human, cultural and social capital possibly provided by the local Deaf community. D/deaf is used when the situation is ambiguous. In the remainder of this thesis, Deaf, D/deaf and deaf will be used where deemed appropriate.

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Van Eldik, Treffers, Veerman and Verhulst (2004) conducted research into potential underlying mechanisms that cause the high percentage of emotional and behavioral problems in D/deaf youth and confirmed that children with poor communication with their parents had more emotional and behavioral problems. Moreover, older children had higher scores on the Anxious/Depressed scale and the Social Problems scale. However, no significant differences were found for ethnic background, gender, socioeconomic status and school environment. Derauf et al. (2011) found that easy temperament and low risk environment are protective factors for language development in infants, which in turn led to lower internalizing problems in children.

There are several interaction effects between the aforementioned temperament of the child and the development of problematic behavior. Parenting styles that are inconsistent, harsh and coercive and the following insecure parent-child relationship, both relate to higher risk of developing problematic behavior, with an aggravating pattern because behavioral problems in turn attract more harsh parenting styles, so the direction of the relation is unclear (Campbell, Shaw & Gilliom, 2000). Easy temperament in a child might ease family conflict, whilst difficult temperament might increase conflicts in the family, which in turn again lead to problematic behavior in the child (Tschann, Kavier, Chesney & Alton, 1996). Moreover, mothers with lower maternal sensitivity towards interpreting the behavioral signals of their children, have offspring with more difficult temperament in first grade (Bradley & Corwyn, 2008).

Causes in the microsystem include the aforementioned difficulties in maternal communication (Calderon, 2000), and the difficulty in creating a solid parent-child relationship (Hintermair, 2006). D/deaf children have lower attention spans, show more language difficulties and spend less time communicating with their parents than their hearing peers, which causes

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problematic behavior (Barker, Quittner, Fink, Eisenberg, Tobey, Niparko & CDaCI Investigation Team, 2009). Moreover, maternal depression is significantly correlated with internalizing, externalizing, and general psychopathology in children (Goodman, Rouse, Connell, Robbins Broth, Hall & Heyward, 2011). Depressed mothers might be less responsive, which in combination with communication difficulties and possible difficult temperament of the child, leads to more problematic behaviors (Kochanska & Kim, 2013). Whether the deafness of the child is also cause for (more) maternal depression, creating a downward spiral, is not yet studied.

Family well-being thus has a vital impact on the development of young children. Jackson and Turnbull (2004) reviewed literature on quality of life as experienced by families of children who are deaf. They support the notion that poor communication between the deaf child and its parents leads to more behavioral problems in children. They view families holistically and argue that family interaction is central to the family’s quality of life. Family interactions might change due to necessity of a different mode of communication. Increased parental stress due to the difficult decisions surrounding the (deaf) identity, language, technology and methodology for the deaf child, might in turn influence family interactions. Parental stress and problematic behavior have an aggravating transactional effect on each other, which makes this an interaction between the microsystem and the chronosystem as well (Neece, Green & Baker, 2012).

One of the factors influencing families as a whole is the socio-economic status (SES) of the family. The socio-economic status is a combined economic and sociologic factor, enveloping race/ethnicity, family income, highest educational level, and occupation. According to Duncan and Magnuson (2011), children from the lowest SES group, have more behavioral problems as

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rated by teachers. This SES-gap only increases over the course of elementary school to almost double that at the start of elementary school.

According to UNICEF (2014), physical discipline or punishment is experienced by over 90% of Sub-Saharan African children in their home and school situation. Early spanking has been shown to increase children’s externalizing problematic behaviors, whilst early externalizing behavioral problems in turn elicit more spanking over time (Gershoff, Lansford, Sexton, Davis-Kean & Sameroff, 2012). Child abuse with and without simultaneous exposure to domestic violence between the parents also increases the child’s risk for both internalizing and externalizing problem behavior (Moylan, Herrenkohl, Sousa, Tajima, Herrenkohl & Russo, 2009). There are no studies to date which compare physical violence used with children with and without severe hearing loss. Quittner, et al. (2010) compared hearing parents with deaf and hearing children and found context specific parental stress and more behavioral problems in the families with deaf children, which might be caused by oral language delays. Thus, parenting stress and maternal depression in families with deaf children are increased, which might lead to increased instances of spanking.

Sexual abuse is another form of violence in the micro-level of the bio-ecological model causing behavioral problems in children. Kiyaga and Moores (2003) conducted research into deafness in Sub-Saharan African context and found that especially deaf Sub-Saharan girls face four types of discrimination due to deafness, gender, age and poverty. They are excluded in many situations which increases their vulnerability to physical and sexual abuse. Studies from North-America and Norway conclude that deaf people have a much higher risk of sexual abuse in childhood than their hearing peers (Sedlack & Broadhurst, 1996; Kvam, 2004). Deaf females

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have a two times higher risk of childhood sexual abuse compared to hearing females whilst deaf males have a three times higher risk in both countries. A possible risk factor is enrollment in a special school for the deaf, regardless of whether it is a boarding school. The reasons for this are not mentioned in the article. Deaf children make an easier target due to their often lower self-esteem, lack of communication skills about such topics, and lack of peer contact (Kvam, 2004).

At least two protective factors can be identified in the link between child maltreatment and later psychopathology in childhood. If the child experiences peer acceptance or learns how to regulate emotions, the effects of child maltreatment on psychopathology are smaller than when the child experiences rejection from peers and does not develop a healthy regulation of emotions (Jungmeen & Dante, 2010). In the case of deaf children in Sub-Saharan Africa, the possibilities of rejection from peers, family members and broader society is large and learning a healthy regulation style for emotions is more difficult when communication within the micro-level is severely hampered. It can thus be carefully assumed that deaf children in Sub-Saharan Africa do not benefit from the two protective factors for developing behavioral problems due to child maltreatment.

2.3.2.2 Mesosystem causes

The mesosystem involves the relationships between the different microsystems. Parental involvement in school as rated by the teachers has a significant influence on positive and negative measures of social-emotional development in deaf children in an early intervention program for 0-3 year olds (Calderon, 2000). Parental involvement in school furthermore is an important indicator of the chances for sufficient maternal communication, the importance of which has been previously described. When parents and teachers are involved together in a

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parental practices improvement program, supported by mental health professionals, teacher ratings of behavioral problems significantly decline, independently of levels of risk or ethnicity (Brotman, et al., 2011).

Most countries have a special organization for the deaf, but research into the influence of contact with such an organization both for the child (microsystem) and for the parents (mesosystem) is lacking. It could be argued that parental involvement in such an organization creates a more realistic image of deafness and creates possibilities for parents to meet other parents in similar situations. Moreover, parents might be able to meet deaf role models.

2.3.2.3 Exosystem causes

There are no known exosystem causes, but there is a known protective factor. The protective factor in the exosystem of the bio-ecological model is if parents know a deaf adult individual. Deaf role models might aid hearing parents of deaf children in a multitude of ways: they serve as an example of the possibilities for deaf children as they grow up, they educate parents about signed languages, they can promote a bilingual-bimodal environment for the children, they can connect them to the Deaf community and they can increase parents’ knowledge and access to information (Hintermair, 2006; Rogers & Young, 2011). Parents who are in contact with a deaf role model have a more positive outlook on the life of their D/deaf child, a higher sign language skill level and are more acceptant towards the deafness of their child (Rogers & Young, 2011). The D/deaf role model his/herself also experiences many different positive outcomes and is therefore important in the acquiring of social capital in the role model, the child and its parents.

2.3.2.4 Macrosystem causes

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Another major factor causing the development of behavioral problems in children is poverty, which aggravates the known microsystem causes of behavioral problems maternal depression and parental stress (Conger, Ge, Elder, Lorenz & Simons, 1994; Shaw & Shelleby, 2014). Of course, poverty is also a microsystem factor and its causes are also in the exosystem of the child, but when a large proportion of the nation is poor, it becomes a macrosystem factor too.

The Gambia is the twelfth poorest country of the world (World Bank, 2014). More details on the Gambian situation will be provided in the contextual background in Chapter 3. Poverty therefore is a macrosystem factor and can be defined as the lack of means for providing material needs or comforts and is an important factor in the contextual background of children with behavioral problems in Sub-Saharan Africa. An important differentiation should be made between absolute poverty, which includes lack of food and shelter, and relative poverty, which signifies income inequality (Yoshikawa, Aber & Beardslee, 2012). Most contemporary research focuses on the link between poverty and behavioral problems in children is on relative poverty and therefore might not fully depict the situation in Sub-Saharan African countries.

A factor closely related to absolute poverty is food insecurity. Slopen, Fitzmaurice, Williams and Gilman (2010) conducted research in over two thousand children in the United States and found that both absolute poverty and persistent food insecurity led to internalizing and externalizing behavioral problems. The effect of persistent food insecurity even remained strong after the absolute poverty was adjusted for, indicating that food insecurity is an important factor in the etiology of behavioral problems in and mental well-being of children from poor families.

2.3.2 Concluding thoughts

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To summarize, different causes have been found of behavioral problems in children. First of all, there are genetic factors, and other biological factors such as IQ and the degree of hearing loss in the child. Second, there are environmental factors that intertwine in all levels of the bio-ecological model and increase or decrease the risk of developing problematic behavior in deaf youth.

2.4 Consequences of behavioral problems

There are several dramatic consequences of problematic behavior in deaf pupils’ social, emotional and academic development. Approximately half or more of the children that score high on problematic behavior during a first measurement in childhood will continue to behave problematically during the rest of their childhood (Bartels, van den Oord, Hudziak, Rietveld, van Beijsterveldt & Boomsma, 2004). This continuity of problematic behavior is based on two mechanisms. First, a constant underlying liability in genes or environment might explain ongoing problem behavior, as described in the previous section. Second, there is the developmental mechanism of transmission of previous experiences and reinforcements into future behavior and development, which creates continuous or exaggerating problematic behavior.

Behavioral problems, in particular depression, are related to lower peer acceptance (Kochel, Ladd, & Rudolph, 2012). Lower peer acceptance in turn can lead to lower academic self-concept, lower mental health, and more internalizing symptoms, which predict lower academic performance in both boys and girls (Flook, Repetti & Ullman, 2005).

Much is known about the association between behavioral problems and academic achievement. High levels of externalizing behavioral problems in boys are associated with low

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levels of academic achievement and with high levels of internalizing behavioral problems, leading to a cascading effect (Moilanen, Shaw & Maxwell, 2010). Children with persistent high levels of behavioral problems during elementary school, are more less likely to graduate from high school or attend college (Duncan & Magnuson, 2011). This association is bidirectional: low levels of academic competences are also associated with internalizing problem behavior in primary school children and more externalizing behavioral problems in the transition from primary school to middle school (Moilanen, Shaw & Maxwell, 2010).

The relationship between behavioral problems is not straightforward but has multiple moments of interaction. In childhood, aggression is a weaker predictor of behavioral problems than hyperactivity and low attention are. Hyperactivity and low attention lead to academic underachievement in childhood, whilst antisocial behavior and criminality in adolescence are related to academic underachievement (Hinshaw, 1992). Criminality in early adulthood is significantly related to early antisocial behavior (Duncan & Magnuson, 2011).

2.5 Addressing behavioral problems

There are different methods of reducing students’ behavioral problems in homes and in schools. Some of these methods are studied quite thoroughly. The difficulty with such methods is the lack of comparability and applicability in Sub-Saharan African contexts. Little is known to date about the way in which behavioral problems are addressed, aside from numbers of physical violence used in educational contexts. Therefore, this section will only provide a short example of one of the most widely used programs of the United States.

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For schools in the United States, there is the School-Wide Positive Behavioral Interventions and Support (SWPBIS) program on more than 16.000 schools, aimed at positive adjustment and preventing early-onset behavior problems. SWPBIS is a ‘noncurricular universal prevention strategy that aims to alter the school’s organizational context to implement enhanced procedures and systems to guide data-based decisions related to student behavior problems and academics (Bradshaw, Waasdorp & Leaf, 2012, p. 1137).’ It applies the same principals to an entire student body across all school contexts, focused on behavioral principles, social learning, and organizational principles. A randomized controlled trial comparing schools with and without SWPBIS showed that the program had significant positive effects on reducing disruptive behaviors and concentration problems, improving pro-social behavior and better emotion regulation, with more improvements for children that were younger when the program started (Bradshaw, Waasdorp & Leaf, 2012).

Whilst addressing problematic behavior, the sanctions for children from different ethnic backgrounds might differ significantly, leading to an even bigger achievement gap for children from non-Caucasian backgrounds in the context of the United States (Gregory, Skiba & Noguera, 2010). Whether these differences in addressing problematic behavior also arise in the context of the Gambia where seven different ethnicities live together, is unknown.

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3. Contextual background

As said before, The Gambia is the twelfth poorest country of the world with a GDP per capita of $512 and 48.4% of the 1.8 million population living below the national poverty line in 2012 (World Bank, 2014). It is also one of the least developed countries in the world, ranking 155 out of 177 countries on the Human Development Index in 2005 (UN-HABITAT, 2011). Only 13% of the population holds a formal job and over twenty percent of the children is underweight, with higher percentage in rural than urban areas (The Gambia Education Country Status Report, 2011). Approximately 16% of the population suffers from malaria each year, 1.3% of the adults suffers from HIV/AIDS, and more than 6 children per 1.000 die before the age of 5 (World Bank, 2014).

There are several ethnic groups in the Gambia living harmoniously together, all with their own language: the Mandinka, the Wolof, the Fulas, the Jolas, the Sarahala, the Manjango, the Serere and the Aku. However, due to former colonization by the United Kingdom, English is the official language in the country and in (most) education. Approximately 80% of the country self-describes as Islamic, whilst Christianity and Animism are also prevalent. It is common in the Gambia to live with an extended family, with an average household size of 6.6 individuals in the region where St. Johns School for the Deaf is located (Serrekunda) and even higher for the region where the deaf unit in St. Josephs School is located (Basse; The Gambian Population and Household Census, 2003).

Approximately half the country is younger than 18 years old, with a life expectancy of 58 years for children born in 2008 (UNICEF, 2014). The life expectancy for people born in 1960 was only 32, so there are not many people in the Gambia over 50 years old. Expenditure on

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children in primary education has increased from 5.8% of the GPD in 2002 to 17.9% of GPD in 2012 (World Bank, 2014). In order to achieve the millennium goal of basic education for all children by 2020, a 70% increase of the school system’s capacity is necessary (The Gambian Education Status Report, 2011). The age at which children start primary school varies largely between four and eight years of age and is sometimes even higher. In January 2014, free basic education for all was introduced in the Gambia. Parents no longer have to pay school fees, and supposedly only pay for the obligatory school uniforms and food. However, schools argue they do not receive the same amount from the government per child as they used to receive from the parents, so materials and transport costs are no longer provided by the schools. The change in fees for the parents has therefore hardly changed for the better. Moreover, children from impoverished backgrounds come to school without stationary or lunch money and can not fully participate in the classroom activities due to lack of material and hunger.

The school system in the Gambia starts with optional nursery school, primary school (Grade 1-6), junior secondary school (Grade 7-9) and senior secondary school (Grade 10-12). Children in government schools are always progressed to the next grade at the end of the year, there is no possibility of doing the same grade twice. If they fail their exams in Grade 6, they can not enter secondary education. Admittance to the two subsequent secondary school levels is only possible with enough credits from the previous level. Grades are less important than percentages and number of classes: if a student passes six courses with 60%, the cumulative score is 360, whilst a student with four courses at 85% scores 350. Every school for secondary education has different admittance scores. Passing the Grade 12 final exam will grant access to the Gambia College, which provides teacher training education, or, if high percentages were scored on the final exam, to the University of the Gambia, which offers different bachelor and master tracks. The Gambia

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College provides teacher training at different levels: for primary education, for junior secondary education, for senior secondary education and for educating adults. Teachers first attain their primary education diploma, and can afterwards follow the programs for the higher education forms.

The Gambian government issues a specialized Gambian method of education that all schools use for each separate topic. There is a small booklet of 50-100 pages for each subject for each grade, adapted fully to the Gambian situation, with Gambian names, examples, drawings and content. Private schools provide a separate work book for each student, government funded schools only provide a copy to the teachers. Most classes consist of copying and completing certain exercises from the books. The teachers at government funded schools will therefore copy the information from the book to the blackboard, whilst the students copy and complete that in their own notebooks. There is little to no interaction in most classes and there is hardly any differentiation between intelligence or age levels, only between grade levels.

The gender parity index for gross enrolment ratio of boys to girls in primary and secondary education in the Gambia was 100 in 2010, indicating there is currently equal access to education for both genders (World Bank, 2014). Eighteen percent of all registered children attend early childhood education before going to primary school, 77% enters primary school, and approximately 70% of those children finish the last grade of primary education, of whom 63% advance to lower secondary education and of whom finally 45% to upper secondary education (MDG Status Report, 2009; World bank, 2014; UNICEF, 2014). This effectively means that of every 100 children, 77 children start primary education, 54 children finish primary education, only 34 start secondary education and a mere 15 finish secondary education. There is an increase

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in literacy rate amongst Gambian older than 15 years from 36.8% in 2000 to 51.1% in 2011 in the Gambia (UNESCO, 2014). However, male and female literacy ratios differ substantially, from 42% for adult females and 61% for adult males (UNESCO, 2014).

There is no exact registration of deaf people in the Gambia, so the percentages of children born deaf and becoming deaf during childhood are unknown. The Gambian Association for the Deaf and Hard of Hearing (GADHOH) has close to a thousand adult members. There are no special laws for disabled people in the Gambia. The Gambia MDG Status Report (2009) states that the integration of disabled children – including deaf and hard of hearing - into mainstream schools is one of the major challenges that remain in the country with regard to the education focused millennium goal.

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4. Method

This section will focus on the method used to answer the main research question: How do deaf pupils and their teachers define, explain, judge and address behavioral problems of deaf pupils in Serrekunda and Basse, the Gambia? There is a huge difference between the planned method and the eventual method. Due to the research report nature of this thesis, the planned methods with their limitations are explained first, followed by a description of the planned data analyses. A description of the school sites is included in this chapter, followed by an extensive elaboration on the procedures, and to what degree of success they were brought into practice. The chapter closes with limitations and ethical considerations.

4.1 Planned mixed methods approach

A mixed method approach is used, combining participatory observations with interviews and focus group discussions. The benefits of a triangulated multi-method approach, such as the methods suggested here, extend further than just data-duplication: it offers contrasting or complementary understandings, which is seen is this research report by the differences between observations and interviews, which will be described in the next chapter. In addition, in order to honor the visual nature of the lives of deaf pupils, a photographic method called photovoice is employed.

4.1.1 Participatory observations

Participatory observations can be conducted overt or covert: overt entails a researcher who is open about the purpose, the target population and what happens with the results, while covert entails going undercover as a researcher without enclosing the goal of the research (O’Reilly, 2012). This proposed research was completely overt. The main goal of the participatory

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observations is to establish a relationship with the content of the research, and, more importantly, with the participants.

Field notes and daily diary entries are made in order to keep track of all observations. This not only includes the research activities that took place, but also more general remarks about the research process and the experiences in the country. These diary entries later serve to structure the data, to look for trending topics, and to see patterns in experiences. Field notes will be largely but not exclusively based on an observation scheme (Appendix I).

4.1.2 Interviews

Interviewing can be defined as a conversation with the purpose to gather information (Berg, 2009). In this proposed research, semi-standardized interviews were conducted, using pre-set questions (Appendix I), which were elaborated upon with follow-up questions or with more voluntary information from the respondents. A schedule for the questions was formulated beforehand but adjusted whenever necessary, roughly following the structure of the sub-questions preceded by inquiries about demographic elements. The process as described by Berg (2009) is as followed: a start to the interview is made with easy, nonthreatening questions, followed by more important but not overly sensitive questions, followed by sensitive questions, which are validated in the next step and those steps are repeated until all topics are covered. Photos taken by the participants are used within the interviews with the pupils to elicit responses about topics.

All respondents are individually asked for oral permission to record the interview and for the use of their anonymised answers for the research. The data is later anonymised by changing

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names and attaching numbers to each of the participants. The interviews are conducted one-on-one in the school. Consent of all participants is included into the process iteratively, not as an informed consent on paper beforehand, but as an implied consent through participation. As mentioned in the previous chapter, the Gambia has low literacy rates: 42% in women and 61% in men, with lower rates among older generations. Also, signing a paper might influence the relationship between the researcher and the participants negatively: only official documents are signed in the country, leading to a false feeling of higher power of the researcher. During the entire research process, participants are repeatedly asked if they understand the consequences of their participation and if not, they are explained again. Emphasis laid on the possibilities of withdrawal and on the anonymisation of the results.

4.1.3 Photovoice

Photovoice is a participatory action research method by which people can identify, represent, and enhance their community. Wang (1999) describes three main goals at which this qualitative method is aimed: 1) to identify the concerns and strengths of the community through photographs taken by different members of that community, 2) to hold group discussions with different stakeholders about these concerns and strengths, and finally 3) to reach policymakers. Besides these three main goals, five main concepts are defined. First of all, images teach: messages can be explicit or hidden in photographs, helping people to identify what is real and what is normal. Second, images can influence policy: a picture paints a thousand words and can thereby enable people ‘without a voice’ to speak clearly to policymakers. Third, participation of people within the community is necessary to create and define the images that shape public policy: without the aid of the community, the strengths and problems of that community are indefinable. The fourth concept yields that policy makers should be involved in the entire

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photovoice project in order to find and select the correct participants and to serve as an audience for the peoples perspectives. Finally, photovoice emphasizes on individual and community action by taking the discussion of the photographs beyond the discussion groups formed by participants to a broader platform of the community, and possibly to journalists, policymakers, researchers and leaders.

The position of the respondents whilst using photovoice as an elicitation method for interviews or focus groups is much more active than whilst using a similar method without photographic material:

‘…the work of extrapolating from personal memories or experiences prompted by photographs is not solely the task of the researcher alone. Research subjects are not treated (or refuse to act) merely as containers of information that is extracted by the research investigator and then analyzed and assembled elsewhere. Rather, the introduction of photographs to interviews and conversations sets off a kind of chain reaction: the photographs effectively exercise agency, causing people to do and think things they had forgotten, or to see things they had always known in a new way. […] They serve to bring about a research-collaboration between the investigator and subject. (Banks, 2010, p. 95)’

Furthermore, participants in photovoice research feel that photovoice balances power between the researcher and them, creates trust, builds capacity, pays mind to cultural preferences and created a sense of ownership over the results (Castleden & Garvin, 2008). Moreover, ‘words are the domain of adult (researchers) and therefore can be disempowering to the young. Images and their mode of production, on the other hand, are central to children’s culture from a very early age and therefore empowering (Prosser & Burke, 2008, p. 407)’, which makes photovoice suitable for deaf minors. Darbyshire, MacDougall and Schiller (2005) conducted research with children using a broad, qualitative multi-methods approach including photovoice. It is not believed that children can not express their experiences verbally, but rather that ‘if a respectful

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and sensitive inquiry approach was taken, children could and would describe and discuss their perceptions, experiences and understandings related to the central questions (p. 423)’. They concluded that children who are reluctant to contribute in interviews or focus groups might feel more autonomous and in control if they had previously taken their own contributing photos.

Three main questions can be asked when conducting photovoice research: who, how, and with what material. Epstein, Stevens, McKeever and Baruchel (2008) focused on two of these main questions relating to photo elicitation methods: who should take the photographs to be used for elicitation when working with children and how should these photos be integrated into the interview situation. One camera can be given to a group of children to document their lives; the researcher and the child can go on walks together to photograph; one camera can be given to each individual child, or the researchers can take all the photographs themselves. In this proposed research, the children received a camera in teams of two to three students, but most switched amongst themselves and made the photos individually.

Epstein, Stevens, McKeever and Baruchel (2008) furthermore argue that a photo has form and content. The form is what we see in the photo, whilst the content is what the message of the picture is. This relates to how the photos should be integrated in the interview: the form of the selected photos should differ as to create a new view into the social lives of the participants and to not bore the participating children. Pretesting is a way to decide which set of photos serves best for focus group elicitation and to decide if there are missing photos. However, even more important than pretesting with regard to the how-question is constant researcher flexibility, which is time consuming and for it to reach its full potential, creating contact and trust with the children is vitally important (Phelan & Kinsella, 2011).

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With regard to the third element focusing on material, eleven digital cameras were gathered in the period of October 2013 – January 2014. The social networking website Facebook was used to ask friends and friends-of-friends for used digital cameras for the project. Appointments were made with the responding individuals to pick up the cameras in person and they were tested in the home environment to ensure faulty equipment was left at home.

Digital cameras are more expensive than disposable cameras but have several advantages (Phelan & Kinsella, 2011; Phelan & Kinsella, 2013). First of all, they provide the respondent with direct feedback and thereby enable the participant to delete the picture and try again if the result is unsatisfactory. A second advantage is the virtual unlimited amount of photos a respondent can take, delete and retake. Moreover, the zoom function of the digital camera allows the participants to change the form of the photo, increasing the different possibilities. The resulting photos can be sent back to the participants via the email of the school, printed out in a print shop or handed to them on a USB device. After the fieldwork period, the cameras were distributed amongst the staff members of the school to use in their education and to acquire funding. This could be achieved because the teachers could potentially make clear photographs of the projects they are working on and the missing of necessary equipment they require funding for.

Since photovoice is a relatively unknown mixed method approach, several examples will be given. Clark (2000) uses photo elicitation with children younger than six years old and compares their photos and map making to that of adults, in which the visual method serves as a meaning-making tool for the children to share knowledge construction tool with adults. Booth and Booth (2003) conducted photovoice with photos shot by mothers with (severe) learning difficulties and

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challenge the notion that these mothers are different than other mums. Survivors of prostate cancer were asked to take photographs for an imagined exhibition about prostate cancer, in which photovoice served as a means to overcome the masculine taboos of talking about disability and dysfunction (Oliffe & Botoroff, 2007). Finally, Wang and Pies (2004) conducted research with sixty participants and focused on the improvements of Maternal and Child Health agencies, on which they concluded that the staff of the agencies were now provided with a tool – photovoice – to conduct their own research in the future and allow their clients to actively participate in improvements of the agency.

To conclude, photovoice can challenge participants, build trust between researcher and participants, trigger memories of participants, lead to new perspectives and possibly change policies (Epstein, Stevens, McKeever and Baruchel, 2008). The three different elements to be used within the photovoice project are participatory observations, interviews, and focus groups, which will now be described in further detail.

4.1.4 Focus groups

A focus group is a qualitative method with a general maximum of seven participants, hosted by a moderator who draws out information by introducing topics, asking questions and appointing speak turns to the participants (Berg, 2009). The focus groups will include pictures taken by the different participants as a method to elicit responses and discussions. Pictures can stimulate conversation, especially in focus groups where sensitive issues discussed (Berg, 2009). The estimated participants-mediator contribution ratio is 90:10 (Berg, 2009). As with the interviews, the participants are separately asked for permission to audiotape, and the consequences of

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participating are described. During the focus group meeting, the moderator will take notes of interaction cues such as facial grimaces and head shakes (Berg, 2009).

Holding a focus group as a method combines participant observation and interviews. It is more collectivistic and focuses on the ‘multivocality of participants’ attitudes, experiences and beliefs (Madriz, 2000, p. 836)’. The downside of focus groups as compared to interviews is that the settings in which the focus groups take place is usually less authentic to the respondents, which will be tried to overcome by conducting the focus groups in locations familiar to the participants. The biggest advantages of focus groups over interviews are the possibility to observe social interaction, the fact that focus groups give more weight to participants’ opinions and less to interviewers’ influence, the huge amount of data collected in a short period of time and the possibility for discussions to crystallize participants’ opinions.

Catalani and Minkler (2009) found no significant relationship between group size of the focus groups whilst using photovoice and quality of participation in a review of 37 unduplicated studies. Quality of participation was mainly influenced by project duration: the longer the project, the more involved the participants got. They conclude that sixty percent of the reviewed studies had an action component whilst using photovoice. Moreover, projects with higher participatory rates contributed to a community’s increased understanding and empowerment of that community with a broader influence than focus groups without an action component.

4.2 Data analysis

The combined interview transcripts, focus groups notes and transcripts, participatory observation field notes and diary entries form the basis of all analyses. A combination of conventional

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content analysis and directed content analysis will be used (Berg, 2009). The inductive conventional content analysis will consist of a grounded theoretical approach through coding categories in the raw data in order to generate theoretically connected explanations. The initial codes are: definition, examples, cause, consequence, and addressing. These five codes were later split up into different sub-terms. For example, the code ‘cause’ was later split up into: parental neglect, poverty/hunger, lack of material, and classroom disruptions.

A second technique of analysis is then applied to the raw data again. The more deductive directed content analysis, in which existing theories and explanations are used, will serve as analytical codes with which the raw data is screened. The units of analysis in the coding will be words, phrases, sentences and paragraphs, organized by concepts which consist of words grouped together by conceptual ideas that constitute the variables. For example, the code ‘cause’ was later coded for biological, microsystem, mesosystem, exosystem, macrosystem, and chronosystem.

For the analyses, raw data was used. However, in the results sections, quotes are given to clarify certain statements, but some are adapted for legibility reasons. Moreover, signed languages do not have an official written format so a close representation of the content in English is displayed where appropriate. Only grammar constructions were altered, not the meaning of the text.

4.3 School sites

There are only two possibilities for deaf children to access education tailored for them with sign language. There is one big school in Serrekunda and one unit in a school in Basse. Both schools

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were visited in order to create a full image of the educational possibilities of the deaf children in the Gambia. Moreover, since the schools are situated in the urban area, Serrekunda, and in the rural inland, Basse, it leads to interesting comparability possibilities. The schools furthermore differ in size, in when they were established and in the fact that Basse offers only two grades where Serrekunda offers 11. The schools will now be separately described.

4.3.1 St. Johns School for the Deaf and Hard of Hearing

St. Johns School for the Deaf and Hard of Hearing (hereafter St. Johns) is the only specialized school for children with hearing deficits in the Gambia. The school is situated near two other schools in Serrekunda. Serrekunda is currently the largest city of the country (300.000 inhabitants) and it emerged out of nine smaller villages that have grown together.

The history of the school has an international and colorful character. The Irish missionary Patrick Nolan was the first known hearing man to attempt teaching the deaf to speak and lip-read in the Gambia in 1978. His class advanced from one to six to twelve students and was then taken over by Amada Brooke. Brooke helped and taught the deaf after whom three other non-Gambian people took over until the Gambian John Jarta became school principal in 1982 and served as principal till 2003. The first curriculum consisted only of speech therapy and lip-reading but was later extended with different preparatory vocational skills. The current school principal since 2003, Daniel Mendy from the Gambia, graduated from teacher training at the Gambian college in 1980 and started teaching at St. Johns in 1982 as a carpentry teacher. In 1984, the school acquired some land from the government and the first building of the school was built, which is currently the administration building. In the next ten years, more academic skills such as reading, mathematics and social sciences were added to the school curriculum. In 1994 the Voluntary

Behavioral problems in deaf pupils : perspectives from teachers and deaf pupils in the Gambia