Page 80-89: Hearing Impairment

Part 2 - Disorders Demystified

Page 80-89: Hearing Impairment

Hearing Impairment

Hearing impairment, also referred to as hearing loss and deafness, is when one or more parts of the ear aren’t working effectively. The ear has two main functions; to take in sound and convert it into a signal that the brain can understand, and to help us balance. Being able to hear is central to our health and wellbeing and is crucial for the development of speech, language and communication skills.

Types of hearing impairment

Hearing loss can occur at any time over a person’s life, from birth through to old age. It can affect one or both ears, to the same or a different degree, and can be stable or fluctuate. Children can have a congenital loss, where they are born with hearing impairment or it can be acquired, for example due to illness or injury.

Children can have bilateral hearing impairment, where both ears are affected or unilateral hearing impairment where there is a difficulty in one ear, but a normal level of hearing in the other.

A conductive hearing loss occurs when there is a problem in the outer ear, ear canal or middle ear, resulting in sound being unable to reach the inner ear, to be processed and understood. The most common cause of conductive hearing loss is a temporary build-up of fluid in the middle ear, known as ‘glue ear’, which often results in ‘otitis media’ or middle ear infection. Depending on the cause, conductive hearing loss can be temporary or permanent.

Sensorineural hearing loss is where there is a problem with the inner ear, meaning that sound is not able to be processed effectively by the cochlea and/or is unable to travel to the brain to be understood. This type of hearing loss is permanent.

Children can have a combination of conductive and sensorineural hearing loss and this is known as a ‘mixed loss’.

Levels of hearing impairment

A child’s hearing impairment is described according to the type and level of impairment, which is determined by the quietest sound that they can hear. Children can be described as having mild, moderate, severe or profound hearing impairment and the level can vary between ears.

Some children with hearing impairment have personal hearing technology, such as hearing aids, bone conduction hearing implants or cochlear implants to support their hearing.

Diagram of the ear.

Diagram of the ear.

Level of Deafness	Use of hearing technology	Conversation in a quiet room, without aids	Conversation in a quiet room, with aids	Conversation with background noise or in a larger group
Mild	Some will use hearing aids	Usually can hear everything but not able to follow a whispered conversation	Usually can hear everything	Difficulty hearing everything clearly, especially if the speaker is far away
Moderate	Most will use hearing aids	Likely to be able to hear most of what someone says, if speaking clearly	Able to follow most of the conversation	Difficulty in following a conversation, especially if the speaker is far away
Severe	Majority will use hearing aids or cochlear implant	Unable to access conversation without hearing technology, but may be able to hear loud sounds, such as a dog barking	Able to follow a conversation provided the speaker is within 2-3 meters, but likely to require communication support, e.g. sign support/lip reading to understand	Extremely difficult to understand speech, even with communication support
Profound	Majority will use hearing aids or cochlear implant	Likely to use a sign-based language system to communicate as unable to hear speech or other sounds	Likely to require additional communication support to access speech	Extremely difficult to understand speech, even with communication support

This audiogram demonstrates the range of familiar sounds and speech sounds in English (represented by the ‘speech banana’) that children with typical hearing and those with different levels of hearing impairment can hear.

Myth Busting

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Will children with hearing impairment have ‘normal hearing’ if they are using hearing technology, such as hearing aids or cochlear implant?

Most children with hearing impairment can hear some sounds and using hearing technologies helps them to be able to hear more sounds. This does not, however, mean that they have ‘normal’ hearing and they will still experience difficulties in hearing some sounds, affecting their ability to understand spoken information, particularly when there is background noise.

If a child responds to some sounds, like their name being called, does this mean they can’t have a hearing impairment?

Most children with hearing impairment are able to hear some sounds and so will be able to respond to some noises that they hear. What they will struggle with, is being able to identify specific sounds within words in order to fully understand and make sense of information within a conversation. This is very different from turning to their name, which is likely to be said with the specific intonation to get them to attend.

If a child doesn’t have hearing aids, does this mean that they definitely don’t have a hearing impairment?

Pupils who have hearing loss as a result of glue ear and many of those with mild hearing loss, do not wear hearing technology and there can be a tendency to underestimate the impact of their hearing impairment. These children have difficulty understanding speech when there is background noise, or if there is more than one person speaking. They still need support in order to understand spoken information and if their hearing needs are not supported, they are at risk for speech and language difficulties, literacy difficulties and poor academic achievement.

Prevalence

NHS England’s ‘Action Plan on Hearing Loss’ (2015) estimated that over 10 million adults and 45,000 children in the UK have hearing impairment, equating to 1 in 6 of the population. It is estimated that at any one time, 20% of children in Year R have glue ear, resulting in temporary hearing loss.

Impact of hearing impairment

The impact of a child’s hearing impairment will vary from individual to individual as it will depend on the level and type of hearing loss they have, support in place and whether they have any other health conditions, such as an additional Learning Disability or language disorder. Children with hearing impairment at are risk for the following difficulties:

Delayed speech and language development, with understanding of vocabulary and concepts a particular weakness. Hearing impairment in children can have a significant impact on the acquisition of language and speech sound skills. The hearing loss results in children having difficulty making sense of what people are saying to them and what is happening around them.
Difficulty socialising with others. Group conversations can be very challenging for children with hearing impairment. These conversations often happen in noisy environments where it can be hard to distinguish speech from background noise and it is easy to lose track of the conversation if you are relying on lip-reading.
Poor attention and concentration. Children with hearing impairment can tire easily due to the increased concentration needed to focus on the speaker and use strategies such as lip-reading to understand. They have to work harder to keep up with the pace of conversation and/or learning.
Difficulties with multi-tasking, for example being able to take notes or complete a piece of work while listening and/or lip-reading at the same time.
Reduced educational attainment.
Increased risk of mental health Children with hearing impairment can have difficulty understanding and expressing what they are feeling in order to manage emotions.
Delayed theory of mind and therefore difficulty understanding from another’s point of view.
Difficulties with incidental learning, for example gaining information through overhearing others.
Struggling to fill in the gaps of missing information, for example speech sounds or parts of words that weren’t heard, as children with hearing impairment lack the knowledge, vocabulary and understanding of the context to be able to do this. This means that they can miss out on lots of spoken information, including vocabulary and concepts being taught.

Strategies

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Every child with hearing impairment is different and will need different strategies for supporting them. Many of the general strategies for supporting children with SLCN will be applicable for children with hearing impairment. Here are some specific strategies:

Communicating with children with hearing impairment

Find out how the child is communicating; using speech, BSL, sign-supported English or a mixture of these.
Ensure you gain the child’s attention before speaking and face them when you’re talking, so they can see your face clearly to support lip-reading.
Use visual cues to support speech, for example pointing to what you are talking about and using natural gestures.
In a group or whole class situation, ensure that only one person is speaking at a time.
Ensure that your face is visible and well-lit, for example do not speak with the light source behind you.

Adapting the environment to support children with hearing impairment

Reduce background noise by closing doors and windows and switching off IT equipment when it is not being used. Even using hearing technology, children with hearing impairment have to concentrate very hard on blocking out background noise and focusing on the speaker.
Use a radio aid, if appropriate, which carries the speaker’s voice directly to a receiver on the pupil’s hearing technology. The microphone can be passed to different people speaking in the classroom and can be connected to TVs or computers to aid clarity.
Reduce the amount of sound reverberation and echo in the classroom as this increases the amount of background noise and can distort the sound heard by the child. This can be done by reducing the number of hard surfaces, e.g. fitting carpets or curtains and covering hard surfaces with fabric.

Top Tip

Speech and Language Top Tip Icon

Speak clearly and naturally, as speaking slowly or too loudly makes lip-reading much more difficult.

Supporting speech and language development and access to the curriculum

Provide pre- and post-teaching of vocabulary and concepts
Use visuals to back up spoken information as this means the pupil does not have to rely on listening for information. Point clearly to visual clues you are using and when other members of the class refer to them during discussion.
Make it clear when there are changes in task or topic, for example when reading is stopped to discuss a specific point in a book. Give extra time between listening to input or watching a video clip for children to be able to take notes, as they may miss information.
Build in time for breaks and adapt activities to include tasks that do not solely rely on listening and/or lip-reading, to reduce fatigue.

In some areas, children with a permanent moderate to profound hearing impairment will receive support from a Teacher of the Deaf (TOD). A TOD advises staff on strategies to support learning, provides deaf awareness training to staff and peers, supports staff with use and maintenance of the child’s hearing technology and recommends improvements to the learning environment to support the pupil.

When should I refer?

Some pupils will already have a diagnosis of hearing impairment when they start school, but some may acquire hearing loss while they are at school, for example following a serious illness such as meningitis. It is important to look out for possible signs of hearing impairment so that difficulties can be identified, and strategies put in place to support them. For children with a diagnosis of hearing impairment, it is important that their hearing levels are monitored, in case of deterioration.

The following may indicate potential difficulties with hearing:

Not responding when their name is called
Mishearing information when they are not looking at you and watching your face and lips intently
Difficulty following instructions correctly and often asking for information to be repeated
Talking too loudly or too quietly
Behavioural difficulties including lack of concentration or attention, becoming withdrawn or frustrated
Difficulty socialising with peers
Delayed speech and language skills
Difficulties with literacy and learning
Repeated ear infections or frequent report of earache

If you are concerned that a child may have an undiagnosed hearing impairment it is recommended that you discuss your concerns with parents who can take the child to the GP to discuss a referral to audiology. If the child is experiencing hearing loss as a result of glue ear, their hearing impairment is likely to fluctuate, so the difficulties observed may improve and deteriorate over time.

It is worth noting that some of the observed behaviours above could indicate other difficulties, such as DLD or language disorder.

Role of SaLT

Many children with hearing impairment are under the care of a range of professionals which may include audiology, TOD and SaLT. The difficulties experienced by a child with hearing impairment will vary depending on the type and severity of their hearing loss, therefore not all children with hearing impairment will need SaLT support.

Many children with hearing impairment have SLCN and some will have an additional speech and/or language disorder. It is important that the language skills of children with hearing impairment are screened, for example using Language Link, to identify areas of difficulty and put support strategies in place. If you are concerned about a child’s speech, language and communication skills, it is recommended that you discuss them with your local SaLT.

Support from SaLT could include assessment and diagnosis of language needs to determine the support needed by the child, providing advice and strategies for optimising the child’s learning environment, providing recommendations and programmes for school staff to support children and/or direct therapy intervention, as appropriate.