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ADHD/ADD or Hearing Loss?

When classroom teachers are confronted with children who ''will not listen,'' ''cannot sit still,'' ''does not finish classroom assignments,'' and ''creates problems for other children,'' hearing loss is not the first problem the teacher considers. Maybe it should be.

Research studies show that one out of three children have enough hearing loss to make learning difficult. Children in every school (public and private) are at risk for this silent epidemic.

Five million school-aged children, or 11.3% of all school children in the U.S.A. exhibit some degree of hearing impairment. This startling finding was reported by Fred Bess Ph.D., from the Department of Hearing and Speech Sciences, at Vanderbilt University Medical Center, in a recent issue of The Hearing Journal. Dr. Bess noted that many children have ''unrecognized'' hearing loss. The largest undetected hearing loss in children affects those considered to have ''minimal sensorineural hearing loss'' (MSHL). Dr. Bess found that the prevalence of MSHL in schools is 5.4%, or more than one of every twenty children.

Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder of childhood, estimated to affect three to five percent of school-age children. ADHD core symptoms include; developmentally inappropriate levels of attention, concentration, activity, distractibility, and impulsivity. Children with ADHD usually have functional impairment across multiple settings including home, school, and peer relationships. ADHD has been shown to have long-term adverse effects on academic performance, vocational success and social-emotional development, according to the National Institute of Health and the office of Special Education Programs.

The diagnosis of ADD/ADHD is often based on doctor, parent, and/or teacher observations of the child's behaviors.

Could these two problems (ADHD and MSHL) overlap, or perhaps be easily confused based on observations of children's behaviors?

Recently, an assistive listening device manufacturer compared the behavioral characteristics of children with ADD/ADHD, to children with mild hearing loss. They discovered extraordinary similarities among the two groups.

Both groups have academic difficulty and both give inappropriate responses to questions. Neither group completes assignments, they both exhibit trouble sustaining attention during oral presentations, and for both, following directions is problematic. Impulsiveness and acting out are common to both groups, as is a poor self concept. Both groups of children exhibited low self esteem, fewer social interactions with their peers, and greater stress. Members of both groups were more likely to drop out of school. Both groups tended to repeat grades imposing a significant financial burden on the schools, and of course, their families.

Could this mean that some children diagnosed with ADHD/ADD could actually have mild or minimal hearing loss?

In young children, the most common type of hearing loss is a ''conductive'' hearing loss. Conductive hearing loss is generally correctable through medical and surgical options. Conductive hearing losses include; broken ear drums, middle ear infections, swimmer's ear, and other ear problems that physically ''block'' the path of sound. Middle ear disease (otitis media) is the leading cause of visits to the pediatrician. Research studies have determined that 50% of the children between birth and five years of age will experience a conductive hearing loss.

Karen Anderson, in her 1995 American Academy of Audiology presentation in Dallas, noted that approximately 80% of elementary school students (ages 4 -10 years) suffer from temporary hearing loss at sometime during the school year. Those hearing losses were largely undetected by parents or teachers, and the typical hearing loss was determined to be 25 -30 dB, similar to the hearing loss that occurs when your ears are plugged with fingers.

Research suggests that some middle ear infections can lead to permanent hearing loss if left untreated and if unresolved. Noise-related hearing impairment is another cause of permanent hearing loss in children. In one school system, Anderson found 22% of high school students suffered from noised induced hearing loss.

Oddly enough, increased survival rates of premature ''at-risk'' infants may be contributing to milder forms and higher numbers of permanent hearing impairment in children.

Bess reported that 37% of children with hearing loss failed at least one grade, compared to a district norm of about 3%. The majority of learning problems in these children included; not understanding, trouble with vocabulary, word usage skills and story telling abilities. Children with minimal sensorineural hearing loss are 4.3 times more likely to experience trouble in communication, than children with normal hearing.

When the SIFTER (Screening Instrument for Targeting Educational Risk) was administered to children in the Bess study, the children exhibited a higher percentage of problems on all SIFTER's subjects; academics, attention, communication, participation, and school behavior.

When children with minimal or mild hearing loss present with behaviors which mimic ADHD/ADD behaviors, the child might receive educational intervention, medications and/or accommodations which are perfectly appropriate for ADHD/ADD, but clearly inappropriate for treating hearing loss!

Anderson found that eighty-nine percent of hyperactive children had three or more episodes of ear problems, while seventy-four percent of the hyperactive children had 10 or more episodes. Of the hyperactive children receiving medication for hyperactivity, ninety-four percent had three or more episodes of ear problems and sixty-eight percent of these children had abnormal hearing. Anderson reported that in the learning disabled (LD) population, twenty to twenty-five percent of the students have histories of, or ongoing, ear problems related to hearing loss. As many as thirty eight percent of the LD student population has been found to have abnormal hearing thresholds.

Unfortunately, a comprehensive audiologic evaluation is often not present in the ADHD/ADD test protocols. According to Dr. Bess, typical hearing screenings in the schools are not very good at identifying children with mild or minimal hearing loss. Some school systems have no programs in place to screen for hearing loss.

In the classroom, undetected hearing loss is more common than teachers realize. Mild, minimal and unilateral hearing loss are not ''loudness'' problems per se, but are distortion and clarity problems which negatively impact the speech signal. In these situations, the teachers' voice may be audible (loud enough to be heard), but not intelligible (not clear)! Children with these hearing loss profiles will respond when their name is called, yet will confuse or not discern distinctive sounds needed for reading and language skills. Background noise tends to block or garble the speech signal even more and, unfortunately, classrooms are very noisy!

Bess pointed out that ''Persons with hearing loss are known to expend considerable effort in processing information, especially understanding speech under poor acoustic conditions as found in most school classrooms. Such a situation increases learning effort, and at the same time, depletes the energy available for performing other cognitive tasks.'' In other words, children with hearing loss have to work much harder to understand the sounds around them, and by working harder they have less energy left for other school tasks. As a result, it might be expected that children with hearing loss will often be tired, frustrated and may ''act out'' as a result of their frustrations.

Many children with minimal or mild hearing loss do not qualify for special education services. However, services for children with hearing loss in all schools are mandated by two specific laws: (1) The Education for All Handicapped Children Act of 1975 (Public Law 94-142) which was later amended and changed to the Individuals With Disabilities Education Act (IDEA) and (2) The Rehabilitation Act of 1973, Section 504.

IDEA provides special education funds to develop an IEP (Individualized Educational Plan) for qualified children. Nevertheless, the Rehabilitation ACT, Section 504, is the most relevant legislation for these children. Unfortunately, in many states it is mandated, but amazingly -- not funded.

Since many children with ADD/ADHD and hearing loss, have difficultly concentrating on speech in a background of noise, improving the signal-to-noise-ratio (making the teacher's voice louder than the background noise) can significantly improve the educational setting for these children. The audiologist can recommend specific FM or sound field amplification systems to achieve these goals.

School systems purchase appropriate lighting systems so most children can see in the classroom without difficulty. However, it is unusual for school systems to purchase classroom PA systems (sound field systems) so children can hear. One study found that noise from 25 students and one teacher can reach 60 to 80 dB -- the equivalent of a noisy business office. Within that classroom, there are likely to be at least one or two children who need a better speech signal due to unresolved and unrecognized hearing difficulties, and there will likely be an additional one or two children with distractability issues - in the same class.

Even through Dr. Bess cautions that a larger sample of children with minimal hearing loss should be studied, he recommends that school systems improve and increase efforts to identify children with minimal hearing loss. Such efforts could result in a meaningful improvement in these children's educational performance, their functional health status, and result in a substantial cost savings to the education system. And it just might prevent a child from having the inappropriate diagnoses of ADHD/ADD.

If you would like a free Behavior Comparison Sheet between ADD and HEARING LOSS, please send a SASE (self-addressed business sized envelope) to the Mid-East Tennessee Regional Speech and Hearing Center, PO Box 258 Dayton, Tenn. 37321

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Margie Littell Ulrich, M.Ed., CCC-A is a clinical audiologist working in the Mid-East Tennessee Regional Speech and Hearing Center in Dayton, Tennessee which serves seven rural counties in southeast Tennessee.

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