Management of Children With Bilateral Mild or Unilateral Hearing Loss Diane L Sabo Faye P McCollister Yusnita Weirather

Management of Children With Bilateral Mild or Unilateral Hearing Loss Research findings Language and academic issues Audiologic assessment Audiologic management Issues for states

Bilateral Mild or Unilateral Hearing Loss May be present at birth May be acquired early in life May be intermittent May be progressive May be fluctuating Behavioral tests difficult with the very young Masking may be a problem Monitoring with Electrophysiological tests becomes expensive

Prevalence Estimates of 5% with mostly being unilateral (3%) 3% conductive hearing losses in children in grades 3-6; impact? MSHL was more prevalent than CHL

Prevalence Approximately 5% of the hearing losses in school age children Close to 2.5 million children Most prevalent are unilateral losses High frequency losses next and then bilateral Some estimate that hearing loss (all forms and degrees) is present in 11% of the school-aged population

Prevalence of Unilateral Hearing Loss >25 dB 13/1000 >45 dB 3/1000 4 Million Annual Birthrate=51,000 per year 5-21 years (School Age)=816,000

Definition Minimal-mild hearing losses Unilateral or bilateral Hearing losses from 15 to 40 dB Unilateral or bilateral Sensorineural or conductive

Normal Mild Moderate Severe Profound

X O O X X O X X O O

Classification of Hearing Loss Stable Less than 10 dB decrease Progressive 10 dB or more decrease Fluctuating 20 dB or more improvement or decrease Delayed Onset Normal hearing documented, with later onset of loss

Etiology of Unilateral HL Unknown Heredity Meningitis Mumps Asphyxia Head trauma Measles Congenital CMV Fistula

Continued Surveillance Unilateral- at risk for progressive and bilateral HL (Brookhouser, Worthington, Kelly, l994) Mild Persistent OM

Vigilant Surveillance Required Estimated that about 16-18 % of hearing loss is delayed in onset Educate parents Educate primary care providers Provide information on normal auditory development Provide information of signs and symptoms of hearing loss

Unilateral Atresia

Why Do We Care? Binaural hearing discrimination binaural summation head shadow squelch effects localization binaural release form masking

Audiological Problems Reported for Children with Unilateral Hearing Loss Sound localization Speech discrimination in noise Speech discrimination in quiet

Why Do We Care? Less known are effects of minimal losses difficulty understanding speech under adverse listening conditions formal testing not available until 3 years

Hard of Hearing Children Speech and Language Issues Vocabulary size Syntax and pragmatics Speech production

Issues of Diagnosis For minimal hearing loss, issue is the accuracy of the physiologic tests and ability to estimate accurately hearing levels

Academic and Speech/Language Greater difficulty in educational system Bess 98 3rd grade children exhibited significantly lower scores on many subtests of the CTBS/4 (comprehensive test of basic skills 4th edition)--a series of comprehensive achievement tests designed to measure the outcome of hearing at different levels in the educational sequence. Good for k-8th grade 6th and 9th grade children differed and id not show the problems--is the test not sensitive at g or do children ‘catch’up largest differences seen in are of language--understanding ability, vocabulary, word usage skill and story telling abilities Sifter data show 37% failed at least one grade no problem behaviors noted in the classroom --teacher report on the RBPC-revised behavior problem checklist COOP-adolescent chart method--findings show greater dysfunction than normally hearing counterpart on social/emotional domains as stress, self-esteem, behavior, energy an social support

Educational Performance of Students with Unilateral HL 24-35% failed at least one grade 15% needed resource services Bess & Tharpe, 1986 Oyler, Oyler & Matkin 1987

Educational Problems Reported Management strategies usually not appropriate Assumed to be normal

Teacher Reported Problems of Students with Unilateral HL Student is: More dependent More easily frustrated More emotionally labile More often aggressive Gives up easily More behavior problems

Other Reported Problems Withdrawal Embarrassment Regression Inferiority Fear Reactions Annoyance

Other Problems Reported Somatic Complaints Confusion Paranoia Helplessness Depression

Additional Concerns Safety with mobility, can not localize sound Stability of loss Additional disabilities Etiology Amplification for child, sound field FM Developmental progress

Intervention When? At identification When confirmed with behavioral findings if physiologic data only available At time of mobility At school age Delays apparent

Intervention For Unilateral Hearing Loss Early Identification Hospital based newborn hearing screening Routine periodic school screening Frequent Audiological Monitoring Children with identified loss Children with risk indicators for progressive hearing loss

Management Hearing aids Other assistive listening technology issues with unilateral losses Other assistive listening technology Classroom management Other supplemental support services (EI or in school) Need to reduce background noise--reverberationCross Hearing Aid FM Auditory Trainer Hearing Aid for Hearing Impaired Ear Counsel Regarding Acoustic Management of Learning Environment Monitor Hearing Loss for Stability

Impact of Early Identification Early research (1960s-1980s) indicated early detection and intervention of educationally significant hearing loss are crucial recent research (1990s) showed children with hearing loss are likely to achieve normal speech and language skills by age 5 when detection and habilitation are initiated before 6 months of age

Intervention From Audiology Cross hearing aid FM auditory trainer Hearing aid for impaired ear Counsel regarding acoustic management of learning environment Monitor hearing loss for stability

Intervention For Unilateral Hearing Loss Interdisciplinary assessment to identify any additional conditions Early intervention program Training to empower child/parent to optimize learning opportunities Parent training regarding federal legislation/state/local regulations developed to address needs of children with disabilities

Learning Environment Assessment Signal/Noise Ratio Lighting Traffic Patterns External Distracters

Needs Parents perspective Impact of degree of hearing loss on developing child

Study of 112 Children in Alabama with Unilateral Hearing Gender Female 40 Male 72 Caucasian 75 Black 25 Other 3

Type Loss for 112 Children with Unilateral Hearing Loss Permanent or chronic conductive 18 (18.6%) Sensorineural 66 (68.0%) Mixed 11 (11.3%) Not Available 2 (2.1%)

Discovery of Unilateral Hearing Loss Hearing screening in school 43 (45.2%) Child complaints 14 (14.7%) Parental observation 15 (15.8%) Newborn screening 5 (5.3%)

Age Parent Recognized Hearing Loss 0-36 months 26 (29.3%) 37-108 months 59 (66.3%) Not known 4 (4.5%)

Degree of Loss for 112 Children with Unilateral Hearing Loss Mild (21-45 dB) 32 (33.0%) Moderate (46-70 dB) 31 (31.9%) Severe (71-90 dB) 14 (13.8%) Profound (>90 dB) 15 (16.0%) No measurable hearing 5 (5.3%)

Stability of Loss for 112 Children with Unilateral Hearing Loss Stable 53 (55.8%) Better 5 (5.3%) Variable 18 (18.9%) X X X X X O O O

In Which Ear Is Hearing Loss for 112 Children with Unilateral Hearing Loss Right 52 (55.6%) Left 45 (46.4%)

Perception of Hearing Difficulty By Student (Sometimes, Often, Always) Face to face 25 (28.1%) Further than 3 feet 46 (51.7%) In a group 55 (62.5%) On side of loss 72 (80.9%) In noise 59 (66.3%) Video, TV, movies 38 (42.7%)

Risk Factors Reported By Parent for Child’s Unilateral Hearing Loss Low birth weight (<3000 grams) 15 (15.8%) Placed in an incubator 12 (12.6%) Breathing problems 8 (8.4%) Low APGAR scores 2 (2.1%) Elevated bilirubin 21 (22.1%) Oxygen required 8 (8.4%) Other 14 (4.7%)

Additional Conditions Reported By Parent Attention Deficit /Hyperactivity 19 (20.0%) Behavior Disorder 12 (12.6%) Cerebral Palsy 2 (2.1%) Cleft Palate 1 (1.1%) Learning Disability 4 (4.2%) Mental Retardation 3 (3.2%) Seizures 3 (3.2%) Speech Language Problems 17 (17.9%)

Additional Conditions Reported By Parent (2) Vision 23 (24.2%) Other 8 (8.4%) Unknown problem 14 (14.7%)

Grades Retained Kindergarten 4 (4.2%) Grades 1-3 21 (22.1%) Total 35 (36.8%)

Resource Services Received LD 19 (27.9%) EC 3 (4.4%) Gifted 4 (5.9%) HI 19 (27.9%) AD/HD 3 (4.4%) Other 13 (19.1%)

Resource Services Currently Received Speech/Language 18 (19.6%) Preferential seating 66 (71.1%) Tutoring/Resource help 29 (32.2%) Management of HI needs 33 (36.3%)

Parental Involvement Meet with teacher about HL 54 (60.0%) Meet with teacher about school 66 (73.3%) Send medical reports to school 21 (23.3%) Send audiology reports to school 34 (37.8%) None of the above 6 (6.7%) Other activities of involvement 9 (10.0%

Parents Interested In Receiving Additional Information About UHL >70% about their role >60% about teaching methods and the teacher and school role for helping their child >60% expected educational performance >60% protection of hearing in their child’s good ear >50% their child’s social development, development of self confidence, and safety issues related to UHL

Parent Training Very Beneficial

Educational Concerns for Children with Unilateral Hearing Loss May need resource service from speech/language/hearing, education, and/or psychology Will need attention to acoustics and lighting in learning environment Will need technological assistance to improve signal to noise ratio Will need frequent monitoring of hearing as well as educational performance

Medical Considerations for Children With Unilateral Hearing Loss Avoid noise exposure Avoid ototoxic medications unless essential Obtain prompt medical attention for otitis media Radiologic evaluation and laboratory test results obtained to evaluate etiology Torch test results Genetic consult report Vestibular findings

Considerations for Parent/ PCP/ Others Involved in Child’s Care Provide printed material on hearing, speech, language, development Provide information regarding risk factors identified, give additional resources for further reading, web sites, etc Give handout on signs and behaviors associated with changes in hearing Give return date for reassessment and advise parent to notify you for reassessment if changes in hearing suspected Document in your report that you did all this

Thank you