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Northland Community and Technical College

Occupational Therapy Assistant Program


Critically Appraised Topics Assignment
by Cindy Johnston
Focused Question: How can occupational therapy promote hearing loss prevention strategies
for infants and children?
Clinical Scenario: Newborn hearing screening is nearly universal, (92%), but more than half of
the newborns with positive screens do not receive follow-up care and may go without a diagnosis
or availability of services until school age with the result of not having developed the needed
language skills to keep up academically or socially with their classmates (Johnson, Newman,
Danhauer, & Williams, 2011).
Additionally, there is the adverse effect of childhood and teen hearing loss due to the impact
of exposure to noise as well as loud or sustained sound. Both sources have an auditory and nonauditory effect on healthy development meaning that loud sound or noise can cause physiological
or psychological harm or damage (Bistrop, 2003). A definition of noise is any sound
independent of loudness that may produce an unwanted physiological or psychological effect in a
person which may interfere with the social ends of an individual or group (Mitzelfelt, 1996).
Groups of children, such as premature infants and young children with ear organs that are
still developing, can be exposed to levels of noise that can harm hearing (Bistrop, 2003).
Although the damage caused by exposure to strong or sustained sound can cause permanent
hearing loss and tinnitus in persons of all ages, exposure at early stages of life has the potential
of damage to the cochlear and auditory neural function. Children with early hearing damage
score considerably lower on the Comprehensive Test of Basic Skills and display more behavioral
difficulties and lower self-esteem (Martin, Griest, Sobel, & Howarth, 2013). There are several
studies that show children are unprotected against damaging sound levels at a routine rate. The
World Health Organization reports that North American children may be exposed to more noise
at school than workers from an 8-hour work day at a factory (WHO, 1997).
Furthermore, 97% of 273 third graders in a survey indicated that they had been exposed to
dangerous sound levels (Blair et al, 1996). Another statistic reports that 30% of the same
students said they occasionally participated in other sound intense activities like shooting
firearms or going to auto races, but only 5.5% of the students used hearing protection during the
time of the activity (Chernack & Peters-McCarthy, 1991). The number of hunters between the
ages of 6 and 15 are estimated to be 1.6 million (USFWS, 2006). Personal music players are a
growing and aggressive source of sound exposure for youth. Statistics say that over 94% of
adolescents listen with these devices and an estimated 28% listen at a level that puts them in

danger of hearing loss (Kim et al., 2009; Vogel et al, 2011). These cumulative daily and weekly
exposure levels can have a substantial effect. Tinnitus, which is a ringing in the ear, is usually
caused by sound exposure and has been reported in 59% of children with 19% saying it was
severe (Coelho et al., 2007).
Examples of children who may be harmed by noise are those who cannot get out of locations
that are defined by adults and who are vulnerable because they cannot control the environment as
adults are able. Susceptible children are those who must be in places that have no regulation to
prevent harmful noise that could affect their hearing (Bistrop, 2003). Settings would include
areas where the exposure level is high, settings where many children are gathered, settings where
exposure is thought to cause harm, and settings that have or include especially vulnerable groups
of children. Common areas may be day care centers, and schools (Bistrop, 2003). An example
could be in an infant/toddler room of a day care where there is lullaby music over a speaker
system set at a high volume by staff during nap time. The speaker system allows the sound to
flood the room at a volume chosen by daycare staff, with no area for toddlers to instinctively
move away from the high level of sound to a quieter area and infants are unaware and unable to
move away. The sound level of the music may be sustained for an entire nap period of 90
minutes daily, accumulating and prolonging the exposure of the children and infants to loud
sound. The plan of staff of a day care in this example may be to have the lullaby music drown
out the sound of play that may disturb the sleep of an infant or toddler during their nap, as the
awake children occupy the same room as sleeping ones. This action on the part of care providers
may be in fact be providing care that is harmful to their hearing with this simple nap time choice.
In addition, according to Axelsson & Jerson (1985), and Nadler (1995), there are certain
childrens toys that emit sounds that exceed safe listening levels.
As children develop, exposure to dangerous sound levels continues and accumulates
throughout life. (Martin, Griest, Sobel, Howarth, 2013). Exposure to any noise at or above 85
decibels can cause gradual hearing loss, which incidentally is the sound of a lawn mower or
heavy traffic and also an MP3 player at around 70 percent of its maximum volume (Stump,
2014).

Summary of Key Findings:


Level I:
Knowledge, habits, preferences, and protective behavior in relation to loud sound
exposures among Brazilian children. International Journal of Audiology. Knobel, & Lima,
(2012).
This study looked for possible mediators for noise-induced hearing loss in Brazilian children
such as gender, parents educational level, habits, preferences and awareness about loud sound

exposures and personal actions for protection from loud sound exposures. Most are aware of
risks involved with loud sound exposure, but hearing loss prevention initiatives are needed for
parents, children, and society.
As expected use of personal stereos at high intensity level was lower among children than
adolescents. Yet children have less control over their environments and daily situations than
adults, so when they become teenagers using leisure activities with exposure to high intensity
music, it is seen as having a grown-up attitude.
Results indicated that 68.5% of children had a large amount of knowledge about the effects of
noise on the auditory system regardless of their gender or their parents educational level even
with the lack of any systematic hearing loss prevention initiatives in Brazil. Results show that
while being aware of the effects of noise adolescents continue to expose themselves to risky
situations. Study also indicates that children feel annoyed by noise to the point that would
interfere with their tasks and they then attempted to avoid it. Study notes that children give
consistent and reliable responses to noise perception. Study shows no significant differences
between genders with regard to preference for loud noises, but the percentage of boys who said
they liked loud music was significantly higher than the percentage of girls which agrees with the
statement that boys expose themselves to more noisy activities than girls. Findings contradict
previous evidence that lower-income families prefer loud sounds in their recreational activities.
Evidence from this study may serve to alert parents, educators, and authorities to take
preventative measures against noise-induced hearing loss in children.
Randomized trial of four noise-induced hearing loss and tinnitus prevention interventions
for children. International Journal of Audiology, Martin, Griest, Sobel, & Howarth, (2013).
This article summarizes four interventions that seek to educate children with messages about
the sources of dangerous sounds to hearing, the consequences of being exposed to dangerous
sound and how to protect oneself from dangerous sounds.
In order to research effective programs of hearing loss education other than lecture based
programs which are less effective, a highly interactive public health program which implements
problem-based learning, called Dangerous Decibels, was chosen. In Dangerous Decibels, four
interventions are presented which seek to reduce noise-induced hearing loss and tinnitus by
educating children with messages about the sources of dangerous sounds and how to protect
oneself from dangerous sounds. The four intervention delivery means were developed as a part
of the Dangerous Decibels partnership between the Oregon Health and Science University,
Oregon Museum of Science and Industry and Portland State University. The four intervention
means are as follows; in the classroom presented by a health professional, in the classroom
presented by an older-peer educator, a self-directed museum exhibit made to encourage hearing
loss prevention, and a self-directed visit to a virtual museum made to encourage hearing loss
prevention on the internet. The programs developed as a part of the Dangerous Decibels program
had activities that were derived from health communication theory principles and were meant to
relay three educational messages.
1. What are the sources of dangerous sounds?

2. What are the consequences of exposure to dangerous sounds?


3. How can I protect myself from dangerous sounds?
The study sought to find which intervention was most successful at educating about the ear and
hearing and influencing prevention behavior and sustaining the duration of the intervention.
There was a randomized trial of the four interventions with a non-intervention comparison group.
Questionnaires were completed before, immediately after, and three months after each
intervention.
Study sample size was 53 fourth grade classrooms (1120 students) that participated in the
study. Descriptions of the 4th grade study participants were 47% male and 53% female. Ethnicity
was self-reported at 47% White, 13% Hispanic, 13% Black, 7% Asian, 3% Native American,
11% other and 6% not sure. Representation of minority and under-represented groups was
sought by seeking schools with high-minority enrollment.
The article states the classroom intervention presented by either the health care professional
or older peer educator proved to be the most effective at making large improvements between pre
and post intervention scores in knowledge based questions for 10 of 11 items. Large
improvements in line with intended behaviors were found for questions right at post-intervention
and still in place at the three month follow-up evaluation. The average long term improvement
was 18.35. The study results show that this method of hearing protection education has a positive
effect on elementary school children by instilling hearing protection behavior that is practiced
and importantly, that it is sustained over time, in this instance 3 months later the study showed
that children still had the messages in place and practice.
.
Level III:
Noise with attitude: Influences on young peoples decisions to protect their hearing.
International Journal of Audiology. Gilliver, Beach, & Williams, (2013).
This article examines how young people can be influenced to make decisions that will prevent
hearing loss when unlike the focus of workplace safety noise reduction, many of the leisure
activities to which they are drawn, are because of the high level of noise involved. Therefore,
hearing prevention strategies must focus on motivation to put noise reduction behavior over
preferred sound-seeking behavior. Secondly, unlike workplace noise, which may be consistent
or predictable, leisure noise is chosen voluntary participation across a few minutes to many
hours. Thus, noise regulation in leisure relies on personal choice to the amount of noise to which
individuals expose themselves and depends on the individual motivation to watch and adjust
their own behavior and exposure. This study looks at the relationship between hearing health
attitudes and hearing loss prevention and is interested to see whether education would promote
hearing loss prevention behaviors and if beliefs about hearing loss would influence personal
choices. The study shows that educating and raising the knowledge of risks is only the beginning
for prevention programs and of itself is not enough to change behaviors. To be successful, noise
reduction messages to do with the risk involved with high noise leisure activities would need to
relate personally to the individual. It was concluded that successful prevention messages need to

be personalized to make the message effective to inform about the risk and reality of hearing
loss. They must be directed toward personal beliefs about hearing health.

Level V:
Hit the Mute Button. Hearing Health. Stump, (2014).
One in five people in the United States have hearing loss which includes children 12 and older.
The Journal of American Medical Association reported a 31 % increase in child and adolescent
hearing loss from the previous decade. This puts children at risk for poor academic achievement,
vocabulary loss, and poor pronunciation, social isolation, and poor self-esteem. Tinnitus can
disrupt sleep and concentration and the earlier the loss happens in a childs life, the more serious
the effects on the childs development. Prevention options are important to introduce and
implement and also role model in the life of a child to promote hearing health. Preventative
behaviors are to identify the source of loud sounds and avoid or limit exposure to them, turn
down the volume of music systems, and lock in settings to limit the maximum volume at which
they can be played, and use hearing protection devices such as ear plugs at loud concerts or
events. Another suggestion is to follow the 80/90 rule for MP3 players to listen at no more than
80 percent of maximum volume for no more than 90 minutes. One should lower the volume
even more and listen for even a shorter amount of time if using a CD player and headphones.
Also, parents need to be good role models for children and use hearing protection when mowing,
using power tools such as leaf blowers, or chain saws and watch how loud your music is played.
The most effective prevention is avoiding strong noise and making hearing protection attractive
or cool.
Prevention of Adverse Effects of Noise on Children. Noise & Health. Bistrup, M.L. (2003).
This article is an overview of a report published on a 2001 project titled Children and NoisePrevention of Adverse Effects which was financed by the European Commission Programme on
Pollution-related Diseases. It describes the effects of decibel levels on children in day care
centers, primary schools, discotheques and festivals. Studies involved recording decibel levels in
classrooms of schools with high traffic volume nearby, airport noise, railway noise and chronic
noise. They showed that high decibel level traffic noise caused lower reading scores and
distraction. When traffic walls or improved sound protection in classrooms was added,
childrens educational scores and concentration improved dramatically. The article shows
evidence of the study that noise levels affect academic performance and when noise is lowered,
academic performance improves. It also examined how renovating a day care center with
acoustic panels to reduce noise by 5 decibels on average improved performance on pre-reading
skills, language skills, and motivations tasks. Installing high-insulation walls, windows, and
roofs in daycare centers reduced sound ranging from 8 to 24 dB. Reducing volume in
discotheques by 10dB, in which the effects of ordinary listening habits show that 10-20% of
adolescents would have slight but verifiable hearing loss of greater than 10dB after 10 years

reduces the level of noise to one tenth of the initial level. These environmental exposure
examples shows a non-auditory effect of noise upon children.
Problem with Babys Hearing? An Intervention Checklist. Journal of Family Practice.
Johnson, Williams, Newman, Danhauer, (2011).
This article discusses the importance of positive screens for hearing loss in infants so they get
the follow-up treatment needed. The article describes the guidance of families in making
intervention plans for children with hearing loss as well as ongoing monitoring for those who
pass their newborn screening but are at high risk for delayed onset hearing loss. Families with
children who have any amount of permanent hearing loss in one or both ears are qualified to
early intervention services. These services may be home or center-base and include education
for the hearing impaired child and family, physical, speech and occupational therapy, and social
work and psychotherapy services.
The Effects of Noise-Induced Hearing Loss on Children and Young Adults. Contemporary
Issues in Communication Science and Disorders. Levey, Fligor, Ginocchi, Kagimbi, (2012).
Noise induced hearing loss occurs commonly in young people from listening too loud for too
long with personal listening devices such as CDs, iPods, and other MP3 players. Childrens toys
that emit sounds that exceed safe listening are another source of noise induced hearing loss in the
young. The National Institute on Deafness and Other Communication Disorders stated that
NIHL results from exposure to sounds that are excessively high, > than 85 decibels, along with
lengthy exposure with the insidious aspect that listeners are frequently unaware that a hearing
disorder is occurring or present. (NICDC, 2007).
A survey by Zogby (2006) found that teens were more likely that adults to report 3 of 4
symptoms of hearing loss which are increasing the volume on their television or radio, saying
what or huh during normal conversation, and reporting tinnitus, (17% students, vs. 12% adults).
College-age PLD users were found to listen louder with listening levels of 189 college students
on a New York City campus showed findings that the average participant had an exposure of 88
dBA which puts them at risk for NIHL from personal device players alone.
A number of toys can reach levels >than 100dBA, which is equal to a power saw, subway train
or power mower. Common toys that exceed volume levels are rattles and squeaky toys that have
been measured as high as 110dBA. Musical toys, drums and horns can be as loud as 120dBA.
Toy phones have been measured between 123 dBA and 129dBA. Toys that make firearm
sounds make sounds as loud as 150 dBA. Squeaky toys at 78-109 dBA that are placed close to a
childs ear for even minutes per day put child at risk for NIHL.
Early prevention is important to prevent communication and academic problems.

Sonic Youth. The ASHA Leader. Folmer, (2013).


Occupational hearing loss is stated as the most common work-related injury in the United
States. Hearing loss and tinnitus are the two most common service connected disabilities among

US military veterans. People with hearing loss experience isolation, frustration, anxiety or
depression which results in reduced quality of life. These are examples of the widespread
prevalence of hearing loss and its effects in adults.
Hearing protection needs to start at a young age but most often does not. Children experience
noise incurred hearing loss and may have more learning difficulties and behavioral problems
than normal hearing classmates. They may fail a grade more frequently showing that even a
small degree of hearing loss can poorly affect a childs development and academic success.
Hearing conservation education programs in schools are recommended by experts to be
implemented. Even so, these programs are absent from U.S. schools. Low public awareness, low
priority of noise induced hearing loss, and ineffective dissemination of hearing loss prevention
materials and programs and lack of a mandate give reasons for this omission. A call to action is
needed. A model program titled Dangerous Decibels is described as a hearing education program
for children. At minimum children should understand 3 protective strategies: 1-Turn down the
volume of music if it is too high meaning greater than 80 dB. 2-Move away from the source of
loud sounds.3- Wear ear plugs or muffs in the event of expected exposure to loud sounds.
.
Bottom Line for Occupational Therapy Practice:
Prevention is an emerging field in occupational therapy. The articles chosen for this critically
appraised topic are about the prevention of hearing loss in infants and children.
Occupational therapy should assist with educating school age children about the importance
of hearing loss prevention to lower the risk from physical health problems, environmental
sources, and high noise leisure activities. This would work to eliminate the negative effect noise
has upon the academic success of children. Children with hearing loss may fail a grade more
frequently, showing that even a small degree of hearing loss can poorly affect a childs
development and academic success (Folmer, 2013). It would also promote the quality of their
life now and as they grow to adulthood because the message of hearing protection has been given
while they are young and can take effect in their early years. According to the study by Knobel
& Lima, (2012), data shows that children should receive better information about the true
possibility of suffering an irreversible hearing loss since it has been shown that adolescents who
reported being concerned prior to noise exposure were more likely to use hearing protection,
versus those who did not report any concern (Widen & Erlandsson, 2004). According to Stump,
(2014), decisions one makes regarding how hearing is valued will influence how you will hear
when you are 20 years old, 40 years old, and 80 years old and that it is never too late to teach a
child healthy hearing habits that will help them all their lives.
Occupational therapy practitioners can encourage teachers to integrate hearing loss
prevention messages into lesson plans on hearing, sound, music, science, math and health.
(Folmer, 2013). They could volunteer as a guest speaker on hearing conservation in classrooms.
(Folmer, 2103). They could seek a mandate for hearing loss prevention instruction to students in
grades 1,4,7 and 10 in all US schools every year (Folmer, 2013).
Occupational therapy practitioners could educate children on the following three simple
protective strategies: 1.Turn down the volume of music if it is too loud. 2. Move away from the

source of loud sounds. 3. If you must be exposed to loud sounds, wear earplugs or ear muffs
(Folmer, 2013). A study completed by Martin et.al, (2013) found that a program titled
Dangerous Decibels should be implemented in classroom settings. This fun and effective
program, which is evidenced based, educates about the hearing process and dangers to hearing,
instilling the above three messages with fun hands on activities and discussions that promote
ongoing dialogue between teachers and students and interpersonal communication with role
modeling as a part of the educational model instead of the self-directed manner of the Dangerous
Decibels internet and museum interventions. Also, the classroom structure enables that all are
given the key educational messages of hearing protection. Occupational therapy practitioners
could also lead the Dangerous Decibels Program as a preventative health method. Furthermore,
they could train high school students as older peer educators to present Dangerous Decibels to
students in elementary schools.
Occupational therapy practitioners should have the awareness that the Dangerous Decibels
museum based intervention has an effect to influence larger numbers of people in a cost effective
manner as it provides an awareness of the hazards of loud sounds and so could be referred to as
an option for education. The museum exhibits disadvantage is that it has educational effects that
are dependent upon the depth of self- direction and attention span and interest in each activity or
exhibition component (average length of engagement for children less than 13 years of age with
a standard component was 41.8 seconds and those designed with average prolonged engagement
protocols was 167.7 seconds), (Martin et. al. 2012). The Dangerous Decibels internet based
intervention may serve multiple roles, according to Martin et. al. (2012), to introduce the topic to
young people, and serve as a limited educational tool or as an adjunct to a classroom program as
a part of a comprehensive approach to hearing health education. Occupational therapy
practitioners should understand that each of the interventions lost some of the beneficiary gains
achieved over time and that the effectiveness and sustainability of any health promotion efforts
are likely to be improved by using multiple interventions of modalities, but this has yet to be
proven in hearing-loss prevention efforts, (Martin et. al. 2012).
Children, adolescents and teens could be educated by occupational therapy practitioners
toward making independent personal choices for protecting their hearing. According to Gilliver,
Beach & Williams (2013), Programs that include an increased focus on personal susceptibility
and that stimulate concern about the consequences of hearing loss, and refer to personalized
examples of high-noise leisure activities may be more effective in motivating unconcerned and
concerned young people alike to actively engage in noise reduction behavior. Program
development for hearing loss prevention would be within the training of occupational therapy
practitioners, and also serve what is an emerging field in OT according to the AOTA.
Occupational Therapy should be conscious about the effects of noise upon the hearing of
infants as well and be concerned about educating for early infant screening for hearing problems,
be alert to the particular diagnoses that are vulnerable to hearing loss. (Johnson, Newman,
Danhauer, and Williams, 2011).
Also, within easy reach for occupational therapy practitioners to recommend and use are
hearing protection aids that raise hearing protection to the cool and fun level. These include

earmuffs by Alpine Muffy, My-T-Muffs, Peltor Kid, Pro-Ears and Silenta. In 2010, Baylen
Brees, when he was one year old watched his dad, football player Drew Brees, win the New
Orleans Super Bowl while wearing Peltor (Stump, 2014). There are also Westone Audios
DefendEar custom earplugs that come in glittery colors and swirly patterns. There is Etymotics
Ety-Kids and KonoAudios Kidsafe volume limiting earbuds for children to enjoy music and
video games (Stump, 2014).
Parents need to be educated toward preventative hearing care for infants and young children.
Infants who pass newborn screenings and have propensity for late onset hearing loss due to
inherited genetic diseases should have parents alerted to schedule follow up screenings. Parents
should be educated on being good role models for their children in choosing to use hearing
protection for themselves while using loud equipment such as lawn mowers and chain saws and
recreational items such as guns. According to Levey et. al. (2012), adults can take on the role of
powerful models by wearing hearing protection in the same way they wear sunscreen and
sunglasses.
Another rule for occupational therapy practitioners to teach children and parents is the 80/90
rule for MP3 players. According to Stump, (2014), applying the 80/90 rule for MP3 players is to
listen at no more than 80 percent of maximum volume for no more than 90 minutes and to lower
the volume even more and listen for a shorter period in using a CD player and headphones.
Stump, (2014), also recommends to identify sources of loud sounds and avoid or limit exposure
to them, turn down the volume of music systems and lock in settings to limit the maximum
volume that they can be played at and use hearing protection devices like earplugs at loud
concerts or sporting events.
Noise induced hearing loss from childrens toys is a concern that occupational therapy
practitioners should include when educating parents and the public to provide a preventative
means of preserving the hearing of infants and children. According to Stump (2014), in a 2012
article in the journal, Communication Science and Disorders, Fligor and colleagues cited a
University of California-Irvine study detailing common toys at decibel levels high enough to
cause permanent hearing damage. Rattles and squeaky toys have been measured at sound levels
as high as 110 dBA. Musical toys, drums, and horns can reach 120 dBA, and toy phones
between 123 and 129 dBA (Stump, 2014). Toys that make firearm sounds such as toy guns
produce sounds as loud as 150 dBA even if a child is standing a foot away from the source of the
noise (Levey, Fligor, Ginocchi, Kagimbi, 2012). Sound levels for moving toys such as toy cars,
were 82-100 dBA with the prediction that exposure for several hours a day may cause NIHL
(Levey et al. 2012). Measurement of stationary toys was 130-140 dBA requiring that children be
monitored for limited frequency and duration of use to prevent NIHL (Levey et al. 2012). The
measurement of toy weapons showed peak values of 143-153 dBA and of firecrackers of 125156 dBA indicating the need for ear protection to prevent NIHL when children are exposed to
these events (Levey et al. 2012). Noisy toys may have a greater impact than sound level
measurements show. For example when a child holds a toy that emits 90 dBA at arms length, the
level is actually 120 dBA when the toy is held at the ear, which equals the take-off level of a jet

(American Speech-Language-Hearing Association, 2011). To summarize, NIHL can result from


innocent play (Levey et al. 2012).
Occupational therapy practitioners should be sensitive to loud environments for early
childhood, and especially for infants, toddlers and preschoolers who are vulnerable to being
captive in places with adults who likely need education on hearing health and are prone to be
unaware of how sound levels may harm the hearing of infants and children in their care and
educate these populations as well.
Monitoring noise levels in the environments of schools and daycares, due to its negative effect
upon the academic achievement and development of children, in addition to the threat of damage
to hearing, give occupational therapy practitioners on staff the opportunity to guide and educate
about hearing loss prevention. Sound level meters are fairly inexpensive and would be a great
tool for OT practitioners to have to teach about sound decibel levels and to assess areas for high
decibel levels for protection of childrens hearing and to help school staff and students be
independent in assessing of how loud is too loud. The meters could be promoted for use of staff
in schools and day cares (Levey et. al. 2012).
Occupational therapy which promotes the therapeutic use of person as an advantage of the
practitioners in its field, can develop personal messages that are an effective promotion for
adopting hearing loss prevention practices. OT practitioners can make hearing loss prevention
interventions client-centered to influence those who are less open to hearing protection practices.
Occupational Therapy can be aware of the signs of hearing loss so they can make a referral
and help clients manage the activities and occupations of their lives and educate others about
hearing improvement. According to Levey et. al. (2012), behaviors of children that exhibit
hearing loss are asking for repetition, misunderstanding what is said to them, appearing
inattentive to tasks involving listening, having problems with certain sounds, watching other
children to understand what they are saying or doing, are fatigued at the end of the day, or
withdraw from situations that require good listening skills.
Occupational therapy is interested in child development and should educate about
developmental milestones and hearing, such as a newborn who does not startle to loud noises and
a four month old who does not react to a familiar voice. (Johnson et. al. 2011). A checklist could
be made for parents to check what their baby can hear in the first year and be advised to speak to
appropriate health professionals if they are concerned. (Johnson et. al. 2011). The checklist could
be made for older children with signs of hearing loss such as they may not respond to sounds,
they may increase the volume of the television or sit very close to it and they may not speak
clearly due to high frequency hearing loss because they cannot hear consonants. (Johnson et al.
2011). Other signs of hearing difficulty can be behavioral changes like attention issues,
academic struggles, and social problems with peers. (Johnson et al. 2011). All of these could be
put onto a checklist for occupational therapy practitioners to give to clients.
Audiologists, speech pathologists, and other professionals like occupational therapy
practitioners can raise public awareness about how hearing can be damaged by excessive sound
exposure, the consequences and permanent nature of hearing loss, and how and why noise
induced hearing loss can and should be prevented. The main source of exposure in a study of

teenagers in a Mexico City public school was to recreational noise such as discotheques and pop
music concerts, use of personal stereos, and noise exposure in school workshops. Occupational
therapy could educate the general community about decibel levels that cause hearing loss and
about the importance of turning down the volume of PLDs and of wearing hearing protection
(Knobel et al. 2011).
Hearing is vital to participation in occupations and involves sensory experience that is
within the scope of occupational therapy which seeks to promote health and wellness with a
healthy balance of activities in order to avoid occupational imbalance, occupational deprivation
and occupational alienation, (Padilla, Connen, Lohman, 2012.) Protecting against hearing loss
assists in promoting optimal occupational performance. According to Scaffia & Reitz (2014),
occupational therapy practice is based on the premise that participation in meaningful
occupations can improve occupational performance and overall health and well-being. Hearing
loss prevention is an important focus for OT practitioners to adopt and promote for the overall
health and well-being of infants and children.

Review Process:
Inclusion Criteria: Peer reviewed articles from 2003-2014. Infants who have a positive
screening for hearing loss, children who are at risk for delayed onset hearing loss, daycare
children, preschool and school age children, and teens. North Americans, occupational therapy,
prevention, preventative hearing loss programs for the young, prevention in schools.
Exclusion Criteria: Adults. Peer reviewed articles before 2003.
Search Strategy: Ebsco host, The American Journal of Occupational Therapy
Categories
Patient/Client Population
Intervention

Key Search Terms


Infants and children
Occupational Therapy and Hearing loss
prevention

Comparison
_____________________________________
Outcome
Occupational therapy interventions for
protection against hearing loss in infants and
children. The role occupational therapy
practitioners can take in promoting hearing
protection interventions in infants and
children.

Databases and Sites Searched:


Databases: Ebsco Host
Sites: JFPonline.com
Quality Control/Peer Review Process: A question using the Patient, Intervention, Comparison,
Outcome method was formed from the emerging field of prevention in occupational therapy
according to the American Occupational Therapy Association website. Hearing prevention was
the desired focus from observation of the importance to protect hearing from the earliest ages.
Peer-reviewed articles were searched using the Northland Community Technical College library
data base. Eight articles were identified and chosen as appropriate to meeting the goal of
providing evidence for occupational therapy to promote effective hearing loss prevention
strategies and focus for this population. This document was peer reviewed by two occupational
therapy assistant students at Northland Community Technical College and the Evidence for
Practice instructor.

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of Evidence Study Design/Methodology of Selected
Number of Articles Selected
Articles
Level I
Systematic reviews, meta-analysis,
two
randomized controlled trials
Level III,

One group, nonrandomized (e.g., before


and after, pretest, and posttest)

one

Level V

Case reports and expert opinion, which


include narrative literature reviews and
consensus statements

five

Limitations of the Studies Appraised:


Level I:
Randomized trial of four noise-induced hearing loss and tinnitus prevention interventions
for children. International Journal of Audiology, Martin, Griest, Sobel & Howard, (2013).
Study limited by only being conducted in fourth grade classrooms in Oregon and Southwest
Washington.

Formal consent for participation by each student was not required. Parents only required to send
back consent form if they did not want their child to participate. No info was collected that could
be used to identify participants and without this, formal tracking of individual participants was
not permitted and so comparison of results analyzed at the classroom level rather than at the
student level. Global impact of the classroom method is limited by the number of individuals that
can be reached. Typical class size is 20-30 students.
Knowledge, habits, preferences, and protective behavior in relation to loud sound
exposures among Brazilian children. International Journal of Audiology, Knobel & Lima,
(2012).
Studys drop-out rate was 31%, although it was similar in private and public schools, and did
not change the basic age and gender distribution. The reliance on self-reported measures of noise
exposure, and the lack of data about how frequent or infrequent the exposures were is a
limitation. History of noise exposure was based on self- report so it may be possible that
children and parents under or over reported noise exposure.
Level III:
Noise with attitude: Influences on young peoples decisions to protect their hearing.
International Journal of Audiology, Gilliver, Beach, & Williams, (2013).
Survey limited to 1000 Australian young adults 18-35 years.
Results based on a number of subjective questions made to prompt attitudes and perceptions of
hearing health by self- report. Online design made it not possible to validate things against
independent objective measures of behavior or hearing health, therefore accuracy of the findings
of the study will be limited by the accuracy of participants responses and their idea of items for
example some may have over-represented how far their involvement with noise reduction
behavior occurred. The extent to which question wording may influence response.
Level V:
Hit the mute button. Hearing Health, Stump (2014).
Research demonstrates an individual susceptibility to NIHL so that two persons with identical
noise exposure will not necessarily end up with the same hearing damage and determining who
is more susceptible is not yet able to be determined. Hearing protection ideas do not include
ways to manage and use peer pressure to promote hearing protection.
Prevention of adverse effects of noise on children. Noise & Health. Bistrup, (2003).
Study consultants limited to Denmark, Germany, Italy, the Netherlands, Sweden and the United
Kingdom. Study limited to environmental preventative hearing protection strategies and does not
include habits or personal actions suggested for children to prevent hearing loss. Settings limited
to European children in day-care centers, primary schools, and discotheques and festivals.
Problem with babys hearing? An intervention checklist. The Journal of Family Practice.
Johnson, Newman, Danhauer, & Williams, (2011).

Clinical tool limited to physicians serving as medical homes for children with hearing loss
and their families.
Checklist has inconsistent or limited quality patient oriented evidence.
Sonic youth. The Asha Leader. Folmer, (2013).
Means of passing on hearing prevention messages outside the classroom not included. Children
who are in nontraditional families not included or in other geographic areas such as reservations
and government military bases not included.
The Effects of Noise-Induced Hearing Loss on Children and Young Adults. Comtemporary
Issues in Communication Science and Disorders. Levey, Fligor, Ginocchi, Kagimbi, (2012).
Most NIHL literature describes sound exposures based on sound pressure levels in A-weighted
decibels. Applying A-weighting to measures of sound exposure over all intensities of sound
capable of causing hearing damage may not be appropriate.
Individuals with identical noise exposure likely wont have the same resulting hearing damage.
Guidelines for dBA levels that are recommended for hearing safety against NIHL vary.

Articles Selected for Appraisal:


Bistrup, M.L.(2003). Prevention of adverse effects of noise on children. Noise and Health,
5;19, 59-64
Folmer, L.Robert (2013). Sonic Youth. The ASHA Leader.
Gilliver, Megan, Beach, Francis Elizabeth, & Williams, Warick, (2013). Noise with attitude:
influences on young peoples decision to protect their hearing. International Journal of
Audiology, 52, 526-532.
Johnson, E. Carol, PhD. AuD; Newman, W. Craig, PhD; Danhauer L. Jeffery, PhD; Williams,
A. Victoria, BA. (2011). Problem with babys hearing? an intervention checklist.

Knobel, Keila, Alessandra, Baraldi,, & Lima, Pinheiro, Marconi, Cecilia, Maria, (2012).

Knowledge, habits, preferences, and protective behavior in relation to loud sound exposures
among Brazilian children. International Journal of Audiology, 51:S12-S19.
Stump, Elizabeth (2014). Hit the mute button. Hearing Health.
Levey, Sandra, Fligor, Brian J., Ginocchi, Caterina, Kagimbi, Loise, (2012). The effects of
noise-induce hearing loss on children and young adults. Contemporary Issues in
Communication Science and Disorders. Vol. 39, 76-83 NSSSLHA 1092-5171/12/39020076
Williams Hal Martin, Griest, Susan E., Sobel, L. Judith, Howarth, C. Linda, (2013). Randomized
trial of four noise-induced hearing loss and tinnitus hearing loss interventions for
children. International Journal of Audiology, 52, s41-s49.
Other resources found:
American Speech-Language-Hearing Association. (2011). Home, community, and
recreational noise. Retrieved from
http://www.asha.org/uploadedFiles/AIS-HomeCommunity-Recreational-Noise.pdf.
Chernak G.D. & Peters-McCarthy E. (1991). The effectiveness of an educational hearing
conservation program for elementary school children. Lang Speech Hear Serv Sch, 22,
308-312.
Coelho C.B., Sancher T.G. & Tyler R.S. (2007). Tinnitus in children and associated risk factors.
In: B. Langguth & A.R. Moller (eds) Progress in Brain Research: Elseevier, pp. 179-191.
Kim M.G., Hong S.M., Shim H.J., Kim Y.D., Cha C.I. et al. 2009. Hearing threshold of Korean

adolescents associated with the use of personal music players. Jonsei Med J, 50, 771-776.
National Institute On Deafness and Other Communicable Disorders. (2007). Noise-induced
hearing loss (NIH Publication No. 97-4233). Bethesda, MD: Author.

USWFS 2006. 2006 national survey of fishing, hunting, and wildlife-associated


Recreation errata sheet for national report. In: U.F.a.W.Service (ed.).

Martinez-Wbaldo M.C., Soto-Vazquez C., Ferre-Calacich I., Zambrano-Sanchez E, NoguezTrejo L. et al. 2009. Snesorineural hearing loss in high school teenagers in Mexico City
and its relationship with recreational noise. Cad Saude Publica, 25, 2553-2561.

Mitzelfelt, R. (1996). Albuquerques environmental story. (www.cabq.gov/aes/s5noise.html).


City of Albuquerque (accessed 19 December 2002).
Niskar A.S., Kieszak S.M., Holmes A.E., Esteban E., Rubin D. et al. 2001. Estimated
prevalence of noise-induced hearing threshold shifts among children 6 to 19 years of age:
The third national health and nutrition examination survey, 1988-1994, United States.
Pediatrics, 108, 40-43.
Trejo L. et al. 2009. Sensorineural hearing loss in high school teenagers in Mexico City and
its relationship with recreational noise. Cad Saide Publica, 25, 2553-2561.
Vogel I., Verschuure H., van der Ploeg C. P., Brug J. & Raat H. 2010. Estimating adolescent risk

for hearing loss based on data from a large school-based survery AJPH, 100, 1095-1100.
WHO (1997). Strategies for prevention lf deafness and hearing impairment. Prevention of
noise-induced hearing loss. No.3 in series. Geneva: Report of a World Health
Organization- Prevention of Deafness/Hearing Impairment Informal Consultation,
www.who.int/pbd/pdh/Docs/NOISREP_V08.pdf,p.6.
Widen S.E.O. & Erlandsson W.I. 2004. The influence of socio-economic status on adolescent
attitude to social noise and hearing protection. Noise and Health, 7, 59-70.
Zogby, J. (2006). Survey of teens and adults about the use of personal electronic devices and
headphones. Retrieved from
http://www.nsslha.org/NR/rdonlyres/10B67FAI-002C-4C7BBAOB-1COA3AF98A63/0/zogbysurvey2006.pdf.

Other sites:
http://www.JEPonline.com

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