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Co-occurring Hearing and Visual Problems Impact Educational Outcomes

Hill, Matilda BA, BM, BCh (Oxon)

doi: 10.1097/01.HJ.0000602916.76319.40
Pediatric Audiology
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Dr. Hill is a pediatric trainee in Bristol, United Kingdom, with an interest in child disability and development. She is an honorary research fellow at The Centre for Child and Adolescent Health at the University of Bristol.

Hearing and visual difficulties are extremely common among children. The majority of affected children have mild, temporary problems that may not be formally diagnosed. An increasing stream of evidence suggests that even mild deficits in hearing or vision may have implications for learning and development.1-3 However, it is not known how often hearing and visual problems co-occur in childhood and how this co-occurence affect children's educational outcomes.

We recently investigated the prevalence and impact of co-occurring, common, mild hearing and visual difficulties on the academic attainment of children attending mainstream schools. The study sample was drawn from the Avon Longitudinal Study of Parents and Children (ALSPAC), a large population-based birth cohort in England.4,5 We identified children with hearing and visual difficulties at age 7, and used data on their achievement in standardized national exams at age 10 to assess educational outcomes. Potential confounding factors were adjusted for.

We found that co-occurring hearing and visual difficulties in childhood have an enduring negative impact on educational outcomes—greater than the effect of hearing or visual difficulties alone. This study provides a clear rationale for the early identification of affected children and early intervention.

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HEARING PROBLEMS

The most common cause of hearing problems in childhood is persistent otitis media with effusion (OME, glue ear). There is no clear consensus regarding the impact of childhood OME on academic attainment. However, there appears to be an association between persistent OME-related hearing loss, reading ability, and cognition.2,3,6

In a cohort of 2,909 children, we identified 261 (9%) children with mild to moderate conductive hearing loss and/or OME. We demonstrated a weak association between mild hearing difficulties at age 7 and poorer academic achievement in standardized national exams at age 10 and age 16, which may have been partly mediated by IQ.

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VISUAL PROBLEMS

Decreased visual acuity in childhood has been associated with reduced literacy,1 but the impact of more common visual difficulties on academic attainment is not well characterized. Amblyopia and strabismus are two of the most common visual problems encountered in childhood;7 both often occur in the context of other conditions, which may in themselves impact development and educational achievement, such as prematurity and low birth weight.8,9 Rigorous adjustment for confounding factors is therefore required to establish the impact of the visual problems in and of themselves.

We identified 189 (6.5%) children with mild visual problems, which were defined as clinically significant strabismus, amblyopia, or mild-to-moderate reduced acuity. We found no negative association between mild visual problems and academic achievement at ages 10 or 16 after adjusting for possible confounding factors.

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CO-OCCURRING ISSUES

To our knowledge, the impact of common, mild hearing and visual difficulties on children's educational outcomes has not previously been studied. However, it is well established that the integration of auditory and visual information underpins many cognitive processes, including speech perception, and is essential to the development of language and communication skills.10,11 A hearing or visual problem may therefore adversely affect a child's development of literary and render him or her vulnerable to the cumulative effect of an additional sensory difficulty.

We identified 14 (0.5%) children with both hearing and visual problems and demonstrated a strong negative association between co-occurring hearing and visual problems and academic attainment at age 10, which persisted after adjustment for confounding factors and was greater than the impact of hearing problems alone. We also found a weak association between co-occurring hearing and visual problems and academic performance at age 16, which was partly explained by poorer educational performance at age 10.

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RESEARCH AND CLINICAL IMPLICATIONS

Children with known visual or hearing difficulties should be routinely screened for additional sensory impairments to facilitate early identification and appropriate intervention. This study is the first to investigate the impact of co-occurring common and mild hearing and visual difficulties upon academic attainment. The study's limitations are largely related to missing data, and include underrepresentation of children from ethnic minorities and lower socio-economic backgrounds. Replication of these results using larger and more representative datasets is therefore required. Future research should also seek to elucidate the factors mediating the apparent negative association between co-occurring common hearing and visual difficulties and educational outcomes.

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REFERENCES

1. Bruce A, Fairley L, Chambers B, Wright J, Sheldon T Impact of visual acuity on developing literacy at age 4–5 years: a cohort-nested cross-sectional study. BMJ Open. 2016;6(2):e010434. doi:10.1136/bmjopen-2015-010434
2. Bennett K Behaviour and developmental effects of otitis media with effusion into the teens. Arch Dis Child. 2001;85(2):91-95. doi:10.1136/adc.85.2.91
3. Hall A, Maw R, Midgley E, Golding J, Steer C Glue Ear, Hearing Loss and IQ: An Association Moderated by the Child's Home Environment. PLoS ONE. 2014;9(2):e87021. doi:10.1371/journal.pone.0087021
4. Boyd A, Golding J, Macleod J et al. Cohort Profile: The ‘Children of the 90s’—the index offspring of the Avon Longitudinal Study of Parents and Children. Int J Epidemiol. 2012;42(1):111-127. doi:10.1093/ije/dys064
5. Fraser A, Macdonald-Wallis C, Tilling K, et al Cohort Profile: The Avon Longitudinal Study of Parents and Children: ALSPAC mothers cohort. Int J Epidemiol. 2012;42(1):97-110. doi:10.1093/ije/dys066
6. Niclasen J, Obel C, Guldager C, Pleinert S, Dammeyer J Associations between childhood hearing loss and behavioural and academic difficulties: A Danish cohort study. Int J Pediatr Otorhinolaryngol. 2016;90:91-98. doi:10.1016/j.ijporl.2016.09.002
7. Williams C, Northstone K, Howard M, Harvey I, Harrad R, Sparrow J Prevalence and risk factors for common vision problems in children: data from the ALSPAC study. British Journal of Ophthalmology. 2008;92(7):959-964. doi:10.1136/bjo.2007.134700
8. Robaei D The Impact of Modest Prematurity on Visual Function at Age 6 Years. Archives of Ophthalmology. 2006;124(6):871. doi:10.1001/archopht.124.6.871
9. Pathai S, Cumberland P, Rahi J Prevalence of and Early-Life Influences on Childhood Strabismus. Arch Pediatr Adolesc Med. 2010;164(3):250. doi:10.1001/archpediatrics.2009.297
10. Erdener D, Burnham D The relationship between auditory–visual speech perception and language-specific speech perception at the onset of reading instruction in English-speaking children. J Exp Child Psychol. 2013;116(2):120-138. doi:10.1016/j.jecp.2013.03.003
11. McGurk H, MacDonald J Hearing lips and seeing voices. Nature. 1976;264(5588):746-748. doi:10.1038/264746a0
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