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Minimal Hearing Loss in Children:
The Facts and the Fiction
Anne Marie Tharpe
Introduction
Since that time, others have adopted these definitions in an effort to enable meaningful comparisons of
data across studies (Centers for Disease Control and
Prevention 2005). Our attempts to evaluate current data
obtained across studies are compromised when we are
not using uniform definitions. For example, prevalence
rates of minimal or mild bilateral hearing loss and unilateral hearing loss are uncertain because of the differences in defining the audiometric thresholds of these
groups. Furthermore, because we do not currently target minimal and mild degrees of hearing loss with our
newborn hearing screening programs, we can only estimate prevalence of such losses in the newborn period.
Johnson and colleagues (2005) offered a conservative
estimate of 0.55/1000 newborns with mild permanent bilateral (25–40 dB at 1.0, 2.0, or 4.0 kHz) and unilateral
hearing loss. The number of babies with unilateral hearing loss in the neonatal period has been estimated at
0.7–1/1000 (Prieve et al. 2000; Davis, DeVoe and Robertson 2005) as compared to 3/100 by school age (Bess et
al. 1998). Bess and colleagues also estimated 2.4/100
school-age children had minimal bilateral hearing loss.
The difference between estimated prevalence rates in
the newborn period and at school age can be the result
of several different factors including:
• misses by the early hearing detection and intervention
systems (EHDI);
• low follow-up rates by newborn screening programs
resulting in low estimates in the newborn period;
• progressive or late-onset hearing loss; and/or
• differing definitions of “hearing loss”.
This chapter will review what we know about the
impact of minimal degrees of hearing loss on children. Perhaps more importantly, what we do not know
about the effects of these degrees of hearing loss will
also be discussed.
Children with minimal degrees of hearing loss have
been of interest to audiologists for decades, but particularly
since the 1980s. Some of the most extensive studies of that
time were conducted under the direction of Bess (1986). It
was at that time that the impact of minimal hearing loss on
child development was realized, and policy changes began
to be implemented in an attempt to improve outcomes. A
starting point in our discussion of this topic should reasonably be the definition of what is meant by minimal hearing
loss. However, even the term “minimal” is controversial as
it might imply that these losses are not important or are inconsequential. Furthermore, it is common for varying degrees and configurations of hearing loss to fall into the general category of “minimal”. In 1998, Bess, Dodd-Murphy
and Parker defined minimal hearing loss as
• unilateral sensorineural hearing loss – average air-conduction thresholds (.5, 1.0, 2.0 kHz) > 20 dB HL in the impaired ear and an average air-bone gap no greater than
10 dB at 1.0, 2.0, and 4.0 kHz and average air-conduction
thresholds in the normal hearing ear < 15 dB HL;
• bilateral sensorineural hearing loss – average puretone thresholds between 20 and 40 dB HL bilaterally
with average air-bone gaps no greater than 10 dB at
frequencies 1.0, 2.0, and 4.0 kHz;
• high-frequency sensorineural hearing loss – air-conduction thresholds greater than 25 dB HL at two or
more frequencies above 2 kHz (i.e., 3.0, 4.0, 6.0, or
8.0 kHz) in one or both ears with air-bone gaps at
3.0 and 4.0 kHz no greater than 10 dB.
Address correspondence to: Anne Marie Tharpe, Ph.D., Professor, Vanderbilt Bill Wilkerson Center, 1215 21st Ave. So., #8310,
Medical Center East, So. Tower, Nashville, TN. 37232-8242,
[email protected].
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A Sound Foundation Through Early Amplification
What We Know
In the 1980s, Bess and colleagues published a series
of papers on the impact of permanent unilateral hearing
loss (UHL) on speech-language, auditory, and psychoeducational outcomes in children (Bess and Tharpe
1986; Bess, Tharpe and Gibler 1986; Culbertson and
Gilbert 1986; Klee and Davis-Dansky 1986). Prior to that
time, most hearing professionals assumed that children
with UHL would experience little if any adverse effects
as long as they received preferential classroom seating.
However, the results of those studies changed our thinking about how children with UHL should be managed.
Perhaps the most surprising finding from those studies
was that children with UHL were at academic and psychosocial risk. In fact, approximately 35% of these children had to repeat at least one grade in school and an
additional 13% required resource assistance for academic difficulty. The academic failure rate was ten times
that of their normal-hearing peers, a finding that was upheld by others (Oyler, Oyler and Matkin 1988). More recent reviews of the literature have confirmed that the academic difficulties experienced by children with UHL in
early studies have not, on average, improved over time
(Watier-Launey, Soin, Manceau and Ployet 1998; English and Church 1999; Lieu 2004).
The revelation of these findings was followed by a
number of studies that were initiated to examine more
closely the potential causative factors (e.g., speech-language, auditory, cognitive abilities) for these academic
difficulties. Children with right ear impairment were
found to be at greater academic risk than those with left
ear impairment (Bess et al. 1986; Oyler et al. 1988;
Jensen, Børre and Johansen 1989) and those with more
severe degrees of unilateral loss were often found to be
at greater risk than those with lesser degrees of loss
(Bess and Tharpe 1986; Brookhauser, Worthington, and
Kelly 1991; Sedey, Stredler-Brown and Carpenter 2005)
but not always (Dancer, Burl and Waters 1995). Although all children enrolled in the Bess et al. studies
had intelligence quotients (IQs) that were within normal limits, those who required grade repetition in
school had significantly lower verbal IQs than those
who were academically successful. But, surprisingly,
speech and language evaluations did not reveal differences between those school-age children with UHL and
their normal hearing peers (Klee and Davis-Dansky
1986). Other studies have also failed to find speech-language deficits in children with UHL (Hallmo, Møller,
Lind and Tonning 1986; Tieri, Masi, Ducci and Marsella
1988; Kiese-Himmel 2002), but at least one study of preschool-age children identified specific language deficits
(Sedey et al. 2005).
Approximately a decade following the publication of
the landmark Bess studies on children with UHL, Bess
and colleagues broadened their investigation to include
children with permanent, minimal bilateral hearing loss
(MBHL; Bess et al. 1998). The psychoeducational findings from that study were remarkably similar to those
from the study of children with UHL. That is, the expanded group of school-age children with MBHL and
UHL, on average, had an academic failure rate of approximately 37% with an additional 8% requiring resource assistance. The Comprehensive Test of Basic
Skills revealed that these children, at the third grade
level, had significantly lower scores than their normalhearing peers on sub-tests of reading, language mechanics, word analysis, spelling and science. Similarly, a
report from the Third National Health and Nutrition Examination Survey (NHANES-III) revealed that children
aged 6–16 years with UHL or MBHL were twice as likely
to score two standard deviations below the norm on standardized math and reading tests than normal hearing
children(Ross, Visser, Holstrum and Kenneson 2005).
Most studies that examined speech and language
abilities of children with MBHL included them as part
of a larger group of children with greater degrees of
loss. For example, Blair and colleagues (Blair, Peterson
and Viehweg 1985) compared a group of children with
mild bilateral hearing loss (25–45 dB in the better ear)
with their normal hearing peers. They found that the vocabulary, reading, comprehension and language use of
the children with mild hearing loss was lagging behind
that of their normal hearing peers. Likewise, Davis,
Elfenbein, Schum and Bentler (1986) found that children with mild bilateral hearing loss (< 45 dB PTA) had
receptive vocabulary, verbal ability and reasoning
scores that were more than one standard deviation below the mean. In addition, numerous investigators have
reported behavior problems in children with UHL relative to children with normal hearing (Keller and Bundy
1980; Stein 1983; Bess et al. 1986; Oyler et al. 1988;
Brookhouser et al. 1991; Dancer et al. 1995; English and
Church 1999), although this has not been a universal
finding (Colleti, Fiorino, Carner and Rizzi 1988).
In addition to traditional psychoeducational and
speech-language evaluations, Bess and colleagues utilized functional health status assessments, the Cooperative Information Project Adolescent Chart Method
(COOP; Nelson et al. 1987; Nelson, Wasson, Johnson
Minimal Hearing Loss in Children: The Facts and the Fiction
and Hays 1996). These charts were designed to assess
the domains of physical, emotional, and social functionality. The COOP scores revealed that school-age children with MBHL and UHL had self-perceived deficits in
the areas of energy, stress, social support, self-esteem
and behavior (Bess et al. 1998).
The findings from the COOP evaluations led to an
interest in examining listening effort and fatigue in children with minimal to moderate degrees of bilateral hearing loss. Listening effort refers to the attentional requirements necessary to understand speech (Downs
1982; Feuerstein 1988) and fatigue refers to the weariness that results from exertion, either physical or mental. When considering children with hearing loss, we are
interested in the potential for mental fatigue that relates
to one’s ability to attend or concentrate and contributes
to a general feeling of being tired (Grandjean 1979;
Kennedy 1988). Bourland-Hicks and Tharpe (2002) utilized salivary-cortisol measures to examine fatigue and
a dual-task paradigm (visual attention and listening-innoise tasks) to examine listening effort. Neither cortisol
measurements nor self-rated measures of fatigue revealed significant differences between children with
minimal to moderate degrees of hearing loss and their
normal-hearing peers. However, the dual-task paradigm
utilized to study listening effort indicated that children
with hearing loss in this study expended more effort in
listening than children with normal hearing. In dualtask paradigms, a decrease in performance on the secondary task has been related to the amount of effort expended in performing the primary task (Broadbent
1958). The primary task in this paradigm was a speech
recognition measure in quiet and noise conditions (+10,
+15, +20 dB), while the secondary task was a visual attention measure requiring the children to push a button
whenever a small light-emitting diode (LED) was activated. Reaction times in pushing the button for the activated LED were significantly slower in all conditions for
the children with hearing loss relative to the children
with normal hearing. Therefore, the children with hearing loss were presumed to be expending more effort in
performing the word repetition task than their normal
hearing peers. The authors concluded that it is reasonable to expect students with minimal to moderate degrees of hearing loss will have similar expenditures of
listening effort in the “real world” as those children under
experimental conditions. That is, children are asked to
perform multiple tasks in the classroom while listening
to their teacher – tasks that can include note taking, answering questions, and/or following directions. There-
215
fore, it is likely that secondary task performance (e.g.,
following directions, taking notes, etc.) might be compromised.
What We Don’t Know
Despite the fact that audiologists and educators are
better informed about the potential impact of MBHL
and UHL on children today than they were in the 1980s
(Reeve, Davis and Hind 2001; McKay 2002), it does not
appear that the psychoeducational outcomes for these
children are, on average, any brighter (Dancer et al.
1995; English and Church 1999). That is, even though
more children with MBHL and UHL appear to be receiving audiological and related services than ever before,
academic difficulties persist in this group. Therefore, it
has been speculated that other factors in addition to
hearing loss alone may be at play. Keeping in mind that
the majority of children with MBHL and UHL demonstrate no academic, speech, language or behavior problems, there must exist some contributing or predictive
factors not yet identified that affect those children who
do not fare as well. For example, the etiology of the hearing loss, rather than the hearing loss itself, might be an
indicator of potential deficits. Consider that approximately 10,000 to 80,000 infants are born in the United
States each year with congenital cytomegalovirus
(CMV) infection (Stagno et al. 1986; Noyola, Demmler
and Nelson 2001) making CMV the most common congenital viral infection and the leading cause of prelinguistic hearing loss in children (Nance 2007). Nance
posited that the neurologic deficits associated with
CMV might be to blame for the poor academic performance of children with UHL secondary to infection,
rather than the hearing loss per se. At this time, we have
not been able to make a convincing link between the academic difficulties of children with MBHL or UHL and
CMV, or any other causative factor. However, should
this speculation hold true, there is the implication that
intervention strategies would need to encompass more
than improvement of classroom acoustics or speech perception and that specific educational and speech/language interventions would also need to be explored.
Another possible contributing factor to the academic difficulties experienced by these children could
be their late age of identification and/or intervention. Although hearing loss of moderate or greater degree can
be identified in the newborn period, universal newborn
screening protocols do not target hearing loss in the
minimal to mild range (Joint Committee on Infant Hear-
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A Sound Foundation Through Early Amplification
ing 2007) and evidence exists to suggest that a large percentage of newborns with these losses are missed during the screening process (Johnson et al. 2005). Furthermore, with no mandated hearing screening prior to
school entrance, children with minimal to mild degrees
of hearing loss are not likely to be identified until approximately five to six years of age. Another potential
contributor to late intervention for these children is that
many families, physicians, and audiologists are either
not concerned about such losses or are understandably
uncertain as to appropriate management for these children (Neault 2005a). Hence, these children, even once
identified, may not receive timely intervention (Reeve
2005; McKay, Gravel and Tharpe 2008).
At the National Workshop for Mild and Unilateral
Hearing Loss held in 2005, discussions ensued regarding when minimal to mild hearing loss could be accurately diagnosed in infants (Cone-Wesson, Sininger and
Widen 2005). Using the definitions of slight hearing loss
(16–25 dB HL) and mild hearing loss (26–40 dB HL), it
was concluded that, under ideal conditions, slight loss
could be identified between 6 and 9 months developmental age and mild loss at 6 months or younger developmental age. Factors that make identification at such an
early age difficult include the presence of otitis media
with effusion, calibration issues and lack of agreement
between physiologic and behavioral test measures (Ross
et al. 2008), and examiner uncertainty (Reeve 2005).
One of the most common audiologic interventions
for minimal bilateral and unilateral hearing loss, frequency-modulated (FM) system technology, enhances
speech perception under adverse listening conditions
(Kenworthy, Klee and Tharpe 1990; Updike 1994;
Flexer 1995; Tharpe, Ricketts and Sladen 2003). Various
types of hearing aids have also been recommended for
those with MBHL and UHL (McKay et al. 2008). However, as noted previously, there is no direct evidence
that improving listening via hearing aids or FM usage
for children with MBHL and UHL improves academic
outcomes for these children, although one would expect
that to be the case.
Conclusions
Although we know that more than a third of children with MBHL or UHL will experience academic difficulty, at this point in time, we do not know which children will be negatively affected or which interventions
might be effective. Until such time that those children
who are at greatest risk for psychoeductional difficulty
can be identified, it is reasonable to institute a proactive
management approach with children who have MBHL
or UHL. This approach includes:
• Counseling. Audiologists can counsel families about
the importance of a good acoustic environment for
communication and how to create a rich language atmosphere within the home. For those with UHL, a discussion regarding safety issues related to poor localization skills should also be included. When appropriate, these discussions can include daycare professionals and schoolteachers. Keeping in mind that the effects of these losses will likely be subtle, parents might
not understand that their child with MBHL or UHL
hears any differently than other children. Therefore,
our counseling challenge is to explain or demonstrate
to families, perhaps through the use of simulations or
other tools, the impact these losses may have on listening, as they may not be readily apparent.
• Etiologic Evaluation. Medical evaluation of children
found with any degree or configuration of permanent
hearing loss should include a search for genetic and
environmental causes. As previously noted, CMV is
the most common causative factor of non-genetic, prelingual hearing loss and must be identified during the
first two to three weeks of life. Other causative factors
associated with MBHL and UHL include prematurity,
genetics, enlarged vestibular aquaduct (EVA), noise
exposure, viral and bacterial infections, and auditory
neuropathy/dyssynchrony (Tharpe and Sladen 2008).
• Acoustic Modifications. Preferential seating arrangements may help to provide children with MBHL and
UHL with enhanced visual and auditory cues needed
for improved communication. Modifications may be
needed in the home, daycare setting, and/or school
environment. These modifications can be inexpensive
and low-tech, like strategic placement of carpet remnants within the room, or might be high-tech, like the
placement of a sound field FM system.
• Speech and Language Monitoring. Although most
studies of speech and language abilities of school-age
children with UHL have not identified specific deficits
(Hallmo et al. 1986; Klee and Davis-Dansky 1986;
Tieri et al. 1988; Kiese-Himmel 2002), at least one
study found that children with UHL who failed a grade
in school had significantly lower verbal IQ scores than
those children with UHL who were academically successful (Klee and Davis-Dansky 1986). However, both
the academically successful and unsuccessful UHL
groups had verbal IQs within the normal range. Examination of the speech and language abilities of chil-
Minimal Hearing Loss in Children: The Facts and the Fiction
dren with MBHL has been lacking. Despite the fact
that no clear pattern of speech and/or language
deficits has emerged in children with MBHL or UHL,
obtaining a speech and language evaluation provides
a good opportunity to document baseline functioning
and allows a speech-language pathologist to talk with
families about how to support a language-rich home
environment.
• Ongoing Audiologic Assessment. As with any degree
of hearing loss, audiological monitoring is important
for identification of progression or fluctuation. Many
of the causative factors of minimal hearing loss, including CMV and EVA, are associated with progression. It is also interesting to note that reports are beginning to emerge of babies who failed newborn
screening in one ear but were later found to have bilateral hearing loss. Neault recently reported an
analysis of two years of newborn hearing screening
data from Massachusetts (2005b). Of the babies who
did not pass the newborn screening in one ear and
had confirmed hearing loss, 40% were later found to
have bilateral hearing loss. These babies could have
had bilateral loss at the time of the screening but were
missed because of screening variables including calibration issues, or the loss could have progressed from
unilateral to bilateral between the time of the screening and the diagnostic evaluation. Regardless of the
reason for a change from a unilateral to a bilateral
hearing loss diagnosis, these data support the need
for close audiologic monitoring of UHL.
• Functional Auditory Assessments. Another source of
information important to the management of MBHL
and UHL is functional auditory assessment. Because
the behavioral effects of such losses are often more
subtle than those of greater degrees of loss, parents,
educators, and other professionals may tend to overlook them and think that no problems exist. Functional
auditory assessments are designed to evaluate listening behavior in real-world settings, where parents,
teachers, and other caregivers spend their time with
children. Tools like the Children’s Home Inventory for
Listening Difficulties (CHILD; Anderson and Smaldino
2000), for use by parents, or the Screening Inventory
for Targeting Educational Risk (SIFTER; Anderson
1989), for use by teachers, can provide valuable information for assisting professionals in developing management plans for children with MBHL and UHL. For
example, such tools may reveal that although a child is
progressing well academically, there may be difficulty
hearing under specific listening conditions (e.g., soft
217
speech or speech in noise). Therefore, the results of functional assessment tools, in addition to other evaluations,
may support the need for FM system technology or hearing aids (McKay et al. 2008). Many of the functional auditory assessment tools do not have published psychometric data at this time. Therefore, they should be considered
as only one part of an assessment battery contributing to
management decision making.
Children with MBHL and UHL are clearly at risk for
academic difficulty. But it is important to keep in mind
that not all of these children have difficulty and, at this
time, we cannot predict with certainty which children
will fare better than others. Furthermore, we do not
have strong evidence to support specific intervention
strategies, including amplification, for all children with
MBHL and UHL (CDC 2005; McKay et al. 2008). Therefore, it is reasonable to monitor the auditory, speech-language, and psychoeducational progress of all children
with MBHL and UHL and determine intervention strategies on an individual basis, as needed.
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