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December 20, 2002

Your child and hearing loss

From: MSNBC - 20 Dec 2002

Early diagnosis is key in developing speech and language

Dec. 20 — Hearing loss is one of the most common birth defects in the United States. More than 30 babies are born here each day with a hearing loss significant enough to affect speech and language development. The key to helping these children is early detection. Audiologist Laurie Hanin, co-executive director of the League for the Hard of Hearing in New York City, gives advice on how to recognize the early symptoms.

PARENTS HAVE MANY questions and must make difficult decisions when their child is diagnosed with hearing loss. Children are not simply small adults — they are different in many respects, and their hearing loss must be evaluated and treated differently than would be the case for adults with similar hearing profiles. Parents who are knowledgeable about hearing, hearing loss and related issues are usually better advocates for their child.
Thanks to improved technology and new legislation across most of the United States, it is now possible, and in some states standard procedure, to test a baby’s hearing within hours after birth through painless, electronic protocols, including auditory brainstem evoked response (ABR) and otoacoustic emissions (OAE) screenings. These procedures are easy to administer, relatively inexpensive, accurate, and cause no discomfort for the infant. Early diagnosis is very important. The earlier the hearing loss is diagnosed the better for the child.
Approximately 6 out of every 1,000 children born have some degree of hearing loss. Children may also acquire hearing loss after birth from illness, trauma, ototoxic medications and genetic factors. An undiagnosed hearing loss can have an impact on the child’s language development, educational achievement and emotional stability. At least 2 in every 1,000 children will experience hearing loss severe enough to prohibit their ability to develop speech and language unless specific therapeutic intervention is provided.
However, when children with hearing loss are identified at an early age, fit with appropriate and beneficial amplification which they use consistently, and are trained to use their residual hearing to the maximal level for understanding speech, they can acquire age-appropriate speech and language skills (listening, speaking, and comprehension) which enable them to function effectively in the hearing world.

The term “hearing loss” is used when audiometric tests demonstrate a child is not responding to sounds which are established as normal hearing levels. Hearing loss does not necessarily mean a complete inability to hear. There are degrees of hearing loss, referred to as: mild, moderate, severe and profound. Sometimes mild hearing loss may go unnoticed, while severe and profound hearing loss makes it impossible for a child to develop speech and language skills without help.

A baby who does not pass the infant screening, or a child for whom there is special concern about hearing or speech development, should have a comprehensive audiological evaluation conducted by an audiologist, preferably one with expertise in pediatric testing. The hearing test results are charted on an audiogram, which documents two important types of information: frequency (the ability to hear a range of sounds from low pitch sounds like bass drums to high pitch sounds like whistles or birds) and decibels (the loudness or intensity of sounds which range from very soft (5dB) to very loud (110dB).
We use the term “deaf” or “profound hearing loss” to refer to hearing loss exceeding 90dB, meaning the child does not respond until the presented sound is 90dB or quite loud. We use the term “hard of hearing” to refer to a hearing loss less than 90dB. The phrase “hearing impaired” is an “umbrella” term that is sometimes used to describe any degree of hearing loss.
The approach to the child’s hearing loss, and how the child learns to function using his/her residual hearing with amplification or other hearing technology is more important than the exact degree of hearing loss represented on the child’s audiogram.

Hearing loss can be present at birth, or it may develop sooner or later in life. It may be hereditary, or it may be caused by problems during pregnancy or delivery. It is often difficult to pinpoint what has caused hearing loss in a particular child. Hereditary factors cause a large percentage of hearing loss in children. The hearing loss may be caused by a defect of the outer or middle ear, but more often the damage exists in the inner ear (cochlea). Genetic counseling can be helpful to the family in determining whether heredity is the cause. Although this information cannot help the child who has hearing loss, it may assist in family planning and ultimately may be important information for the child.
Hearing loss may also be the result of maternal illness during pregnancy, exposure to certain drugs, or complications during delivery. Acquired hearing loss occurs after birth, and may result from prematurity, low birth weight, incompatibility of the Rh factor of blood between the parents, use of ototoxic drugs during the neonatal period, cytomegalovirus (CMV) or oxygen deprivation. Illness or accidents may also cause acquired hearing loss. Some illnesses which may cause hearing loss include meningitis, encephalitis, mumps, and jaundice. Any disease which is accompanied by a high fever may cause hearing loss in a child. There are certain medications, such as gentamicin, neomycin, streptomycin, kanamycin and quinine sulfate which are medically necessary to treat serious illnesses — but may cause hearing loss. These medications are referred to as ototoxic.

There are basically two types of hearing loss. Conductive hearing loss indicates there is a problem with the mechanism that conducts sound from the environment to the inner ear. Problems in the external auditory canal (outer ear), ear drum or the bones of hearing (the ossicles) may cause a conductive loss. This type of loss can usually be corrected by medication or surgery. If it cannot be corrected, the child with conductive hearing loss can usually do very well with hearing aids.
Sensorineural hearing loss indicates a problem in the organ of hearing (cochlea) or the nerve of hearing. There may be damage to the inner ear, auditory nerve, or the auditory centers of the brain. This kind of loss cannot be medically “cured” at this time. However, children with sensorineural hearing loss can benefit from hearing aids, FM systems, cochlear implants, communication therapies, and a careful analysis and implementation of educational and communication approaches.

For children with known hearing loss, colds, upper respiratory infections, and ear infections should be treated immediately to prevent additional hearing loss. When a child has a cold or is congested, the eustachian tube (which connects the middle ear with the back of the throat) and nose can become blocked. In this situation, fluid in the middle ear can prevent the ossicles from vibrating normally, and can cause additional temporary conductive hearing loss. This fluid in the ear or “otitis media” is common in children. Young children may have no symptoms. Older children and adults will usually be aware of hearing loss or a sense of ear fullness or pressure. While this hearing loss is usually reversible, children can fall behind in speech and language development and may not progress in school until their hearing improves! When middle ear fluid persists for months or years, it can lead to irreversible hearing loss or chronic ear infections.

Parents have many options to choose from regarding their child’s method (or mode) of communication. The Children’s Communication Program at the League takes a multi-disciplinary team approach and follows an auditory/oral method. If this approach is not appropriate for a particular child, or the parents choose to pursue an alternative method, the League will discuss referrals to other programs with the family. Professionals in different geographic areas should explain various approaches, and refer parents to different programs, reading material, and websites for information.
The League’s multi-disciplinary team includes the parents of the child and professionals including: a physician, audiologist, speech-language pathologist, psychologist, teacher of the deaf, and sometimes a social worker.
The first step is a complete evaluation.
Through a complete and comprehensive diagnostic evaluation, the child’s capabilities, skills, and needs are assessed. These initial evaluations help clarify the appropriateness of options parents may choose for their individual child.
The diagnostic team includes the child’s pediatrician, who evaluates the child for general health problems and an otologist or otolaryngologist, a physician who specializes in diseases and medical problems of the ear. The otologist determines any medical cause of the hearing loss, and determines if the hearing loss can be medically or surgically treated.
The audiologist “provides comprehensive diagnostic and rehabilitative services for all areas of auditory, vestibular and related disorders” (see ASHA, 1996). The audiologist initially determines the type and degree of hearing loss, evaluates the child for use of amplification (i.e., hearing aids, FM systems) and can dispense the amplification. The audiologist can also evaluate the child to determine if he or she might receive more benefit from a cochlear implant than from amplification. Most typically, this decision is not made until the child has had a trial period with amplification. Frequent visits to the audiologist are typically needed for infants and very young children to monitor their hearing levels and use of amplification. The audiologist typically follows the child through school and into adult life with yearly re-evaluations and determines whether the child can receive increased benefit from different hearing aids or devices.
The speech-language pathologist evaluates language understanding, expressive use and speech clarity. She is responsible for developing and implementing a specific program of communication intervention, with appropriate goals and expectations to develop auditory or listening skills, intelligible speech and receptive and expressive language. The speech-language pathologist monitors progress in these areas, and in language development, speech production and overall communication skills, and sets new goals over time. The earlier this therapy program begins, the better the chances are the child will develop oral language and speech skills enabling him/her to participate fully in the world of sound.
The psychologist is responsible for assessing the child’s cognitive ability, learning style, and interpersonal relationship skills. The results of these evaluations need to be communicated to parents and professionals in a manner which can be understood by the parents and with recommendations that can be implemented. The psychologist helps the parents develop an understanding of how hearing loss impacts cognitive, communication, social/emotional growth, daily living and academic abilities and can also assist in establishing realistic expectations, exploring parental feelings, reactions to the hearing loss, and the impact on the family. The child’s needs and abilities change over time, and the psychologist may follow the child as he or she progresses through school. Parents may seek counseling initially after diagnosis and at various times throughout their child’s formative years to assist them in managing the changing needs of their child who has a hearing loss.
Once the clinical evaluations are completed, a teacher of the deaf becomes involved with the family. This professional is on the League’s team and may be involved in conducting functional evaluations of a child within his/her daycare, preschool or school program, assisting in locating appropriate programming, attending and assisting with the development of the Individual Family Service Plan (IFSP) or the Individual Educational Plan (IEP), and supporting the school-based staff.
A social worker may also be part of the team. This professional assesses the family history, support structure, and may help locate various sources of assistance for the family, including funding sources and additional counseling, if needed.
The parents are most essential to the teamwork that will enable the child to achieve full potential. Parents have in-depth knowledge of their child and are most familiar with the world the child is trying to understand and participate in. They have shared many of their child’s experiences, and are their child’s first and most important teachers and advocates. The way parents talk, behave, and communicate with their child has tremendous impact on how the child thinks and feels about him/herself. Children are more likely to explore and learn when they feel secure and loved.

Early diagnosis is of paramount importance. The earlier the hearing loss is diagnosed and effectively managed, the better for the child and the family. Research indicates babies without hearing loss hear while in the womb, and newborns are comforted by their mother’s familiar voice rather than the voice of a stranger. By the time hearing babies speak their first words, they have been listening to language for 10 to 15 months.
Meanwhile, children who have hearing loss are deprived of auditory information; they do not have the input of speech and language until the loss is diagnosed, the child is fitted with hearing aids, and a program of intervention therapy begins. Whatever direction or mode of communication a family chooses for the child, the child needs language. Language, whether spoken or signed, enables the child to communicate with others, to express and understand needs, desires, feelings, and ideas.

When parents choose an auditory/oral approach extensive speech and language input is necessary, and this takes time. We often suggest to “bathe your child in sound,” teaching the meaning and source of each sound, and literally immersing your child in auditory/oral language. However, exactly when the child will start to talk depends on the child, the degree of hearing loss, the family’s support system, the child’s age when the hearing loss was identified and amplification provided, the benefit received from the amplification, and other factors. Learning to talk is a process that requires significant time and effort. Every child is unique.

Hearing aids and similar technologies are the basis of the program for a child with a hearing loss. Appropriate hearing aids or an FM system allow the child to make contact with the world of sound. There are many recent breakthroughs related to hearing aids, FM systems, assistive listening devices and cochlear implants. If you have not investigated amplification devices in the last year or two, you will be surprised at the options available. Unlike eyeglasses, which usually restore normal sight, neither hearing aids nor cochlear implants restore normal hearing. Hearing aids make things louder but cannot necessarily make words and sounds clearer. In general, the “clarity” of the sound is more dependent on the ear itself, rather than the hearing aid. One of the things done in communication therapy is to help the child learn to make sense of distorted signals his/her ears perceive. However, it takes time to learn to use a hearing aid.

For most children, two hearing aids are better for many reasons. Your audiologist will help determine which is best for your child.
People with normal hearing can lose hearing from excessive noise or too much loud sound. This is also true for people who use hearing aids. Hearing aids amplify all sound, so sometimes they are very loud. The audiologist will try to find a hearing aid that your child does well with, and that is not too loud. If your child does not respond well to the hearing aids, consult with your audiologist.

Some children’s hearing can get worse, and most of the time we do not know why. This condition may be referred to as a progressive loss or degenerative loss. Your audiologist and otologist are the professionals to speak with regarding this issue.

Cochlear implants were first approved by the FDA (Food and Drug Administration) almost 20 years ago. A cochlear implant is an electronic device that provides sound information for children who have severe-to-profound sensorineural hearing loss in both ears and obtain limited (minimal) benefit from appropriate hearing aids. Unlike hearing aids that amplify sound to the damaged auditory system, the implant technology sends electrical signals directly to the auditory nerve. Some of the components of the device are surgically placed. The external parts of the implant system look very much like a body-worn or a behind-the-ear hearing aid.
While using a cochlear implant, the child receives auditory sensations that vary in pitch and loudness and she/he learns to interpret these sounds and develop auditory/oral language skills. Research has shown that many children with cochlear implants do very well and can understand normal spoken language; many children and adults using cochlear implants can use the telephone effectively. In general, children who are implanted early, enrolled in intensive auditory/oral training, have strong family involvement and support, and no other complicating factors are demonstrating high levels of performance in auditory perception, language and academic skills. The results with cochlear implants have improved dramatically over the last 5 to 10 years. If you are interested in learning more about the cochlear implant ask your audiologist or contact the League for the Hard of Hearing.

Air Conduction Test — measures hearing loss by placing earphones over the child’s ear and measuring the entire hearing mechanism.
Amplification — to make louder, increase volume.
Aplasia — malformation of the inner ear.
Atresia — absence or malformation of the outer or middle ear.
Audiogram — a graphic description of a person’s hearing.
Audiologist — a clinician trained to diagnose, evaluate, and treat hearing loss.
Audio therapy — a method of training people to use their residual hearing to the best of their ability, also referred to as auditory training.
Auditory brainstem evoked response test (ABR) — measurement of brain waves in response to sound; can provide objective information regarding hearing sensitivity when this information cannot be obtained reliably through behavioral measures.
Auditory/oral therapy — speech-language therapy and educational programming to develop maximum use of residual hearing, oral language and intelligible speech.
Bilateral — both ears.
Bone Conduction Test — measures hearing loss by placing a vibrator on the mastoid process (behind the external ear) and measuring the auditory nerve.
Cochlea — the organ of hearing within the inner ear converts the sound vibrations to nerve impulses and sends these to the brain.
Conditioned Orienting Response (C.O.R.) - -a method of evaluating a child’s responses to sound by conditioning the child to respond to a flashing light, or a moving puppet.(same as Behavioral Tests used with a child old enough to respond to sounds either by turning their head or by playing a game).
Conductive Hearing Loss — a hearing loss caused by damage or disease of the outer or middle ear.
Congenital — existing at or dating from birth, but not necessarily hereditary.
Digital Hearing Aid-(Programmable) — aids capable of sophisticated signal processing strategies.
Ear mold — a device which fits into the ear canal to which a hearing aid is attached. It is made individually for each person.
FM system (auditory trainer) — amplification device utilizing a wireless remote microphone that reduces the negative effects of noise and distance on the understanding of speech.
Functional Hearing Loss — a hearing loss that is not caused by an organic condition.
Geneticist — a medical doctor who evaluates and traces causes and counsels people about the risk of producing children with certain genetic problems.
Hearing Aid — a device which amplifies sound. There are basically four types of hearing aids: post auricular (ear level) which fits behind the child’s ear; “all-in-the-ear”, which fits directly into the child’s ear canal; a body aid worn in a pocket on the child’s chest with a cord going to the ear, or an eyeglass aid, which is connected to the eyeglasses.
Hearing Aid Dealer — a person who sells hearing aids, arranges for repair of hearing aids and sometimes counsels in their use.
Heredity — the physical condition which determines characteristics or traits which are passed down in a family from parents to children.
Impedance Testing — a method of evaluating the functioning of the middle ear.
Lip-reading or Speechreading — using visual clues to supplement auditory skills to understand oral languages.
Middle Ear — portion of the hearing mechanism between the outer ear and the cochlea, consisting of the eardrum, the ossicles (bones), the opening of the Eustachian tube, the oval window and the round window.
Monaural — referring to one ear or one hearing aid.
Neurologist — the medical doctor whose area of expertise is problems of the peripheral and central nervous systems, and their connection to the senses.
Organic — a hearing loss caused by a physical condition.
Otoacoustic emissions test — (OAE) screening test for cochlear functioning involving the measurement of low-level, inaudible sounds produced by vibrations in the cochlea.
Otolaryngologist — a medical specialist of the ear, nose and throat.
Otologist — a medical specialist of the ear.
Peri-Natal — occurring at birth.
Pinnea — outer ear.
Post-Natal — occurring after birth.
Pre-Natal — occurring before birth.
Prognosis — a forecast of the probable outcome of a particular condition.
Psychologist — a clinician trained to administer a battery of tests for the purpose of evaluating abilities and personality characteristics and to counsel the individual and/or his family.
Residual Hearing — the hearing which remains after hearing loss.
Sensorineural Hearing Loss — a hearing loss caused by damage to the cochlea, eighth auditory nerve or auditory pathways.
Speech/Language Pathologist — a clinician trained and certified to evaluate, diagnose and treat speech, language and communication problems.
Unilateral — one ear.

Article courtesy of League for the Hard of Hearing. Copyright © 2002 by League for the Hard of Hearing. All rights reserved.
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