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Flora Nassrallah, Ken Tang, JoAnne Whittingham, Huidan Sun, Elizabeth M Fitzpatrick, Auditory, Social, and Behavioral Skills of Children With Unilateral/Mild Hearing Loss, The Journal of Deaf Studies and Deaf Education, Volume 25, Issue 2, April 2020, Pages 167–177, https://doi.org/10.1093/deafed/enz041
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Abstract
This study explored the impact of mild bilateral or unilateral hearing loss on auditory, social, and behavior skills in early school-aged children. Thirty-two children (aged 5–9 years) were evaluated with parent and teacher questionnaires. Most outcomes were within the range of expected scores. However, functional auditory skills were below published results for children with typical hearing. On the social skills scale, about 21.4% (parent-reported) and 20.0% (teacher-reported) of children were below one standard deviation (SD) of the normative mean (i.e., a standard score below 85). On the parent-reported behavior test, over a quarter of children scored beyond 1 SD on some subscales. Laterality of hearing loss had no effect on outcomes (p > .05). Agreement between parents and teachers varied from poor (intraclass correlation coefficient [ICC]: .162) to moderate (ICC: .448). Results indicate that these children are functioning in most areas like their peers with typical hearing. Additional research on this population of children who may benefit from early identification and amplification is warranted.
Permanent hearing loss (PHL) is one of the most common childhood disorders, prevalent in 3–4 per 1,000 births when considering all degrees of loss (Prieve & Stevens, 2000; Watkin & Baldwin, 2011). Population-based studies have shown that 40–50% of PHL is unilateral or mild bilateral (Consortium for Deafness in Deaf Education, 2017; Durieux-Smith, Fitzpatrick, & Whittingham, 2008; Fitzpatrick, Durieux-Smith, & Whittingham, 2010; Russ et al., 2003). Historically, children with mild bilateral or unilateral hearing loss (MUHL), without risk factors, were not identified until 5–6 years of age (Durieux-Smith et al., 2008; Fitzpatrick, Whittingham, & Durieux-Smith, 2014; Tharpe, 2008). Since the implementation of newborn hearing screening programs, these children are identified early in jurisdictions where better than moderate PHL is targeted (Fitzpatrick et al., 2014; Ghogomu, Umansky, & Lieu, 2014).
While the benefits of early identification and management are known for children with greater degrees of PHL (Ching et al., 2017; Kennedy et al., 2006; Laugen, Jacobsen, Rieffe, & Wichstrom, 2017; Pimperton & Kennedy, 2012; Yoshinaga-Itano, 2003),advantages of early identification of MUHL children are still being investigated. Knowledge on the effects of this degree of PHL is primarily based on the studies of late-identified cases. A series of studies in the 1980s and 1990s, now summarized in more recent reviews (Appachi et al., 2017; Lieu, 2004; Tharpe, 2008), addressed speech-language, auditory, and educational challenges encountered by late-identified MUHL children. Delays in narrative skills (Young et al., 1997), verbal reasoning (Martinez-Cruz, Poblano, & Conde-Reyes, 2009), verbal cognitive skills and oral language (Lieu, Karzon, Ead, & Tye-Murray, 2013), morphology, syntax, and vocabulary (Sangen, Royackers, Desloovere, Wouters, & van Wieringen, 2017), and overall language development (Borg et al., 2002; Borg, Edquist, Reinholdson, Risberg, & McAllister, 2007; Culbertson & Gilbert, 1986; Fischer & Lieu, 2014) have been noted in children with unilateral hearing loss (UHL). Children with MUHL have also demonstrated delays in phonological processing such as phonological memory (Anne, Lieu, & Cohen, 2017; Lieu, 2004; Tharpe, 2008; Wake et al., 2006).
In particular, early studies summarized in Tharpe (2008) reported education concerns for this group of children. In a study of 60 children with a UHL, approximately 35% failed at least one grade and an additional 13.3% needed a tutor or special academic assistance (Bess & Tharpe, 1986). Of this same sample of 60 children, only half performed satisfactorily in school (Bess & Tharpe, 1986). Similarly, children with mild bilateral hearing loss did not perform at expected academic levels and exhibited about a 1.11 grade delay when compared with children with typical hearing (Quigley & Thomure, 1968).
Auditory Skills
Several studies have investigated the auditory skills of children with MUHL. Auditory skills involve the ability to carry out a range of hearing-related tasks and are frequently viewed as consisting of a hierarchy of integrated skills in the areas of detection (e.g., sound detection, localization, and auditory attention), discrimination, identification, and comprehension (Erber, 1982; Nevins & Garber, 2006). Research by Bess, Tharpe, & Gibler (1986) showed that 60 children with UHL between 6 and 18 years of age demonstrated lower localization scores and poorer speech recognition scores in both quiet and noisy settings when compared with their peers with typical hearing. These findings are consistent with numerous other studies with children who have MUHL (Sangen et al., 2017; Tharpe, 2008). Bourland-Hicks & Tharpe (2002) examined listening effort and fatigue in children with minimal to moderate hearing loss. They reported that these children used more effort in listening to speech in quiet or in noisy environments than children with typical hearing. These findings implied that children with a mild degree of hearing loss require more energy to listen in the classroom (Bourland-Hicks & Tharpe, 2002). However, overall improvements were noted in speech perception, speech recognition in noise, and sound localization with a hearing rehabilitation device (Appachi et al., 2017). Additionally, early identification may be associated with better auditory and communication outcomes (Fitzpatrick, Durieux-Smith, Gaboury, Coyle, & Whittingham, 2015).
Behavioral and Social Skills
Generic quality of life ratings is similar in children and adolescents with hearing loss to children with typical hearing (Warner-Czyz, Loy, Evans, Wetsel, & Tobey, 2015). However, difficulties in peer acceptance, social-emotional adjustment, and self-esteem have been reported compared with peers (Cappelli, Daniels, Durieux-Smith, McGrath, & Neuss, 1995; Theunissen et al., 2014). In the review by Tharpe (2008), several studies discussed behavioral and psychosocial problems noted in children with MUHL. Bess & Tharpe (1986) reported that 20% of children ranging in age from 6 to 18 years with UHL exhibited behavioral problems and were, therefore, receiving preferential classroom seating as a management option at the time. Similarly, behavior reports from parents and teachers revealed behavior problems including social withdrawal and aggression in 42% of a group of school-aged children with UHL (Stein, 1983). Noted behavior problems included uncooperative attitude, inattention, social withdrawal, and aggression (Dancer, Burl, & Waters, 1995; Keller & Bundy, 1980; Stein, 1983). Giolas & Wark (1967) reported the feelings of embarrassment, annoyance, confusion, and helplessness in youth with UHL. Borton, Mauze, & Lieu (2010) investigated health-related quality of life in children with UHL ranging in age from 6 to 17 years using focus groups and a survey. Results of the content analysis and of the survey revealed no differences between children with UHL and those with typical hearing. However, children with UHL had much more variability in scores related to social functioning compared with their peers with typical hearing or those with a bilateral hearing loss. Additionally, during the focus group discussion, the participants with hearing loss reported frequent academic related problems involving memory and attention (Borton, Mauze, & Lieu, 2010). Finally, a longitudinal study uncovered that while the initial speech problems of a group of children (ages 6–12 years) with UHL improved over time, academic difficulties and behavioral problems persisted (Lieu, Tye-Murray, & Fu, 2012). In children from grades 3, 6, and 9 with mild bilateral hearing loss, Bess, Dodd-Murphy, & Parker (1998) observed a lower level of energy and a greater level of fatigue, as well as more dysfunction in the domains of stress, social support, and self-esteem. A recent article by Laugen et al. (2017) examined the extent to which 35 children age 4–5 years with MUHL were at risk for social skills difficulties compared with children with typical hearing and with children with moderate hearing loss using the Norwegian version of the Social Skills Rating System. According to Gresham & Elliott (1990), social skills are learned behaviors enabling effective interaction with others. Children with MUHL had lower social skills scores than those with moderate to severe hearing loss who obtained scores similar to children with typical hearing (Laugen et al., 2017). Early detection and amplification of the group of children with moderate-to-severe hearing loss were noted and seemed to have been beneficial. Therefore, results suggested that early detection and amplification would have likely had substantial positive effects on the social skills of the children with MUHL.
Many studies highlight the negative consequences of MUHL (Anne et al., 2017; Winiger, Alexander, & Diefendorf, 2016), but there remain inconsistent findings regarding the effects of these losses on children’s outcomes. Furthermore, much of the evidence stems from children identified at school age. While some individuals experience considerable difficulties, others appear to have no observable academic delays (Wake et al., 2006; Winiger et al., 2016). The goal of this study was to explore the impact of mild bilateral and UHL on functional auditory, social, and behavior skills in early school-aged children. We compared their results to test norms from age-matched children with typical hearing. A need for a multiple-informant approach was warranted due to differences in informant-ratings since children may exhibit difficulties in certain contexts and not in others [i.e., school or home] (Wong et al., 2018). As in a recent study by Wong et al. (2018) that addressed the emotional and behavioral difficulties in 224 young children who use hearing aids or cochlear implants, we obtained perspectives for social and behavior skills from both parent- and teacher-rated questionnaires to capture information from different settings.
Method
Participants
Thirty-two children (males = 12, females = 20) participated in this study. A detailed description of their characteristics is presented in the results section.
English speaking children with a permanent MUHL and chronological age between 5 and 9 years were invited to enroll in the study. It was also essential for one parent to be able to complete the questionnaires in English. None of the families were using sign language. Children with acquired PHL were excluded from the study. These children would have passed screening in infancy and acquired their hearing loss secondary to a known cause (e.g., meningitis). Children with auditory neuropathy, severe developmental delay, or cognitive delay that would prevent them from completing the assessments were also excluded.
Degree of hearing loss was defined with three-frequency pure tone average (average of the thresholds at 500, 1000, and 2000 Hz). Definitions were based on those from the National Workshop on Mild and Unilateral Hearing Loss Research (Centers for Disease Control and Prevention, 2005). UHL was defined as a PTA greater than 20 dB HL or thresholds greater than 25 dB HL at two or more frequencies above 2 kHz in the impaired ear. The contralateral ear had a PTA better than 20 dB. Mild bilateral hearing loss was defined by a PTA between 20 and 40 dB HL in the better ear. To address participant enrollment challenges, the upper hearing threshold was extended from 40 to 50 dB HL in the better ear, thus including some moderate hearing loss cases.
This project was conducted in the context of the Universal Newborn Hearing Screening publicly funded Infant Hearing Program (IHP) of Ontario (Hyde, Friedberg, Price, & Weber, 2004) and as part of the Mild and Unilateral Hearing Loss in Children Research Program. In the province of Ontario, MUHL is specifically targeted as part of the provincial screening program. The Ontario IHP has established protocols to ensure standardized practices for screening, assessment, amplification, and early communication development (Bagatto et al., 2016; Brown & Mackenzie, 2005; Hyde et al., 2004; Ontario Ministry of Children and Youth Services, 2014). The program aims to screen children by one month by one month of age and to identify children with PHL by three months of age (Joint Committee on Infant Hearing, 2007). Children who do not pass screening at birth are referred to a pediatric audiology center. Children with risk indicators are placed on a surveillance list and monitored. Hearing technology is recommended to children diagnosed with PHL when appropriate. For children diagnosed with hearing loss, ongoing audiological management and intervention services (i.e., hearing aids and communication development services such as auditory verbal therapy) are provided as part of the program (Ontario Ministry of Children and Youth Services, 2014).
The site for this project was the Children’s Hospital of Eastern Ontario, a teaching hospital and a regional Canadian pediatric audiology center, which serves a population of approximately one million people. The CHEO Audiology Clinic diagnoses 40–50 children in the context of the IHP program annually. Respecting research ethics requirements, health care providers invited families to participate in the study. In addition, families from Eastern Ontario and Southern Ontario regions already participating in another longitudinal study on the effect of MUHL in preschool children, and who met the school-age requirement at the time of enrollment, were invited to participate. It was not possible to collect information on the total number of families invited to participate. Research ethics approvals were obtained from the Children’s Hospital of Eastern Ontario Research Institute (12/98X) and the University of Ottawa (A02–13-04).
Procedures
At time of enrollment, families completed a study-specific intake questionnaire which included baseline family and hearing characteristics (e.g., family demographics including maternal education, household income, language(s) spoken at home, and hearing health) and an intervention form with questions related to hearing loss (e.g., degree of loss, amplification, and therapy services). With parental consent, we contacted each child’s audiologist to obtain information about diagnosis, degree of hearing loss, and amplification. After enrollment, parents and general education teachers completed questionnaires on auditory function, social skills, and behavioral skills. The questionnaire forms provide written instructions to guide respondents. The outcomes mentioned above are the focus of this current report. Children also completed a battery of auditory and speech-language assessments administered by a speech-language pathologist or listening and spoken language specialist. Results from the parent auditory questionnaire and the speech-language assessments have previously been reported (Nassrallah et al., 2018) and will not be discussed here.
Functional auditory skills (TEACH and PEACH). The Parents’ Evaluation of Aural/Oral Performance of Children (PEACH) and the Teacher’s Evaluation of Aural/Oral Performance of Children (TEACH) are questionnaires designed to gather information on a child’s hearing and communication based on parent and teacher observations. Behavior in various communication environments, at home and at school, is rated on a five-point scale in everyday relatively quiet or noisy settings. Ratings from each question are added to obtain a percentage for “PEACH-Noise,” “PEACH-Quiet,” “TEACH-Noise,” and “TEACH-Quiet” subscales with a maximum possible score of 100%. Scores for children with typical hearing as a function of age are published (Ching & Hill, 2007).
Social skills (SSIS). The Social Skills Improvement System (SSIS) is used to evaluate social skills, problem behaviors, and academic competence for children age 3–18 years. The form is available for parents and teachers, with different questions to provide a comprehensive picture in the home and school setting, respectively. Each scale is composed of a number of subscales: (a) Social skills: communication, cooperation, assertion, responsibility, empathy, engagement, and self-control; (b) Problem behaviors: externalizing, bullying, hyperactivity/inattention, internalizing, and autism spectrum; (c) Academic competence: reading achievement, math achievement, and motivation to learn (Gresham & Elliott, 2008). A standard score of 100 is the mean for a sample of age-matched hearing children with scores between 85 and 115 (±1 SD) representing skills within the average range.
Behavioral skills (BASC-2). The Behavior Assessment for Children (BASC-2) measurement tool is designed to assess emotional disorders, personality constructs, and behavioral problems in children and youth 4–18 years of age with the use of three components (teacher, parent, and self-reported scales). The specific questions differ depending on the respondent (parent vs. teacher). The test yields four composite scores (externalizing problems, internalizing problems, behavioral symptoms index, and adaptive skills) that are based on 14 scales. The teacher component also includes a school problems composite score (Reynolds & Kamphaus 2004). T-scores are provided for each scale whereby a score of 50 represents the mean for a sample of age-matched children with typical hearing. Scores between 40 and 60 are ±1 SD from the mean. The different scores are combined to create two profiles: Clinical and Adaptive. The clinical scales (e.g., hyperactivity, aggression, conduct problems, etc.) measure maladaptive behaviors, and high scores (at risk: 60–69; clinically significant: 70 and above) on these scales represent negative characteristics that cause impaired functioning. The adaptive scales (e.g., adaptability, social skills, etc.) measure positive behaviors. Contrary to the clinical scales, high scores on the adaptive scales represent positive or desirable characteristics, and low scores (at risk: 31–40; clinically significant: 30 and below) represent possible problem areas.
Data Analysis
Data were analyzed using SPSS version 24 (IBM Corporation, 2016) and R version 3.3.2 (R Core Team, 2016). Descriptive statistics summarized sociodemographic and baseline clinical characteristics of the participants. Functional auditory outcomes, social skills, and behavioral skills are reported as percentages, standard scores, and T-scores, respectively. We examined normality, means and standard deviations (SD), or medians and interquartile ranges (IQR) for each variable, as appropriate. Differences in the outcomes between the parent- and teacher-reported questionnaires were compared using paired-sample t-tests at a significance level of .05. Afterwards, agreement between parent- and teacher-report on each outcome was determined with a two-way random-effect model (absolute agreement, single measure)—Intraclass Correlation Coefficients (ICC). The ICCs can provide a more stringent comparison of the scores obtained by parents and teachers at the individual level if no differences are uncovered by the t-tests. Differences in the outcomes were also compared between the unilateral group and the bilateral group using independent t-tests at a significant level of .05. In addition, we conducted an ordinary least squares (linear) regression with sex as a covariate to assess the relationship between the laterality of hearing loss and scores on the social and behavioral assessments.
Results
Description of Participants
Table 1 provides a summary of characteristics of the study participants. Fifteen of the 32 children had a bilateral hearing loss with a mean three-frequency PTA of 33.1 dB HL (SD = 11.8; range = 10.0–50.0) in the better ear and 40.9 dB HL (SD = 14.6; range = 18.3–73.3) in the worse ear at the time of enrollment. Four of these children had hearing in the 40–50 dB range in the better ear. The other 17 children had a unilateral loss with a mean PTA of 67.3 dB HL (SD = 25.4; range = 18.3–110.0) in the impaired ear; seven of these had a PTA greater than 70 dB HL. The median age of identification for all children was 14.8 months (IQR = 4.7, 47.5). In terms onset of hearing loss, 12 (37.5%) children had congenital, 3 (9.4%) children had early onset (<6 months of age), and 10 (31.3%) had late onset hearing loss (>6 months of age). Specific time of onset was unknown for seven children. Information on amplification was available for 29 of the 32 children. Of these, 22 children (75.9%) used hearing aids (17 of whom also reported using a remote microphone system), and another seven children (24.1%) used a remote microphone system only in school. The seven children who were not using any amplification had a UHL. According to parent report (responses received for 30 children), 22 children (73.3%) were receiving services related to their hearing loss at the time of the study (i.e., auditory-verbal therapy, speech-language pathology, itinerant teacher of the deaf and hard of hearing services, and/or additional resources at school), and eight reported not receiving any special services. In terms of socio-economic status, maternal education was high overall with an average of 17.7 years (SD = 3.2) and family income was above the median for the region.
Characteristics of children
| Characteristics . | Participants (n = 32) . |
|---|---|
| Sex, n (%) | |
| Male | 12 (37.5) |
| Screening status, n (%) | |
| Screened | 25 (78.1) |
| Not screened | 3 (9.4) |
| Unknown | 4 (12.5) |
| Age at confirmation hearing loss (months), median (IQR) | 14.8 (4.7, 47.5) |
| Age at assessment (months), mean (SD) | 86.1 (15.0) |
| Onset of hearing lossa, n (%) | |
| Congenital | 12 (37.5) |
| Early onset | 3 (9.4) |
| Late onset | 10 (31.3) |
| Unknown | 7 (21.9) |
| Hearing loss at assessment, n (%) | |
| Unilateral—impaired ear | 17 (53.1) |
| Mild | 2 (6.3) |
| Moderate | 3 (9.4) |
| Moderate-severe | 4 (12.5) |
| Severe | 4 (12.5) |
| Profound | 4 (12.5) |
| Bilateral—better ear | 15 (46.9) |
| Mild | 11 (34.4) |
| Moderate | 4 (12.5) |
| Type of hearing loss, n (%) | |
| Sensorineural | 28 (87.5) |
| Permanent conductive | 3 (9.4) |
| Mixed | 1 (3.1) |
| Amplificationb (months), median (IQR) | 37.0 (11.6, 50.9) |
| Amplification, n (%) | |
| Hearing aidsc | 22 (75.9) |
| Remote microphone system only | 7 (24.1) |
| Unknown | 3 (9.7) |
| Maternal educationb (years), mean (SD) | 17.7 (3.2) |
| Family incomeb, n (%) | |
| < 80,000$d | 4 (12.9) |
| > 80,000$ | 27 (87.1) |
| Characteristics . | Participants (n = 32) . |
|---|---|
| Sex, n (%) | |
| Male | 12 (37.5) |
| Screening status, n (%) | |
| Screened | 25 (78.1) |
| Not screened | 3 (9.4) |
| Unknown | 4 (12.5) |
| Age at confirmation hearing loss (months), median (IQR) | 14.8 (4.7, 47.5) |
| Age at assessment (months), mean (SD) | 86.1 (15.0) |
| Onset of hearing lossa, n (%) | |
| Congenital | 12 (37.5) |
| Early onset | 3 (9.4) |
| Late onset | 10 (31.3) |
| Unknown | 7 (21.9) |
| Hearing loss at assessment, n (%) | |
| Unilateral—impaired ear | 17 (53.1) |
| Mild | 2 (6.3) |
| Moderate | 3 (9.4) |
| Moderate-severe | 4 (12.5) |
| Severe | 4 (12.5) |
| Profound | 4 (12.5) |
| Bilateral—better ear | 15 (46.9) |
| Mild | 11 (34.4) |
| Moderate | 4 (12.5) |
| Type of hearing loss, n (%) | |
| Sensorineural | 28 (87.5) |
| Permanent conductive | 3 (9.4) |
| Mixed | 1 (3.1) |
| Amplificationb (months), median (IQR) | 37.0 (11.6, 50.9) |
| Amplification, n (%) | |
| Hearing aidsc | 22 (75.9) |
| Remote microphone system only | 7 (24.1) |
| Unknown | 3 (9.7) |
| Maternal educationb (years), mean (SD) | 17.7 (3.2) |
| Family incomeb, n (%) | |
| < 80,000$d | 4 (12.9) |
| > 80,000$ | 27 (87.1) |
Note. IQR = interquartile range; SD = standard deviation.
aCongenital = hearing loss present at birth; Early onset = hearing loss diagnosed before 6 months of age; Late onset = children who passed screening in infancy and were diagnosed after 6 months of age; Unknown = children not screened or screened outside the local area.
bInformation not available for one child.
cSeventeen children with a hearing aid also used a remote microphone system.
dMedian family income reported by Statistics Canada in 2014 for the three metropolitan regions where children were recruited.
| Characteristics . | Participants (n = 32) . |
|---|---|
| Sex, n (%) | |
| Male | 12 (37.5) |
| Screening status, n (%) | |
| Screened | 25 (78.1) |
| Not screened | 3 (9.4) |
| Unknown | 4 (12.5) |
| Age at confirmation hearing loss (months), median (IQR) | 14.8 (4.7, 47.5) |
| Age at assessment (months), mean (SD) | 86.1 (15.0) |
| Onset of hearing lossa, n (%) | |
| Congenital | 12 (37.5) |
| Early onset | 3 (9.4) |
| Late onset | 10 (31.3) |
| Unknown | 7 (21.9) |
| Hearing loss at assessment, n (%) | |
| Unilateral—impaired ear | 17 (53.1) |
| Mild | 2 (6.3) |
| Moderate | 3 (9.4) |
| Moderate-severe | 4 (12.5) |
| Severe | 4 (12.5) |
| Profound | 4 (12.5) |
| Bilateral—better ear | 15 (46.9) |
| Mild | 11 (34.4) |
| Moderate | 4 (12.5) |
| Type of hearing loss, n (%) | |
| Sensorineural | 28 (87.5) |
| Permanent conductive | 3 (9.4) |
| Mixed | 1 (3.1) |
| Amplificationb (months), median (IQR) | 37.0 (11.6, 50.9) |
| Amplification, n (%) | |
| Hearing aidsc | 22 (75.9) |
| Remote microphone system only | 7 (24.1) |
| Unknown | 3 (9.7) |
| Maternal educationb (years), mean (SD) | 17.7 (3.2) |
| Family incomeb, n (%) | |
| < 80,000$d | 4 (12.9) |
| > 80,000$ | 27 (87.1) |
| Characteristics . | Participants (n = 32) . |
|---|---|
| Sex, n (%) | |
| Male | 12 (37.5) |
| Screening status, n (%) | |
| Screened | 25 (78.1) |
| Not screened | 3 (9.4) |
| Unknown | 4 (12.5) |
| Age at confirmation hearing loss (months), median (IQR) | 14.8 (4.7, 47.5) |
| Age at assessment (months), mean (SD) | 86.1 (15.0) |
| Onset of hearing lossa, n (%) | |
| Congenital | 12 (37.5) |
| Early onset | 3 (9.4) |
| Late onset | 10 (31.3) |
| Unknown | 7 (21.9) |
| Hearing loss at assessment, n (%) | |
| Unilateral—impaired ear | 17 (53.1) |
| Mild | 2 (6.3) |
| Moderate | 3 (9.4) |
| Moderate-severe | 4 (12.5) |
| Severe | 4 (12.5) |
| Profound | 4 (12.5) |
| Bilateral—better ear | 15 (46.9) |
| Mild | 11 (34.4) |
| Moderate | 4 (12.5) |
| Type of hearing loss, n (%) | |
| Sensorineural | 28 (87.5) |
| Permanent conductive | 3 (9.4) |
| Mixed | 1 (3.1) |
| Amplificationb (months), median (IQR) | 37.0 (11.6, 50.9) |
| Amplification, n (%) | |
| Hearing aidsc | 22 (75.9) |
| Remote microphone system only | 7 (24.1) |
| Unknown | 3 (9.7) |
| Maternal educationb (years), mean (SD) | 17.7 (3.2) |
| Family incomeb, n (%) | |
| < 80,000$d | 4 (12.9) |
| > 80,000$ | 27 (87.1) |
Note. IQR = interquartile range; SD = standard deviation.
aCongenital = hearing loss present at birth; Early onset = hearing loss diagnosed before 6 months of age; Late onset = children who passed screening in infancy and were diagnosed after 6 months of age; Unknown = children not screened or screened outside the local area.
bInformation not available for one child.
cSeventeen children with a hearing aid also used a remote microphone system.
dMedian family income reported by Statistics Canada in 2014 for the three metropolitan regions where children were recruited.
Results of functional auditory outcome measures
| Outcome measures . | Parents . | Teachers . | ||||
|---|---|---|---|---|---|---|
| . | N . | Mean (SD) . | # below 1 SD of the test mean . | N . | Mean (SD) . | # below 1 SD of the test mean . |
| Auditory skillsa (percentage) | ||||||
| Quiet | 29 | 84.7 (16.4) | N/A | 20 | 85.9 (14.2) | N/A |
| Noise | 29 | 73.3 (18.5) | N/A | 20 | 71.6 (22.7) | N/A |
| Outcome measures . | Parents . | Teachers . | ||||
|---|---|---|---|---|---|---|
| . | N . | Mean (SD) . | # below 1 SD of the test mean . | N . | Mean (SD) . | # below 1 SD of the test mean . |
| Auditory skillsa (percentage) | ||||||
| Quiet | 29 | 84.7 (16.4) | N/A | 20 | 85.9 (14.2) | N/A |
| Noise | 29 | 73.3 (18.5) | N/A | 20 | 71.6 (22.7) | N/A |
Note. SD = standard deviation; N/A = not applicable.
aAuditory skills were collected with the Parents’ Evaluation of Aural/Oral Performance of Children (PEACH) and Teachers’ Evaluation of Aural/Oral Performance of Children (TEACH).
| Outcome measures . | Parents . | Teachers . | ||||
|---|---|---|---|---|---|---|
| . | N . | Mean (SD) . | # below 1 SD of the test mean . | N . | Mean (SD) . | # below 1 SD of the test mean . |
| Auditory skillsa (percentage) | ||||||
| Quiet | 29 | 84.7 (16.4) | N/A | 20 | 85.9 (14.2) | N/A |
| Noise | 29 | 73.3 (18.5) | N/A | 20 | 71.6 (22.7) | N/A |
| Outcome measures . | Parents . | Teachers . | ||||
|---|---|---|---|---|---|---|
| . | N . | Mean (SD) . | # below 1 SD of the test mean . | N . | Mean (SD) . | # below 1 SD of the test mean . |
| Auditory skillsa (percentage) | ||||||
| Quiet | 29 | 84.7 (16.4) | N/A | 20 | 85.9 (14.2) | N/A |
| Noise | 29 | 73.3 (18.5) | N/A | 20 | 71.6 (22.7) | N/A |
Note. SD = standard deviation; N/A = not applicable.
aAuditory skills were collected with the Parents’ Evaluation of Aural/Oral Performance of Children (PEACH) and Teachers’ Evaluation of Aural/Oral Performance of Children (TEACH).
Results of social outcome measures
| Outcome measures . | Parents . | Teachers . | ||||
|---|---|---|---|---|---|---|
| . | N . | Mean (SD) . | # below 1 SD of the test mean . | N . | Mean (SD) . | # below 1 SD of the test mean . |
| Social skillsb (standard score) | ||||||
| Social skills | 28 | 99.9 (14.9) | 6 (21.4%) | 20 | 99.1 (15.1) | 4 (20.0%) |
| Problem behaviors | 29 | 97.3 (13.7) | 3 (10.3%) | 20 | 98.6 (11.2) | 1 (5.0%) |
| Academic competencec | N/A | N/A | N/A | 20 | 99.8 (15.8) | 3 (15.0%) |
| Outcome measures . | Parents . | Teachers . | ||||
|---|---|---|---|---|---|---|
| . | N . | Mean (SD) . | # below 1 SD of the test mean . | N . | Mean (SD) . | # below 1 SD of the test mean . |
| Social skillsb (standard score) | ||||||
| Social skills | 28 | 99.9 (14.9) | 6 (21.4%) | 20 | 99.1 (15.1) | 4 (20.0%) |
| Problem behaviors | 29 | 97.3 (13.7) | 3 (10.3%) | 20 | 98.6 (11.2) | 1 (5.0%) |
| Academic competencec | N/A | N/A | N/A | 20 | 99.8 (15.8) | 3 (15.0%) |
Note. SD = standard deviation; N/A = not applicable.
bSocial skills were collected with the Social Skills Improvement System (SSIS) versions for parents and teachers.
cParent questionnaire does not include the “Academic competence” subscale.
| Outcome measures . | Parents . | Teachers . | ||||
|---|---|---|---|---|---|---|
| . | N . | Mean (SD) . | # below 1 SD of the test mean . | N . | Mean (SD) . | # below 1 SD of the test mean . |
| Social skillsb (standard score) | ||||||
| Social skills | 28 | 99.9 (14.9) | 6 (21.4%) | 20 | 99.1 (15.1) | 4 (20.0%) |
| Problem behaviors | 29 | 97.3 (13.7) | 3 (10.3%) | 20 | 98.6 (11.2) | 1 (5.0%) |
| Academic competencec | N/A | N/A | N/A | 20 | 99.8 (15.8) | 3 (15.0%) |
| Outcome measures . | Parents . | Teachers . | ||||
|---|---|---|---|---|---|---|
| . | N . | Mean (SD) . | # below 1 SD of the test mean . | N . | Mean (SD) . | # below 1 SD of the test mean . |
| Social skillsb (standard score) | ||||||
| Social skills | 28 | 99.9 (14.9) | 6 (21.4%) | 20 | 99.1 (15.1) | 4 (20.0%) |
| Problem behaviors | 29 | 97.3 (13.7) | 3 (10.3%) | 20 | 98.6 (11.2) | 1 (5.0%) |
| Academic competencec | N/A | N/A | N/A | 20 | 99.8 (15.8) | 3 (15.0%) |
Note. SD = standard deviation; N/A = not applicable.
bSocial skills were collected with the Social Skills Improvement System (SSIS) versions for parents and teachers.
cParent questionnaire does not include the “Academic competence” subscale.
Results of behavioral outcome measures
| Outcome measures . | Parents . | Teachers . | ||||
|---|---|---|---|---|---|---|
| . | N . | Mean (SD) . | # beyond the 1 SD range of the test mean . | N . | Mean (SD) . | # beyond the 1 SD range of the test mean . |
| Behavior skillsd (t-score) | ||||||
| Externalizing problems | 26 | 50.5 (11.2) | 3 (11.5%) | 20 | 49.9 (8.8) | 3 (15.0%) |
| Internalizing problems | 26 | 53.3 (13.1) | 7 (26.9%) | 20 | 51.4 (8.0) | 4 (20.0%) |
| Behavioral symptoms | 26 | 53.3 (13.9) | 7 (26.9%) | 20 | 50.8 (11.0) | 3 (15.0%) |
| Adaptive skills | 26 | 50.0 (11.4) | 5 (19.2%) | 20 | 52.7 (9.5) | 1 (5.0%) |
| School problems | N/A | N/A | N/A | 18 | 50.1 (10.6) | 3 (16.7%) |
| Outcome measures . | Parents . | Teachers . | ||||
|---|---|---|---|---|---|---|
| . | N . | Mean (SD) . | # beyond the 1 SD range of the test mean . | N . | Mean (SD) . | # beyond the 1 SD range of the test mean . |
| Behavior skillsd (t-score) | ||||||
| Externalizing problems | 26 | 50.5 (11.2) | 3 (11.5%) | 20 | 49.9 (8.8) | 3 (15.0%) |
| Internalizing problems | 26 | 53.3 (13.1) | 7 (26.9%) | 20 | 51.4 (8.0) | 4 (20.0%) |
| Behavioral symptoms | 26 | 53.3 (13.9) | 7 (26.9%) | 20 | 50.8 (11.0) | 3 (15.0%) |
| Adaptive skills | 26 | 50.0 (11.4) | 5 (19.2%) | 20 | 52.7 (9.5) | 1 (5.0%) |
| School problems | N/A | N/A | N/A | 18 | 50.1 (10.6) | 3 (16.7%) |
Note. SD = standard deviation; N/A = not applicable.
For Clinical scales (Externalizing problems, Internalizing problems, Behavioral symptoms, and School problems), T-scores from 60–69 are “at-risk” and T-scores 70 and above are “clinically significant”. For the Adaptive scales (Adaptive skills), T-scores from 31–40 are “at-risk” and T-scores 30 and below are “clinically significant.”
dBehavioral skills were collected with the Behavior Assessment System for Children (BASC-2) versions for parents and teachers.
| Outcome measures . | Parents . | Teachers . | ||||
|---|---|---|---|---|---|---|
| . | N . | Mean (SD) . | # beyond the 1 SD range of the test mean . | N . | Mean (SD) . | # beyond the 1 SD range of the test mean . |
| Behavior skillsd (t-score) | ||||||
| Externalizing problems | 26 | 50.5 (11.2) | 3 (11.5%) | 20 | 49.9 (8.8) | 3 (15.0%) |
| Internalizing problems | 26 | 53.3 (13.1) | 7 (26.9%) | 20 | 51.4 (8.0) | 4 (20.0%) |
| Behavioral symptoms | 26 | 53.3 (13.9) | 7 (26.9%) | 20 | 50.8 (11.0) | 3 (15.0%) |
| Adaptive skills | 26 | 50.0 (11.4) | 5 (19.2%) | 20 | 52.7 (9.5) | 1 (5.0%) |
| School problems | N/A | N/A | N/A | 18 | 50.1 (10.6) | 3 (16.7%) |
| Outcome measures . | Parents . | Teachers . | ||||
|---|---|---|---|---|---|---|
| . | N . | Mean (SD) . | # beyond the 1 SD range of the test mean . | N . | Mean (SD) . | # beyond the 1 SD range of the test mean . |
| Behavior skillsd (t-score) | ||||||
| Externalizing problems | 26 | 50.5 (11.2) | 3 (11.5%) | 20 | 49.9 (8.8) | 3 (15.0%) |
| Internalizing problems | 26 | 53.3 (13.1) | 7 (26.9%) | 20 | 51.4 (8.0) | 4 (20.0%) |
| Behavioral symptoms | 26 | 53.3 (13.9) | 7 (26.9%) | 20 | 50.8 (11.0) | 3 (15.0%) |
| Adaptive skills | 26 | 50.0 (11.4) | 5 (19.2%) | 20 | 52.7 (9.5) | 1 (5.0%) |
| School problems | N/A | N/A | N/A | 18 | 50.1 (10.6) | 3 (16.7%) |
Note. SD = standard deviation; N/A = not applicable.
For Clinical scales (Externalizing problems, Internalizing problems, Behavioral symptoms, and School problems), T-scores from 60–69 are “at-risk” and T-scores 70 and above are “clinically significant”. For the Adaptive scales (Adaptive skills), T-scores from 31–40 are “at-risk” and T-scores 30 and below are “clinically significant.”
dBehavioral skills were collected with the Behavior Assessment System for Children (BASC-2) versions for parents and teachers.
Outcomes—Descriptive Statistics
Table 2a–c provides a summary of the outcome measures for functional auditory, social, and behavioral skills. The number of children with complete assessments varied from 26 to 29 for the parent-reported questionnaires and from 18 to 20 for the teacher-reported questionnaires. Mean scores for all outcome measures fell within the average range of test normative means (Table 2a–c). We also examined the data excluding the four children with a bilateral moderate loss (from 40 to 50 dB) to determine if their scores influenced the results. Group mean scores remained within the average range of test norms.
Figure 1 illustrates the results from parent- and teacher-reported questionnaires on functional auditory, social skills, and behavioral skills by unilateral and bilateral groups.
Results on parent- and teacher-reported questionnaires for children grouped by laterality of hearing loss. The mean scores and the standard deviation for functional auditory (PEACH and TEACH; percentage scores), social (SSIS; standard scores), and behavior (BASC-2; T-scores) outcomes are shown. The dashed lines on the SSIS graphs represent scores between 85 and 115 indicating ±1 SD or social skills within the average range for the normed sample. The dashed lines on the BASC-2 graphs represent scores between 40 and 60 indicating ±1 SD or behavior skills within the average range for the normative sample. PEACH = Parents’ Evaluation of Aural/Oral Performance of Children. TEACH = Teacher’s Evaluation of Aural/Oral Performance of Children. SSIS = Social Skills Improvement System. BASC-2 = Behavior Assessment for Children.

Functional auditory skills (TEACH and PEACH). Based on visual analysis mean results on functional auditory skills were lower for the unilateral group than the bilateral group for both the quiet and noise subscales based on parents’ responses on the PEACH. The opposite pattern was noted for the TEACH, that is, when teachers reported functional auditory abilities observed in the classroom environment (Figure 1).
Social skills (SSIS). As previously noted, the SSIS social skill measures have a mean standard score of 100 based on a normed sample of age-matched children with typical hearing. Scores between 85 and 115 represent ±1 SD and indicate skills within the average range for these outcomes. Mean scores for all SSIS outcome measures (social skills, problem behaviors, and academic competence) fell within the average range of test normative means (Table 2b). However, more children fell below 1 SD (i.e., below a standard score of 85) on the SSIS social skills scale compared with other measures. This was observed in both the parent-reported SSIS and the teacher-reported SSIS where 6 (4 unilateral, 2 bilateral) out of 28 children (21.4%) and 4 (3 unilateral, 1 bilateral) out of 20 children (20.0%) obtained a score below 85 (Figure 2). Overall, this represents a total of 8 out of 28 children (28.6%) who obtained scores below 1 SD of the test mean on parent-reported and/or teacher-reported SSIS. Table 3 also describes the characteristics of these eight children who obtained a score below 1 SD on the social skills scale. These eight children all had a mild hearing loss (≤40 dB HL). Median age of diagnosis was 16.4 months (IQR = 5.1, 59.3) and mean maternal education was 17.3 (SD = 2.9), both similar to the full sample. Median age of amplification was 48.5 months (IQR = 30.8, 61.3), higher than the full sample.
Individual standard score results on the SSIS social skills scale. Unilateral and bilateral hearing loss is differentiated. Children with a bilateral hearing loss, with a moderate degree in the better ear, are identified with a dotted pattern. The dashed lines represent scores between 85 and 115 indicating ±1 SD of the mean standard score, i.e., scores within the average range for the normed sample.

Characteristics of children who obtained results below 1 SD on the SSIS social skill scale
| Case ID . | Parent-reported score . | Teacher-reported score . | Laterality . | Onset of HL . | Age at Dx (months) . | HA use . | FM use . | Age at HA fitting (months) . | Maternal education (years) . |
|---|---|---|---|---|---|---|---|---|---|
| 5 | 73 | 101 | Bilateral | LO | 26.8 | Yes | No | 28.5 | 21 |
| 31 | 73 | 76 | Unilateral | Unk | 59.9 | Yes | No | 62.0 | 16 |
| 9 | 75 | NIA | Unilateral | C | 3.7 | No | Yes | NA | 14 |
| 16 | 76 | 83 | Unilateral | C | 5.9 | No | Yes | NA | 14 |
| 25 | 80 | 90 | Bilateral | LO | 59.3 | Yes | No | 71.0 | 18 |
| 12 | 81 | 108 | Unilateral | EO | 5.1 | Yes | Yes | 37.7 | 15 |
| 14 | 100 | 76 | Unilateral | C | 4.9 | Yes | Yes | 18.7 | 20 |
| 6 | 109 | 84 | Bilateral | LO | 59.3 | Yes | No | 59.3 | 20 |
| 16.4 (5.1, 59.3)a | 48.5 (30.8, 61.3)b | 17.3 (2.9)c |
| Case ID . | Parent-reported score . | Teacher-reported score . | Laterality . | Onset of HL . | Age at Dx (months) . | HA use . | FM use . | Age at HA fitting (months) . | Maternal education (years) . |
|---|---|---|---|---|---|---|---|---|---|
| 5 | 73 | 101 | Bilateral | LO | 26.8 | Yes | No | 28.5 | 21 |
| 31 | 73 | 76 | Unilateral | Unk | 59.9 | Yes | No | 62.0 | 16 |
| 9 | 75 | NIA | Unilateral | C | 3.7 | No | Yes | NA | 14 |
| 16 | 76 | 83 | Unilateral | C | 5.9 | No | Yes | NA | 14 |
| 25 | 80 | 90 | Bilateral | LO | 59.3 | Yes | No | 71.0 | 18 |
| 12 | 81 | 108 | Unilateral | EO | 5.1 | Yes | Yes | 37.7 | 15 |
| 14 | 100 | 76 | Unilateral | C | 4.9 | Yes | Yes | 18.7 | 20 |
| 6 | 109 | 84 | Bilateral | LO | 59.3 | Yes | No | 59.3 | 20 |
| 16.4 (5.1, 59.3)a | 48.5 (30.8, 61.3)b | 17.3 (2.9)c |
Note. HL = hearing loss; Dx = diagnosis; HA = hearing aid; NIA = no information available; NA = not applicable (i.e., child does not wear HA); LO = late onset; Unk = unknown; C = congenital; EO = early onset.
aMedian age of diagnosis (interquartile range).
bMedian age at HA fitting (interquartile range).
cMean age of maternal education (standard deviation).
| Case ID . | Parent-reported score . | Teacher-reported score . | Laterality . | Onset of HL . | Age at Dx (months) . | HA use . | FM use . | Age at HA fitting (months) . | Maternal education (years) . |
|---|---|---|---|---|---|---|---|---|---|
| 5 | 73 | 101 | Bilateral | LO | 26.8 | Yes | No | 28.5 | 21 |
| 31 | 73 | 76 | Unilateral | Unk | 59.9 | Yes | No | 62.0 | 16 |
| 9 | 75 | NIA | Unilateral | C | 3.7 | No | Yes | NA | 14 |
| 16 | 76 | 83 | Unilateral | C | 5.9 | No | Yes | NA | 14 |
| 25 | 80 | 90 | Bilateral | LO | 59.3 | Yes | No | 71.0 | 18 |
| 12 | 81 | 108 | Unilateral | EO | 5.1 | Yes | Yes | 37.7 | 15 |
| 14 | 100 | 76 | Unilateral | C | 4.9 | Yes | Yes | 18.7 | 20 |
| 6 | 109 | 84 | Bilateral | LO | 59.3 | Yes | No | 59.3 | 20 |
| 16.4 (5.1, 59.3)a | 48.5 (30.8, 61.3)b | 17.3 (2.9)c |
| Case ID . | Parent-reported score . | Teacher-reported score . | Laterality . | Onset of HL . | Age at Dx (months) . | HA use . | FM use . | Age at HA fitting (months) . | Maternal education (years) . |
|---|---|---|---|---|---|---|---|---|---|
| 5 | 73 | 101 | Bilateral | LO | 26.8 | Yes | No | 28.5 | 21 |
| 31 | 73 | 76 | Unilateral | Unk | 59.9 | Yes | No | 62.0 | 16 |
| 9 | 75 | NIA | Unilateral | C | 3.7 | No | Yes | NA | 14 |
| 16 | 76 | 83 | Unilateral | C | 5.9 | No | Yes | NA | 14 |
| 25 | 80 | 90 | Bilateral | LO | 59.3 | Yes | No | 71.0 | 18 |
| 12 | 81 | 108 | Unilateral | EO | 5.1 | Yes | Yes | 37.7 | 15 |
| 14 | 100 | 76 | Unilateral | C | 4.9 | Yes | Yes | 18.7 | 20 |
| 6 | 109 | 84 | Bilateral | LO | 59.3 | Yes | No | 59.3 | 20 |
| 16.4 (5.1, 59.3)a | 48.5 (30.8, 61.3)b | 17.3 (2.9)c |
Note. HL = hearing loss; Dx = diagnosis; HA = hearing aid; NIA = no information available; NA = not applicable (i.e., child does not wear HA); LO = late onset; Unk = unknown; C = congenital; EO = early onset.
aMedian age of diagnosis (interquartile range).
bMedian age at HA fitting (interquartile range).
cMean age of maternal education (standard deviation).
A visual examination of SSIS scores by laterality showed that the unilateral group obtained lower scores on the SSIS social skills subscales than the bilateral group based on parent responses but the opposite was noted from the teachers’ responses. Both groups obtained similar results on the other subscales of this test.
Behavioral skills (BASC-2). The behavior measures have a mean T-score of 50 based on a normed sample of age-matched children with typical hearing. Scores between 40 and 60 are ±1 SD from the mean. For clinical scales, T-scores 60 and above are considered “at risk” or “clinically significant.” In contrast, for the adaptive scales, T-scores of 40 and below indicate “at risk” or “clinically significant” cases. Mean T-scores for all BASC-2 outcome measures fell within the average range of test normative means (Table 2c). However, some children scored beyond 1 SD from the mean. Namely, based on parent responses, about one-fourth of children obtained scores above 60 on the internalizing problems and behavioral symptoms composite scores. Of these, three or two children obtained results beyond 2 SD from the mean on the internalizing problems and behavioral symptoms composite scores.
Outcomes—Comparisons and Relationships
Respondents. Paired-sample t-tests were conducted to determine if questionnaire respondents had an effect on the various outcomes. In all cases, there was no significant difference between the scores from parent- and teacher-reported questionnaires (p > .05). Since no differences were uncovered, two-way random-effects models (absolute agreement, single measure)—ICC were computed to assess agreement between parent and teacher raw scores at the individual level on each outcome (Table 4). ICCs are designated as ≤ .40 poor-to-fair agreement, .41 to .60 moderate agreement, .61 to .80 good agreement, and .81 to 1.00 excellent agreement (Varni, Limbers, & Burwinkle, 2007; Wilson, Dowling, Abdolell, & Tannock, 2001). Results varied from poor (ICC: .162) to moderate (ICC: .448) agreement depending on the outcome.
Two-way mixed-effect model (absolute agreement) intraclass correlation coefficients (ICC) between parent-reported and teacher-reported scores on the SSIS and the BASC-2. (N = 32)
| Outcomes measures . | Single ICC . | 95% Confidence interval . |
|---|---|---|
| Social skillsa | ||
| Social skills | .332 | −.134 to .673 |
| Problem behavior | .162 | −.243 to .541 |
| Behavior skillsb | ||
| Externalizing problems | .448 | .025 to .745 |
| Internalizing problems | .220 | −.285 to .620 |
| Behavioral symptoms | .337 | −.161 to .691 |
| Adaptive skills | .441 | .015 to .741 |
| Outcomes measures . | Single ICC . | 95% Confidence interval . |
|---|---|---|
| Social skillsa | ||
| Social skills | .332 | −.134 to .673 |
| Problem behavior | .162 | −.243 to .541 |
| Behavior skillsb | ||
| Externalizing problems | .448 | .025 to .745 |
| Internalizing problems | .220 | −.285 to .620 |
| Behavioral symptoms | .337 | −.161 to .691 |
| Adaptive skills | .441 | .015 to .741 |
aSocial skills were collected with the Social Skills Improvement System (SSIS) from parents and teachers.
bBehavioral skills were collected with the Behavior Assessment System for Children (BASC-2) from parents.
| Outcomes measures . | Single ICC . | 95% Confidence interval . |
|---|---|---|
| Social skillsa | ||
| Social skills | .332 | −.134 to .673 |
| Problem behavior | .162 | −.243 to .541 |
| Behavior skillsb | ||
| Externalizing problems | .448 | .025 to .745 |
| Internalizing problems | .220 | −.285 to .620 |
| Behavioral symptoms | .337 | −.161 to .691 |
| Adaptive skills | .441 | .015 to .741 |
| Outcomes measures . | Single ICC . | 95% Confidence interval . |
|---|---|---|
| Social skillsa | ||
| Social skills | .332 | −.134 to .673 |
| Problem behavior | .162 | −.243 to .541 |
| Behavior skillsb | ||
| Externalizing problems | .448 | .025 to .745 |
| Internalizing problems | .220 | −.285 to .620 |
| Behavioral symptoms | .337 | −.161 to .691 |
| Adaptive skills | .441 | .015 to .741 |
aSocial skills were collected with the Social Skills Improvement System (SSIS) from parents and teachers.
bBehavioral skills were collected with the Behavior Assessment System for Children (BASC-2) from parents.
Laterality. Independent t-tests were conducted to determine if laterality had an effect on the various outcomes. For all outcomes, there was no significant difference between the scores of the group with unilateral loss and the group with mild bilateral loss (p > .05). We also assessed the relationship between the laterality of hearing loss with SSIS and BASC-2 outcome measures. We conducted an ordinary least squares regression with covariate adjustments of age at diagnosis, sex, and setting (i.e., school and home), and cluster-adjusted standard errors to account for the inclusion of multiple ratings (parents/teachers) for the same observation (i.e., clustering of data). Results showed no statistical difference between scores for children with unilateral and bilateral hearing loss (p > .05).
Discussion
Since the implementation of UNHS programs, MUHL in children is identified and managed at an earlier age. In this study, functional auditory, social, and behavioral skills of a contemporary cohort of young school-aged children with MUHL were evaluated using a series of parent and teacher questionnaires. Of the 32 children who participated in this study, 21 were identified before their third birthday, which is considerably earlier than in the past. The median age at identification was 14.8 months. This study is important because the consequences of milder hearing loss on outcomes remain unclear for children identified in early childhood (Fitzpatrick et al., 2014).
In terms of functional auditory skills, individual scores ranged from 40 to 100%, and means scores were 84.7% (SD = 16.4) and 73.3% (SD = 18.5) on the PEACH-Quiet and PEACH-Noise subscales, respectively. Ching and Hill (2007) reported that PEACH scores reached close to 90% by 50 months of age for children with typical hearing. The PEACH results for our group are similar to those of a preschool group (age 3 to 4 years) of children with MUHL from a previous study by Fitzpatrick et al. (2019), where scores obtained were 86.2 (SD = 12.3) and 76.9% (SD = 15.7) for PEACH-Quiet and PEACH-Noise subscales, respectively. Results of our study are, therefore, consistent with the literature and indicate that functional auditory skills for this group of children with hearing loss are behind when compared with peers with typical hearing (Beattie, 1989; Bess et al., 1986; Hawkins, 1984). For the TEACH, individual scores ranged from 45 to 100% and mean scores were 85.9 (SD = 14.2) and 71.6% (SD = 22.7) on the TEACH-Quiet and TEACH-Noise subscales, respectively. One study has used the TEACH to assess children with moderately severe to profound hearing in a rural community (Emerson, 2015). However, to our knowledge, there are currently no studies that administered the TEACH to teachers of children with MUHL for comparison purposes. Unlike the PEACH, children with a unilateral loss scored better than children with a bilateral loss on both the quiet and noise subscales of the TEACH. It is possible that these differences reflect not only the observations of different respondents (teachers rather than parents) but also children’s functioning in different environments since the TEACH captures children’s functioning in the classroom situation. Nevertheless, the overall implications of lower scores on the PEACH and TEACH when compared with children with typical hearing may reflect more difficulty learning especially in noisy environments.
The mean results on all the social outcomes ranged between 85 and 115, or within ±1 SD of the expected scores for children with typical hearing from both the parent and teacher completed forms. These results contrast with other studies such as Laugen et al. (2017) who reported that children with MUHL aged 4–5 years had lower social skills than children with typical hearing. However, the ages of their study population were in the lower range of the children in our study. Interestingly, Laugen et al. (2017) noted that children with moderate hearing loss received scores similar to those with typical hearing, which they concluded was likely due to early identification and amplification. Our sample population was fairly early identified (median = 14.8 months). In addition, the majority of the sample were using amplification; 22 children (75.9%) used hearing aids, while another seven children (24.1%) used a remote microphone system in school. Therefore, exposure to optimized auditory input and intervention services before school entry may help to explain our results.
While mean SSIS social skills scale standard scores (99.9 ± 14.9 from parents and 99.1 ± 15.1 from teachers) for our sample were within the average for peers with typical hearing, 6 of 28 cases (21.4%) from parent questionnaires and 4 of 20 cases (20%) from teacher questionnaires were below 1 SD of the normative mean. When grouping questionnaires from both informants, 8 of 28 children (28.6%) scored below 1 SD on the parent and/or teacher questionnaires. Due to the small sample size, these results should be interpreted with caution; however, they could highlight the need to monitor social skills in children with MUHL. The social skills scale involves many components: communication, cooperation, assertion, responsibility, empathy, engagement, and self-control. We, therefore, further explored the results to try to identify trends in this group of children below 1 SD of the mean. Other than a later median age of amplification, no particular trends were observed.
The mean results on all the behavioral outcomes (BASC-2) ranged between 40 and 60, or within ±1 SD of the expected mean T-score of 50 for children with typical hearing from both the parent and teacher competed forms. However, over one-fourth of children obtained scores beyond 1 SD on the internalizing problems and behavioral symptoms scales from parent-reported questionnaires. Nevertheless, the overall results are in contrast to those reported in other studies with a population of MUHL, where behavioral problems such as aggression, uncooperative attitude, and annoyance were noted (Bess & Tharpe, 1986; Dancer, Burl, & Waters, 1995; Giolas & Wark, 1967; Keller & Bundy, 1980; Stein, 1983). Since results compared in the literature are based on older studies and refer to children generally diagnosed at later ages with MUHL, often at school age and beyond, perhaps early intervention and amplification could account for our encouraging results.
Several analyses were conducted to compare groups or relationships between different variables. First, mean comparisons were completed to explore whether there were differences between the children with unilateral and bilateral loss on the different outcomes. These tests revealed no differences between the unilateral and bilateral groups. Second, we examined the agreement between parent- and teacher-completed questionnaires more stringently using intraclass correlation coefficients. The multiple-informant approach we used has been shown to be useful in other studies to capture differences in informant-ratings since children demonstrate different difficulties depending on the context (Wong et al., 2018). Our results varied from poor to moderate agreement depending on the outcome and, therefore, do not show a clear relationship between informants. It is possible for sample means to be similar, as uncovered by the mean comparisons, while scores do not agree well at the individual level between multiple testing. This is particularly true in a small sample size. Perhaps the low-to-moderate agreement could imply that children behave differently at home than at school; an observation noted by Wong et al. (2018). In the case of children with hearing loss, since the classroom setting would typically be noisier than a home setting, a child’s behavior could be expected to differ in various settings and social contexts. Alternatively, different individuals’ perceptions of the child’s functioning could also be a factor in explaining the lack of agreement. Winsler & Wallace (2002), for example, highlighted that parents perceived their children to have more behavioral problems than teachers. Additional qualitative research, such as interviews or focus groups, could help to uncover more insight about the level of agreement between parents and teachers on the different tests. Third, we attempted to assess the relationship between the laterality of hearing loss with SSIS and BASC-2 outcomes measures with an ordinary least squares regression with covariate adjustments but results showed no evidence of statistical difference between scores for children with unilateral and bilateral hearing loss. Results of these three sets of analyses could be attributed to a smaller sample size.
This study has a few limitations. With participant enrollment being a challenge throughout the course of the study, a smaller group of children with MUHL participated. This may be because milder hearing loss is not as obvious or does not cause as much concern for parents and providers of these children. Consequently, these families may be less motivated to participate in this type of study. As a result, the smaller sample size limited the type of analyses and the strength of the conclusions. We attempted to increase participation by extending our inclusion criteria to children with a loss of up to 50 dB. With this, we obtained four cases of children with a moderate hearing loss. Our analyses showed that the inclusion of these cases did not affect our results. Furthermore, families who participated were generally from a high socio-economic status whereby 87% had a household income over the median reported by Statistics Canada in 2014 for their region. These families may thus not have been representative of the broader population of parents. In addition, we encountered a challenge in collecting completed questionnaires from the teachers. In some cases, parents did not consent to the involvement of their child’s teacher in the study; while in other cases, the teachers were not able to complete the questionnaires. Consequently, we obtained almost 30% fewer questionnaires from the teachers compared with the parents. Due to these limitations, results should be interpreted with caution and findings may not generalize to larger groups. Lastly, we did not have a control group of peers with typical hearing due to funding constraints and could only compare performance to standardized test normative means. Tomblin et al. (2015) argue that the comparison of outcomes with typical hearing peers from the same population would be more meaningful. Using standardized test scores can suggest that children with hearing loss are at the level of age-matched hearing peers when they are delayed compared with their peers drawn from the same population (Blair, Peterson, & Viehweg, 1985). This finding is consistent with our previous research with preschool age children with MUHL, which showed that their language scores were within test normative means but lower than a control group of children with typical hearing from the same population (Nassrallah et al., 2018).
This research study focused on the effects of mild-to-moderate bilateral and UHL on auditory, social, and behavioral outcomes. Of particular interest, functional auditory skills were lower than those expected for children with typical hearing when considering responses from both parents and teachers. Additionally, while as a group, performance on social skills scales was within the expected range for children with typical hearing; a select group (8 out of 28) of children demonstrated scores lower than their age-matched peers on social skills. Overall, findings from our study show encouraging results for this group of children with unilateral or mild bilateral hearing loss who seem to be benefiting from earlier identification and amplification. Building on the contributions of this study and on those of a previous work by Nassrallah and et. al (2018), future research on a similar population of earlier identified school-aged children would be beneficial to better understand the consequences of hearing loss on this contemporary population of children with a milder loss. A similar longitudinal study with a larger sample size and a control group would allow for more analyses between groups of children with mild bilateral hearing loss, UHL, and typical hearing.
Funding
Ontario Ministry of Research and Innovation (Early Researcher Award) to Elizabeth Fitzpatrick.
Acknowledgments
We are grateful to the families who participated in this research and to the providers who informed parents about the study and provided us with audiological information. We would also like to thank the research assistants who did the assessments and the scoring.