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The Journal of Deaf Studies and Deaf Education logoLink to The Journal of Deaf Studies and Deaf Education
. 2022 Feb 14;27(2):137–150. doi: 10.1093/deafed/enab042

Parent-Reported Stress and Child Behavior for 4-Year-Old Children with Unilateral or Mild Bilateral Hearing Loss

Elizabeth M Fitzpatrick 1,2,✉, Wu Jiawen 3, Olds Janet 4,5, Whittingham JoAnne 6, Nassrallah Flora 7,8, Gaboury Isabelle 9, Durieux-Smith Andrée 10,11, Coyle Doug 12
PMCID: PMC8929680  PMID: 35156118

Abstract

Children with unilateral or mild bilateral hearing loss are increasingly identified in early childhood. Relatively little is known about how hearing loss affects their developmental trajectory or whether it contributes to parenting stress for these parents. This study aimed to examine child behavior and parenting stress in parents of children with unilateral/mild bilateral hearing loss compared to children with typical hearing. This prospective study involved 54 children with unilateral/mild bilateral hearing loss identified at a median age of 4.5 months (IQR 2.6, 6.5) and 42 children with typical hearing. At age 48 months, child behavior and parenting stress were measured. Auditory and language results were also analyzed in relation to child behavior and parenting stress. Parents of these children did not report significantly more parenting stress or behavior problems than parents of children with typical hearing. However, both parenting stress and child behavior were related to functional hearing in noise.

Introduction

Early detection of permanent unilateral and mild bilateral hearing loss has become common through early hearing detection and intervention programs (EHDI). Early detection for all degrees of hearing loss is advocated by the Joint Committee on Infant Hearing (2019). However, there is some uncertainty around the consequences of milder hearing loss when it is identified in early childhood. It is well recognized that more severe degrees of hearing loss can negatively affect many developmental areas including language, social, behavioral functioning, and academic performance and that early detection can improve language outcomes (Ching et al., 2017; Pimperton & Kennedy, 2012; Stevenson et al., 2015). The advantages of early identification of unilateral and bilateral loss of mild degree loss in children are less well-documented particularly in social and behavioral domains. Given that these children account for about half of all children identified with permanent hearing loss (Barreira-Nielsen et al., 2016; Fitzpatrick et al., 2014), and that the majority are diagnosed in infancy (Fitzpatrick et al., 2017; Holte et al., 2012), it is important to continue to update our understanding of the impact of milder hearing loss.

Studies in children with unilateral or mild bilateral loss, summarized in several reviews have shown that these children are at risk for difficulties, particularly in auditory, language, and academic development (Anne et al., 2017; Appachi et al., 2017; Lewis, 2014; Purcell et al., 2020; Purcell et al., 2016; Tharpe, 2008). However, the majority of studies in these reviews relate to older children or stem from a preuniversal hearing screening era when unilateral/mild hearing loss was late diagnosed. Studies in recent years have continued to highlight developmental concerns in children with both unilateral and mild bilateral hearing loss. Historically, prior to screening, unilateral hearing loss in children went undiagnosed, was late-diagnosed, or when identified, was assumed to be of little consequence. Research in the 1980–1990s drew attention to the disadvantages for these children particularly when listening in noise, and in academic and behavioral functioning (Bess et al., 1986; Bess et al., 1998). In the last decade, investigators have shown in a series of studies (Fischer & Lieu, 2014; Lieu et al., 2010, 2012) that unilateral hearing loss places school-aged children at risk for communication and academic difficulties. Compared to their siblings, these children had lower oral language skills and were 2.5 times more likely to need speech-language services and had more academic and behavioral difficulties in later school years (Lieu et al., 2010). Other researchers have also documented poorer cognitive level outcomes in these children with a systematic review showing a difference of 6.4 points (95% CI −0.2, −3.5) in intelligence scores between children with unilateral hearing loss and those with typical hearing (Purcell et al., 2016).

Historically, children with mild bilateral hearing loss, like children with unilateral loss, were frequently late diagnosed, often not until school-age when difficulties became more apparent (Fitzpatrick et al., 2014; Tharpe, 2008). Studies targeting children with mild bilateral hearing loss have reported somewhat mixed results depending on the linguistic areas examined (Lewis, 2014), however, taken together, the research points to difficulties in some areas of functioning. For example, a recent study on 4th-grade children with mild bilateral hearing loss (15–45 dB HL) reported no significant differences in vocabulary or reading skills but important delays in listening comprehension and morphological awareness compared to age-matched hearing peers (Walker et al., 2020). In a relatively large study of 144 children with late-identified mild bilateral loss, Doković et al. (2014) found they performed lower in the areas of morphosyntax and verbal reasoning at age 7–12 years than their age-matched peers with typical hearing, but they achieved similar scores in vocabulary development. Overall, the research on both unilateral and mild bilateral hearing loss shows that the effects of reduced access to sounds particularly in noise, are apparent in some areas of development in school-aged children.

Recent research on early-identified children with unilateral or mild bilateral loss have shown language development closely aligned with typically developing children in some studies, but with some delays in auditory performance, receptive and expressive language (Fitzpatrick et al., 2019), or phonological memory skills (Nassrallah, Fitzpatrick, et al., 2020). Other reports continue to suggest that a substantial portion of children are at risk for difficulties. In an investigation of 34 infants, evaluated at a median age of 9.4 months, Kishon-Rabin et al. (2015) provided convincing evidence that even in infancy, children with unilateral loss show differences in communication development, with delays in auditory behaviors and preverbal vocalizations four and nine times more common compared to infants with typical hearing. In another study of 26 infants who were identified with unilateral loss by 6 months of age, 27% had persistent language delay (Sedey et al., 2005). Tomblin et al. (2015) reported that children with mild hearing loss (25–45 dB) obtained lower scores on vocabulary and on morphosyntax than a matched group of typical hearing children. An earlier report found that up to one third of young children with unilateral/mild loss had difficulties in language, academic, and social development (Yoshinaga-Itano et al., 2008). Collectively, the literature points to negatives effects for both unilateral and mild bilateral hearing loss for some children even when hearing loss is identified early.

Early childhood hearing loss of any degree may present unique challenges for parents, including communication concerns, amplification decisions, and educational challenges (Fitzpatrick et al., 2007; Fitzpatrick et al., 2016; Young & Tattersall, 2007). In our previous research, parents of both preschool and school-age children with unilateral/mild hearing loss also expressed concerns about the potential impact of hearing loss on their child’s development (Fitzpatrick et al., 2016; Grandpierre et al., 2018). It is well recognized that early childhood hearing loss is accompanied by special developmental concerns and challenges for families particularly related to communication, behavioral, emotional, and social development (Whicker et al., 2019). Studies comparing children with hearing loss to their peers with typical hearing have also shown that they are at increased risk of behavioral problems (Stevenson et al., 2015; Theunissen et al., 2014). These concerns have been related to lower language abilities in children with hearing loss, on the basis that frustration related to communicating and being understood may translate to behavioral issues (Barker et al., 2009; Quittner et al., 2010; Stevenson et al., 2010). Most of these studies have included children with severe to profound hearing loss, or combined bilateral loss across the hearing loss severity spectrum and have not included unilateral loss. Information is therefore considerably more limited for children with unilateral/mild bilateral hearing loss. In a large study of 213 mothers and fathers of children with hearing loss of different degrees, 37.6% of whom had bilateral mild, moderate, or moderate–severe loss, Hintermair (2006) showed that more frequent socioemotional problems in children was associated with parenting stress. One of the most important predictors was related to the child’s communication abilities but there was no relationship with the degree of hearing loss in children. In a study of 30 early-identified children (12 with unilateral/mild bilateral loss) and 91 children with typical hearing, Topol et al. (2011) found that parents of children with hearing loss reported more behavior problems at age 18–24 months. These authors reported that the results were not different according to hearing loss groups (12 unilateral/mild bilateral vs. 18 moderate to profound) except for the withdrawn score (CBCL subscale), which was higher in the unilateral/mild group. In another small study of 32 school-aged children with unilateral/mild bilateral hearing loss, although overall mean results for behavior outcomes on parent and teacher rated scales were within normative means on standardized assessments, a quarter of the children were at risk on the internalizing and behavior symptom scales (Nassrallah, Tang, et al., 2020).

It is well-accepted that parents of children with hearing loss play a pivotal role in their child’s development and assume much of the responsibility for their child’s communication and social progres (Hintermair, 2006; Pipp-Siegel et al., 2002). Their ability to be emotionally present and sensitive to their child in the early developmental period would seem to be of heightened importance for children with hearing loss. Parenting stress is one factor that can interfere with parents’ ability to adjust to caring for a child who may require additional support to develop optimally in communication and related areas (Calderon & Greenberg, 1999; Hintermair, 2006; Pipp-Siegel et al., 2002). There is some evidence that parenting stress affects parent–child relationships with elevated stress levels leading to poorer social–emotional development and more behavior problems (Hintermair, 2006; Quittner et al., 2010). A study by Pipp-Siegel et al. (2002) included 184 mothers, 54% of whom had mild, moderate, or moderate–severe hearing loss and the remaining severe or profound loss. Notably, in that study, mothers of children with less hearing loss showed more parent–child dysfunction on the Parenting Stress Index (PSI). The authors proposed that parents may not fully comprehend the impact of less severe hearing loss on their child’s functioning, which could disrupt typical parent–child interactions even when hearing loss was mild, leading to more parenting stress. Meadow-Orlans (1994) reported no differences in stress levels in 20 parents of early-identified infants with hearing loss (five with mild to moderate–severe hearing loss) compared to children with typical hearing.

Overall, studies on parenting stress have delivered rather mixed results with some research showing more stress in parents of children with hearing loss compared to children with typical hearing (Lederberg & Goldbach, 2002; Quittner et al., 1990, 1991) whereas others have not shown differences (Blank et al., 2020; Meadow-Orlans, 1994; Pipp-Siegel et al., 2002; Sarant & Garrard, 2014; Topol et al., 2011). Studies using hearing loss or disability-specific measures seem to demonstrate higher parenting stress levels in parents of children with hearing loss compared to children with typical hearing (Lederberg & Golbach, 2002; Quittner et al., 2010; Quittner et al., 1990), suggesting that at least some stress for these parents is likely specifically related to hearing and communication. A frequent finding is that the communication abilities of children with hearing loss are associated with both parenting stress and/or behavior (Blank et al., 2020; Quittner et al., 2010; Zaidman-Zait & Most, 2005). Communication issues can impact parenting style and in turn affect parent–child interactions (Quittner et al., 2010). Lower language levels therefore appear to be associated with parenting stress and parent perceptions of behavior difficulties (Pipp-Siegel et al., 2002; Quittner et al., 2010).

Relatively little is known about whether parenting stress issues are a concern in children with unilateral/mild hearing loss. One of the key differences between children with milder degrees of hearing loss is their enhanced auditory function and communication abilities compared to children with more severe hearing loss (Ching et al., 2010, 2017; Tomblin et al., 2015) who have been the focus of most of the previous studies investigating parenting stress and child behavior. Although these children may not experience the negative effects on communication development typically associated with early childhood hearing loss, our qualitative research has indicated that parents are nevertheless concerned about the impact of unilateral/mild hearing loss on language, social development, and their child’s general well-being (Fitzpatrick et al., 2016) and for some, these concerns extend well into the school years (Grandpierre et al., 2018). In these studies, parents also talked about stress related to learning about the diagnosis of permanent hearing loss, and the uncertainty around making decisions regarding amplification for their children. In particular, there are uncertainties in the early years of diagnosis around the need for and the benefits of amplification and parents sometimes need to revisit their early decisions as school-age approaches. Inconsistent and uncertain information for parents during the early years may affect their child’s behavior and their perceptions of their own well-being. Similar uncertainties related to the need for amplification were documented in a study by Walker et al. (2017). Walker et al. also reported that confirmation of hearing loss and hearing aid fitting was later for early-identified children with mild bilateral hearing loss compared to those with moderate-to-severe loss. One third of the parents reported that hearing aid fitting was delayed due to the child not having received an initial recommendation from audiology or indecision on the part of the family about the need for hearing technology. Furthermore, what constitutes appropriate intervention and technology support for these children has been less well-defined (Fitzpatrick et al., 2016; McCreery et al., 2020; Walker et al., 2015) which may lead to more inconsistent services, uncertainty, and decisional conflict for parents. These additional uncertainties related to hearing and technology coupled with everyday stress within the family system around raising a child (Blank et al., 2020) may contribute to an increase in parenting stress even when hearing loss is mild.

To date, little attention has been accorded specifically to the effect of unilateral/mild hearing loss on parenting stress and on child behavior for early-identified children. One challenge in applying previous research in this area to children with unilateral/mild hearing loss is that for the most part, the research has included children across the spectrum of hearing loss (e.g., Hintermair, 2006; Pipp-Siegel et al., 2002) or has focused uniquely on children with severe to profound hearing loss, including children with cochlear implants (e.g., Quittner et al., 2010; Sarant & Garrard, 2014). Of note is that several studies were conducted before the widespread early identification of children with milder losses which may explain why these children have received less attention. Based on the mixed results in the literature, the mechanisms underlying parenting stress for children with hearing loss are not well understood and even less so, for early-identified children with milder hearing loss. Essentially, these children represent a new clinical population with hearing loss where parents are now making decisions about intervention and especially hearing technology not only at an early age, but often throughout the preschool and early school-age years as they observe their children’s development. Historically, given that these children were identified on average at school age, decisions were likely influenced by observations about the child’s overall functioning at school. In the current context, parents are learning and making decisions about hearing loss for their children, who do not appear to have difficulties in everyday functioning, against a background where there remains uncertainty about optimal interventions (Walker et al., 2017).

Little research has examined whether these parental concerns translate to more parenting stress which can potentially also affect behavioral functioning and communication development in young children with milder losses. As noted, these early-identified children constitute a relatively recent clinical subgroup, and we are still learning about how hearing loss may affect their developmental trajectory. Collecting multiple developmental outcomes allows us to better appreciate their abilities in the usual areas of concern such as auditory and communication development and to develop some understanding of their behavioral functioning and the related area of parenting stress during the preschool years.

Our study was undertaken in the context of a larger project examining developmental outcomes in preschool children with early-identified unilateral or mild bilateral hearing loss. The purpose of this component of the research was to examine children’s behavior and emotional functioning and parenting stress at 48 months of age and compare it to peers with typical hearing. We also examined the relationships between parenting stress and child behavior problems and auditory and language functioning in these preschool children.

Methods

Design and Setting

This study is based on data collected as part of the Mild Bilateral and Unilateral Hearing Loss study, a multicenter, longitudinal cohort investigation of developmental outcomes of preschool age children with minimal hearing loss (unilateral or mild bilateral hearing loss). Data for this report were based on two parental self-report measures on child behavior and parenting stress completed at study end (age 48 months). We also compared the results with data from auditory and language assessments published in a previous report (Fitzpatrick et al., 2019).

Children with hearing loss were followed through a province-wide EHDI program in the province of Ontario known as the Infant Hearing Program. The program established in 2002 diagnoses approximately 350–400 children per year and includes unilateral and mild bilateral hearing loss in the target disorder. During the study period, the program had well-established protocols for screening, assessment, and intervention (Ontario Ministry of Children and Youth Services, 2014; Ontario Ministry of Children and Youth Services Ontario Infant Hearing Program, 2017). After screening and diagnosis of hearing loss, this publicly funded program provides ongoing audiological follow-up according to established protocols up to age 6 years. Services are provided at designated centers in the child’s region and the provision and duration of therapy and other family supports are determined by the child’s intervention program.

Participants

Inclusion criteria for children in the study were: (1) permanent unilateral or mild bilateral hearing loss, (2) less than age 3 years at enrollment, (3) English spoken as one language in the home. Children with a known diagnosis of severe developmental delay were excluded from the study, which involved numerous oral language assessments. The definition for unilateral and for mild bilateral hearing loss for this study was applied from the National Workshop on Mild and Unilateral Hearing Loss (2005). Unilateral hearing loss refers to a hearing loss in one ear only with a pure-tone average (0.5, 1, and 2 kHz) ≥ 20 dB HL or >25 dB HL at two or more frequencies above 2 kHz. Mild hearing loss is defined as average pure-tone thresholds (0.5, 1, and 2 kHz) between 20 and 40 dB HL or thresholds >25 dB HL at two or more frequencies above 2 kHz. Children were classified as having mild bilateral loss based on better ear thresholds. Eligible controls were children with typical hearing who had passed the newborn hearing screen and who met the same age and language criteria for children with hearing loss.

Children with hearing loss and their families were invited to enroll in the study through their early intervention providers in three regions in Ontario, Canada (Ottawa, Toronto, and Southern Ontario). Clinicians in the programs were asked to invite all eligible families by sharing written information about the study. The number of families invited to join the study was unknown. Children were enrolled from 2010 to 2014, entered the study between 12 and 36 months of age, and completed all assessments by age 48 months. Children with typical hearing were invited to join the study through parent–baby play groups at Early Years Centers located in four regions in Ontario and through provincial Infant Hearing Program Community Screening Clinics.

Research ethics approval was received from CHEO, a pediatric hospital in Ottawa (file #09-64X), which was the main study site, and the University of Ottawa (file #H10-09-11). The study followed ethics requirements for all participating clinical sites. All parents provided informed consent for participation in the study.

Figure 1 summarizes the number of available assessments for children with and without hearing loss. Of the 120 children (69 with hearing loss and 51 without hearing loss) initially enrolled in the study, 103 (61 with and 42 without hearing loss) remained in the study through to the 48-month follow-up session. Of these 103 children, 54 parents of children with hearing loss (29 unilateral, 25 mild bilateral) and 42 parents of children without hearing loss completed a Child Behavior Checklist (CBCL) questionnaire. The assessments available for the PSI and for the language assessments analyzed are also shown in Figure 1. A description of the measures is provided below.

Figure 1.

Figure 1

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Flowchart for parent questionnaires and language assessments. CBCL, Child Behavior Checklist; HL, hearing loss; PEACH, Parents’ Evaluation of Aural/Oral Performance in Children; PLS, Preschool Language Scale; PSI, Parenting Stress Index.

Procedures

Parents completed an intake questionnaire at study enrollment and an intervention questionnaire at each annual assessment. Through these questionnaires, information was collected to document baseline characteristics including demographic and hearing loss data (e.g., age diagnosis, degree of hearing loss, amplification). With parents’ consent, audiologic results were requested from the child’s audiologist throughout the study.

Measures

The primary measures analyzed for this report included the CBCL (Achenbach & Rescorla, 2000) and the PSI (Abidin, 1995). Throughout the study, questionnaires (CBCL, PSI, auditory function questionnaires) were mailed to parents with a return envelope approximately 1 month prior to the test interval (age 48-months for this component of the study). Parents completed and returned the questionnaires by paper mail. Three reminders were sent via email if questionnaires were not returned prior to the scheduled 48-month assessment in the home. All direct language assessments were conducted by a speech-language pathologist or teacher of the deaf and hard of hearing during home visits at annual intervals. For the current analysis, scores from the Parents Aural/Oral Performance in Children (PEACH) (Ching & Hill, 2007) and scores from the Preschool Language Scale (PLS) (Zimmerman et al., 2011) collected at the 48-month follow-up interval were also used. As noted, detailed results for hearing and language measures for the full cohort of 69 children with hearing loss and 51 without hearing loss have been previously reported (Fitzpatrick et al., 2019).

Child Behavior Checklist 1.5–5

Child behavior problems were assessed using the CBCL 1.5–5 (Achenbach & Rescorla, 2000), a well-validated checklist of behaviors for children 1.5–5 years of age. The tool includes 100 questions; the caregiver is required to rate 99 child behaviors from the previous 2 months and to answer one open-ended question. Each behavior is rated on a 3-point Likert scale as not true, somewhat true, or often true. The measure provides a Total Problems Score which can be divided into two composite scales, Internalizing and Externalizing Behavior Problems. These comprise several subscales (referred to as “syndrome” scales). The internal consistency reported for the CBCL (Chronbach’s alpha) is 0.95 for the Total Problems Scale, 0.89 for the Internalizing Problems and 0.92 for the Externalizing Problems Scale. Raw scores are standardized into T-scores, with higher scores representing more behavior concerns. The test has a mean standard score of 50 and a standard deviation of 10. T-scores are reported in this paper (raw scores were used in all analyses).

Parenting Stress Index

Parenting stress was measured using the short form of the Parenting Stress Index (PSI, 3rd edition) (Abidin, 1995), which consists of 36 items from the full PSI version. This is a well-validated measure that has been widely used internationally. Parents rate each item on a 5-point scale, ranging from 1 (strongly agree) to 5 (strongly disagree). The test is comprised of three subscales: Parental Distress, Parent–Child Dysfunctional Interaction, and Difficult Child. A Total Stress score is calculated by combining scores on all 36 items, with a higher score indicating greater parenting stress. The internal consistency reported for the PSI (Cronbach’s alpha) is 0.91 for Total Stress, 0.87 for Parent Distress, 0.80 for Parent–Child Dysfunctional Interaction and 0.85 for Difficult Child (Abidin, 1995). We report raw and percentile scores, and raw scores were used in all analyses. Parents who obtain scores at or above the 90th percentile are considered to be experiencing clinically significant levels of stress.

Parents’ Evaluation of Aural/Oral Performance in Children

The PEACH is a measure of functional auditory performance in everyday life based on parents’ observations. Reliability and normative data have been reported (Ching & Hill, 2007). On the short form of the PEACH, parents complete a questionnaire consisting of 13 questions, two of which probe information about the child’s use of hearing devices. The remaining 11 questions collect information about the child’s listening behavior in quiet (six questions) and in noisy situations (five questions). Parents estimate the percentage of time they observe specific listening behaviors and provide a rating from never (0% of the time) to always (75–100% of the time). Scores on the PEACH are converted to a percentage with higher scores representing better performance. The measure provides an overall functional auditory performance score as well as PEACH-quiet and PEACH-noise subscores. Based on previous findings of differences between children with hearing loss and those with typical hearing in this study (Fitzpatrick et al., 2019) we used the PEACH-noise subscore.

Preschool Language Scales, 5th Edition

Receptive and expressive language were measured using the Preschool Language Scales, Fifth Edition (PLS-5) (Zimmerman et al., 2011), a validated measure which is widely used to assesses receptive and expressive language from birth to age 6 years, 11 months. The test involves receptive and expressive language tasks using a picture book and toys as stimuli. A standard score is provided for two subscales, auditory comprehension (AC) and expressive communication (EC). The test has a mean standard score of 100 and a standard deviation of 15.

Data Analysis

Statistical analyses were carried out using SPSS Version 24 (IBM Corporation). Demographic and clinical characteristics of the participants were summarized by group (unilateral, mild bilateral, typical hearing) using descriptive statistics and included frequency counts as well as means and standard deviations or medians and interquartile ranges (IQR), as appropriate. Distributions of all continuous variables were visually examined to assess normality. For categorical variables, differences between groups were assessed using chi-square tests. For continuous variables, differences between groups were tested using parametric or nonparametric tests as appropriate. Missing data were not imputed, and examination suggested that data were randomly missing with no patterns evident in the missing data.

Based on the distributions of the data, nonparametric or parametric statistics were applied to assess differences in outcomes. Due to the skewed distribution of the results, the Kruskal–Wallis test was used to examine behavior (CBCL T-scores) and parent stress (PSI raw scores) comparing children with unilateral hearing loss, mild bilateral hearing loss, and typical hearing. The association between parenting stress and child behavior was examined using Pearson correlations as the distribution of data showed a linear pattern. Mean scores between groups on auditory functioning (PEACH-noise score) and receptive/expressive language (PLS) were assessed with ANOVA testing based on the distribution of the data. Pearson correlations were used to study the association between parent report measures (parenting stress, child behavior) and communication measures (auditory function, receptive, and expressive language). All analyses used two-tailed tests with statistical significance set at p < .05.

Results

Table 1 shows the clinical characteristics of the 54 children with hearing loss separately for unilateral (n = 29) and mild bilateral (n = 25) and for the hearing group (n = 42). Age at assessment, shown in Table 1, was based on age for the PSI/CBCL/PEACH questionnaires and did not significantly differ across all three groups at the 48-month follow-up (p = .20). The median age at assessment for the PLS for all participants was 48.4 (IQR 47.5, 48.8) months. Across all children, the full 48-month assessment including auditory and language assessments showed a gap of 2.1 (IQR 0.92, 3.6) months between the parent questionnaires and the language assessment. The three groups were well-matched on maternal education level with high levels of education from 17.6 to 17.9 years. As shown, almost 91% of children with hearing loss underwent newborn hearing screening, consequently, this was an early-identified group of children with hearing loss with a median age of diagnosis of 4.5 months (IQR 2.6, 6.5) for the unilateral group and 3.8 months (IQR 2.9, 6.7) for the bilateral group. The majority of children had congenital or early onset (<6 months) hearing loss (89.7% unilateral to 92.0% bilateral). Based on questionnaire responses, no parents reported having a hearing loss.

Table 1.

Characteristics of children whose parents completed the 48-month follow-up questionnaires

Characteristics Unilateral HL n = 29 Mild bilateral HL n = 25 Normal hearing n = 42 p-value
All groups
Sex-male, n (%) 15 (51.7) 9 (36.0) 21 (50.0) .44
Ethnicity, n (%)
 Canadian/Canadian–Other 28 (73.7) 20 (64.5) 45 (88.2) .04
 Other 10 (26.3) 11 (35.5) 6 (11.8)
Maternal education, years, mean (SD) 17.6 (3.3) 17.9 (3.4) 17.6 (1.9) .91
Income1, n (%)
 Up to 80K 14 (37.8) 12 (40.0%) 10 (20.0) .10
 Greater than 80K 23 (62.2) 18 (60.0%) 40 (80.0)
Age enrolment, months, median (IQR) 14.4 (9.1, 31.6) 21.3 (14.9, 28.1) 5.7 (3.4, 13.5) <.001
Age assessment, months, median (IQR) 47.9 (47.2, 48.5) 48.1 (47.8, 49.0) 48.1 (47.7, 48.8) .20
Hearing loss groups
Screening status, n (%) .572
 Screened 26 (89.7) 23 (92.0)
 Not screened or unknown status 3 (10.3) 2 (8.0)
Age at diagnosis, months, median (IQR) 4.5 (2.6, 6.5) 3.8 (2.9, 6.7) .332
Onset of hearing loss, n (%)2
 Congenital 26 (89.7) 20 (80.0)
 Early onset (<6 months) 0 3 (12.0%)
 Late onset (>6 months) 2 (6.9) 0
 Unknown 1 (3.4) 2 (8.0)
Type of hearing loss, n (%) .001
 Sensorineural 17 (58.6) 24 (96.0)
 Conductive 12 (41.4) 1 (4.0)
Etiology .077
 Etiology unknown, n (%) 14 (48.3) 18 (72.0)
 Etiology known, n (%) 15 (51.7) 7(28.0)
  ENT malformations 11 (37.9) 0
  Hereditary/genetic 2 (6.9) 4 (16.0)
  Syndromes 1 (3.4) 2 (8.0)
  Cytomegalovirus 1 (3.4) 1 (4.0)
Degree of hearing loss at diagnosis2, n (%)
 High frequency3 0 4 (16.0)
 Mild (20–40 dB HL) 2 (6.9) 16 (64.0)
 Moderate (41–55 dB HL) 5 (17.2) 4 (16.0)
 Moderately severe (56–70 dB HL) 9 (31.0) 1 (4.0)
 Severe (71–90 dB HL) 8 (27.6) 0
 Profound (>90 dB HL) 5 (17.2) 0
Age amplify rec, months, median (IQR)4 8.3 (4.7, 31.9) 6.2 (3.3, 12.7) .063
Age fitting amplif, months, median (IQR)5 13.7 (7.4, 29.8) 9.7 (5.0, 21.4) .156
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amplif, amplification; ENT, ear nose throat (anomalies included atresia and microtia); HL, hearing loss; IQR, interquartile range; rec, recommendation; SD, standard deviation.

1Income not reported by three families.

2Based on impaired/worse ear; Chi-square analysis was not carried out when more than 50% of cells had expected counts less than 5.

3Defined as ≥25 dB HL at ≥2 frequencies above 2 kHz.

4Amplification was recommended for 25 of 29 children with UHL and for 24 of 25 with mild bilateral loss.

5Amplification was fitted on 18 of 29 children with UHL and 23 of 25 with mild bilateral loss.

More children with unilateral hearing loss had permanent conductive hearing loss (p = .001; 41.0% unilateral compared to 4.0%—1 child in bilateral group). In the unilateral group, loss in the impaired ear ranged from mild to profound with 55.1% in the mild, moderate, or moderately severe range in the impaired ear. Five of the 25 children in the mild bilateral group had asymmetrical hearing loss (≥15 dB difference in three frequency PTA at 0.5, 1, 2 kHz) including four with moderate and one with moderate–severe loss in the worse ear. The majority of children with hearing loss were fitted with amplification (18/29–62.1% in the unilateral group and 23/25–92.0% in the bilateral group) at a median age of 13.7 months (IQR 7.4, 29.8) for the unilateral and 9.7 months (IQR 5.0, 21.4) for the mild bilateral group.

Children in the Ontario Infant Hearing Program are eligible for intervention services which include technology, language intervention (signed or spoken language options) and family support through audiology and preschool speech and language programs (Ontario Ministry of Children and Youth Services Infant Hearing Program, 2017; 2018). In this group of 54 children, 45 parents reported that their children received language intervention services, and all were enrolled in programs with a focus on oral language development.

Child Behavior Profile

CBCL scores (median T-scores) for the three groups of children are presented in Table 2. For the study sample there was high overall internal consistency for the CBCL items Chronbach’s alpha = 0.91). Parents of children with unilateral and mild bilateral hearing loss did not report significantly more child behavior problems than those of children with typical hearing based on the Total Problems (p = .618), Internalizing (p = .808), and Externalizing (p = .186) scores. Results for the individual syndrome scales are also detailed in Table 2. On all of these scales, children with hearing loss performed similarly to children with typical hearing with T-scores on all scales ranging between 50 and 74. On this test, scores on these scales are truncated at 50 (minimum value) to prevent an individual from receiving a score below 50 which could result in overinterpretation of unimportant differences between low scores (Achenbach & Rescorla, 2000). Most children (close to two thirds) scored close to this minimum value with small but similar proportions of children in the hearing loss and typical hearing groups falling within the borderline clinical range (shown in Table 2), indicating that a child may be at risk for behavior difficulties (T-score ≥ 65 on the syndrome scales) (Achenbach & Rescorla, 2000).

Table 2.

CBCL composite scores and syndrome scores by study group

Measures1 Unilateral HL n = 282 Mild bilateral HL n = 25 Normal hearing n = 42 p-value
Total Problems Scale, median (IQR) 41.0 (37.0, 49.3) 45.5 (36.3, 56.3) 45.0 (37.0, 53.0) p = .618
Internalizing Scale, median (IQR) 41.0 (37.0, 49.0) 43.0 (33.0, 52.0) 46.0 (41.0, 56.5) p = .808
 Emotionally reactive, range n ≥ 65 50.0, 70.0 2/28 50.0, 69.0 2/25 50.0, 70.0 5/42
 Anxious/depressed, range n ≥ 65 50.0, 74.0 1/29 50.0, 69.0 1/25 50.0, 63.0 0/42
 Somatic complaints, range n ≥ 65 50.0, 74.0 1/29 50.0, 62.0 0/25 50.0, 68.0 3/42
 Withdrawn, range n ≥ 65 50.0, 67.0 1/29 50.0, 67.5 1/25 50.0, 63.5 0/42
Externalizing Scale, median (IQR) 42.5 (35.5, 53.0) 44.0 (35.0, 55.0) 43.0 (37.0, 51.3) p = .186
 Attention problems, range n ≥ 65 50.0, 70.0 3/28 50.0, 67.0 2/25 50.0, 73.0 2/42
 Aggressive, range n ≥ 65 50.0, 59.0 0/28 50.0, 60.0 0/25 50.0, 65.0 2/42
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1Composite scores (Total Problems, Internalizing, Externalizing scales) are reported as median (IQR) of T-scores. Syndrome scales are reported as T-scores truncated at 50 and presented with minimum and maximum values; number of children scoring ≥65 (borderline clinical range) is shown.

2For one child in the unilateral group, not all questions were completed on the CBCL, therefore composite scores could not be calculated, however this child is represented in most of the syndrome scale scores.

Parenting Stress Profile

A total of 51 parents of children with hearing loss (28 unilateral, 23 mild bilateral) and 39 parents of children with typical hearing completed the PSI assessment. Table 3 shows the median raw scores for the PSI Total Stress Scale as well as the three subscales that comprise the total score, Parental Distress, Parent–Child Dysfunctional Interaction and Difficult Child. Overall internal consistency for the PSI in this research was 0.80 (Chronbach’s alpha). As shown, parents of children with unilateral and mild bilateral hearing loss did not report more stress than parents of children with typical hearing for the Total Stress Scale or on any of the subscale scores (p-values shown in Table 3). The PSI also includes a Defensive Responding Scale, which may be used to determine if there is a response bias including a bias toward either positive ratings and/or defensive responding. Within the full cohort of parents, 27/90 (30.0%) had scores within this range (raw score ≤ 10). This included a similar proportion of children in each of the three groups (28.6% unilateral; 30.4% mild bilateral; and 30.8% typical hearing). Figure 2 shows the median percentile scores for Total Stress and the three subscales. Percentile scores ranging between 15 and 85 are considered to reflect typical parenting stress levels (Abidin, 1995).

Table 3.

Parenting Stress Index results by group

PSI Scales (raw scores) median (IQR) mean (SD) Unilateral HL n = 28 Mild bilateral HL n = 23 Typical hearing n = 39 p-value
Total Stress 57.5 (48.3, 68.3) 70.0 (43.0, 75.0) 65.0 (53.8, 74.3) p = .350
60.8 ± 15.0 63.7 ± 16.7 65.5 ± 13.6
Parental Distress 19.5 (16.3, 26.8) 24.0 (16.0, 26.0) 22.0 (16.0, 28.0) p = .842
23.1 ± 9.8 21.6 ± 5.7 22.9 ± 7.3
P-CDI 15.0 (14.0, 17.8) 19.0 (14.0, 22.0) 16.0 (13.8, 20.5) p = .399
16.6 ± 4.4 18.5 ± 5.0 17.8 ± 5.2
Difficult Child 20.0 (16.0, 25.0) 25.0 (15.0, 29.0) 23.0 (20.0, 29.0) p = .059
21.1 ± 5.7 23.7 ± 7.9 25.0 ± 6.3
Defensive Responding 12.0 (10, 16.3) 14.0 (9.0, 15.0) 13.0 (9.0, 17.0) p = .777
13.8 ± 6.0 12.8 ± 3.6 13.8 ± 4.8
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HL, hearing loss; IQR, interquartile range; P-CDI, Parent–Child Dysfunctional Interaction; PSI, Parenting Stress Index; SD, standard deviation.

Figure 2.

Figure 2

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Boxplot of Parenting Stress Index Total Stress score and subscales by study group. The box indicates the 25th, 50th, and 75th percentiles. The whiskers above and below the box boundaries show the largest and smallest observed values (except for one outlier for Total Stress in the unilateral group).

Relationship between Child Behavior and Parent Stress

We examined the relationship between parent reports of behavior and stress in the 90 parents (28 unilateral; 23 mild bilateral; 39 typical hearing) who completed both CBCL and PSI questionnaires. Figure 3 shows the correlations between the CBCL Total Problems Score and the PSI Total Stress Score for each group. There was a strong positive relationship between total parenting stress and child behavior scores for both the mild bilateral hearing loss (r = 0.735, p < .001, n = 22) and the typical hearing groups (r = 0.709, p < .001, n = 38), and a moderate association for the unilateral hearing loss group (n = 27, r = 0.428, p = .028).

Figure 3.

Figure 3

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Scatterplot of Child Behavior Checklist Total Problems Score (T-scores) and Parenting Stress Index Total Stress (raw scores).

We explored whether there was any relationship between maternal education and parenting stress or child behavior and found no significant relationships for any subscales (p > .05 for all subscales). We also explored whether there was any relationship between amplification and parenting stress or child behavior. There were no significant differences between children fitted with amplification and those without amplification on any of the PSI or CBCL subscales (p > .05 for all scales).

Communication Development Profile

We examined the relationship between parenting stress, child behavior, and communication development based on previously reported language (PLS scores) and functional hearing outcomes (PEACH-noise score) for this cohort of children (Fitzpatrick et al., 2019). For this analysis, two measures, the PLS (auditory comprehension and expressive communication scales) and the PEACH questionnaire (PEACH-noise score) were selected as these measures showed some differences (not significant for PLS scales) between children with unilateral and mild bilateral hearing loss and their hearing peers. Scores on these measures for the study groups are shown in Table 4; scores were available at the 48-month follow-up for 71 children on the PLS and 96 children on the PEACH. As shown, children with unilateral/mild hearing loss obtained scores on the PLS within test normative data (mean standard scores ranging between 104.1 on the PLS-EC and 106.5 on the PLS-AC). Differences between the groups did not reach statistical significance (p = .067-PLS-AC; p = .057-PLS-EC), however, overall children with typical hearing obtained slightly higher scores (approximately 0.5 SD higher on the PLS measures). For the PEACH-noise, there was a significant difference between groups (p = .02) with significantly lower scores (difference of 9.8%) for children with unilateral hearing loss compared to children with typical hearing. This difference in scores between the unilateral and typical hearing groups translated to a medium effect size of 0.67 (as represented by Cohen’s d). In the children with bilateral hearing loss, due to the small sample, we did not statistically compare differences in outcome between symmetric and asymmetric hearing loss. However, results for the four children with moderate and one child with moderate–severe loss in the worse ear were explored visually for all outcomes and no meaningful differences were noted for any measures.

Table 4.

Language and auditory function scores by group

Measures Unilateral HL Mild bilateral HL Typical hearing Significance
PLS-AC Standard Score, mean (95% CI) 104.2 (96.7, 111.7) n = 19 106.5 (97.8, 115.2) n = 20 113.8 (109.4, 118.1) n = 32 F = 2.818, p = .067
PLS-EC Standard Score, mean (95% CI) 104.9 (99.1, 110.7) n = 19 104.1 (96.0, 112.1) n = 20 113.8 (107.6, 120.1) n = 32 F = 2.988, p = .057
PEACH-noise %, mean (95% CI) 77.6 (71.7, 83.5) n = 29 83.4 (76.4, 90.4) n = 25 87.4 (83.9, 90.9) n = 42 F = 4.054, p = .021
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CI, confidence interval; HL, hearing loss; PEACH, Parents’ Evaluation of Aural/Oral Performance in Children; PLS-AC, Preschool Language Scale—Auditory Comprehension; EC, expressive communication.

As shown in Table 5, there were no significant associations between the receptive and expressive language scores and parenting stress or child behavior. There were, however, weak to moderate correlations between the PEACH-noise score and both parenting stress and child behavior for children in the unilateral and typical hearing groups.

Table 5.

Correlations between language development (PLS scores), child behavior (CBCL Total Problems) and parent stress (PSI Total Stress Score)

Correlated with Unilateral HL Mild bilateral HL Typical hearing
CBCL Total Problems Scale PEACH-noise r = −0.449 p = .017, n = 28 r = −0.358 p = .086, n = 25 r = −0.421 p = .006, n = 42
PLS-AC r = −0.426, p = .088, n = 18 r = −0.149, p = .543, n = 20 r = 0.012, p = .962, n = 32
PLS-EC r = −0.352, p = .166, n = 17 r = 0.044, p = .812, n = 20 r = 0.201, p = .270, n = 32
PSI Total Stress PEACH-Noise r = −0.390 p = .040, n = 28 r = −0.347 p = .105, n = 23 r = −0.325 p = .046, n = 38
PLS-AC r = −0.157, p = .533, n = 19 r = −0.170, p = .500, n = 18 r = −0.120, p = .537, n = 29
PLS-EC r = −0.367, p = .134, n = 18 r = −0.075, p = .768, n = 18 r = 0.331, p = .080, n = 29
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CBCL, Child Behavior Checklist; HL, hearing loss; PEACH, Parents’ Evaluation of Aural/Oral Performance in Children; PLS-AC, Preschool Language Scale—Auditory Comprehension; EC, expressive communication; PSI, Parenting Stress Index.

Discussion

This prospective study examined parent-reported child behavior and parenting stress for children with unilateral and mild bilateral hearing loss. Parents of early-identified children with unilateral and mild bilateral hearing loss did not report more behavioral problems in their children at age 48 months when compared to parents of children with typical hearing. In addition, these parents also did not report higher stress levels than parents of children with typical hearing. We did however find that, for all three groups of children, higher level of parenting stress was related to parents’ reporting more child behavior concerns. Both child behavior and parenting stress were related to auditory function in everyday environments, although no relationships with children’s language abilities were found.

Although behavior has often emerged as a serious concern for children with hearing loss (Barker et al., 2009; Quittner et al., 2010), we did not find this to be applicable to this cohort of young children with unilateral or mild bilateral hearing loss. Most of these studies were conducted with cohorts that combined children with all degrees of hearing loss, or primarily with severe to profound loss. In a large cohort of 214 children, (almost 40% with <70 dB HL), Hintermair (2006) found that parenting stress was associated with more frequent reporting of socioemotional problems but did not find a relationship with the degree of hearing loss. This is consistent with our findings that higher stress levels were associated with more behavioral issues, not only in children with hearing loss but also in typically developing children. This finding suggests that supporting families of young children, regardless of hearing loss may offer advantages for healthy child development (Calderon & Greenberg, 1999; Hintermair, 2006). Our findings related to behavior outcomes do not support the results in the Topol et al. (2011) study, however that study included a smaller number (n = 12) of children with unilateral/mild hearing loss than our study. In the Topol et al. study, early-identified children with hearing loss (including 12 of 30 with unilateral/mild loss), had higher scores than children with typical hearing in the areas of withdrawn behavior, internalizing behavior, and total problems at 18–24 months. The authors reported that the 12 children with unilateral/mild bilateral loss were not different in their functioning from children with moderate to profound loss when compared to typical hearing children. In the Topol et al. (2011) study, the measures were collected at age 18–24 months, closer to the time of diagnosis, when parents are learning about hearing loss and amplification compared to age 48 months in our study when parents had more experience and were possibly more adjusted to their child’s hearing loss and more comfortable with their child’s overall development. Although parents in the Topol et al. (2011) study, did not present with higher parenting stress levels on the PSI, age might have partly affected the different ratings of child behavior between the two studies.

Our findings related to parenting stress levels are largely in line with those from several other investigators who used a general parenting stress measure such as the PSI (Blank et al., 2020; Lederberg & Goldbach, 2002; Pipp-Siegel et al., 2002; Quittner et al., 2010; Sarant & Garrard, 2014). Most of these studies have included severe-profound hearing loss or all degrees of hearing loss. However, our findings for parent–child dysfunction (PSI) are not aligned with those of Pipp-Siegel et al. (2002) who found that parents of children with lesser degrees of hearing loss exhibited more parent–child dysfunction, suggesting parent–child interactions were more affected with less severe hearing loss. Our results are also consistent with those reported in the Topol et al. (2011) study that included 12 children with unilateral/mild bilateral hearing loss. In that study, parenting stress scores obtained with the PSI were similar for 30 children with hearing loss and 91 children with typical hearing and the authors reported no difference based on degree of hearing loss. However, based on measures of disability or hearing loss-specific parenting stress, several researchers have shown that parents of children with hearing loss report higher levels of stress than parents of hearing children (e.g., Lederberg & Golbach, 2002; Quittner et al., 2010). Because our study did not include a hearing loss-specific measure, it is possible that we were not able to capture specific parent stressors related to amplification or hearing concerns in some settings.

In previous studies, language delays seem to account for some of the perceived differences in behavior problems between children with and without hearing loss (Stevenson et al., 2015; Theunissen et al., 2014). Studies suggest that there is an association between language delays and child behavior problems which then may influence parenting stress (Quittner et al., 2010; Sarant & Garrard, 2014). Unlike these previous findings we did not find a significant relationship between receptive and expressive language scores and behavior or parenting stress. Given that the children in our cohort did not have important gaps in language relative to their hearing peers, this may explain some of the differences compared to other studies on children with hearing loss, which included primarily or only children with severe and profound hearing loss (e.g., Quittner et al., 2010; Sarant & Garrard, 2014). These findings seem to align with the conclusions of a large study (Hintermair, 2006) in which more than a third of the 213 children had mild to moderate–severe loss. The author found that parenting stress was related to the child’s communicative competence but not to degree of hearing loss. It is also possible that the broader language measures used in this study were not sensitive enough to capture more subtle differences in linguistic development. Recent studies on school-age children suggest that broad measures of vocabulary and language may not identify concerns for children with mild bilateral hearing loss, but that these children are at risk in specific areas such as morphological and phonological processing skills (Doković et al., 2014; Nassrallah, Fitzpatrick, et al., 2020; Walker et al., 2020). We did, however, find that children’s auditory functioning (as measured by the PEACH-noise score) was weakly to moderately associated with both parenting stress and child behavior for children with unilateral hearing loss as well as for children with typical hearing. This suggests that parents’ concerns about their child’s functional hearing abilities may be influencing their perceptions. Further examination of this area is warranted in a larger cohort of children with unilateral/mild bilateral hearing loss.

Early-identified children with unilateral/mild bilateral hearing loss are developing their communication skills similar to their hearing peers and most may not require specific intervention in communication development. In our study, children in the unilateral and mild bilateral hearing loss groups did not show important differences in behavior or parenting stress scores. However, as noted, one difference that emerged between groups was that we found a relationship between auditory function in noise and behavior as well as parenting stress scores for children with unilateral hearing loss but not for children with mild bilateral hearing loss. Children with unilateral hearing loss had slightly more difficulty in noise (PEACH-noise score of 77.6% vs. 83.4%). Consideration of specific training related to listening in noise such as practicing conversation and early phonological activities in the presence of noise (e.g., using recordings of different environments) might be beneficial in early intervention programs, particularly for children with unilateral hearing loss. Difficulties in listening may affect areas such as attention and following conversation, which has important implications for incidental learning, early social interactions, and language development. Further research may shed light on the potential benefits of these types of targeted interventions. Based on this small study, it is difficult to speculate why parenting stress and behavior were also weakly associated with PEACH-noise scores for children in the typical hearing group. Given these findings, it would be worth investigating whether noisy listening environments might lead to increased difficulties for children and potentially increased stress for parents.

It is not entirely surprising that parents of children with milder loss may not experience the same level of stress as those of children with more severe hearing who are more likely to present with more pronounced language delays. Our qualitative data have suggested that parents are stressed about their child’s hearing and development, however, these comments were often specifically related to audiological concerns such as number of visits to establish the diagnosis of permanent hearing loss during the early stages of learning that their child had a hearing loss (Fitzpatrick et al., 2016). Children in our study were identified with hearing loss on average as infants (approximately 4 months of age) and our results were collected at age 48 months. By this time, the uncertainties of most parents around hearing may have largely resolved. As parents observe their children developing language and hearing skills that are relatively appropriate for their age, their early concerns are likely attenuated. During the early preschool years, children are relatively sheltered and close to their parents. However, as they enter the school years and are required to interact with their peers in multiple and complex learning environments, it is important to follow the developmental trajectory of this unique group of children.

A potential limitation of our study is that we did not include a parenting stress measure specific to children with hearing loss. By limiting our study to the PSI, a general parenting stress measure, we may not have captured stresses specific to raising a young child with unilateral or mild bilateral hearing loss. A second limitation is the relatively small sample size. Results should be interpreted with caution as the study could be underpowered to detect associations between outcomes and parenting stress/behavior outcomes. In addition, although we reached out to multiple centers where children were diagnosed through the Ontario Infant Hearing Program, this was a group of well-educated families who may generally have been less stressed than families who were unable to take on the commitment of participating in the research, a characteristic that is common to many longitudinal studies of this type. Parents of higher socioeconomic status may also have better support systems and be more resourceful when they do experience stress and uncertainty than families from less advantaged backgrounds. Therefore, our results may represent a best-case scenario for children with unilateral/mild bilateral hearing loss whereas a more heterogeneous group of families and children might present less encouraging results. However, all children were recruited in one province in Canada where a publicly funded EHDI program is well-established such that all families had access to early intervention and support. It is unknown whether these results would generalize to children with unilateral or mild bilateral hearing loss who are identified in other contexts. Finally, our observational study design did not permit us to analyze whether early detection contributed to these outcomes as we did not have a comparison group of later identified children.

A strength of our study is that our data were collected from a cohort of early-identified children from a province where well-established early detection and intervention protocols have been in place for several years. We also collected data on typical hearing children drawn from the same population. and we adopted well-validated measures that are used internationally. The findings of this study are encouraging in that children with unilateral and mild bilateral loss appear to be developing similar to their peers with typical hearing in multiple domains including language, behavior and their parents do not appear to be more stressed than parents of typically developing young children. We did not objectively examine the effects of intervention programs on the outcomes of these children. However, it is reasonable to infer that maintaining programs of early detection, intervention, and parent support for children with milder hearing losses can develop age-appropriate hearing and communication skills and reduce potential socioemotional and behavioral problems in children and elevated levels of stress in their parents. To date, little attention has been given to these domains for contemporary cohorts of children with mild degrees of hearing loss. Our study provides empirically derived information for parents of young children, as well as educators and health care providers, to understand how mild hearing loss affects children’s development. In future studies, it would be important to examine hearing loss-specific parenting stress that might better identify whether additional supports are required for families of children with unilateral and mild bilateral hearing loss.

Our findings suggest that early-identified children with unilateral and mild bilateral hearing loss and their families, are developing receptive and expressive language skills at preschool age that are closely aligned with their hearing peers although slightly lower on average. However, in everyday auditory functioning, children with early-identified unilateral hearing loss are experiencing more difficulties and the long-term effects and how this might affect other more advanced linguistic domains remain unknown. For both children with unilateral and mild bilateral loss, there is no good evidence to assist in predicting which children will encounter difficulty as they advance to more complex learning environments during the school years. Given past findings for school-age children with unilateral and mild bilateral hearing loss in other areas of linguistic and academic functioning, (Anne et al., 2017; Doković et al., 2014; Lewis, 2014; Walker et al., 2020) and the challenging situation that school presents, it will be important to follow cohorts of children through the school years to examine whether these areas continue to show positive results.

Acknowledgments

We thank the parents and children for joining this study and helping us better understand the impact of unilateral and mild bilateral hearing loss. We also thank the research assistants and students who contributed to data collection, scoring and data entry throughout the study.

Contributor Information

Elizabeth M Fitzpatrick, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada; Child Hearing Lab, Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.

Wu Jiawen, University of Illinois at Urbana-Champaign, Urbana, IL, USA.

Olds Janet, Child Hearing Lab, Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; Audiology Clinic, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada.

Whittingham JoAnne, Child Hearing Lab, Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.

Nassrallah Flora, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada; Child Hearing Lab, Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.

Gaboury Isabelle, Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Longueuil, Québec, Canada.

Durieux-Smith Andrée, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada; Child Hearing Lab, Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.

Coyle Doug, School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Canada.

Funding

This study was funded through a grant from the Canadian Institutes of Health Research-CIHR (CIHR #93705) and a CIHR New Investigator Award (2009-14) to the first author.

Conflict of Interest

The authors have no conflict of interest to declare.

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