Parent-reported ease of listening in pre-school aged children with bilateral and unilateral hearing loss

Abstract

Objectives:

Evidence from school-aged children suggests that the ease with which children listen varies with the presence of hearing loss and the acoustic environment despite the use of devices like hearing aids. However, little is known about the ease of listening in pre-school aged children with hearing loss—an age at which rapid learning occurs and increased listening difficulty or effort may diminish the required capacity to learn new skills. To this end, the objectives of the present study were to: (i) assess parent-reported aided ease of listening as a function of hearing loss configuration (hearing loss in one versus both ears) and device configuration among children with hearing loss in one ear (unilateral hearing loss), and (ii) investigate factors that influence children’s ease of listening.

Design:

Parents of 83 children with normal hearing, 54 aided children with bilateral hearing loss (hearing loss in both ears) and 139 children with unilateral hearing loss participated in the study. Of the 139 children with unilateral loss, 72 were unaided, 54 were aided with a device on the ear with hearing loss (direct aiding) and 13 were aided with a device that routed signals to the contralateral normal-hearing ear (indirect aiding). Mean age of children was 40.2 months (1 SD=2.5; range: 36 to 51). Parents completed the two subscales of the Parents’ Evaluation of Aural/Oral Performance of Children+ (PEACH+) questionnaire, namely functional listening and ease of listening. Individual percent scores were computed for the quiet and noisy situations. Linear mixed effects models were used to assess the effect of hearing loss configuration and device configuration in children with unilateral hearing loss. Multiple regression was used to assess factors that influenced ease of listening. Factors included hearing thresholds, age at first device fit, consistency in device use, condition (quiet/noise), presence of developmental disabilities, and functional listening abilities.

Results:

Children with direct aiding for their hearing loss, either unilateral or bilateral, had similarly lower functional listening skills and ease of listening than their normal hearing peers. Unaided children with unilateral hearing loss had lower functional listening skills and ease of listening than their normal hearing peers in noise but not in quiet. All aided children with unilateral hearing loss, irrespective of direct or indirect aiding had lower functional listening skills and ease of listening relative to normal hearing children in both quiet and noise. Furthermore, relative to unaided children with unilateral hearing loss, those with indirect aiding had lower functional listening and ease of listening. Regression analyses revealed functional listening as a significant predictor of ease of listening in all children with hearing loss. In addition, worse degrees of hearing loss and presence of noise reduced ease of listening in unaided children with unilateral hearing loss.

Conclusions:

Bilateral hearing loss is associated with poorer-than-typical ease of listening in pre-schoolers even when aided. The impact of unilateral hearing loss on ease of listening is similar to that observed in children with bilateral hearing loss, despite good hearing in one ear and aiding. Given increased difficulties experienced by children with unilateral loss, with or without a device, additional strategies to facilitate communication abilities in noise should be a priority.

Introduction

In children with hearing loss (HL), improving access to speech to support accurate speech understanding and oral communication has been a key focus in aural habilitation. However, since access to speech (i.e. audibility) and performance accuracy in speech understanding can be poor indicators of the difficulty (e.g., cognitive load) experienced during listening, there is increasing interest in measuring the effort exerted during listening. Assessing listening effort is expected to lead to a better understanding of the functional impact of listening tasks, especially when audibility is optimized and speech understanding accuracy remains high despite task difficulty or adverse acoustics that may demand greater cognitive resources. Given that the phenomenon of listening effort is more frequently studied in older children with HL, the purpose of the present study was to explore it among preschool-aged children with unilateral and bilateral hearing loss (UHL and BHL, respectively). Assessing listening effort at younger ages could assist with identifying additional/alternative strategies (e.g., remote microphone use) to improve ease of listening and possibly reduce listening fatigue well before children need to start school and demands on listening and multitasking/learning while listening rapidly increase.

Listening effort is referred to as the allocation of mental resources to overcome obstacles in goal pursuit when carrying out a task that involves listening (Pichora-Fuller et al., 2016). It is multidimensional (Alhanbali et al., 2019), and has been commonly measured in children using behavioural, physiological, and subjective techniques. The varied methods are thought to reflect different underlying cognitive processes that give rise to listening effort, thus providing different perspectives of the same construct termed listening effort (Shields et al., 2023; Hughes et al., 2018; Alhanbali et al., 2019). The behavioural measures have included the use of dual-task paradigms and verbal reaction times. Dual-task paradigms infer listening effort based on the deterioration in children’s performance on a secondary task (e.g., joining dots) while completing speech understanding as the primary task. Since children have difficulty allocating attention as expected in dual-tasks (i.e., they may have difficulty prioritising the primary task as instructed), this method has been challenging to interpret in children (Choi et al., 2008; McFadden & Pittman, 2008). Instead, the use of verbal reaction times during a single task has been preferred (Houben et al., 2013; McGrarrigle et al., 2019). In the case of physiological methods, P300 (Gustafson et al., 2018; Key et al. 2017) and pupillometry have been probed as metrics of listening effort in children (e.g., Steel et al., 2015). Subjective methods include having the child or parent rate their listening difficulty after a specific task or an observation period. Relative to behavioural and physiological methods of measuring listening difficulty, subjective ratings are more convenient, do not require additional equipment or set up. When sampled over a certain observation period, they could be more reflective of everyday performance in the child’s own communication environment. Further, subjective reports are likely the only feasible method to assess effort in children <4–5 years. A potential limitation of subjective report, however, is the possible disparity between child (self)-report and parent (proxy) report.

Multiple formats have been used to assess listening effort subjectively. The Speech, Spatial, and Qualities of Hearing-C Listening Effort pragmatic subscale (Galvin & Hughes, 2013) with a 10-point rating scale has been used with parents to track changes pre- and post-intervention in 3.7- to 12.7-year-old children (Lopez et al., 2021). Some studies in older children (7–12 years old) have employed single questions like “How did you find the listening task?” expecting answers on a 5-point emoji rating scale from very easy to very hard (Oosthuizen et al., 2021a). Alternative questionnaires for young children include the PEACH+. The PEACH refers to Parent-Evaluation of Aural/oral performance of Children questionnaire that was originally developed to assess functional listening in 0–6-year-old children with HL (Ching & Hill, 2007). PEACH+ has two subscales; the first subscale asks parents about the child’s functional listening in quiet and complex acoustic situations. This subscale has been widely used to monitor intervention outcomes clinically (e.g., King, 2010; Bagatto et al., 2011) as well as in research. The second subscale, relatively new, asks the parent/caregiver to rate their child’s ease of listening. For each of the 10 scenarios used to assess functional listening, the parent is also asked “How easy or hard do you think this is for your child?”. The parent is instructed to respond on a 5-point scale from “very hard” to “very easy”. Similar to the functional listening subscale of the PEACH+ questionnaire, the ease of listening scale demonstrated good internal consistency (Quar et al., 2023; Johansen et al., 2023), and high test-retest reliability (Quar et al., 2023). The two subscales have been found to be highly correlated in a group of children with typical development and normal hearing (NH; Johansen et al., 2023). The current study, the first to use the PEACH+ in children with NH as well as HL, allows exploring the additional benefit of using the ease of listening subscale over and above the functional listening subscale. Acknowledging that subjective scales reflect certain aspects of listening effort, we use both listening effort and ease of listening as inverse terms of each other in this paper when referring to previous study results (i.e., more effort aligned with poor ease of listening). For findings related to the current study, we predominantly use the term ease of listening to be consistent with the tool used.

Evidence from older children suggests that the presence of HL, the configuration of HL (UHL vs BHL), the type of intervention/hearing device, and the listening scenario (presence and location of noise) influence the degree of effort involved during a listening task. In one of the first studies that assessed listening effort using a dual-task paradigm, children with mild to moderate or high frequency sensorineural HL were found to exert more effort while listening compared to age-matched peers with NH (Hicks & Tharpe, 2002). They were all tested unaided. A similar finding was found in children with BHL (better ear pure tone average [PTA] ranging between 41 and 70 dB HL) using verbal reaction times captured during word recognition in noise (primary of the dual tasks), when tested unaided as well as aided (McGarrigle et al., 2019). The use of amplification did not reduce the effort of listening in noise (McGarrigle et al., 2019). In children with lower degrees of HL, specifically mild, Lewis et al. (2016) found no evidence of increased listening effort even when tested unaided.

Children with UHL have also been found to experience increased effort in specific acoustic conditions. When the PTA exceeded 70 dB HL in the ear with HL, children were found to experience more effort when the speech source was on the side of the ear with HL and the noise was the side of the ear without HL compared to the reverse configuration (inferred from verbal response times; Oosthuizen et al 2021a). When speech and noise were presented from the front (midline), such increased effort in children with UHL was not evident (Oosthuizen et al 2021a). This finding is similar to Lewis et al., (2016) who included lower degrees of UHL (mean PTA of 55 dB HL, SD=11.7 dB), although, Lewis et al. (2016) also included mild BHL (all children tested unaided). Compared to unaided conditions, the use of a remote microphone in children with UHL resulted in the least listening effort during a speech recognition in noise task, irrespective of the spatial location of speech and noise. Compared to unaided conditions, the use of a CROS aid reduced listening effort only when the speech source was on the side of the poorer ear and the noise source was on the side of the better ear (Oosthuizen et al. 2021b). These studies suggest that the ease of listening is likely to vary among children with HL who may use different amplification strategies or devices, which in turn depends on the etiology (e.g., atresia) and HL degree. For example, a bone conduction device or a Bone Anchored Hearing Aids (BAHA) is often recommended for children with unilateral atresia. By contrast, children with sensorineural HL or those without an external ear deformation may be prescribed a hearing aid or a CI in the ear with HL or a CROS device, depending on the HL degree. Whether or not the ease of listening varies by the device-configuration, which may in turn depend on the HL degree, remains to be understood.

In summary, listening effort or the ease of listening has been characterised mainly in school-aged children with HL but not younger, and often in specific experimental configurations. Further, irrespective of age, the factors that contribute to the ease of listening, are not well understood. To this end, the objectives of the present study were to: (i) investigate the influence of HL configuration (UHL or BHL) on parent-reported aided ease of listening, (ii) investigate the effect of different device configurations on parent-reported ease of listening in children with UHL, and (iii) identify the factors that influence parent-reported ease of listening.

Methods

We gathered parent/carer ratings from 83 children with NH, 54 children with BHL and 139 children with UHL (see Table 1). The study protocol was approved by the Hearing Australia Human Research Ethics Committee. Written consent was provided by parents.

Table 1:

Participant characteristics.

Parameters	Normal hearing (n=83)	Aided BHL (n=54)	UHL Unaided (n=72)	UHL DirectAid (n=54)	UHL IndirectAid (n=13)
Age at Assessment in months, mean/SD/range	40.3/0.3/36–47	40.5/2.7/36–49	40/2.6/36–49	40/2.4/36–51	40.5/2.2/37–45
HL ear: R/L/Both	NA	NA/NA/54	30/42/NA	29/25/NA	5/8/NA
HL type: Sensorineural/conductive/mixed/ANSD		54/0/0/0	40/9/3/20	26/24/3/1	8/0/0/5
Degree of hearing loss at assessment
Normal (≤20 dB HL)	83	0	0	0	0
Mild (21–40 dB HL)	0	16	5	1	0
Moderate (41–60 dB HL)	0	28	11	17	0
Severe (61–90 dB HL)	0	10	17	26	1
Profound (> 90 dB HL)	0	0	39	10	12
4-frequency PTA (dB HL; mean, 1 SD)	<20	49.2 (12.3)	90.7 (31.8)	74.0 (23.1)	110.4 (15.0)
Device fitted: Hearing aid/ BC or BAHA/ CROS/ CI	NA	54/0/NA/0	NA	23/21/0/10	0/11/2/0
Age at first fitting in months, mean/SD/range	NA	3.1/4.7/1.1–29	NA	8.5/8.9/1–40*	10.8/10.7/2–33*
Etiology, n (%)
Absent/abnormal auditory nerve		0	9 (12.5)	0	2 (15.4)
ANSD		0	20 (27.8)	1 (1.9)	5 (38.5)
Atresia/Microtia		1 (1.9)	6 (8.3)	20 (37.0)	0
Cochlear dysplasia		0	1 (1.4)	0	0
CMV		0	1 (1.4)	6 (11.1)	1 (7.7)
Syndromes (incl LVAS)		1 (1.9)	4 (5.6)	4 (7.4)	0
Unknown		52 (96.2)	31 (43.1)	23 (42.6)	5 (38.5)
Additional Disability present (n)	0	0	4 (5.5)	7 (12.9)	0
Primary carer education level, n (%)
7th – 12th grade	2 (2.4)	6 (11.1)	4 (5.6)	10 (18.5)	1 (7.7)
Diploma or Certificate	16 (19.3)	13 (24.1)	27 (37.5)	14 (25.9)	4 (30.8)
University or above	65 (78.3)	35 (64.8)	41 (56.9)	29 (53.7)	8 (61.5)
Unknown	0	0	0	1 (1.9)	0
SES quartile
1	4 (4.8)	3 (5.6)	9 (12.5)	6 (11.1)	2 (15.4)
2	3 (3.6)	4 (7.4)	12 (16.7)	12 (22.2)	0
3	7 (8.4)	15 (27.8)	23 (31.9)	14 (25.9)	3 (23.1)
4	69 (83.1)	32 (59.3)	28 (38.9)	21 (38.9)	8 (61.5)
unknown	0	0	0	1 (1.9)	0
Device use (from PEACH+): mean/SD/range	NA	3.4/1.1/0–4	NA	3.2/0.9/1–4	2.5/1.3/1–4
Device use (from question): mean/SD/range	NA	3.5/1.0/0–4	NA	2.8/1.1/0–4	2.8/1.1/1–4

Degree of HL, based on the 4-frequency average, applies to both ears for the NH group, to the ear with HL for the UHL group and to the better ear for the BHL group. SES quartiles are based on the census-based SEIFA Index of Relative Advantage/Disadvantage scores (Australian Bureau of Statistics 2021) with higher scores reflecting greater advantage. Device use scores from 0 to 4 represent Never, A little, Sometimes, A lot, and Always categories in the PEACH+ scale, and Never, <1 hr/day, 1–4 hrs/day, 4–8 hrs/day, and >8 hrs/day options in the independent device usage question.

^*Combines the age at first device fit across all device types.

ANSD, auditory neuropathy spectrum disorder; BHL, bilateral hearing loss; CMV, cytomegalovirus; HL, hearing loss; LVAS, large vestibular adequate syndrome; SEIFA, Socio-Economic

Indexes for Areas; SES, socio-economic status; UHL, unilateral hearing loss, dB HL, decibel hearing level.

Children with NH were recruited through study flyers in parent groups, day care centers, and word of mouth. Children with HL were approached through the national service provider Hearing Australia soon after their diagnosis. All children with BHL were bilateral hearing aid users. Of the 139 children with UHL, 72 were unaided (i.e. did not use a device during everyday listening at the time of the study). Of the 72, 32 were prescribed/used a device at some point and eventually became non-users. The remaining 67 used a device at the time of the study. Among these 67 children with UHL who used a device, 54 were fitted with a device in the ear with HL. We refer to this aiding configuration as ‘direct aiding’ as this is intended to improve access to sound by compensating for the HL through the ear with HL. The remaining 13 children with UHL had significant enough HL that warranted routing of signals to the better hearing ear. We refer to this aiding configuration as ‘indirect aiding’. Typically, these children had limited useable hearing in the ear with HL. Children’s HL and device details were gathered through chart review of the Hearing Australia database or evaluation by a research audiologist at the time of the study. Demographic details describing HL degree, age of diagnosis and intervention, device used, presence of additional developmental disabilities (e.g., autism, syndromes or attention-deficit/hyperactivity disorder), and etiology, when known, are provided in Table 1. The degree of HL in Table 1, based on the 4-frequency averaged HL level (4FAHL; including 0.5, 1, 2 and 4 kHz), was applied to both ears for children with NH, to the ear with HL for children with UHL, and to the better ear for children with BHL. In all children with UHL, the 4FAHL in the better ear was ≤20 dB HL. The mean 4FAHL (1 SD, range) in the worse ear of aided children with BHL was 53.1 dB HL (13.5, 27.5 to 91.3).

The devices used by children included conventional behind-the-ear hearing aids, bone conduction (BC) aids, bone anchored hearing aid on soft bands (BAHA), contralateral routing of signal (CROS) aids or cochlear implants (CI). Hearing device selection and fitting followed the standardized national protocol for paediatric amplification in Australia (King, 2010), with the exception that NAL-NL2 prescription was used for behind-the-ear hearing aids. Cochlear implants were managed by the children’s respective cochlear implant centers. Table 1 provides the age of first device fit, combined across all device types. In the UHL DirectAid group, the ages (mean/SD/Range) of first device fit in current hearing aid, BC/ BAHA, and CI users were 10.7/10.4/2–40, 6.4/7.4/1–36, and 9.3/6/3/2–20 months, respectively. CI switch on age in current CI users was 20.3/9.2/10–41 months. In the UHL IndirectAid group, the ages (mean/SD/Range) of first device fit in current BC/BAHA and CROS were 9.9/10.1/2–33 and 16/17/4–28 months, respectively. One of the two children with CROS were initially fit with BC/BAHA at 4 months.

 Parents were asked to complete the PEACH+ questionnaire with the two sub-scales: functional listening and ease of listening. Caregivers were instructed to reflect on the past two weeks and rate their child’s listening and communicative behaviour in 10 situations on a five-point scale. The functional listening subscale included the five options, never (0%), seldom (1–25%), sometimes (26–50%), often (51–75%), and always (>75% of the time). The ease of listening sub-scale included five options, ranging from very hard to very easy. The scores were pooled into a score for “quiet” and “noise”, and an overall percent score. We refrained from also using the overall score as it would have been the average of quiet and noise scores, and it could have obscured situation-specific difficulties experienced by each group. Although the focus of the study was the ease of listening subscale, we collated responses from the functional listening subscale as well for analysis. Using both allowed us to infer the degree to which they were associated.

For the children who wore devices, device usage information per day was gathered through two sources. Parents were asked to rate usage per day on a five-point scale including never worn, 1 hour or less, 1–4 hours, 4–8 hours, and more than 8 hours. Responses from this question were corroborated with the device usage question in the PEACH+ that asked the parents to rate device use on a 5-point scale from never to always. When device usage information was available from only one source, that was taken for analysis. Of the total of 121 children fit with devices, device use information was missing in the PEACH+ for 33 children and in the independent usage question for two children. When device usage information was available from both sources (n=87), the scores were aligned in 68.9%. In 14.9% (n=13), the PEACH ratings were higher by at least 1 category relative to the independent question. In 16.1% (n=14), the PEACH ratings were lower by at least 1 category relative to the independent question. Differences were within 1 category for 95.4% (83 of 87 observations). Similar to past work (Marnane & Ching, 2015), when the data from the two sources were not aligned, the higher value was taken as the final usage per day. Table 1 provides the device usage information per group.

Statistical analyses

Questionnaire scores that were in percentages were transformed to rationalised arcsine units to make the variance more similar across the entire range of scores (Studebaker, 1985). For both objectives, linear mixed effects models were used to evaluate the effect of group and condition (quiet/noise) on both functional listening and ease of listening. Child was used as a random effect in all analyses. For the first objective, three groups (NH, aided BHL, UHL with direct aiding [DirectAid]) were included, and the fixed effects included condition and group. Only UHL DirectAid were included in this analysis because aiding the ear with HL was akin to group with aided BHL who used a device for each ear with HL. For the second objective, four groups (NH, UHL – unaided [UHL Unaided], UHL DirectAid, UHL with indirect aiding – [UHL IndirectAid]) were included. Similar to the first analysis, the fixed effects were condition and group. post hoc analyses following significant main or interaction effects entailed pairwise comparisons corrected for multiple testing with the false discovery rate (FDR) approach (Benjamini & Hochberg, 1995). Reported p-values are corrected and hence p<0.05 is to be interpreted as statistically significant. Factors that influenced ease of listening were assessed using multiple regression. For the multiple regression, children with incomplete data were excluded.

Results

Effect of HL configuration on functional listening and ease of listening

Percent scores from the functional listening and ease of listening subscales of the PEACH+ as a function of condition are shown in Figure 1 for children with NH, aided BHL and UHL DirectAid. For both metrics, the linear mixed effects models indicated significant main effects of group (functional listening: F[2,191]=20.41, p<0.001; ease of listening: F[2,182]=22.7, p<0.001) and condition (functional listening: F[1,191]=148.7, p<0.001; ease of listening: F[1,182]=185.9, p<0.001) as well as a 2-way interaction between condition and group (functional listening: F[2,191]=11.4, p<0.001; ease of listening: F[2,182]=9.9, p<0.001). This suggests that the effect of condition varied by group for both functional listening as well as ease of listening. post hoc pairwise analysis compared the difference between scores in quiet and noise within each group and FDR-corrected significantly different pairs are shown in Figure 1A. In general, all children experienced a significant deterioration in scores from quiet to noise for both metrics (all p<0.001), however, the degree of change varied by group. The least change due to noise was evident in children with NH (functional listening: 93.2% in quiet to 89.8% in noise, mean change =−3.4%; ease of listening: 90.4% in quiet to 85.0% in noise, mean change=−5.4%) and the largest change was experienced by aided children with UHL (Functional listening: 83.9% to 71.1%, mean change=−12.9%; ease of listening: 78.6% to 61.3%, mean change=−17.2%). The mean change experienced by children with aided BHL fell within these extremes (functional listening: 88.1% to 78.8%, mean change=−9.2%; ease of listening: 82.3% to 68.1%, mean change= −14.2%).

Fig. 1.

Functional listening and ease of listening scores of children with NH, aided BHL, and UHL DirectAid. Solid horizontal lines mean significant (FDRcorrected) pairwise difference in post hoc analysis. A, Illustrates the pairwise comparisons as a function of condition within each group and metric. B, Illustrates the pairwise comparisons between groups within each metric and condition. BHL indicates bilateral hearing loss; FDR, false discovery rate; NH, normal hearing; UHL, unilateral hearing loss.

To evaluate deviance from typically developing children with NH and to evaluate whether the configuration of HL matters, we also completed pairwise comparisons between groups within each condition (Figure 1B). Outcomes of analyses in both functional listening and ease of listening subscales were similar. For functional listening, children with NH had significantly higher scores than both groups of children with HL in quiet (mean differences in functional listening: NH-UHL DirectAid=9.2%, NH-aided BHL=5.1%; both p<0.012; mean differences in ease of listening: NH-UHL DirectAid=11.8%, NH-aided BHL=8.1%; both p<0.002) as well as noise (mean differences in functional listening: NH-UHL DirectAid=18.6%, NH-aided BHL=10.9%; mean differences in ease of listening: NH-UHL DirectAid=23.7%, NH-aided BHL=16.9%; all p<0.001). Differences from the NH group were larger in noise and for children with UHL. There was no evidence of a significant difference between the two groups with HL although there was a tendency for higher scores in aided children with BHL than those with UHL (mean differences in functional listening: aided BHL-UHL DirectAid=4.1% in quiet and 7.8% in noise; mean differences in ease of listening: 3.7% in quiet and 6.8% in noise). For individual scores as a function of device type within each group (mainly UHL DirectAid), see supplementary Figure 1A.

In summary, both functional listening and ease of listening deteriorated in the presence of noise for all children, with the largest change occurring for children with UHL DirectAid. Compared to NH peers, both groups of children with HL demonstrated poorer functional listening and ease of listening.

Effect of aiding and aiding configuration on functional listening and ease of listening among children with UHL

Percent scores from the functional listening and ease of listening subscales of the PEACH+ as a function of condition are shown in Figure 2A for children with NH and UHL Unaided, UHL DirectAid, and UHL IndirectAid. For both metrics, the linear mixed effects models indicated a main effect of group (functional listening: F[3,222]=17.7, p<0.001; ease of listening: F[3,209.1]=16.6, p<0.001), condition (functional listening: F[1,222]=145.5, p<0.001; ease of listening: F[1,208.3]=188.3, p<0.001) and a 2-way interaction between group and condition (functional listening: F[3,222]=10.9, p<0.001; ease of listening: F[3,208.4]=11.7, p<0.001). In the post hoc pairwise comparisons within each group for functional listening, all children experienced a significant deterioration in scores with the addition of noise, however, the degree of change varied by group. Children with NH experienced the least change (mean change from quiet [93.2%] to noise [89.8%]= 3.4%) while all other children with UHL experienced similar change (UHL Unaided: mean change from quiet [89.3%] to noise [77.2%]=12%; UHL DirectAid: mean change from quiet [83.9%] to noise [71.1%]= 12.9%; UHL IndirectAid: mean change from quiet [78.1%] to noise [62.3%] = 15.8%; all p<0.001). Similar trends were evident in ease of listening, however, relatively larger degrees of change were noted. The smallest change was evident in NH children (mean change from quiet to noise=5.4%) and the largest was evident in children with UHL IndirectAid (26.2%; all p<0.001).

Fig. 2.

Functional listening and ease of listening scores of children in the NH group, and those in UHL Unaided, UHL DirectAid, and UHL IndirectAid groups. A, Displays pairwise comparisons between conditions within each group. B, Displays between-group differences in each condition. NH indicates normal hearing; UHL, unilateral hearing loss.

To evaluate deviance from NH children and to evaluate whether the configuration of aiding matters, post hoc pairwise comparisons were also completed between groups within each condition (Figure 2B). In quiet, functional listening was significantly better in children with NH than the two aided groups of children with UHL (mean difference from NH=9.2% for UHL DirectAid to 15.1% for UHL IndirectAid; all p<0.001). UHL Unaided had higher scores than children in the UHL IndirectAid group by 11.2% (p=0.009). Patterns in ease of listening were somewhat similar. Children with NH had higher scores than both groups of aided children with UHL (mean difference from NH=11.8% for UHL DirectAid to 11.9% for UHL IndirectAid; both p<0.016) but not unaided children with UHL (mean difference of 3.9%; p=0.10). Unaided children with UHL scored higher than children with UHL DirectAid (mean difference of 8%; p=0.016). For individual scores as a function of device type within each group, see supplementary Figure 1B.

In noise, functional listening and ease of listening was significantly better in NH than all groups of children (mean differences from NH in functional listening: 12.5% (UHL Unaided), 18.6% (UHL DirectAid), 27.5% (UHL IndirectAid); mean differences from NH in ease of listening: 16.7% (UHL Unaided), 23.7% (UHL DirectAid), 32.7% (UHL IndirectAid; all p<0.001). UHL Unaided children had higher scores than children in the UHL IndirectAid group (functional listening: 14.9%; ease of listening: 16.0%; both p<0.016).

In summary, children with UHL experienced greater-than-typical deterioration in functional listening and ease of listening in the presence of noise. With or without a device, children with HL tended to perform more poorly in functional listening and ease of listening relative to their NH peers.

Categorical interpretation of scale scores

We assessed the proportion of children in each group who fell within the normative range (mean +/− 1 SD; Fitzpatrick et al., 2019). We calculated z-scores for each child based on the NH group mean and SD. The group means (1 SD; in %) of the NH group were 93.2 (8.6) and 89.8 (10.3) for functional listening in quiet and noise, respectively. The analogous group means and SD for ease of listening were 90.4 (10.8) and 85.0 (13.2), respectively. Figure 3 illustrates the proportion of children per group that were below the normal range (below 1 SD, z score <−1). Overall, the proportion of children who scored 1 SD below the group mean was more frequent in noise and most frequent in children with UHL receiving indirect aiding.

Fig. 3.

Proportion of children per group whose scores were below 1 SD of the mean in the normal hearing group. BHL indicates bilateral hearing loss; UHL, unilateral hearing loss.

Factors that influenced ease of listening

Multiple regression analyses were completed for each group to identify factors that contributed to their ease of listening scores. Factors considered as predictors were 4FAHL, age at first device fit, consistency in device use, condition (quiet/noise), and the presence of developmental disabilities (yes/no). Since not all factors were relevant for all groups (e.g., device use was not relevant for unaided children), the number of factors included varied. Children with NH were excluded as none of the hearing/device-related factors explored applied to this group. Results of the regression analyses are provided in Table 2. In children with aided BHL, condition was the only factor that was significant; scores in noise were lower than in quiet, consistent with the results above. Similarly, in children with UHL DirectAid, condition was the only factor that significantly influenced the ease of listening scores. In children with UHL IndirectAid, condition and device use were significant predictors of ease of listening scores. Ease of listening scores in noise were lower than in quiet, consistent with analyses above. Better consistency in device use was associated with lower ease of listening scores. In unaided children with UHL, 4FAHL and condition influenced ease of listening. Higher 4FAHL and noisy conditions were associated with lower ease of listening scores.

Table 2:

Parameter estimates for each factor in predicting ease of listening in aided children with BHL or UHL

Group	Factor	Estimate (B)	SE	t value	p value
Aided BHL	Better 4FAHL	−0.21	0.18	−1.15	0.25
	Condition (noise)	−18.14	4.10	−4.43	<0.001
	Age of first fit (in months)	0.80	0.70	1.14	0.26
	Parent-reported device use	−4.33	2.49	−1.74	0.08
UHL DirectAid	4FAHL in HL ear	0.06	0.19	0.34	0.73
	Condition (noise)	−21.76	4.89	−4.44	<0.001
	Age of first fit (in months)	−0.41	0.30	−1.36	0.18
	Parent-reported device use	−3.55	2.49	−1.42	0.16
	Developmental disability (Yes)	−1.13	7.84	−0.14	0.88
	Device type (Bone ref hearing aid)	1.67	5.62	0.29	0.77
	Device type (CI ref hearing aid)	14.02	11.96	1.19	0.24
UHL IndirectAid	4FAHL in HL ear	0.78	0.40	1.92	0.72
	Condition (noise)	−26.45	8.34	−3.17	0.006
	Age of first fit (in months)	−0.96	0.60	−1.59	0.13
	Parent-reported device use	−15.97	6.53	−2.45	0.03
UHL Unaided	4FAHL in HL ear	−0.19	0.06	−3.03	0.003
	Condition (noise)	−24.13	3.23	−6.15	<0.001
	Developmental disability (Yes)	−1.02	8.57	−0.12	0.91

Significant predictors are indicated in bold. Condition (quiet) and developmental disability (no) are not listed in the table as they were used as the reference condition in the analysis.

BHL, bilateral hearing loss; CI, cochlear implant; HL, hearing loss; UHL, unilateral hearing loss.

We repeated the above regression models with functional listening scores as an additional independent variable to assess whether the identified predictors continued to explain variance in ease of listening after controlling for changes in functional listening. For all four groups of children, the addition of functional listening scores significantly increased the variability explained in the ease of listening scores (all p<0.001). The adjusted R² increased from 18.4 to 63.4% in aided children with BHL, from 19.6 to 74.5% in children with UHL DirectAid, from 36.6% to 78.9% in children with UHL IndirectAid, and from 24.9% to 70.3% in unaided children with UHL. Addition of functional listening scores also changed the factors that were significantly associated with ease of listening scores (Table 3). In aided children with BHL, first fit age emerged as a significant predictor, with later ages of fit being associated with improved ease of listening. In both groups of aided children with UHL, previously significant predictors became non-significant with the addition of functional listening scores (i.e., functional listening was the only significant predictor of ease of listening). In unaided children with UHL, condition and 4FAHL remained significant predictors even after accounting for functional listening scores. Since the number of children with developmental disabilities were few in each group and the nature of developmental disabilities varied across children, we also repeated both the above analyses without that factor. No differences in outcomes were observed.

TABLE 3.

Parameter estimates for each factor, including functional listening, in predicting ease of listening in aided children with BHL and unaided and aided children with UHL

Group	Factor	Estimate (B)	SE	t value	p value
Aided BHL	Functional listening	0.91	0.08	11.19	<0.0001
	Better 4FAHL	0.16	0.13	1.28	0.20
	Condition (noise)	−3.70	3.03	−1.22	0.22
	Age of first fit (in months)	0.99	0.47	2.11	0.04
	Parent-reported device use	−2.65	1.67	−1.58	0.12
UHL DirectAid	Functional listening	0.88	0.06	14.37	<0.001
	4FAHL in HL ear	−0.07	0.10	−0.69	0.49
	Condition (noise)	−5.68	2.96	−1.92	0.06
	Age of first fit (in months)	−0.02	0.17	−0.13	0.90
	Parent-reported device use	−1.49	1.41	−1.06	0.29
	Developmental disability (Yes)	6.05	4.42	1.37	0.17
	Device type (Bone ref hearing aid)	0.62	3.15	0.20	0.85
	Device type (CI ref hearing aid)	6.29	6.59	0.95	0.34
UHL IndirectAid	Functional listening	1.00	0.17	5.94	<0.001
	4FAHL in HL ear	−0.10	0.28	−0.37	0.71
	Condition (noise)	−10.45	5.51	−1.90	0.08
	Age of first fit (in months)	−0.33	0.36	−0.91	0.38
	Parent-reported device use	−4.23	4.25	−1.00	0.33
UHL Unaided	Functional listening	0.86	0.06	14.18	<0.001
	4FAHL in HL ear	−0.09	0.04	−2.31	0.02
	Condition (noise)	−9.00	2.69	−3.35	0.001
	Developmental disability (Yes)	0.11	5.39	0.02	0.98

Significant predictors are indicated in bold. Condition (quiet) and developmental disability (no) are not listed in the table as they were used as the reference condition in the analysis.

BHL, bilateral hearing loss; CI, cochlear implant; HL, hearing loss; UHL, unilateral hearing loss.

Correspondence between ease of listening and functional listening

Since the above regression analyses indicated that a significant proportion of variance in the ease of listening scores was explained by the functional listening scores, we also explored the extent to which categorical interpretation of the two metrics were congruent or incongruent in individual children. The congruency in outcomes was quantified to explore whether tracking both metrics yield additional information over tracking functional listening alone. To infer this, we used z-scores (explained above) and assessed whether each child would fall within the normal range (within 1 SD) or below 1 SD of the mean, the latter indicating delays in functional listening or worse-than-typical ease of listening. The percentage of children with matched and mismatched outcomes (functional listening worse than ease of listening or functional listening better than ease of listening) in each group are provided in Table 4. Mismatches occurred most frequently in unaided children with UHL and those with BHL (aided); in all groups except children with UHL IndirectAid, children often fell below the normative range for ease of listening despite falling within the normal range for functional listening. In children with UHL IndirectAid, no child fell outside the normal range in ease of listening when functional listening was below the normal range.

TABLE 4.

Comparison of functional listening and ease of listening scores

			Matches			Mismatches
Group	Condition	Total	No. Matched	% Matched	No. Matched	% Mismatched	% EL 1SD below Norm	% FL 1SD below Norm
Aided BHL	Quiet	53	45	84.9	8	15.1	11.3	3.8
	Noise	53	42	79.2	11	20.8	17.0	3.8
UHL DirectAid	Quiet	52	45	86.5	7	13.5	7.69	5.8
	Noise	52	45	86.5	7	13.5	11.5	1.9
UHL IndirectAid	Quiet	13	11	84.6	2	15.4	0.0	15.4
	Noise	13	12	92.3	1	7.7	0.0	7.8
UHL Unaided	Quiet	68	55	80.9	13	19.1	13.2	5.9
	Noise	67	54	80.6	13	19.4	13.4	5.9

Matched implies the same categorical outcome in both metrics. Mismatched refers to a different categorical outcome in the two metrics. The column % EL 1SD below norm indicates the proportion of children who scored below the normative range in ease of listening while scoring within the normative range in functional listening. % FL 1SD below norm indicates the proportion of children who scored below the normative range in functional listening while scoring within the normative range in ease of listening. EL, ease of listening; FL, functional listening; HL, hearing loss; UHL, unilateral hearing loss.

Discussion

The present study aimed to evaluate factors like the configuration of HL when aided (UHL vs BHL), and the effect of aiding configuration among pre-school aged children with UHL primarily on parent-reported ease of listening. In addition to group level differences, the study aimed to assess individual variability in parent-reported ease of listening. Since the questionnaire used to assess ease of listening also included a functional listening scale, we evaluated functional listening in parallel and measured the extent to which it explains individual variability in ease of listening.

Effect of HL configuration: Children with BHL vs. children with UHL with direct aiding

We observed that parent-reported functional listening and ease of listening in both groups of aided children with UHL and BHL were similar and similarly worse than their NH peers, despite aiding (Figure 1). Lower-than-normal functional listening scores in 3-year-old aided children with BHL are akin to previous reports in a larger cohort, although that also included children with CI and later ages of diagnoses (Ching et al. 2013). Poorer functional listening has been reported in an earlier study in 3–4-year-old children with UHL, who were aided and unaided (both merged as there was no difference; Fitzpatrick et al. 2019). However, the difference between NH and children with UHL was statistically significant only in noise. This pattern of results aligns with the present study where group differences were found in quiet and in noise, however, they were larger in noise. It is possible that the larger sample in the current study cohort (51 in the present study vs 38 in Fitzpatrick et al., 2019) could have led to better statistical power in the current study.

To our knowledge, this is the first study to report ease of listening in a large cohort of preschool-aged children with HL. We therefore compare our ease of listening findings with the available literature on listening effort in older children as well as listening fatigue—a potential downstream effect of sustained listening effort (Shields et al., 2023; review by Bess et al., 2020). Lower ease of listening scores (aligned with increased effort) in children with HL is consistent with increased effort evident in older children (5+ years) in behavioural experiments (McGarrigle et al., 2019; Hicks & Tharpe, 2002). Lower ease of listening is also aligned with increased fatigue, measured using generic and listening-specific parent/child-reported scales in 5–16-year-old children with BHL and UHL (Adams et al., 2023; Sindhar et al., 2021; Bess et al., 2020; Carpenter 2022; Hornsby et al., 2014). Similar results have been observed in adults with HL too; similar listening effort and fatigue were found between adults with UHL and BHL, and increased effort and fatigue in adults with HL were found relative to NH peers (e.g., Alhanbali et al., 2017).

Of note is the finding that children with UHL with direct aiding experience similar levels of impact, in both functional listening as well as ease of listening, as the aided children with BHL despite good or normal hearing in one ear (Figure 1B). Further, despite aiding in the ear with HL, their functional listening was not similar to their NH peers. This suggests that aiding the ear with HL—the intervention strategy that improves audibility in the ear with HL—did not compensate for the UHL. Since direct aiding conceptually has better chances at restoring binaural/spatial hearing than indirect aiding that routes signals to the better ear, lower ratings for children with UHL also points to sub-optimal spatial/binaural hearing—a major facilitator for hearing in dynamic and noisy environments (Litovksy et al., 2021). While children with BHL wore hearing aids in both ears, children with UHL wore a range of devices such as a hearing aid, BC and even a CI. Poorer-than normal sensitivity to binaural cues with all these devices has been documented in older children/adults (e.g., Dirks et al., 2019; Arras et al. 2022; Wazen et al. 2005; Canfarotta et al., 2021; Bogaert et al., 2006). That said, children with UHL have worse performance even when there are no spatial cues involved, probably due to the lack or reduced binaural summation (e.g., Corbin et al., 2021; Reeder et al., 2015; Griffin et al., 2019).

An expected observation was that, irrespective of the presence of HL, all children experienced lower functional listening and ease of listening scores in the presence of noise (Figure 1A), and the largest differences between children with NH and HL were evident in noise. This study demonstrates that the impact of noise is observable even in preschool-aged children (~40 months of age). Questions in the PEACH+ cover a range of situations, such as outdoor environments (e.g., How often does your child understand what you say in the car/bus/train?) and without visual cues (e.g., when you call your child and they can’t see your face, do they respond to their name?). Further, in some questions, the specific type of challenging situation is not described/prescriptive (e.g., does your child follow simple instructions to do a simple task in a noisy situation?). This implies that the cause of poorer functional listening and subsequently reduced ease of listening could be due to energetic masking and/or informational masking along with a general increase in difficulty due to the need to rely on auditory cues only (e.g., spatial cues), while supplementary visual input is reduced. The poorer performance and the reduced ease of listening in noisy environments in children with HL broadly agrees with higher signal-to-noise ratios needed by children with HL to achieve similar performance accuracy as their NH peers or lower performance accuracy at fixed signal-to-noise ratios (e.g., Corbin et al., 2021; Leibold et al., 2019; Leibold, 2017; Browning et al., 2019). Since parent-report functional listening questionnaire are better correlated with in-lab speech recognition measures that involve informational masking in children with BHL and UHL (Hillock-Dunn et al., 2015; Corbin et al., 2021), we infer that the lower scores of children with HL in the present study mainly reflect the greater-than-normal informational masking experienced by them (demonstrated at older ages; Leibold et al., 2016; Goldsworthy & Markle, 2019; Griffin et al., 2019).

Aiding and type of aiding in children with UHL influence functional listening and ease of listening

Compared to children with NH, all children with UHL, irrespective of aiding or aiding configuration, have poorer functional listening and ease of listening in situations with adverse acoustics (Figure 2B). Among children with UHL, those with indirect aiding performed worse than unaided children. Together, these suggest that: (i) hearing well with one ear is inadequate for optimal listening performance in noise/adverse acoustics, (ii) a device in the hearing ear does not adequately restore binaural processing essential for hearing in noise (as discussed above), and (iii) providing indirect aiding (where signals are routed to the better ear) may not be beneficial in listening situations or styles of preschool-aged children. The observation that children in the UHL IndirectAid group have the lowest group average ratings, and are significantly worse than unaided children with UHL suggests that the benefit of providing access to sounds in the hemifield of the HL ear is probably overestimated or under-realized in these young children. While we are aware from studies in older children that the benefits to speech recognition may be specific to certain configuration of source and noise locations (e.g., Oosthuizen et al. 2021b; Kenworthy et al., 1990), it is possible that they do not occur frequently enough to influence parent observations over a period. Even in older children, the benefits of CROS were found to be inconclusive (systematic review Apachi et al., 2017). Some studies even highlight the detriments of indirect aiding in noise (Updike, 1994). It is also possible that these children will gain benefits over time with more device use and acclimatization. A detailed study of their listening environments and head turn behaviours may help assess if alternate configurations may be more helpful.

Unaided children with UHL did not vary significantly from NH children in both measures in quiet situations. These results pattern concur with findings on functional listening skills in 3–4-year-old children assessed using the PEACH (aided and unaided included; Fitzpatrick, 2019). However, we also observed that even in quiet situations, aided children with UHL had poorer functional listening or ease of listening than their unaided and NH peers (Figure 2B). The poorer ease of listening in aided children with UHL is akin to a prior study where parents of 2–8-year-old children with aided UHL rated more fatigue than those that were unaided (Bakkum et al., 2022). Group means (their Figure 2) indicate that aided children with UHL exhibited greater fatigue than unaided in all three domains (sleep/test, cognitive, general), however the differences were statistically significant only for the cognitive domain (which includes aspects like attention, concentration, remembering, speed of thinking). Another point to note is that children with UHL in the present study had a change in fitting status. As mentioned in the methods, among unaided children with UHL, 32 of the 72 children were aided at some point but were deemed unaided at the time of the data collection due to returned devices or non-use. Among aided children with UHL, 15 of 67 children were originally in the unaided group, however, they were fitted at the time of data collection. Since device use/non-use often relies on perceived benefit, it is possible that the switch overs may have led to a higher likelihood of children facing difficulties in the aided group. This may have contributed to worse performance of aided (not unaided) children with UHL relative to NH peers.

Factors that influence ease of listening varies by HL configuration and use of devices

The common factor that significantly influenced ease of listening in all children with HL was functional listening. Better functional listening abilities were associated with improved ease of listening. The strong association between the two subscales of PEACH+ has been shown earlier in a wide age range of 1–6-year-old NH children (Johansen et al., 2023). The present study suggests that the positive association extends to children with HL, with HL in one or both ears, and with the use of a device. The evidence for this was the strongest in both groups of aided children with UHL since no other factor predicted ease of listening after functional listening was controlled for.

In aided children with BHL, later ages of first fit were associated with improved ease of listening when differences in functional listening skills were accounted for. One hypothesis is that children fitted later were probably diagnosed later or fitted with devices later due to milder degrees of HL. However, the correlation analysis between the better ear degree of HL and age of first fit was non-significant (r[52]=−0.14, p=0.298). Factors that may have contributed to these results are not readily clear.

We observed that the factors that are significantly associated with ease of listening in unaided children with UHL differed from all other aided children in two ways (Table 4). First, the presence of noise led to lower ease of listening even after the deterioration in functional listening was accounted for, and second, lower degrees of HL was associated with improved ease of listening even after the variability in functional listening was considered. The lack of association between the HL degree and ease of listening in bilaterally aided children agrees with previous studies in children who had BHL (e.g., McGarrigle et al., 2019; Hicks & Tharpe 2002). The stronger influence of HL degree in unaided than aided children with UHL is also aligned with the parent/child-reported fatigue in children with UHL (Bakkum et al., 2022). In Bakkum et al. (2022), stronger correlations were observed between rated fatigue and HL degree in unaided children (r=0.22 to 0.41, p-values>0.051) than their aided peers (r=−0.130 to 0.240; p-values >0.166; their Table II). Together, these findings suggest that poorer hearing sensitivity in one ear and thus increased asymmetry in hearing can make listening harder and increase listening effort of children with UHL above and beyond their negative impact on functional listening. Likewise, the presence of noise negatively impacts ease of listening beyond the extent of impact evident with functional listening alone.

Clinical implications

The present study has highlighted the negative impact of adverse acoustics in preschool-aged children with HL, particularly those with UHL. Use of a device such as a hearing aid, BC or CI did not necessarily help bridge the gap between children with NH and HL. Since children are exposed to speech in the presence of noise about twice as long as in quiet (e.g., Easwar et al., 2016), use of alternate or additional strategies like remote mic or FM systems that truly improve signal-to-noise ratio may help children communicate in everyday environments like preschools. While a remote microphone may be the most desirable option to help hear in situations with adverse acoustics, it is often routinely provided in school-aged children (5 years+) and it may not be feasible in all occasions. Thus, non-device-based solutions like communication strategies and classroom modifications could assist. This could be facilitated by increasing awareness among parents and teachers regarding the ill effects of adverse acoustics, providing support/training for effective use of communication strategies and advising improvements in home/classroom acoustics.

The present study findings do not provide compelling evidence for device benefit in preschool children with UHL. Furthermore, the present study reveals that indirect aiding may be associated with worse parent-reported functioning listening and ease of listening. However, we only probed a narrow range of parent-reported outcomes in the auditory domain. Moreover, the number of children in the UHL group with indirect aiding was quite small (relative to other groups). Although previous studies have demonstrated larger benefit in parent-report outcomes than speech perception tasks (Briggs et al, 2011), considerations for device benefit assessment and candidacy should consider other developmental outcomes (language, vocabulary etc) alongside auditory outcomes. Furthermore, since increased effort may reduce cognitive resources necessary for other tasks and learning, whether or not these hearing-related outcomes influence other developmental outcomes (language, vocabulary, literacy, academic, etc) at the same ages or later (downstream effects) will be of interest to consider short- and long-term efficacy of fitting devices.

Although the age of first device fitting was 3.1 months (1 SD=4.6) among children with BHL, the age of first device fitting ranged between 8.5 and 10.9 months in children with UHL. The later ages of fitting in children with UHL likely speaks to the difficulties in decision-making clinicians and parents continue to face (e.g., Fitzpatrick et al., 2016) considering limited evidence for device benefit among these children. Despite early device fitting in children with BHL, lower functional listening and poorer ease of listening relative to NH peers was evident at preschool age.

Lastly, our findings provide preliminary support for using both subscales of the PEACH+ questionnaire as preschool children with HL more frequently fall 1 SD below the mean for ease of listening despite being within 1 SD of the normative mean for functional listening. Consistent performance below the normative range could assist in counselling parents and/or identifying the need for change in intervention strategies. Further, it may improve the questionnaire’s sensitivity to benefit evident with devices.

Limitations and future work

The present study was a between-subject study design. Therefore, the large between-subject variability in children with HL (Figures 2, 3) may obscure some of the benefits experienced by individual children. Although we attempted to consider factors to explain individual variability, future studies should consider longitudinal observations (pre-post treatment; change over time) to evaluate which child may benefit from what type of device.

Parameters that parents use to gauge ease of listening were not systematically probed in the present study and the same instructions were provided to all parents. They may judge based on response time, need for repetition, increased selective attention needed to be paid by the child. Furthermore, recall from over the past few weeks could be biased by recall bias. Future studies could adapt methods like ecological momentary assessment to sample the perceived listening performance repeatedly, measure acoustics at the time of the ratings and get qualitative feedback that contributed to their ratings.

The present study categorized aided children with UHL as indirect vs indirect aiding. Both of these groups varied in device type. While our analysis did not reveal any effect of device type (Tables 3 & 4), certain groups were dominated by users of certain devices (supplementary Figure 1). While this likely represents a typical clinical situation, larger sampling across different device types could have increased statistical power to assess the effect of device type.

HL degree and some demographic characteristics were not matched between groups and may have played a role in the differences observed (Table 1). For example, when better ear 4FAHL is used as the criterion, children with UHL have superior sensitivity than those with BHL due to their ear with NH, however, when hearing sensitivity in the ear with HL is considered, they have worse degrees of HL than the better ear of BHL. Some of the groups also varied in terms of developmental disabilities reported by caregivers and etiology.

Conclusions

The objective of the study was to evaluate parent-report ease of listening and the factors that influence it in preschool-aged children with HL. Our findings suggest that: (i) adverse acoustics reduces ease of listening more significantly in aided children with HL relative to their NH peers, even if hearing is good or normal in one ear, (ii) aided children with UHL experience reduced ease of listening as much as those with BHL, (iii) relative to NH peers and across different device configurations in children with UHL, children with limited useable hearing in one ear needing indirect aiding (routing of signals to the better ear) experience the most lag in functional listening skills and ease of listening, and (iv) better functional listening is associated with better ease of listening in all children with HL. Together, our findings add to the growing evidence base for the efficacy of early HL detection and intervention in children with UHL and BHL.

Data availability statement

Data will be made available upon request to the corresponding author