Guidelines for managing school-age children with unilateral hearing losses
An estimated 3 per 1,000 school-age children have permanent unilateral hearing loss. These children typically have problems in one or more of the following areas:
- difficulty locating the source of sounds
- difficulty understanding speech in background noise, particularly if the "good" ear is close to the competing noise
- difficulty maintaining attention and following classroom instructions, especially if it's noisy
- difficulty with schoolwork, particularly with language-based subjects (i.e., reading, writing, spelling, etc.)
Research continues to reveal that children with unilateral hearing loss are at a higher risk for grade failure. Two clinical reports suggest that at least 35% of these children repeat one or more grades compared to 3.5% of their normal hearing counterparts.
To minimize potential problems, we suggest the following guidelines:
- Hearing healthcare
- Monitor the child's hearing status at least once a year. Be particularly alert for middle ear infections, which may compound the negative effects of unilateral hearing loss. The possibility of a progressive hearing loss should also be considered. Your child should be seen immediately for hearing testing if you suspect additional hearing loss.
- Always provide ear protection (plugs or muffs) during activities with high levels of noise, such as concerts, snowmobiling, lawnmowing, use of fireworks, driving farm equipment, etc. It's critical to protect the "good" ear from damage.
- Crossing busy streets and riding bicycles in heavy traffic can be dangerous since children with unilateral hearing loss have difficulty localizing sounds. Mirrors on bicycles and careful training in street crossing are needed.
- Communication strategies
- Gain the child's attention before initiating a conversation or giving instructions. Providing a visual supplement may prevent confusion or misunderstanding.
- Favor your child's "good" ear, but anticipate problems if speaking from a distance since noise may interfere with comprehension.
- Rephrase rather than repeat statements and instructions if they are misunderstood.
- Maximize comprehension by using familiar vocabulary and less complex sentence structures.
The following mnemonic device highlights basic strategies for communicating with children with hearing impairments:
- State the topic to be discussed before initiating a conversation.
- Pace your conversation at a moderate rate and at a normal conversational loudness with occasional pauses to permit comprehension.
- Enunciate clearly without exaggerated lip movement.
- Enthusiastically communicate, using body language and natural gestures.
- CHeck comprehension before changing topics.
- Classroom management
- Provide a structured environment with the least amount of noise and reverberation.
- Provide good lighting to maximize visual input.
- Provide seating so the child can favor the "good" ear, ideally no more than 5 to 6 feet from the teacher and away from the hall, street or playground noise. Such preferential seating allows the child to better use hearing and supplemental cues.
- Use a variety of visual aids to enhance learning such as listing key vocabulary on the chalkboard or whiteboard, use of overhead transparencies, etc.
- Check comprehension before changing topics.
- Speech and language assessment
- Schedule a comprehensive evaluation of your child's speech and language development (comprehension and expression) upon identification of a permanent unilateral hearing loss. These findings can serve as a baseline so your child's progress can be objectively monitored over time. If a language delay is present, early intervention may minimize later difficulties in academic achievement and classroom performance.
- Psychoeducational evaluation
- Monitoring of classroom performance and academic achievement is essential. Children with unilateral hearing loss are at a higher risk for grade failure. It's imperative to assure that all children with a hearing loss have normal or corrected vision since many of the above recommendations require the use of vision as a supplement to hearing.
- Annual monitoring may be accomplished with minimal time and cost by using a teacher rating instrument such as the Pupil Rating Scale (Revised) developed by Myklebust. Children identified with deficient classroom performance should be referred for a comprehensive assessment of cognitive, motor, social-emotional and language skills. Such a strategy will minimize grade failure and identify those children who need support services.
- Amplification options
- A trial of amplification should be considered to proactively try to prevent speech/language delays and school failure. Candidates are children with hearing loss between 25-65dBHL in the impaired ear and usable speech recognition in that ear. Decisions regarding children who fall outside this criteria should be made on a case by case basis.
- Use of a personal amplification system in the classroom should be considered to minimize comprehension problems. This will be important in situations where controlling classroom noise or preferred seating is not feasible. With a wireless FM system, the student FM receiver may be coupled to the child's personal hearing aid or to the child's unaided "good" ear with either a non-occluding earmold or a walkman-type headset. Studies suggest that speech recognition abilities improved in all listening environments with FM systems.
- An alternate possibility is the use of a free-field amplification system in a noisy room, by which the teacher's voice is amplified for all children.
Since many unilateral hearing losses are congenital (at birth) or of early onset, these guidelines should be considered as soon as a hearing impairment is identified. Education and guidance for parents regarding these strategies are essential components of aural habilitation.