Foreword

I am delighted that in 2006 the Centers for Disease Control and Prevention (CDC) was able to report 91.7% of infants born in the United States were screened for hearing loss, exceeding the 90% screening target of Healthy People 2010 for the national Early Hearing Detection and Intervention (EHDI) objectives. I look forward to the day when we can report that all infants are screened for hearing loss before 1 month of age and that every infant and child with hearing loss is identified and receiving appropriate early intervention services at the earliest possible time.

Whereas the defined targeted hearing loss for universal newborn screening programs was to identify children with hearing loss averaging 30 to 40 dB or more in the frequency region important for speech recognition, undetected hearing loss of any degree can have a significant impact on speech, language, cognitive, and psychosocial development. It is not just the moderate to profound hearing loss we need to be concerned with; it is these “minimal” losses as well. It is no longer reasonable to think that children with mild and unilateral hearing losses are not at risk for speech and language delays, academic failure, and poor self-esteem. These children do score lower on tests of speech, language, school achievement, and behavior than do their peers with normal hearing. Unfortunately, the tendency has been to overlook the needs of these children and their families. It is only in the past few years that wider efforts have been made to identify this group as early as possible and to provide intervention.

Such efforts have been informed by our new understanding of what is a “significant hearing loss” for an infant and older child. We have always known that the loss of hearing in one ear produces a reduction in hearing of about 10 dB. Now that we understand how important it is for an infant to hear speech and language perfectly in the first months of life, that lost 10 dB in a congenital unilateral hearing loss becomes critical to an infant. Studies of grade-school children with unilateral hearing loss have confirmed significant adverse effects of such a loss on the development of the academic, social, and behavioral skills of these children. We can extrapolate such effects to bilateral losses of similar degree, whether sensorineural or conductive in origin.

For far too long, the impact of mild and unilateral hearing loss on the development of children has been largely unrecognized or ignored by audiologists, educators, and physicians. Many children are now being identified with unilateral hearing loss from birth, and we are able to identify mild hearing loss in the mid- and high-frequency ranges that previously has not been detected prior to school age. Recognition of these effects associated with minimal degrees of hearing loss in children has resulted in a recent increase of attention toward the needs to support the success of these children.

As EHDI programs become the standard of care across the nation, there has been an increase in the early identification of mild and unilateral hearing loss, and many audiologists are facing the need to manage these types of hearing losses in infants and toddlers for the first time. As audiologists, we cannot easily predict the developmental outcome of a given child on the basis of their audiogram alone. Every child is different, and the potential effects of a hearing loss depend on many factors. But many children have been recognized as having behavioral/attention problems or have already been receiving speech therapy services before anyone recognized their underlying hearing problem. Now that these children are being identified earlier, we must question what services should be expected from the early intervention program. In many locations, children with a unilateral hearing loss or a mild bilateral hearing loss are not automatically eligible for early intervention services provided by the state. Parents, physicians, the educational community, and policymakers have questions about how these hearing losses can be expected to impact child development and how this relates to needed early intervention services, educational management, and school readiness. There is a definite need to have a habilitation plan for this group and a need to monitor them for any progressive loss. However, once they have been identified, the best course of management for these children is still undetermined.

As these children grow, they face difficulties in school and later academic performance. Typical classrooms, which are often noisy and reverberant, are not the optimal listening environment for any child and in particular for a child with hearing loss. Children with minimal hearing loss often expend a higher level of effort to pay attention and may become more fatigued than do peers with normal hearing because of the extra effort children with minimal hearing loss make to hear. They may miss subtle conversational cues causing them to respond inappropriately and resulting in their being mislabeled as immature or low performers.

To further our understanding of mild and unilateral hearing loss in infants and young children, we need more research on prevention, on better diagnostic methods, and on treatments for these forms of hearing loss. Major uncertainty still surrounds the aspects of best practice and management for children with mild or unilateral hearing impairment, and there are no definitive answers as yet. We continue to need more information on the impact of a mild or a unilateral hearing impairment on the quality of life for the child and his or her family and on the current service provision and management options for these children. Questions remain as to how to identify the child for whom we should have unusually high expectations but whose functioning has been brought down to “normal” and is not identified as having problems related to a mild hearing loss.

The success of early identification has increased the demand for professionals with demonstrated competencies in early identification of and interventions for infants and children. Such expertise and skill is urgently needed and at present is not available in every community or region. Programs in audiology will be forced to meet this challenge and tailor educational training to meet this need.

In summary, mild and unilateral hearing losses place children at risk for speech, language, and academic problems. We are at the beginning of a new era for defining hearing loss. All children with hearing loss have the potential to participate in regular classrooms and obtain reading and language scores equal to their hearing peers. We must seize the current opportunity placed before us with the success of EHDI to search, find, and intervene early for all children with hearing loss, regardless of degree. To quote my good friend and colleague Fred Bess, “Minimal is not inconsequential.”