Hearing Loss | Chapter 2: Definitions, Identification, and Professionals

Definitions, Identification, and Professionals

Author:��Dolly Bhargava, M. Spec. Ed.

Hearing plays an important role in student development and daily performance.�� Hearing impairment occurs when there's a problem with or damage to one or more parts of the hearing mechanism.�� It is identified as one of the ten most prevalent causes of disability in the United States.�� The U.S. Department of Health and Human Services (1991) reported that five percent of children 18 years and under have a hearing loss.�� A student with a hearing impairment is part of a heterogeneous group whose one common characteristic is some degree of hearing loss.�� To effectively teach students with hearing impairment, teachers need to become familiar with hearing related concepts.�� The purpose of this chapter is to briefly outline the nature of hearing impairment and provide you with useful current definitions.�� The chapter will provide you with information on how we hear, how hearing is assessed, ways of identifying students with hearing impairments in the classroom and discuss their learning characteristics.�� Some information on the several types of professionals who can be of assistance in diagnosing and educating students with a hearing impairment will also be provided.

The Individuals with Disabilities Education Act (IDEA), defines “hearing impairment” and “deafness” separately.�� Hearing impairment is defined as an “impairment in hearing, whether permanent or fluctuating that adversely affects a child’s educational performance.”�� Deafness is defined as a “hearing impairment that is so severe that the child is impaired in processing linguistic information through hearing, with or without amplification.”

Components of the Ear

The organ of hearing is the ear and it is composed of three major parts: the outer, middle and inner ear.�� It is important to understand the basic anatomy of each part and how it works before reading about the different types of hearing impairments. The anatomy and contribution of each part of the ear has been described below:

Outer Ear

Includes the external visible part of the ear (pinna) and the ear canal.

Sound waves are received by the pinna from the environment.
Sound waves travel through the ear canal.
Sound waves make their way to the beginning of the middle ear called the eardrum (thin membrane that separates the outer ear from the middle ear).�� (Dugan, 2003; Scheetz, 2000)

Middle Ear

Includes the eardrum, ossicles or three tiny bones(hammer/malleus; anvil/incus; stirrup/stapes) and Eustachian tube.

Sound waves reach the eardrum.
The eardrum begins to vibrate and makes the three tiny bones / ossicles to move together.
These bones help sound move into the inner ear.

The middle ear is filled with air and for optimal hearing the air pressure inside the middle ear and outside of the ear needs to be the same.�� The Eustachian tube connects the middle ear to the back of the nose.�� The Eustachian tube helps keep the air pressure in the middle ear equal to the air pressure in the environment.�� (Dugan, 2003; Fraser, 1996)

Inner Ear

Includes a snail-shaped, fluid filled structure called the cochlea, tiny hair cells (cilia) and the auditory nerve, which travels from the inner ear to the brain.

The vibration of the sound waves causes the cilia to move.
This movement creates electrical impulses or signals that are sent to the brain via the auditory nerve.
The hearing centers in the brain interpret these signals as sound and help give them meaning. (Lysons, 2003)

Some Definitions

A hearing impairment results when there is a problem in one or more components of the hearing mechanism.�� When describing hearing impairment, three attributes are considered:

Type of hearing loss -�� part of the hearing mechanism that is affected

Degree of hearing loss - range and volume of sounds that are not heard

Configuration - range of pitches or frequencies at which the loss has occurred

Type of Hearing Loss

Hearing impairment can be classified into four categories depending on the site of the problem in the ear - conductive, sensorineural, mixed, and central auditory processing disorder.

A. Conductive Hearing Loss

A conductive hearing impairment results from a blockage or damage to the outer or middle ear structures.�� This problem interferes with the transmission of sound through the outer and middle ear to the inner ear, resulting in reduced loudness of the sound (quantity of sound). A conductive hearing loss can fluctuate according to the presence or severity of the blockage. During these periods of reduced hearing the student may miss out on learning, negatively affecting all aspects of development (Pagliano, 2005). Some of the common causes of conductive hearing impairment include excessive earwax (cerumen); middle ear infections (such as Otitis Media, where there is pus or fluid build-up or inflammation which causes pain and reduces the ability of the eardrum to vibrate); a hole or perforation of the eardrum; and otosclerosis (the eardrum and the ossicles have decreased mobility) (Scheetz, 2000). In many cases, a conductive hearing impairment can be corrected with medication, hearing aids or surgery.

B. Sensorineural Hearing Loss

A sensorineural hearing loss results from damage to the inner ear or the auditory nerve.�� A sensorineural hearing loss can range from mild to profound and often affects the student’s ability to hear certain frequencies more than others.�� Thus, even with amplification to increase the sound level, a student with sensorineural hearing loss may perceive distorted speech sounds, resulting in difficulty with understanding speech and interpreting various sounds (quantity and quality of sound). Some of its causes include genetic disorders (which can interfere with proper development of inner ear structures); injuries; complications during pregnancy or birth; infections or illnesses (such as mumps, measles, chickenpox) and medication side effects (Lysons, 1996). This type of hearing impairment is usually permanent and irreversible.�� Sensorineural hearing impairments are frequently not medically or surgically treatable.�� However, most people with a sensorineural loss find wearing hearing aids and using sound amplification technology to be of significant benefit (Dugan, 2003).

C. Mixed Hearing Loss

A mixed hearing loss refers to a combination of conductive and sensorineural hearing loss, indicating that there may be damage in the outer or middle ear and the cochlea or auditory nerve.�� Treatment depends on the severity of the conductive (i.e. hearing aid, medical or surgical intervention) and sensorineural (i.e. hearing aid) portions of the hearing impairment (Dugan, 2003).

D. Central Auditory Processing Disorder

This form of hearing impairment occurs when the auditory centers of the brain are affected by injury, disease, tumor, heredity, birth trauma, head trauma or unknown causes. Although the outer, middle and inner parts of the ear deliver sound signals, these signals are unable to be processed and interpreted by the brain.�� Thus, even though the person’s hearing may be normal, there are difficulties with understanding what is being said, resulting in learning problems.�� Central auditory processing involves a variety of skills such as localizing the sound, attending to it, perceiving it accurately through auditory discrimination and auditory recognition to make sense of the sound (ASHA Task Force on Central Auditory Processing Consensus Development, 1996).�� Difficulties in one or more of the above-listed behaviors may constitute a central auditory processing disorder. The use of assistive technology and environmental modifications to the listening environment can provide acoustic enhancement by amplifying the incoming speech signal, thereby improving the auditory signal to noise ratio, that is, the ratio between the signal and any unwanted background noise (Pagliano, 2005).�� According to the ASHA Task Force on Central Auditory Consensus Development (1996) audiologists are best qualified to understand breakdowns in central auditory processing and to guide management of the condition.

Understanding these four categories of hearing impairment will be helpful to you as a teacher, as they suggest the teaching and learning frameworks that must be set in place so that each student can properly access the curriculum.

Degree of Hearing Loss

It is important to understand each specific type of hearing impairment in terms of the continuum of degree of hearing impairment.�� The degree or severity of impairment ranges across mild, moderate, severe and profound.�� Sometimes a hearing impairment may be borderline between two categories, such as “moderately severe” (Northern & Downs, 2002).�� Having an understanding of the student’s degree of hearing loss is useful for determining the types of supports that will be required.

It is important to note that the parameters of these categories are not universally accepted and different authorities may assign different degrees of loss to each category.�� However, for our purposes, degree of hearing loss will be classified using the descriptions given below.�� First, it is important to understand that sound is measured by its loudness or intensity (measured in units called decibels, dB).�� The greater the number of decibels the louder the sound.�� For example, a 70 dB sound is much louder than a 30 dB sound.�� A person without a hearing impairment can hear sounds ranging from 0 to 140 dB.�� A whisper is around 30 dB.�� Conversations are usually 45 to 50 dB and with background noise, about 60-65dB.�� Sounds that are louder than 90 dB can be uncomfortable to hear. A loud rock concert might be as loud as 115 dB (Marschark, Lang, & Albertini, 2002).�� Sounds that are 120 dB or louder can be painful and can result in temporary or permanent hearing loss.��

The following information has been collected from a range of sources: Dugan (2003), Lysons (1996) and Pagliano (2005):

A. Normal Hearing

Threshold - Children with hearing thresholds (softest sound that the child can hear) for both ears that fall between 0 to 25dB are said to have hearing within normal limits.
Can hear – The child can hear all speech sounds.

B. Mild Hearing Loss

Threshold - Children with hearing thresholds between 26 to 40 dB have a mild hearing loss.��
Can hear - The child with a mild hearing loss can hear sounds of 26 to 40 dB or louder.�� He/She will be able to hear the vowel sounds��a, e, i, o, u as well as most consonants clearly.
Hearing difficulties - Consonants, especially voiceless consonants such as p, h, f, s and th are not heard clearly.�� Speech that is especially faint, distant, rapid or with background noise present will be difficult to understand.
Speech – A child with mild hearing loss learns speech through hearing.�� The child may have some speech production difficulties.�� The child will benefit from speech reading, favorable acoustics, hearing aids, and/or a personal FM system, and speech therapy (professional support for understanding and producing speech and language correctly).�� Speech and language may develop normally in a child with a mild hearing loss.��

C. Moderate Hearing Loss

Threshold - Children with hearing thresholds between 41 to 70 dB have a moderate hearing loss.��
Can hear - The child with a moderate hearing loss can hear sounds of 41 to 70 dB or louder.��
Hearing difficulties – The child will miss most of the speech sounds at conversational level, without a hearing aid or other technology to amplify sound.�� Due to inaccurately hearing sounds and missing sounds completely, children with a moderate hearing loss may have a language delay (i.e. limited vocabulary, difficulty with grammatical rules, word meanings, multiple meaning of words, and word placement in a sentence).�� The child will have difficulty understanding speech in group situations.
Speech – Speech articulation of the student with moderate hearing loss may exhibit omitted and distorted consonants (Northern & Downs, 2002).�� The student will require sound amplification by hearing aids, assistive devices such as personal FM systems and favorable classroom acoustics.�� In conjunction with this, the student will require auditory training, speech reading, and speech therapy.��

D. Severe Hearing Loss

Threshold - Children with hearing thresholds between 71 to 90 dB have a severe hearing loss.��
Can hear - The child with a severe hearing loss can hear sounds of 71 to 90 dB or louder, such as a vacuum cleaner or lawn mower at close range.��
Hearing difficulties – No sounds can be heard at normal conversation level, without a hearing aid or sound amplification technology.�� The student may benefit from a cochlear implant. If a severe loss is not detected at birth, or shortly thereafter, language and speech will not develop spontaneously and learning difficulties may arise.��
Speech – Students will use speech reading, hearing aids and/or sign language to communicate.�� If a severe hearing loss is identified early, and the child is fitted with hearing aids, auditory training and speech therapy are provided, the child has a more positive outlook for speech and language development and overall learning.�� He/She may also use technology such as text phones, and loop systems.

E. Profound Hearing Loss

Threshold - Children with hearing thresholds from 91 dB or more have a profound hearing loss.��
Can hear - The child with a severe hearing loss can hear sounds of 90 dB or louder such as a chain saw at close range or the vibrating component of loud sound.
Hearing difficulties – No speech sounds can be heard without amplification by a hearing aid or other amplification technology.�� The student may benefit from a cochlear implant.
Speech – The student will use speech reading, hearing aids, and/or sign language to communicate.�� He/She may also use technology such as text phones, FM systems and loop systems.�� It is essential that the student has a favorable acoustical environment. The student may also benefit from the use of a sign language interpreter and/or a notetaker in the classroom.

Types of Hearing Loss

“Configuration” refers to the overall shape or pattern of the hearing loss, depending on the extent of hearing loss across the range of sounds.�� To determine the configuration, an audiologist (a professional who works with people who have hearing, balance, and related ear problems) performs a test that involves using a machine called an “audiometer” to measure hearing.�� The audiometer makes sounds (pure tones) which go into headphones over the child’s ears.��

Information about the child’s hearing abilities is plotted on an “audiogram,” a graph displaying intensity in relation to frequency.�� The softest sounds the child can hear (hearing thresholds) are plotted on the audiogram.�� The vertical axis of the graph shows the volume (intensity) of the sound (in decibels).�� The dB are listed from top to bottom starting from –10 dB to 120 dB.�� The greater the number of decibels the louder the sound.�� The horizontal axis shows the pitch (frequency) of the sounds tested (measured in cycles per second or Hertz). The lower the frequency numbers the lower the pitch.�� The frequency starts on the left side with 250 Hz and ranges up to 8000 Hz.�� Usually frequencies of 250-8000 Hz are used in testing because this range represents most of the speech spectrum, although the human ear can detect frequencies from 20-20,000 Hz (Marschark et al., 2002).

For example of audiograms, refer to��.

There are three types of configurations: rising, sloping, and flat.�� The shape of the configuration provides insight into the type of speech-understanding errors that a student may be experiencing and the nature of the hearing impairment.�� A rising configuration means that a person can hear high pitch tones better than low pitch tones. A sloping configuration means that a person can hear low pitch tones better than high pitch tones.�� Finally, a flat configuration means that a student is experiencing the same amount of hearing loss for low and high sounds (Schwartz, 1987).�� For examples of the different configurations refer to the Internet site

Other descriptors associated with hearing loss as described in ASHA (n.d):

Bilateral vs. Unilateral – A bilateral hearing loss means hearing is affected in both ears, whereas a unilateral hearing loss means hearing in only one ear is affected.
Fluctuating vs. Stable Hearing Loss -��Some hearing losses change - sometimes getting better, sometimes getting worse. Such a change commonly occurs in young children who have hearing loss as a result of Otitis Media, or fluid in the middle ear. Other hearing losses will remain the same year after year and are regarded as stable.
Progressive vs. sudden hearing loss - Progressive hearing loss is a hearing loss that becomes increasingly worse over time. A sudden hearing loss is one that has an acute or rapid onset and therefore occurs quickly, perhaps as a result of head trauma, or perhaps a tumor in the auditory nerve.
Symmetrical vs. asymmetrical - Symmetrical hearing loss means that the degree and configuration of hearing loss are the same in each ear. An asymmetrical hearing loss is one in which the degree and/or configuration of the loss is different for each ear.

To summarize, there is no “typical” student with a hearing impairment.�� Although all have some degree of hearing loss, it is important to note that hearing loss affects each individual differently. The effect that a hearing impairment has on a student will depend on a number of factors beyond the attributes described above.�� Other important factors include the age of onset, when it was detected, how the student manages the hearing impairment (for example, level of compliance with wearing their hearing aids), the student’s abilities, personality, and the quality and type of auditory intervention programs.�� Hence, it is extremely important to consider each student as an individual and find out the specific type of loss in order to accommodate needs.

Identifying a Student with Hearing Loss

Niemann, Greenstein & David (2004) describe the impact of a hearing impairment where a child can see people talking but cannot understand what is being said.�� This results in the child having difficulties understanding the world and in expressing personal needs, resulting in limited interactions and social isolation.�� Thus, it is important to identify the hearing impairment as early as possible; otherwise the child will also miss out on important educational experiences (Pagliano, 2005).�� Sometimes hearing impairment can go unidentified partly because it is not immediately visible.�� A hearing impairment could be so mild that it may have gone unnoticed for many years (Smith, Polloway, Patton & Dowdy, 1998).�� On the other hand, a hearing impairment may develop over time.�� The student is often the last one to recognise or report a loss in hearing unless it has deteriorated significantly.�� If the hearing impairment remains undetected, it can result in the student facing a substantial educational disadvantage.�� The adverse effect of the hearing impairment can create challenges of a personal, academic and social nature for the student and interfere with reaching full potential.�� Teachers need to be aware of the indicators that signal the possibility that a student has an undiagnosed hearing loss.�� On a medical note, if the hearing problem is undetected and untreated, it can cause permanent loss of hearing and the long-term consequences for the quality of life can be serious.

Consider the case of Sue, a 10 year old girl who had undiagnosed conductive hearing impairment with a mild hearing loss in her left ear.�� She thought most of her friends mumbled a lot.�� Sue stated that she had to strain to listen to them and found it difficult following a conversation, especially in group situations.�� She would often have to ask her friends to repeat themselves.�� Often Sue wouldn’t realize that someone was calling her, especially if they were in another room or if it was a very noisy classroom.�� She would often ask for the volume of the TV or stereo to be turned up or would sit closer to them to hear properly.�� Without adult awareness, her impairment continued unrecognized.

Table 1 is a simple��Yes/No checklist of the signs and symptoms that are indicative of whether a student in your class has a hearing impairment.�� If any of these behaviours are present, teachers should consider suggesting to the student’s caregivers that they refer the student to a health professional for a formal hearing assessment (Fraser, 1996; Kuster, 1993).�� Smith et. al. (1998) state “A teacher’s careful observations and referral can spare a student months or years of struggle and frustration” (p. 217).

Table 1: Identification of Students with Hearing Impairments

Possible Sign of a Hearing Impairment	Yes	No
Turning head to position ear in the direction of the speaker	��	��
Favoring one ear over another	��	��
Using a loud voice when speaking	��	��
Mispronouncing words (such as misarticulation of certain speech sounds or omitting certain consonant sounds)	��	��
Asking for information to be repeated frequently	��	��
Not responding when addressed	��	��
Difficulty with following directions or instructions	��	��
Seeming distracted and/or confused	��	��
Appearing to be inattentive, restless, tired or daydreaming	��	��
Distracted easily by visual or auditory stimuli	��	��
Lack of, or delayed development of speech and language	��	��
Intently watching faces during conversation	��	��
Giving incorrect answers to questions	��	��
Not startled by loud noises	��	��
Preferring to be by themselves (i.e., playing alone rather than with a group, or withdrawing from social situations)	��	��
Problems hearing environmental sounds (i.e., doorbell, telephone ringing, people calling and/or talking to the student from behind)	��	��
Sitting close to the sound source (i.e.,TV, radio, and/or turning up the volume	��	��

(Sources: Adapted from Pagliano (2005), Smith et al. (1998), and Waldron (1996)

Learning Characteristics

Hearing is one of the most important senses.�� It plays a vital part in the learning process.�� It is held that more than 80% of education is received through hearing (Pagliano, 1994).�� American Speech-Language-Hearing Association (ASHA) stipulates that hearing impairment�� can affect children in the following ways:

It causes delay in the development of receptive and expressive spoken language skills. It also usually causes delay in general language acquisition and receptive and expressive communication. (However, in the minority of deaf children born to signing Deaf families, language and communication skills usually develop at a normal rate.)
The language deficit can cause learning problems that result in reduced academic achievement.

* Communication difficulties may often lead to social isolation and poor self-concept.

* It may have an impact on vocational choices.

Hearing impairment can impose basic limitations on an individual in terms of

access to spoken language
access to environmental auditory experiences
ease of interacting with a wide range of people, due to the above restrictions.

Difficulty in accessing spoken language may appear to be an obvious result of hearing impairment. On the contrary, there are many variables which affect just how much access a hearing impaired person has to spoken language.�� As noted earlier, there are different levels of hearing loss; yet, even within these levels many layers exist.�� For example, two different people may have the same type of hearing loss, the same level of hearing loss and all practical, physiological processes could be almost identical, but they may not have the same access to spoken language.�� Person A may have acquired the hearing loss post-lingually, which has provided the opportunity to hear and the hearing nerves to be used.�� Person B may have had to learn to listen without ever experiencing sound, and would have had to learn that sound itself has meaning before beginning to interpret what those sounds mean.

Clear access to speech is contingent upon many variables, including:

background noise being at a minimum
well-functioning and optimal hearing technology
clear speech being expressed by the speaker

Hearing technology continues to improve but still has limitations.�� One of the limitations is that background noise is not usually completely eliminated when a person with hearing impairment is listening to some source of sound.�� This means that the important information (i.e., speech) has to be separated from the background noise during cognitive processing.��

Clear speech is not exaggerated speech, and the student with hearing impairment uses all the visual and auditory information available to aid understanding of the message.�� If any of these are exaggerated or distorted, the student has to cognitively explore the possibilities of what was said before trying to repair their misunderstanding of the message.�� Accents, speech impediments, prostheses (braces), moustaches and beards can all contribute to the challenge of understanding with ease.

Environmental auditory experiences enable hearing students to retrieve information about what is happening in their environment.�� Hearing students are able to learn incidentally about the world around them and about important functions of language.�� In contrast, students with a hearing impairment are rarely able to hear enough (without attending to a specific interaction) to learn incidentally from:

Discussions and interactions between parents, teachers, other adults or peers
Disagreements or resolutions between these same people
Television or radio
Conversations on the telephone.��

(Calderon & Greenberg, 2003, p. 179)

Most environmental sounds are very informative. Hearing sounds around the house can indicate where a person is and what that person might be doing. �� For example, hearing water boiling or the microwave timer lets you know that someone is cooking in the kitchen. Environmental sounds can help you predict what might happen next. For example, hearing the phone ring tells you that someone will get up and move to another area, or start you wondering if that the phone call might be for you. When they hear such things, subconsciously, hearing people make predictions and assumptions without effort.�� For persons with hearing impairment, some of these environmental sounds may be heard and some may not, which in turn means that the appropriate assumptions and predictions may not be made.�� A student with hearing impairment may not understand why the teacher and all the students are looking out the window, when they heard a car crash on the road outside, or why the teacher stops talking and looks at some other students in the room who have been whispering.��

Warnings of danger, such as smoke alarms, fire alarms and car horns are usually given by sound signals, and the student with a hearing impairment may not be aware of the location of the sounds or what they mean. Some of these auditory signals can be supplemented by a range of visual ones, such as flashing strobe lights.�� These accommodations should be considered by schools with students who are hearing impaired.

All these factors are challenges to students with hearing impairments. While most will be aware of the challenges, they may not always be aware of the strategies they can employ to help them glean information to stay abreast of the happenings in their environment.�� These strategies can be utilized and encouraged by teachers.��

The student with hearing impairment obviously has to consider events and make predictions more consciously than the average hearing student.�� This can be extraordinarily tiring (Calderon & Greenberg, 2003) and can have the effect of causing the ability to do these very things to deteriorate.�� On a given day some students may be easily able to understand what the teacher is saying even though there is construction work happening outside, but on another day, may not be able to understand at all.��

There are a number of factors that can contribute to ease of understanding, and these are covered in the��Accommodations section of this web site.

The student’s ability to access spoken language, environmental auditory experiences, and ease of interaction with others will depend on the type and degree of hearing impairment, self-awareness and acceptance, and on the educational, personal and practical support available.��

How do students who are hearing impaired develop an understanding of concepts, communication, and social skills as well as the ability to independently participate in everyday activities? �� The following areas are underscored by a variety of authors (Marschark, n.d.); Smith, Polloway, Patton & Dowdy (2004); and ASHA (n.d) as some of those that are affected by a hearing impairment:

Early relationships, experience and early learning opportunities of the hearing impaired student will have made a lasting impact upon that student’s ongoing social, language, cognitive, and emotional development.

Communication and language are greatly affected by hearing impairment.�� Early delay in receptive and expressive communication skills may have an ongoing impact upon the student’s ability to understand, process and use the information being acquired throughout one’s educational life. Individual students with hearing impairment may have varying abilities in their communication abilities.�� The student may have difficulties with reading or with subjects incorporating jargon specific to that subject, but not used much in everyday language. There may also be difficulties with hypothesizing or with seeing things from another person’s perspective.

Social skills refer to those skills necessary for effective communication with other people.�� They include both verbal and non-verbal behaviors. Some of the skills include eye contact, proximity, word choice, intonation, ability to read non-verbal cues, facial expressions, take the perspective of another, shift attention, and maintain topic of conversation (Disability News, 2001).�� Social skills are crucial to our lives for personal, academic and vocational success. A student with a hearing impairment has difficulty with accessing auditory information and expressing ideas in a way that others can understand.�� The Learning Disabilities Association of Ontario (1999) states that a student with hearing impairment may appear disoriented, distracted, or at times confused because of difficulties with accessing accurate auditory information.�� The student may try to cope with difficult situations by copying peers or pretending to understand what is going on in the class while actually misunderstanding the situation.�� The student with hearing impairment may appear to hear normally, when in fact the student can not hear speech sounds clearly enough and is misinterpreting the information. The student may have difficulties pronouncing speech sounds correctly,�� poor vocal quality, or trouble explaining ideas clearly.�� All of the above- stated factors can negatively impact social skill development as well as the ability to freely communicate, resulting in the student becoming shy, socially isolated, or displaying behaviors of concern (Learning Disabilities Association of Ontario, 1999).

It is important to be aware of potential areas of difficulty and to note when any confusion or misunderstandings begin to occur.�� Rectifying confusion or misunderstandings early is imperative in order to ensure the foundational information is understood before placing more scaffolding information on top.�� One suggestion is offering to give more information or background material to the student, parents, or the visiting support teacher, to preview or review the information being covered.�� It can be helpful to have students act out or present information visually to enable clearer and deeper understanding of complex information.

Marschark (2002) suggests that these students “may have different knowledge, cognitive strategies and experiences” from hearing students and that we need to support the student with hearing impairment by utilizing skills and acknowledging areas of difficulty (p. 10).��

As discussed above, the student may lag behind in achievement in comparison to hearing peers due to the impact of hearing impairment on learning.�� Therefore, the student may require skills in these areas to be specifically and explicitly taught, along with additional time and opportunities to practice these skills.

Professionals Who Diagnose and Treat Hearing Loss

This section presents information on the assessment process and the various team members that can assist the student.�� A comprehensive evaluation of the student’s functional hearing needs to take place so that the student receives appropriate intervention and services (Lewis & Allman, 2000).�� To fully evaluate the hearing condition, abilities and needs of the student, a two-fold approach is required, involving diagnosis and assessment.

Initially, the diagnosis of a hearing impairment is based upon a comprehensive evaluation by a multidisciplinary evaluation team, which includes a physician, an audiologist, and an otolaryngologist or otologist.�� Table 2 below describes the roles of the various professionals involved in the hearing assessment process and information they can provide to educators to help the student.��

Table 2

Health Professional	Role
Doctor/General Practitioner	Examines the ears by carrying out a basic hearing screening. Refers patients to the appropriate health care professionals such as audiologists, otolaryngologists or otologists.
Audiologist	Trained specialist in the evaluation and non- medical treatment of hearing impairment: Performs an extensive hearing test, Completes a diagnostic assessment, Prescribes and fits hearing aids Offers counseling and auditory rehabilitation, Gives advice about hearing conservation and assistive devices.
Otolaryngologist	Physician specializing in the medical and surgical management and treatment of patients with diseases and disorders of the ear, nose, throat (ENT), and related structures of the head and neck.�� In the domain of the ear, is trained in both the medical and surgical treatment of hearing, ear infections, balance disorders, ear noise (tinnitus), and congenital (birth) disorders of the outer and inner ear.�� Pediatric otolaryngologist receives advanced training in the medical and surgical care of children. (Dugan, 2003)
Otologist	A physician specializing in the medical and surgical diagnosis and treatment of disorders associated with the ear. Pediatric otologists treat children from the newborn period through the teenage years. They have advanced training in the medical and surgical care of children.

Hearing Assessments

Audiological Exam

Once the referral to the appropriate professional has been made, an audiological examination is performed.�� An audiological examination is conducted by an audiologist to determine:

if a hearing loss is present;��
which tones are affected;
the degree of the hearing loss;
the type of hearing loss (i.e. conductive, sensorineural, or mixed);
the best method of treating the hearing loss; including selection of an appropriate hearing aid, if appropriate.

The audiologist then performs several tests in order to obtain an accurate measure of the child’s hearing abilities to determine the existence and extent of the hearing impairment.��

When these tests have been completed, the audiologist may conduct more specialized procedures, such as the evaluation of the mechanical functioning of the eardrum and bones of the middle ear (“intermittence teats”), and other measures to assess the function of the cochlea. Alternatively, if deemed necessary, the audiologist will make referrals to other professionals.

After reviewing the child’s information and test results, the audiologist will be able to describe a hearing loss as unilateral (affecting one ear) or bilateral (affecting both ears), the degree of hearing impairment (mild, moderate, severe or profound), and the type of loss (conductive, sensorineural or mixed). The audiologist will make recommendations regarding amplification and provide suggestions on how to best manage the hearing impairment.�� It is important to remember that every student is an individual and as Scheetz (2000) emphasizes, “One must be careful not to pigeonhole or label someone based on this information” (p. 52).�� To help the student we need to then individualize the supports that we provide by consulting with other professionals.

Below is information about some of the tests that are performed to assess hearing.�� They include:

Otoscopy.�� Otoscopy is a physical examination of the ear that involves looking into the ear with an instrument called an “otoscope” (or “auriscope”) to examine the structures of the outer ear and the eardrum.�� Otoscopy can help detect problems such as a hole (perforation) in the eardrum and infections of the middle ear (such as acute Otitis Media, an infection that produces pus, fluid, and inflammation within the middle ear). The nose, nasopharynx (space within the skull that is above the roof of the mouth, and behind the nose), and upper respiratory tract are also examined.
Tympanometry. Tympanometry measures the ability of the middle ear to conduct sound.�� It is particularly useful in detecting fluid in the middle ear; Eustachian tube dysfunction (such as negative middle ear pressure); disruption of the ossicles (bones); tympanic membrane (ear drum) perforation; and otosclerosis (abnormal growth of bone in the middle ear).�� To perform this test, a soft probe is placed into the ear canal and a small amount of pressure is applied.�� The instrument then measures mobility of the tympanic membrane and its response to the pressure changes.�� The results of the test are printed as a graph, called a “tympanogram” which can help identify middle ear problems.�� For example,��a flat line on the tympanogram may indicate that the eardrum is not mobile or not vibrating properly due to fluid in the middle ear (Hain, 2002).

The audiologist begins the examination of the child by first taking a case history.�� The audiologist asks questions about the child’s medical conditions, hearing behaviors, hearing loss in the family, and any concerns of the child and the family.

Audiometry

Audiometry is the testing of a person’s ability to hear sounds at a range of frequencies. This includes air conduction tests, bone conduction tests, and speech audiometry tests.�� An audiometric test is used to determine the types of sounds the child can and cannot hear.��

Air conduction tests involve the presentation of beeps and whistle-like sounds, called “pure tones,” through headphones in a soundproof room.�� Sounds are of varying loudness (intensity measured in dB) and of different pitch (or frequencies measured in Hz)�� The pure tones go via the air, down the ear canal, through the middle ear into the inner ear.�� The child is asked to respond when he or she detects a sound (such as by raising a hand or pushing a button).�� The loudness of each tone is reduced until the child can just hear the tone.�� The softest sounds the child can hear constitute the hearing threshold.�� This is marked on a graph called an “audiogram,” which can be used to identify and diagnose hearing impairment (Martin & Clark, 2003).

A bone conduction test involves using a skull vibrator such as a vibrating tuning fork.�� It is placed behind the ear to measure the softest sounds that the child can hear to test the functioning of the inner ear.�� The child is asked to respond when detecting a sound produced by the device.�� As the sound travels through the bones of the skull to the inner ear (cochlea, auditory nerves), the sound sidesteps the outer and middle ear.��

Interpretation of Air Conduction and Bone Conduction Results

If air conduction and bone conduction thresholds are within normal limits, then hearing is normal.
If the air conduction thresholds indicate a loss and the bone conduction thresholds do not indicate a loss, then a conductive hearing loss is present.�� In other words a person does not hear normally when sound has to go through the outer, middle and inner ear, but if the sound bypasses the conductive mechanism (i.e. the outer and middle ear), and goes directly to the inner ear, then hearing is normal.
If there is a loss by both air- and bone - conduction and the abnormal thresholds are essentially similar, then a sensorineural hearing loss exists.�� In other words, there is a hearing loss by air conduction, such as when the sound goes through the outer, middle and inner parts of the ear.�� There is the same amount of hearing loss when the sound bypasses the outer and middle ear and goes directly to the inner ear. If there is a loss by both air conduction and bone conduction, but the loss by air conduction is worse than the loss by bone conduction, a mixed hearing loss exists.�� Both conductive and sensorineural components are present.

Speech Audiometry

This involves presenting the child with a series of simple recorded syllables, words and sentences spoken at various volumes into the headphones.�� The test is designed to assess speech threshold (i.e., when the child can first hear speech) and the child’s ability to understand speech (Scheetz, 2000). The test requires the child to repeat each word back to the audiologist as it is heard.�� This provides information on the volume (quantity) of the speech sound that the child can hear and also the quality of the sound (clear vs. distorted) the child hears.�� The level at which the child can repeat 50% of test materials correctly provides information about the type and degree of hearing impairment (Lysons, 1996).�� This is useful to determine the candidacy for hearing aid and reaffirm the findings of the pure-tone audiometry test.

Designing the Individual Educational Plan

Once a hearing impairment has been identified, the next step involves creating a plan of action, or the Individual Education Plan (IEP), that meets the abilities and needs of the student.�� It is important to do this by using a team approach.�� Table 3 below describes the various team members. The team can be comprised of a variety of educational specialists, such as a certified teacher and assessment professionals.�� The team also includes a variety of other health professionals such as Occupational Therapists, Audiologists, and Speech and Language pathologists. The composition of the team will depend on the needs and abilities of your student.�� Hence your team may not necessarily include all the people listed below.

Educational staff	Role
Visiting teacher or Hearing Support Teacher	Assesses and evaluates the needs of each child�� Explains the impact of hearing impairment to staff and students without a hearing impairment in terms of current and future implications Assists teaching staff understanding of audiological equipment (such as sound amplification technology) Offers support to the student (such as note-taking, assisting with concerns related to academic work, social matters, audiological issues, speech, listening, language and literacy goals) Provides advice on adaptations to the school environment needed for the student Assists with educational programming for the student Provides advice to teaching staff regarding instructional and classroom management strategies�� Liaises and consults with parents and outside agencies

Educational staff

Role

Visiting teacher or Hearing Support Teacher

Assesses and evaluates the needs of each child��
Explains the impact of hearing impairment to staff and students without a hearing impairment in terms of current and future implications
Assists teaching staff understanding of audiological equipment (such as sound amplification technology)
Offers support to the student (such as note-taking, assisting with concerns related to academic work, social matters, audiological issues, speech, listening, language and literacy goals)
Provides advice on adaptations to the school environment needed for the student
Assists with educational programming for the student
Provides advice to teaching staff regarding instructional and classroom management strategies��
Liaises and consults with parents and outside agencies

Health Professional	Role
Occupational Therapist	Develops daily living skills (educational skills such as writing, and self-help skills such as washing, dressing, eating) Advises on special equipment, aids and adaptations to the environment to maximise independence
Physiotherapist (Physical Therapist)	Assesses student’s gross-motor skills (ability to sit, stand or walk) Recommends exercises to develop motor skills, increase flexibility, balance and coordination Provides mobility aids
Psychologist	Provides psycho-educational assessments Identifies student’s learning style and educational needs Addresses learning, behavior and emotional concerns Provides counseling as needed
Social Worker	Provides family support and counseling Supports the family in accessing community services Assists the student in accessing programs in the community
Speech/ Language Pathologist	Assesses communication skills Provides communication intervention (Receptive skills intervention may include awareness of sound, localization of sound, discrimination of sound differences, recognition of sound and comprehension of speech.�� Expressive skills intervention may include developing breath control, vocalization, voice patterns and sound production. Social skills intervention could involve support with making friends, requesting clarifications, problem solving skills and developing a positive self concept.)

In conclusion, teachers can work with a variety of professionals to plan an appropriate educational program that will help the student with hearing impairment participate successfully in the classroom. This chapter has provided an overview of hearing impairment by detailing information on how we hear, how hearing is assessed, ways of identifying students with hearing impairments in the classroom, and learning characteristics of students with hearing impairments.�� Additional information has been provided on the types of professionals who can be of assistance in diagnosing and educating students with a hearing impairment.

References

continue to Chapter 3

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