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

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

3. 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

4. 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

5. 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

6. 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

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

8. Normal
Mild
Moderate
Severe
Profound

9. X O O X X O X X O O

12. 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

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

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

15. Vigilant Surveillance Required
Estimated that about % 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

16. Unilateral Atresia

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

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

19. 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

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

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

22. 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

23. 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

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

25. 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

26. Other Reported Problems
Withdrawal
Embarrassment
Regression
Inferiority
Fear
Reactions
Annoyance

27. Other Problems Reported
Somatic Complaints
Confusion
Paranoia
Helplessness
Depression

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

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

30. 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

31. 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

32. 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

33. 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

34. 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

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

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

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

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

39. Discovery of Unilateral Hearing Loss
Hearing screening in school (45.2%)
Child complaints (14.7%)
Parental observation (15.8%)
Newborn screening (5.3%)

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

41. 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 (5.3%)

42. 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

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

44. 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 (62.5%)
On side of loss 72 (80.9%)
In noise (66.3%)
Video, TV, movies 38 (42.7%)

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

46. Additional Conditions Reported By Parent
Attention Deficit /Hyperactivity (20.0%)
Behavior Disorder (12.6%)
Cerebral Palsy (2.1%)
Cleft Palate (1.1%)
Learning Disability (4.2%)
Mental Retardation (3.2%)
Seizures (3.2%)
Speech Language Problems (17.9%)

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

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

49. Resource Services Received
LD (27.9%)
EC (4.4%)
Gifted (5.9%)
HI (27.9%)
AD/HD (4.4%)
Other (19.1%)

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

51. 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 (6.7%)
Other activities of involvement 9 (10.0%

52. 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

53. Parent Training Very Beneficial

54. 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

55. 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

56. 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

57. Thank you