Even Mild Hearing Loss Tied to Worse School Outcomes in Kids

Diana Swift

November 27, 2019

In this era of loud music and booming video games, experts worry about noise exposure and hearing impairment, because even mild impairment can affect educational outcomes.

Now a large cross-sectional study finds that slight to mild hearing loss appears to be associated with slightly worse behavior and school performance. The researchers recommend considering slight hearing loss as a possible factor in social problems or difficulties regarding attention or academic performance.

The study found a small linear correlation between increasing audiometric pure-tone average (LPTA) hearing thresholds and higher scores on a measure of behavioral problems, as well as lower scores on standardized academic testing.

Carlijn M. P. le Clercq, MD, of the Department of Otorhinolaryngology and Head and Neck Surgery at Erasmus University Medical Center in Rotterdam, the Netherlands, and colleagues report their findings in an article published online November 27 in JAMA Otolaryngology–Head and Neck Surgery.

Boys with minimal to mild hearing loss appeared to have slightly more attention and social problems than similarly affected girls. In boys, a higher audiometric LPTA in the better-hearing ear was associated with a higher total problem score on a parental questionnaire that assessed child behavior after adjustment for all relevant covariates (per 1-decibel [dB] LPTA, β = .010).

In girls, higher speech reception thresholds (SRTs) correlated with greater attention problem scores (per 1-dB SRT, β = .039).

As to the relationship between hearing acuity and academic outcomes, greater high-frequency pure-tone averages (HPTA) in a child's worse-hearing ear correlated with lower total school performance test scores (β = –.006). Higher SRTs were also tied to lower school test scores (β = –.061). For each 1-dB higher HPTA, total academic test scores were 0.1 point lower, and for each 1-dB higher SRT, total scores were 0.6 point lower.

Although the associations observed in the study may be small, the authors conclude that children with increased hearing thresholds but who are without overt hearing loss may need extra support to improve function.

"Slightly impaired development of auditory perception may underlie problems in behavior and school performance among children with slight to mild hearing loss," they conclude.

The analysis is part of the Generation R Study, a prospective, population-based birth cohort study that follows participants from early fetal life to young adulthood. Participants were born between January 2002 and December 2006.

The mean age of the study participants was 9.8 years, and 50.8% were girls; 4471 children (93.6%) were analyzed for behavioral problems, and 2399 (50.2%) were analyzed for school performance.

Emotional and behavioral status were assessed using the Child Behavior Checklist, and academic proficiency was evaluated with a standard school achievement test. Pure-tone audiometric testing was conducted at seven frequencies: 0.5, 1, 2, 3, 4, 6, and 8 kilohertz. Some children also underwent speech-in-noise testing. Both ears were tested separately to determine which had better hearing acuity.

The extra effort required to listen and hear may help drive functional difficulties. "The association with attention and social problems in these children could be explained by increased difficulties listening to speech under adverse conditions, requiring more energy compared with normal-hearing peers," the authors write.

The association of moderate or severe hearing loss with poor school performance has been previously documented even when impairment is unilateral only, Noel Jabbour, MD, and David Chi, MD, of the Department of Otolaryngology at the University of Pittsburgh School of Medicine and UPMC Children's Hospital in Pennsylvania, write in an invited commentary.

"What is provocative about the findings of le Clercq et al is that degrees of hearing impairment that many physicians and parents may have considered slight or mild may actually be associated with both school performance and behavior," they write. Hearing loss at low levels may be ignored or missed; some audiologic screening tests may fail to identify hearing loss of less than 30 dB.

The commentators caution, however, that the observed effect sizes of slight hearing loss in relation to behavioral and academic problems are quite small and appear only at the highest levels of mild hearing loss.

Moreover, statistical significance should not be confused with clinical significance, they warn. "What is truly the significance of a 2-point difference in the standardized test score for an individual, especially when there are years separating the hearing data and the testing data?" they ask.

Stressing that the findings are associative, not causative, Jabbour and Chi nevertheless acknowledge the importance of asking about academic and behavioral problems in patients suspected of having even slight hearing impairment. "Further audiometric testing would be warranted in children with behavioral and school performance concerns who have passed traditional hearing screenings but for whom slight or mild hearing loss has not been ruled out," they write. If such impairment is found, appropriate interventions are in order.

The study was supported by the New Opportunities for Research Funding Agency Cooperation in Europe initiative. Coauthor Baatenburg de Jong is a shareholder of RiverD International. The commentators have disclosed no relevant financial relationships.

JAMA Otolaryngol Head Neck Surg. Published online November 27, 2019. Abstract, Commentary

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