Hearing loss in children: the effects on speech and language understanding, psychosocial development, and potential educational accomodations

Hearing loss is typically referred to in terms of type, configuration, and degree. This week I will be discussing the different degrees of hearing loss as they pertain to children and the impact that the hearing loss can have on the children educationally, psychosocially, and developmentally.

Minimal Hearing loss (16-25 dB)
This category of hearing loss is specific to children. In adults, normal limits of hearing sensitivity range from 25 dB and less (i.e., 25 dB to 0 dB or below 0dB). In children however, it is very important that an audiologist consider a minimal hearing loss to be a true loss as this degree of hearing loss can have an impact on the child.

Potential effects of hearing loss on the understanding of language and speech:

• A loss of 20 dB is comparable to someone listening with their index finger placed in the ear canal.
• The child with a minimal hearing loss may have difficulty hearing faint or distant speech, such as a classmate on the opposite side of the room answering a question or reading aloud.
• A loss of 20 dB or more in the child's better ear (if the hearing loss is not symmetrical) can result in parts of speech being absent, inconsistent, or distorted, both in production of these sounds by the child and when the child is listening to someone else speak.
• About 25% of the speech signal will be missed in a quiet environment, but even more will be missed in the presence of background noise, such as in classrooms.

Possible psychosocial impact of hearing loss:

• The child may be unaware of subtle conversational cues which may cause others to view the child as awkward or inappropriate.
• The child may miss parts of of fast-paced interactions with peers which may impact their socialization and/or self-concept.
• They may act immaturely for their age.
• The may appear to be more fatigued at the end of the school day due to the extra effort put forth to understand speech in class.

Potential educational accommodations and services:

• The student may benefit from improved acoustic treatment of the classroom, such as the addition of carpeting and other absorbent material to reduce acoustic reverberation; and the addition of sound-field classroom amplification. This may also provide benefit to students with normal hearing.
• The student with minimal hearing loss should certainly have favorable, or preferential seating in the classroom. This could be at the front of the class if the teacher does not move around the classroom extensively, however, this is not always the case. Anywhere in the classroom that the student will receive the most benefit can be considered preferential.
• In children with minimal hearing loss, especially those who have a history of ear infections and other middle ear problems, special attention to development of vocabulary or speech through individual speech therapy may be warranted.
• If the hearing loss is conductive and due to some sort of middle ear problems, such as a middle ear infection (otitis media), appropriate medical management is warranted.
• The student may receive some benefit from a low-power hearing aid or from a personal FM-system. These two devices can help to increase the speech signal the child is missing, without enhancing the background noise present.
• Finally, some kind of in-service training on the impact of "minimal" hearing loss on language development and listening in noise is certainly recommended for teachers who have children with a minimal hearing loss in their classes.

Mild Hearing Loss (26-40 dB)
This category, and all others discussed from here on, is the same for children and adult patients alike. As such, the information presented is specific to children, and similar information applies to adults, with some obvious differences.

Possible effects of hearing loss on the understanding of speech and language:

• With this degree of hearing loss the child can hear conversations, however, they may miss fragments of the conversation which may lead to confusion and misunderstandings.
• The degree of difficulty experienced by the child in school will be dependent upon multiple variables including noise levels in the classroom, the distance of the child from the teacher, and the configuration, or shape, of the hearing loss.
• With a 30 dB hearing loss, the child may miss between 25% and 40% of the speech signal. A hearing loss between 35-40 dB can result in missing 50% or more of the speech signal when voices are faint or the speaker is not in direct line of sight.
• When a high frequency loss is present, brief or under-emphasized words and/or consonants will likely be missed.

Possible psychosocial impact of hearing loss:

• Barriers are built up with a negative impact on the child's self-esteem as they are accused of "hearing when they want to", also referred to as selective hearing, or "daydreaming and not paying attention".
• Due to the difficulties experienced in class, the child may believe s/he is less capable of performing well.
• The child begins to lose the ability for selective hearing and has increasing difficulty ignoring, or suppressing, background noise which causes the learning environment to be more stressful.
• With even greater effort needed to listen and focus on what is being said, the child is greatly fatigued by the end of the day.

Potential educational accommodations and services:

• Due to the background noise found in most classrooms, the student will benefit from the use of hearing aids and personal FM systems or sound-field classroom amplification.
• Adjustments in classroom acoustics can be made to make a less reverberant, more conducive learning environment. Also, favorable classroom seating and lighting for visual cues will be necessary.
• A referral to special education for a speech/language/educational evaluation may be necessary to determine if placement in a mainstream classroom is appropriate.
• The student may need additional attention to language development, auditory skills, articulation, speechreading and/or support in reading and self-esteem.
• An in-service training for teachers and educators on the impact of mild hearing loss on students performance is warranted.

Moderate Hearing Loss (41-55 dB)
Possible effects of hearing loss on the understanding of language and speech:

• Even with use of hearing aids, the child can hear, but typically will miss fragments of what is said.
• Without the use of amplification, the child can understand conversational speech at a distance of 3-5 feet only if the sentence structure and vocabulary are controlled.
• When the hearing loss is 41 dB and greater, the child can miss 50+% of the speech signal, and if the hearing loss is 50 dB or greater they can miss 80+% of the speech signal.
• The child is likely to have delayed or disordered syntax, limited vocabulary, imperfect speech production, and a flat or monotone voice quality.
• Consistent use of amplification and language intervention from early on can increase the probability that the child's speech, language, and learning will develop in a more natural progression.
• It is usually necessary to to use a personal FM system to overcome the background noise present in the classroom.

Possible psychosocial impact of the hearing loss:

• These are the same as for a mild hearing loss, with one exception: with this degree of hearing loss, communication can be significantly affected and socialization with peers can be difficult, especially in very noise environments such as lunch or recess.

Potential educational accommodations and services:

• Consistent use of amplification, both hearing aids and FM systems is essential to overcome background noise.
• Favorable classroom seating, lighting, and acoustics.
• Program supervision by a hearing impairment specialist is essential for coordination of educational services.
• Special academic support may be necessary, especially for students in elementary grades.
• Attentional to growth of oral communication, reading, written language skills, auditory skills development, speech therapy, and self-esteem improvement are services likely to be needed.
• Teacher in-service training on the hearing loss and attention to peer acceptance.

Moderately-severe hearing loss (56-70 dB)
Possible effects of hearing loss on the understanding of language and speech:

• With the use of hearing aids, the child can usually hear people talking around him or her, but will miss fragments of what is said which can result in difficulty communicating in situations which require verbal communication such as one-on-one and group conversations.
• Without the use of hearing aids, in order for the child to understand any conversation, it must be very loud.
• With a 55 dB hearing loss, a child can miss up to 100% of the speech information without the aid of working amplification.
• A child with this degree of hearing loss will have delayed spoken language, syntax, reduced speech intelligibility, and a flat or monotone voice.

Possible psychosocial impact of hearing loss:

• Typically with this degree of hearing loss, communication is significantly affected and socialization with peers is difficult, especially in noisy environments.
• The child will have a tendency for a poorer self-concept and social immaturity will contribute to a sense of rejection.
• It is helpful to have someone speak to the child's peers about the hearing loss and what they can do to help the child fit in more and feel more welcome.

Potential educational accommodations and services:

• Full time, consistent use of amplification in the form of both hearing aids and possible FM systems is absolutely essential.
• Use of sign language becomes increasingly helpful for access to instructions as they become more linguistically complex.
• The child may require intense support for language skills, speech, aural rehabilitation, reading, and writing.
• Note-taking, captioned films, and visual aids are necessary accommodations.

Severe Hearing Loss (71-90 dB)
Possible effects of hearing loss on the understanding of language and speech:

• Without amplification, the child may hear loud noise that are at a distance of roughly one foot from the ear.
• With amplification, the child with hearing sensitivity of 90 dB or better should be able to detect the sounds of speech presented from a close distance or through the use of an FM system.
• Individual ability and early intensive intervention will determine the degree that sounds being detected by the child will be discriminated and processed into meaningful input.
• The child will be reliant on their sense of sight to complement hearing to achieve functional access to communication.
• The use of a visual communication system is often recommended.
• It is essential that the mode of communication the child uses is also used by the family when communicating with them.

Possible psychosocial impact of hearing loss:

• Communication is significantly affected by this hearing loss.
• Socialization with hearing peers is often very difficult.
• The child may feel more comfortable interacting with other deaf or hard-of-hearing peers due to the ease of communication between them.
• Relationships with peers and adults who have hearing loss can lead to positive contributions toward the development of a healthy self-concept and a sense of cultural identity.
• A child with this degree of hearing loss in a mainstream classroom may have greater dependence on adults due to the difficulties experienced with comprehension of spoken communication.

Potential educational accommodations and services:

• It should be stated that there is no single communication system that is right for all hard-of-hearing or deaf children and their families.
• No matter what system is being used (visual communication or auditory/oral), early and extensive language intervention. full time consistent amplification use, and constant integration of the communication practices will dramatically increase the chances that the child will have success at learning.
• Self-contained educational placement with other deaf and hard-of-hearing students may be a less restrictive option due to access to free-flowing communication.
• Specialized supervision, support services, and continual appraisal of communication is necessary.
• Depending on the configuration of the hearing loss, a hearing aid with frequency transposition technology or a cochlear implant may be very possible options.

Profound Hearing Loss (91+ dB)
Possible effects of hearing loss on the understanding of language and speech:

• The detection of speech sounds will be dependent on the configuration of the hearing loss and on optimal use of amplification.
• The child may be more aware of vibrations than tonal patterns in speech.
• The degree and configuration of the hearing loss, use and appropriateness of amplification, quality of early intervention and individual ability are all contributing factors which influence the degree to which the child can detect, discriminate, process, an understand the sounds of spoken language.
• Most children who are profoundly deaf are unable to use hearing alone for communication and learning, and the use of visual communication system and languages is common.

Possible psychosocial impact of hearing loss:

• Parents and families who are fluent in the communication mode of the child are essential to the development of acceptance, self-esteem, and optimal communication development for the child.
• The child is often more comfortable communicating with other deaf or hear-of-hearing peers because of the ease of communication.
• Being a member of a signing club or being part of classes that utilize sign language are beneficial to the child and their hearing peers.

Potential educational accommodations and services:

• These are similar to those of the child with severe hearing loss.
• If a cultural Deaf emphasis is utilized at home and within the family, then exposure to other Deaf individuals who utilized American Sign Language is vital for self- and social-identity development.
• In-service training on profound hearing loss and the effects of the loss on the student is essential for mainstream educators.
• School for the Deaf is a social and educational program consideration.

It is important to remember that when a child has any degree or hearing, even a minimal hearing loss, they're missing out on communication with teachers, peers, and family, and this can affect them in the ways mentioned above as well as in ways completely unique to the individual child. As a parent or teacher, it is important to be an advocate for the child's learning and development and getting that child the help that is necessary to facilitate a more normal life and development, both educationally and socially.

Hearing Loss: What are the different types and what do they mean to you?

Some of you reading this may already know that there are different kinds of hearing loss, but there are many people who don't and a good deal of people who think hearing loss is hearing loss. My hope for this week's post is to shed some light on the three main kinds of hearing loss and to give some insight to what these can mean if you or someone you know is diagnosed with one of them.

1. Sensorineural Hearing Loss (SNHL):
Sensorineural hearing loss (SNHL, as is will be referred to henceforth) is the most common type of hearing loss diagnosed. It is commonly associated with hearing loss due to aging, hearing loss due to noise exposure, and many other causes. A SNHL is one in which the hearing loss is due to damage caused to the tiny sensory hair cells within the inner ear. Unfortunately these hair cells do not grow back after they are damaged and the hearing loss caused by their loss is permanent. Researchers and scientists are currently working toward finding a way to regenerate these tiny sensory hairs, but to date, this has not been accomplished.

People with this type of hearing loss typically complain that they have a hard time hearing soft spoken people, children's and women's voices, and that they have a very difficult time hearing in the presence of background noise. This is because typically SNHL affects the higher frequency region of the inner ear first and these frequencies are necessary for providing clarity to speech and separating speech from background noise. Due to the difficulty experienced in conversations, people with this type of hearing loss often become frustrated to the point that they remove themselves from conversations and from social interactions, isolating themselves. Naturally, this can be very upsetting and often times people with this form of hearing loss become depressed.

Luckily, however, even though there is no way to re-grow the sensory hair cells that have been damaged, and there is nothing medically that can be done to restore the hearing, people with SNHL are prime candidates for help through the use of amplification, or hearing aids. Hearing aids can provide a great deal of help in a myriad of situations, especially in background noise. Current hearing aid technology can provide this benefit in background noise through the use of directional microphones which are designed to analyze the auditory inputs and separate out the speech signal from the noise and turn down the background noise by focusing the microphones toward the speech signal. More on that in a later entry.

2. Conductive Hearing Loss(CHL):
Conductive hearing loss, or CHL, is a form of hearing loss that often afflicts children, but can be seen in any age group. In this kind of hearing loss, there is nothing wrong with the inner ear (cochlea) or the sensory hair cells therein. Instead, there is something wrong in the middle or outer ear, and as the name suggests, there is a reduction in how much sound is conducted to the the inner ear. A quick lesson in the anatomy of the ear will help to explain my point.

The ear is made up of three parts, the outer, middle, and inner ear. The outer ear consists of the pinna or auricle, and the external auditory canal (ear canal). The middle ear consists of the tympanic membrane (eardrum), middle ear cavity, and a chain of three tiny bones, called ossicles, the malleus (hammer), incus (anvil), and stapes (stirrup). These three bones are what conduct the vibrations of the sound from the outer ear to the inner ear. They are connected to the tympanic membrane on one end and the oval window of the cochlea on the other end. When sound waves hit the eardrum, they vibrate the bones which in turn move fluids within the cochlea to stimulate the auditory nerve and hair cells within the cochlea.

A conductive loss indicates that somewhere before the sound reaches the cochlea there is a break down of communication. This can occur in the outer ear, mainly the ear canal, when it becomes blocked by some kind of debris (wax, cotton from q-tips, dirt, etc.), or during testing if the canal wall collapses due to the headphones being used. This can also occur if there is something wrong in the middle ear. Within the middle ear, a number of problems can occur which can cause a conductive loss including, ear infections, perforated eardrum, a disconnection of the three bone chain, fluid build-up from ear infections, dysfunction of the eustachain tube, or a stiffening of the three tiny bones, a condition known as otosclerosis. Of course, these are simply a few of the possible causes of a conductive hearing loss and there are many more that can be responsible.

The typical complaint of a person with a conductive hearing loss that things just aren't loud enough. Once the TV or the person with whom they're speaking get loud enough, they can hear and understand what is being said just fine. That is because in a conductive loss, people lose something called the middle ear transfer function which basically maintains the energy in the original sound as it passed from the outer ear to the tiny inner ear. When this function is lost or somehow dampened, there a loss of energy, which we perceive as loudness.

Additionally, unlike people with SNHL, someone who has a CHL may actually do well in background noise or at a loud party because the people with whom they're interacting will naturally be talking louder to be heard over the noise. This is exactly what the person with a CHL needs to be able to understand the conversation. Generally speaking, a CHL is something that can typically be corrected with some kind of medical intervention and amplification is not necessary. In cases of middle or outer ear infection, medical treatment to clear up the infection and drain the fluid typically alleviates the CHL and after treatment, hearing is restored to normal or near-normal hearing. This, however, is not always the case, and sometimes the CHL cannot be treated medically. In this case, use of amplification which generates enough power to overcome this loss is suggested.

3. Mixed Hearing Loss:
A mixed hearing loss is a combination of both the conductive and sensorineural hearing losses. This means that there is something causing a loss of energy and transmission of the sound waves to the inner ear and that there is structural damage to the sensory hair cells in the inner ear. Unlike someone with a purely conductive loss, these people will not do well at a loud party or in background noise because even though the speech is loud enough to be heard, there is a loss of clarity due to the SNHL. Amplification is usually warranted in these cases to address the SNHL, and medical correction of the CHL may or may not be possible.

A condition which may cause a mixed hearing loss is a stiffening of the three tiny middle ear bones in older adults. In this condition there is a loss of sound transmission to the inner ear due to the reduction of movement on the chain of bones, and in most older adults some SNHL is common due to the aging process. This is not to say that all older adults have a hearing loss, as there are a great number who do not. In general, however, as we age we tend to lose at least some hearing sensitivity. This coupled with the conditions mentioned, otosclerosis, can lead to a mixed hearing loss.

For more information on these three kinds of hearing loss, and other information related to hearing loss, please visit http://www.asha.org/public/hearing/disorders/types.htm.

What is audiology and what are audiologists?

Quite simply, audiology is is the study of hearing and the disorders related to hearing.

So, what is an audiologist?

An audiologist is a professional health care provider who is specially trained in the diagnostic testing of hearing and balance and the rehabilitation of individuals with hearing loss, central auditory processing disorders, and vestibular or balance disorders. An audiologist is a highly educated and specialized health care professional who holds either a Masters or Doctoral degree. Currently, the field of audiology has set the minimum educational requirements for practicing audiologists to the professional doctoral level degree known as the Au.D., this is not the same as a Ph.D. or M.D.

Audiologists have extensive education in the nature of hearing and the mechanisms by which humans hear and comprehend auditory information; hearing aids and how hearing aids work and provide help to those who have a hearing loss that is able to be helped by amplification; and diagnostic tests and procedures to accurately diagnose a hearing loss or make the appropriate referrals to medical professionals for additional testing and follow-up procedures.

Where does an audiologist work?

Audiologists work in a variety of settings including hospitals, private practices, ENT clinics, and in school systems. Typically, you will find an audiologist working in any of the first three settings previously mentioned. Additionally, audiologists can work for hearing aid manufacturers in research and development departments, as hearing aid representatives providing services to other audiologists and audiology clinics, and also at universities which have an undergraduate and graduate level audiology and speech sciences clinics.

If you have any questions regarding your hearing or are noticing that communication with others is becoming increasingly difficult, contact an audiologist and schedule a hearing evaluation. The sooner a hearing loss is detected, the better the treatment and management of the hearing loss can be.

If there are topics or questions you as the reader would like me to address, please feel free to leave a comment and I will be sure to try to answer your questions as soon as possible.