Meeting the educational needs of children with hearing loss

Paediatric hearing loss is a growing public health issue that is currently a significant barrier to achieving sustainable development goal 4 (SDG 4), that is, quality education for all.1 When children with hearing loss do not receive treatment, they might have difficulty accessing mainstream schooling and therefore obtain worse educational outcomes. The severity of these implications is correlated with level of hearing loss and earlier age of onset.2,3 Children with any degree of hearing impairment have been shown to exhibit poor language development, leading to lower literacy rates, diminished social skills and impaired executive function capacity.3 Different severities of hearing loss must be considered, as a child’s ability to access schooling and participate in integrated education is highly dependent on level of hearing loss.4 A child’s educational ability can be affected at a milder severity of hearing loss than what was considered as disabling. Consequently, the global burden of educationally disabling hearing loss is larger than previously estimated by the World Health Organization (WHO).5 Mild hearing loss, that is, a hearing level threshold between 26–40 decibel (dB) in the better ear, affects almost 50 million children worldwide, yet is frequently overlooked and undertreated.6 A 2016 review concluded that children with mild hearing loss, overall, tend to have compromised speech recognition and poorer language skills.7 Therefore, these children are over 2.5 times more likely to have academic difficulties and they more commonly experience grade retention. One study indicated that 37% (24/66) of children in a cohort with mild hearing loss had failed at least one grade.7,8 With respect to children affected by moderate hearing loss (41–60 dB), educational impairments mirror the deficits of those with mild losses, yet are more common and impactful. A study from France reported nearly half of children with moderate hearing loss had experienced one or more years of grade retention.8 Standardized academic test scores for children at all levels of hearing impairment are significantly lower than those of children with normal hearing, and notably demonstrate a strong correlation with the severity of hearing loss.2 Academic achievement for children with severe (61–80 dB) to profound (> 80 dB) hearing loss is significantly hindered relative to peers, with one third of children functionally illiterate upon graduation from secondary school.9 Furthermore, severe to profound hearing loss has been shown to have a significant effect on a child’s ability to participate in mainstream education. A study in the United States of America showed that only 22% (1536/6980) of children with severe hearing loss and 10% (1517/15 174) of those with profound hearing loss participated in integrated mainstream education for more than half of their school day.4 These data identify a crucial objective for improvement, as those with hearing loss who are unable to access mainstream education face impaired academic and language outcomes.2 Children with unilateral hearing loss (that is, who are hearing impaired in one ear only) should also be included, as they may experience similar educational barriers as children with mild deficits. Unilateral hearing loss causes difficulty in localization of sound and impairs the ability to hear in noisy settings such as a classroom. Additionally, this deficit has been associated with lower oral language scores when compared to normal-hearing counterparts.7 The global prevalence of hearing loss must be discussed to better understand the burden of this condition. Research has traditionally focused on characterizing the prevalence of disabling hearing loss (> 30 dB) – identifying 34 million children worldwide affected at this threshold or greater.5 However, even mild hearing loss has potential for detrimental effects on education.7,8 Therefore, educationally disabling hearing loss should include all thresholds of mild hearing loss, significantly increasing the number of children characterized as at risk. To calculate updated numbers of children affected at each level of disability, global prevalence rates were applied to the most recent 2018 population data.6 These estimates identify 61 million children from birth to 14 years of age, globally, who have some degree of hearing impairment with potential effect on their educational outcomes. This number nearly doubles the previous estimate of children whose hearing loss met thresholds traditionally considered disabling.5,6 Latest available global prevalence estimates of childhood hearing loss range show significant regional variability. Lowand middle-income countries in geographical areas, such as south Asia, are disparately affected: 82.5% (95% confidence interval, CI: 45–151.4) for mild hearing loss; 14.3% (95% CI: 7.4–29.7) for moderate hearing loss; 0.7% (95% CI: 0.3–1.4) for severe hearing loss; and 0.2% (95% CI: 0.1–0.4) for profound hearing loss, while high-income countries contribute only a small fraction of the global burden. In these countries, the prevalence for mild hearing loss is 17% (95% CI: 12.4–25); for moderate hearing loss is 2.7% (95% CI: 2.0–4.0); for severe hearing loss is 0.1% (95% CI: 0.1–0.2); and for profound hearing loss is 0.0% (95% CI: 0.0–0.1).6 Rates of disabling hearing loss have been shown to increase Meeting the educational needs of children with hearing loss Karissa L LeClair & James E Saunders