The Hearing Report

Fndngs and initial recommeridations of the Board of Health Committee on Hearing

\

1984

LIBRARY DEPARTMENT OF HEAlTH!r1J" WELlJNGTON ':)" COPYRIGHT

With due acknowledgment, this report may be freely copied or quoted; but no.t for a commercial .ageI1cy or for commercial purposes.·

11 FOREWORD

Hearing impairment is one of the most prevalent, preventable, yet ignored disabilities. Such an invisible handicap evokes little sympathy, yet thousands of New Zealanders and their families are affected by its complex personal and social ramifications. One of the main outcomes of deafness and hearing impairment is difficulty with interpersonal communication, leading to learn­ ing difficulties and failure to develop skills necessary for self advocacy. Social growth. may be compromised sometimes to a severe degree. While deaf and hearing impaired people were consulted in the course of producing this report, it is essential that further working parties involve the 'consumer' much more extensively. We, the hearing, often choose to 'turn a deaf ear' to the needs of the hearing impaired. This report draws together information from a wide range of sources. In the course of gathering data on deafness and hearing impairment in New Zealand, large gaps in our knowledge became apparent. A mismatch between needs and available services was also found, despite recommendations in earlier reports such as Deafness the invisible handicap. It is hoped that the. recom­ mendations set out in Part 4 of the Hearing Report will be followed by multidisciplinary cooperation and action, at national, regional, and local level. The work of the committee has culminated in a result which is required reading for those with responsibilities for the wellbeing of hearing impaired people. A /J (J1 ' ~rI d.U~

D Short Chairman Board of Health November 1984

III BOARD OF HEALTH

Dr Douglas SHORT (Chairman) Mrs Betty BIDDLES Professor Michael COOPER Dr Mason DURIE Dr Bruce FOGGO Mrs Myra GRAHAM Mrs Jean McCORKINDALE Mrs Val O'SULLIVAN Mr Clive ROSS Professor Fred SHANNON Mr Nelson SPIERS Dr Ron BARKER-Director General of Health (ex officio) Ms Val TAYLOR (Secretary) .

COMMITTEE ON HEARING

Chairman Kenneth W NEWELL MD MB ChB MFCM MCCM DPH -Professor of Community Health, Wellington Clinical School of Medicine (until December 1983) . John W ROSE (from December 1983) - Parent of two profoundly deaf boys. Twenty years with parent and deaf organisations. Worked on the report, Deafness the invisible handicap Members Joy BAIRD BA(Hons) -Senior Advisory Officer, Department of Social Welfare Sefton BARTLETT TIC -Principal, van Asch College, Christchurch (until May 1984) Richard Campbell BEGG MB BCh D Obst RCOG DPH DIH MCCM -Director, Division of Health Promotion, Department of Health Michael (Mike) CODDINGTON BSc (Psychol) Dip Aud -Senior Audiologist, Middlemore Hospital Patrick W Eisdell MOORE OBE MB ChB FRCS FRACS·DLO RCP -Surgeon, Consultant in Otolaryngology to the Department of Health Edward (Ted) C GALLEN -Chief Executive Officer (Development), Department of Social Welfare

v .1. Hazra ISMAIL MSc (Soc Med) MB BCh DCH. MFCM MCCM -Principal Medical Officer, Division of Health Promotion, Department of Health (Co-opted to the committee) William (Bill) J KEITH BA MA (Hons) PhD - Principal Audiologist, Audiology Centre, Division of Health Promotion, Department of Health (Technical Secretary to the committee) Janet LAUDER RGON RM DipN . -Principal Public Health Nurse, Timaru District Office Murray LAUGESEN MB ChB Dip Obst FRCS MCCM ' -Principal Medical Officer (Research), Management Services and Research Unit; Department of Health (Co-opted to the committee) John MILLS MB ChB DComH' -Principal Medical Officer, Hospitals Division, Department of Health (until November 1982) . Keith W RIDINGS MB ChB DA RCP RCS MCCM (from November 1982) Mary ROBERTS BA Dip Tchg TTC endorsed -Education Officer (Special Education), Department of Education (from May 1984) Ian A STEWART MB ChB FRCS -ENT Surgeon, Senior Lecturer in Otolaryngology and Head and Neck Surgery, University of Otago S Rae WEST MB ChB Dip Obst FRCGP FRNZCGP MCCM -Associate Professor of General Practice, Helj,d of Department of Com­ munity Health and General Practice, University of Auckland , Rex E WRIGHT-ST CLAIR MD MB ChB MRNZCGP MCCM , -Medical Superintendent, Extramural Hospital Waikato Hospital Board Secretaries Antonia COCHRANE 'BSc -Advisory Officer, Department of Health (until February 1983) Florence CAUGHEY BA(Hons) -Advisory Officer, Department of Health (until February 1984) Paula McIVOR MA (Hons) -Assistant Advisory Officer, Department of Health (from February 1984) Hearing Research Project Kenneth W NEWELL MD DPH MCCM MFCM -Principal Investigator, Professor of Community Heaith, Wellington Clin­ ical School of Medicine Kathleen C BOSWELL MA Dip Ed - Research Investigator, Department of Community Health, Wellington Clinical School of Medicine

Vi ACKNOWLEDGMENTS

Parts 1, 2 and 3 of this report were written by Kathleen Boswell and Kenneth Newell. Part 4, the recommendations, was written by Kenneth Newell as part of an interim report to the Minister of Health, and revised by Bill Keith. Funding for the Hearing Research Project was provided by the Health Services Research Committee of the Medical Research Council for one year from February 1983. Since February 1984, Kath Boswell's salary has been paid by the Management Services and Research Unit of the Department of Health. The authors would like to thank Lucy Carpenter, MRC Statistician, Wel­ lington Clinical School, and a1l members of the Committee on Hearing. Specific help from individuals is acknowledged at the end of the appropriate section. Many other organisations and individuals provided information for this report. Help from staff within the following organisations is gratefully acknowledged: • Audiology Centre (formerly National Acoustics Centre), Department of Health, Auckland • Dunedin Multidisciplinary Health and Development Research Unit • Christchurch Child Development Study • Management Services and Research Unit, Department of Health • Division of Health Promotion, Department of Health • Bureau of Public Health and Environmental Protection, Department of Health • District Offices of Health throughout New Zealand • Kelston School for the Deaf, Auckland • van Asch College, Christchurch • Speech therapy clinics throughout New Zealand • Wellington Field Office for the Deaf • Wellington Hospital Board ENT and audiology clinics

We would also like to thank: • the necessarily anonymous persons who are the 'case histories' • the industries and institutions which have provided data but whose request for anonymity we have respected

vii • Winifred Lamb for her help with collecting data • Colin Boswell for the computer graphics • Pat Stanton, Mary Tuipulotu (Wellington Clinical School), Elaine McKenna and Niargaret Brown (MSRU) for typing assistance • Emma Mihaere for her patience and word processing skills • Paula McIvor for editorial assistance • Karen Smyth for editorial and production assistance • Erina Chapman and Marjorie VandenBerg for help with proofreading.

TERMS OF REFERENCE OF THE COMMITTEE ON HEARING

To make recommendations to the Minister of Health in respect of:

1 The identification of the extent and nature of problems relating to defective hearing and ear disease'in New Zealand. 2 The measures necessary to ensure prevention, early detection and adequate management, including rehabilitation. 3 The effective coordination and expansion of services which will be required to meet present and future needs.

viii PREFACE

The initial tasks of the Committee on Hearing were to examine the extent and implications of hearing impairment in the community in New Zealand, and to review hearing services. Both tasks were daunting, the first because so little quantitative information on the extent of hearing impairment in New Zealand has been recorded and the second because of the difficulty of con­ sidering all types of hearing impairment as a single entity. A further problem that faced the committee was that of trying to quantify the often tragic effects of hearing loss on individual lives. The far-reaching consequences of hearing impairment on education, personal development, the realisation of potential and the quality of life are less apparent than the effects of most other hand­ icaps or health problems. In the course of their deliberations committee members have become aware of, and felt frustrated by, the limitations of statistics in conveying the implications of deafness. The lack of basic quantitative information meant that the committee had first to address itself to remedying this deficiency. In this regard the com­ mittee gratefully acknowledges the assistance of the Health Services Research Committee of the Medical Research Council of New Zealand which pro­ vided funds for a research officer to assist the committee in the tasks of gathering and reporting data on the incidence and prevalence of hearing . impairment, and describing hearing services in New Zealand. These studies, known as the Hearing Research Project, have been reported in Parts 1-3: • Part 1 presents a series of case histories to illustrate some of the effects of hearing impairment on everyday life • Part 2 brings together existing data on the incidence and prevalence of hearing loss and ear disease in New Zealand • Part 3 describes the provision of services for the hearing impaired. The Committee on Hearing has presented its recommendations in Part 4, based on information collected in the course of the Hearing Research Pro­ ject, together with other important concerns which have been brought to the attention of the committee. ~

IX CONTENTS

Page

PART 1 INTRODUCTION AND CASE HISTORIES 1 WHY GATHER DATA ON HEARING IMPAIRMENT?. 3

2' WHAT ARE THE EFFECTS OF HEARING IMPAIRMENT?...... ,...... 4 2.1 John ...... :...... 5 2.2 Diana ...... :...... 8 2.3 Tony ...... '...... 9 2.4 Peter ...... 10 2.5 Moana...... 11 2.6 Josie ...... 12 2.7 Eruera...... 14 2.8 Sam ...... 15 2.9 Mary ...... :...... :...... '...... 15 2.10 Frederick ....;...... :...... 17 2.11' George ...... 18 2.12 Don ...... , . 18

PART 2 INCIDENCE AND PREVALENCE OF HEARING LOSSAND'EAR DISEASE 3 INTRODUCTION ...... :...... 23

4 THE PRELINGUALLY DEAF AND SEVERE DEAF­ NESS ACQUIRED IN CHILDHOOD ...... ,...... 25 4.1 Effects of early deafness ...... 25 4.2 Type and cause of deafness...... 26 4.3 Incidence and prevalence of deafness in children .. 28 . 4.4 Rubella...... 32 4.5 . Regional differences ...... '...... 33 4.6 Summary ...... :...... 34 5 OTHER HEARING IMPAIRMENT IN CHILDHOOD ...... 36 5.1 Type and cause of hearing loss ...... 36 5.2 Prevalence of hearing loss ...... 37 5.3 Incidence and prevalence of ear disease ...... 40 5.4 Longitudinal data on' otitis media ...... 43 5.5 Spontaneous improvement and regression ...... 47 5.6 Regional variation in school screening failure rates...... :...... 50

x 5.7 Prevalence in special populations ...... 53 5.7.1 Children with speech and language problems ...... 53 5.7.2 Intellectuall y handicapped children ...... 53 5.7.3 Children with multiple handicaps ...... 54 5.8 Summary·...... :.....:...... 'S5

6 HEARING IMPAIRMENT IN ADULTS ...... 61 6.1 Type and cause of hearing loss ...... 61 6.2 Prevalence estimates ...... 62 6.3 Severity of hearing loss ...... :..... 68 6.4 Noise-induced· hearing loss ...... 70 6.4.1 Criteria for notification ...... 70. 6.4.2 Prevalence ....:...... 70 6.4.3 Occupational data ...... 75 6.5 The elderly .:...... 77 6.6 Special populations of adults ...... 78 6.6.1 Armed forces ...... 78 6.6.2 Psychiatric hospital patients ...... 81 6.6.3 Intellectually handicapped adults ...... 82 6.6.4 Prison inmates ...... :...... 82 6.7 Summary ...... 83

PART 3 SERVICES FOR THE HEARING IMPAIRED 7 OVERVIEW OF SERVICES ...... 89 7.1 Listing of hearing services in New Zealand ...... 89 7.2 Available data on general services pertaining to hearing loss and ear disease ...... 92 7.2.1 Number and distribution of ENT specialists....:...... 92 7.2.2 Number and distribution of audiologists 93 7.2.3 Number and distribution of vision hear­ ing testers ...... :....:...... 93 7.2.4 Admissions to public hospitals for dis­ eases of the ear ...... :...... 93 7.2.5 Ear operations carried out in public and private hospitals ...... ;...... 94 7.2.6 Waiting lists for ENT surgery...... 94 7.2.7 PubliC/private working time of ENT specialists...... :...... :...... 94 7.2.8 Notifications of occupational deafness to the:: Department of Health...... 94

xi 7.2.9 Occupational hearing loss compensated by the Accident CO'mpensation Corporation...... 94 8 SERVICES FOR THE PRELINGUALLY DEAF ...... 95 8.1 Screening services ...... 95 8.1.1 Neonatal screening ...... 95 8.1.2 Infant screening...... 95 8.1.3 Screening of children with multiple handicaps...... ,...... 96 8.2 Medical and audiological services ...... 96 8.2.1 Preventive services ...... 96 8.2.2 Audiological services ...... 97 8.2.3 Medical services ...... 97 8.2.4 Age of detection of deafness...... 98 8.2.5 Notification of deaf children ...... 99 8.2.6 Psychiatric services for deaf adults...... 99 8.3 Educational services ...... 99 8,4 Rehabilitative and social services ...... 102 8.4.1 Voluntary groups ...... 102 8.4.2 Field Offices...... 102 8.4.3 Hearing aids...... 103 8.5 Consumers of the services...... 104 8.5.1 Findings from a report on physical disability ...... 104 8.5.2 A statement from the New Zealand Fed­ eration for Deaf Children...... 104 8.5.3 A statement from the New Zealand Asso­ ciation of the Deaf...... 106 9 SERVICES FOR CHILDREN WITH EAR DISEASE AND ASSOCIATED HEARING LOSS ...... 111 9.1 Screening services ...... ,.:...... :...... III 9.1.1 Impedance screening ...... 111 9.1.2 Pure tone screening ...... 111 9.1.3 Screening of special populations ...... :..... 113 9.2 Medical and audiological services ...... 114 9.2.1 Referral system ...... 115 9.2.2 Treatment for otitis media ...... 117 9.2.3 Diagnosis of central auditory perceptual dysfunction...... ,...... "...... ,...... ,' ..,.. ,',.,.... . 118 9.3 Educational services, ...... ,""',...... "...... ," ... ,...... 119 9.3.1 Developmental effects of conductive hearing disorders...... ,...... ,.. , 119 9.3.2 Preschool provision ...... 119 9.3.3 Classroom provision ...... 119

xu 9.3.4 Intervention studies ...... 120 ·9.3.5 Information services...... 121 10 SERVICES FOR ADULTS WITH ACQUIRED HEARING LOSS...... :...... :...... 123 10.1 Screening services ...... 123 10.1.1 Pre-employment and employment screening ...... :...... 123 10.1.2 Screening of the general population and the elderiy...... ,...... 123 10.1.3 Screening of special populations ..:...... 123 10.2 Medical and audiological services ...... 124 10.2.1 Referral system ...... 124 10.2.2 Hearing aids and hearing aid services ... .. 126 10.3 Rehabilitative (post hearing aid) services ...... 128 10.3.1 Audiologists ...... 128 10.3.2 Hearing Association ...... 128 10.3.3 Technological advances ...... 129 10.4 Consumers of the services ...... 130 10.4.1 Hearing News survey results ...... 130 10.4.2 A statement from a Hearing Association tutor ...... :...... 131 11 SERVICES RELATED TO NOISE-INDUCED HEARING LOSS...... :...... :...... 133 11.1 Introduction:...... :...... 133 11.2 Preventive services ...... 135 11.2.1 Control of noise and recording of noise . levels.: ...... "...... :...... '...... 135 11.2.2 Hearing protection...... :...... 136 .11.2.3 Hearing conservation. programmes ...... 136 11.4.4 Public .education ...... 137 11.3 Screening services ...... 137 12 OTHER ASPECTS Of·HEARING SERVICES ...... 139 12.1 Community education and awareness ...... 139 12.1.1 Publicity...... 139 12.1.2 Education ...... 139 12.2 Professional education ...... 140 J 2.2 .1 Training of professionals...... 140 12.2.2 Establishment of an otolaryngology and audiology unit ...... 141 12;3 Organisational aspects.: ...... :...... 142 12.3.1 Goals and priorities ..... :...... 142 12.3.2 Distribution of resources ...... :...... 142 12.3.3 Alternative patterns or strategies ...... 143 12.3.4 Implications .....:...:...... 145 xiii PART 4 RECOMMENDATIONS.

13 BACKGROUND...... 149

14 PRINCIPAL RECOMMENDATIONS...... 151 14.1 Public and professional awareness ...... 151 14.2 A national academic research focus ...... 153 15 GENERAL RECOMMENDATIONS...... 154 15.1 Congenital and prelingual deafness ...... 154 15.2 Other hearing impairment in childhood ...... 156 15.3 Acquired hearing impairment in adults ...... 157 15.4 Noise-induced hearing loss ...... 159 16 COMPLETE LIST OF RECOMMENDATIONS ...... 161 \

APPENDICES 4a Deaf children aged 5-15 years recelVlng special educational provision expressed as a percentage of total New Zealand school-age children, by age and region...... 167 Sa New and repeat episodes of otitis media, longitu­ dinal data...... 168 Sb Hearing testing at two schools for .the intellectually handicapped ...... 170 6a Prevalence of hearing defe<.::ts in the adult British population...... 172 6b New Zealand full-time workforce by type of occu­ pation, number in potentially noisy occupations ..... 173 7a (1) Number of ENT specialists by location, hos­ pital board areas in regional groupings, 1982­ 1984, actual and required ...... 174 (2) Number of ENT registrars by hospital board area 1982-1984...... 175 7b Number of audiologists by location, hospital board areas within regional groupings, March 1984, actual and required ...... ~...... 176 7c Estimated population served by vision hearing t~st- ers, December 1983 ...... :...... 178 7d Admissions to public hospitals for diseases of the ear and mastoid process, 1982, by race and age group...... 179

xiv 7e All ear operations carried out in public and private hospitals, 1982 ...... 180 7f Waiting lists for surgery as at 31 March 1982 ...... 181 7g Public/private working time of ENT specialists...... 182 7h Notifications of· occupational deafness to the Department of Health ...... :...... :...... 18~ 7j N umber of occupational hearing loss cases com­ pensated by the Accident Compensation Commis­ sion, by region ...... 184 8a Copy of form for notification of deaf persons ...... 185 8b Types of assistance received by J:tearing impaired students on the rolls of advisers on deaf children, as at 31 March 1984...... 187 8c Survey of services provided by the Wellington Field Office for the Deaf...... ,...... 188 8d Obtaining new hearing aids and other technologi­ cal aids to hearing .: a case study of a disadvantaged, congenitally deaf adult ...... 191 8e New Zealand Federation for Deaf Children survey...... 192 9a A description of a special referral system in a Dis­ trict Health Office ...... 194 9b Suggestions for improving vision hearing testing in schools : comments from a vision hearing tester ..... 196 9c (1) Number of myringotomies carried out in pub­ .. lie and private hospitals combined, 1982, by age and sex ...... 199 (2) Age at which myringotomies carried out, pub­ lic and private hospitals, 1982 ...... ,...... 199 lOa Obtaining hearing aids: a case history of an adult with acquired hearing loss ...... ;...... 200 lOb A statement from a Hearing Association tutor ...... 201 12a The subject of hearing impairment and care of the hearing impaired in medical and nursing school curricula...... :.....:...... ;...... ;...... 204

xv TABLES Page 4.1 Effects of severe and profound hearing loss in children, and service requirements ...... 25 4.2 Relative contributions to cause' of deafness in New Zealand children...... :...... :...... 27 4.3 Causes of profound deafness in Glasgow children ...... 27 4A Incidence of deafness in the New Zealand population ... 28 4.5 Prevalence of deafness in children by age, estimated rates per 1000 population...... 29 4.6 Prevalence rates for prevocational deafness and signifi­ cant bilateral impairment in non-institutionalized chil­ dren 'and young persons under 25 years of age, according to age and sex : United States, 1971 ...... 31 4.7 Number of children receiving special educational assist­ ance for the deaf,' by degree of hearing loss and deaf school catchment areas, as at 31 March 1984...... 31 4.8 Known deafness in children born 1980-81 with labora­ tory-confirmed rubella at birth, number and rate per 1000 by health district ...... 32 4.9 Regional comparison for children receiving special edu­ cation for the deaf, expressed as rate per 1000 of school- age children ...... 34 5~ 1 Prevalence of children failing school screening expressed as rate per 1000 population ...... 38 5.2 Prevaience of hearing loss in Dunedin cohort, expressed as rate per 1000 population ...... 39 5.3 Prevalence of hearing impairment in some small studies ...... 39 5.4 Incidence of otitis media by age, estimated rates per 1000 population ...... :...... 42 5.5 Longitudinal data on otitis media, calculated from data. provided by the Christchurch Child Development Study...... :... . 43 5.6 Percentage of· 5-year-olds by number of years with at least one attack of otitis media ...... :...... 44 5.7 Longitudinal classification of OME groups between the ages of five and nine, Dunedin cohort ...... 47 5.8 Degrees of 'significant' hearing loss in a psychopaedic popUlation ...... :...... :...... ;...... 55 6.1 Cause of hearing loss in Danish males aged 49-69...... 62 6.2 Prevalence of hearing loss across four frequencies by age, rate per 1000, USA 1971-75 ...... :...... 63

xvi 6.3 Prevalence of speech reception difficulties by level of amplification required to miss no more than five words from lists of sentences; by age, rates per 1000, USA 1971­ 75 ...... :...... 64 6.4 Severity of hearing loss, estimated percentage in differ­ ent severity categories, by age group...... 69 6.5 . Estimated prevalence of severe, profound and to.tal deaf­ ness in the New Zealand adult population, 15 years and over, extrapolated from the British' National Study of Hearing ...... ;...... :...... ,...... :...... :...... 69 6.6 Percent distribution o,f hearing loss exceediQg 50dB at 4kHz, right ear orily (HANES I) applied to correspond­ ing age groups in the New Zealand population...... 71 6.7 New Zealand full-time workforce by age group, esti­ mated number exposed to potentially hazardous noise:.. 72 6.8 New Zealand full-time workforce by type of ind'ustry, estimated number exposed to potentially hazardous noise ...... :...... : 72 6.9 High frequency hearing loss greater than 25dB in paper mill employees (aged 18-65), by frequency (Hz)...... 75 6.10 Prevalence of hearing loss in the workforce, some New :Zealand 'data .. ,...... :...... :;...... 75 6.1O(a) Biographical characteristics of those with hearing loss in a food processing plant ...... ,.-...... 76 6.11 . Prevalence of hearing loss in the elderly, recent overseas audiometric data ...... ;...... 78 6.12 Hearing loss in the armed forces, rate per 1000...... 79 6.13 Percent hearing loss in a psychiatric .population greater than 25dB in the better ear, averaged across 0.S-4Hz, by age...... 81. 6.14 Percent hearing loss in prison inmates, averaged across the frequencies of 0.5-2kHz, by race...... 82 6.15 Overall percentage hearing disability in prison ·inmates registered on the NAL scale, by race ...... ;...... 83 8.1 Number of deaf children receiving special educational provision expressed as rate per J000 of specified age groups...... :...... 100 8.2 Number of hearing impaired children and young people receiving spc:cial educational assistance, by schooling level and deaf school c~tchment area, as at 31 March ·1984...... :...... :...... 100 . 9.1 Preschoolers screened by vision hearing testers as a pro­ portion of 4-year-olds within each health district, 1983 112

xvii FIGURES'

Page 3a Model showing movement between' categories of hear­ ing ·lossand no hearing loss as a function of age ...... 24 Sa Incidence of otitis media, Christchurch and Finland, estimated rate per 1000 population ...... 42 Sb Estimated number of incidents of otitis media in chil­ dren 0':"5 years," Christchurch data ...... ::...... 45 5c Propor~ion of 5-year-old~ failing screening test by.Health District, 1982 ...... 51 5d Percent failing hearing screening tests by health dis­ tricts, 1982 ...... :...... 52 5e Percent failing hearing screening tests by health dis­ tricts, 1983 ...... 52 6a Prevalence of hearing defects overall ,ages by type of hearing loss, British adult population ...... :...... 65 6b Prevalence of hearing defects, by age group and 'type of hearing loss, British adult population, better hearing ear ...... 66 6c Prevalence o'f hearing defects, by age group and' type of hearing loss, British adult population, worse hearing ear...... 67 6d Hearing impairment in adults across age groups, com­ bined overseas data...... 68 6e Mean hearing levels for both ears combined in men, Norway...... :...... 74 6f Mean hearing levels for both ears combined in women, N'orway ...... ;...... :...... 74 6g Hearing loss in the New Zealand armed forces, by cate­ gory of force and age group ...... ,...... 79 6h Hearing loss in the New Zealand armed forces by age group, all forces combined ...... :...... 80 9a' Referral system for children failing preschool or school screening .:...... :...... :...... 114 lOa Referral system for adults with sensorineural hearing loss...... ,...... :...... :...... 124

XV111 Part 1

Introduction and case histories . 1 WHY GATHER DATA ON· HEARING IMPAIRMENT?_

Hearing impairment may be mild, moderate, severe, profound, or. total. It may be congenital, or acquired before or after· language is fully mastered; conductive, sensoririeural or mixed; stable, progressive or fluctuating; and/or the result of congenital or acquired diseases affecting the ear and its central auditory connections. [1 p !i1] In the United States, hearing impairment is. the single most prevalent dis­ ability. More persons suffer a hearing defect than have visual impairments, heart disease or other chronic conditions [2. p 7]. In a survey of physical disability in the Wellington Hospital Board area, deafness was shown to be a major cause of physical handicap. Of all handicapped persons, 4S percent were deaf, some also having another disabling condition [3 p 24]. Despite the frequency with which it occurs in the gener~l population however, hear­ ing impairment receives far less national attent~on than is justified by the number of persons so afflicted. [2 p 7] . Questions to be addressed by the Hearing Research Project for ·the Com­ mittee on Hearing were: • How many deaf and. hearing impaired New Zealanders are there, both children and adults? • What are the gaps in our information? • What services are provided for the deaf and for those with less severe hearing impairment? • Is there a discrepancy between. the numbers' requiring services and the actual provision of services?

3 2 WHAT ARE THE EFFECTS OF HEARING IMPAIRMENT?

The objective effects of hearing impairment have been described in Deafness the invisible' handicap [4 p 4-6] and are outlined in a Canadian health and welfare document as follows: The effects of hearing impairment are many and diverse, varying according to the degree of impairment, its nature and cause, age of onset, and level of language acquired prior to the occurrence of the impairment. The effects of hearing impairment are pervasive, longlast­ ing and cumulative. [1 p 61]

Deafness in in/ants In the infant, inability or severely reduced ability to hear sounds and speech produces early differences in parent-infant and infant-parent communication; vocalization tends to remain at a rudimentary level; phonetic repertoire is impoverished in comparison to that of normal hearing infants; vocal quality deteriorates in the absence of~ auditory feedback; comprehension of spoken language fails to develop (or does so only minimally); personal, social, and cognitive skills may be 'delayed; and cognitive strategies may differ. As the infant enters the second year of life, behaviour problems are frequently observed. In the absence of habilitative services for the child and his family, increasing deviance will appear; the child may cease vocalizing and rely on a primitive sys­ tem of gestures to communicate his needs. The prospect of normal schooling becomes less with each successive year during which little or no skilled help is made available. Hence, it has long been recognized that there is a need for early identification of children with severe or profound hearing impairment and for provision of habilitative and edu­ cational programs. [1 p 61]

Less severe hearing impairment in young children Those with less severe impairments also require help. The presence of a mild or moderate hearing impairment'ha~ a much graver impact when it occurs in infancy or early childhood than in later life.' Diminished ability to hear results in reduced exposure to spoken language, delaying language acquisition. The child who enters kindergarten with a mild or moderate loss, or history of such, almost inevitably has a language deficiency, and is therefore at risk of becoming academically and/or emotionally disadvantaged. Such cumulative effects can be minimized by a relatively small habilitative investment during early childhood. [1 p 611

4 Hearing impairment in adults When hearing impairment occurs in adults, the effects are not in the area of language acquisition, but in communication, especiaUy the reception of speech. The immediate impact of a sudden loss of hearing after normal language has developed is psychological in nature. The effect of a slowly progressing hearing impairment, such as is common among -senior- citizens, is to some extent the same. Difficulty in com­ munication will tend to. lead to withdrawal from social interaction and to feelings of loneliness arid worthlessness. Depending on the stage of life at which the loss of hearing occurs, the individual's career and life style may be adversely affected. As soon as hearing impairment is detected, the individual and his family should have access to a broad range of rehabilitative services. [1 P 61]

In this report the subjective effects of deafness are presented in the case histories of: • John: a young adult with profound prelingual deafness • Diana: a young adult with profound prelingual deafness • Tony: a 4-year-old with a history of ear disease and an obstructive general practitioner • Peter: a preschooler with glue ear • Moana: an 8-year-old with ear disease and hearing loss who is not receiving appropriate educational assistance • Josie: an II-year-old with deafness and speech problems, a victim of parental and educational neglect • Eruera: a IS-year-old victim of untreated discharging ears, untreated deafness, parental neglect and cultural alienation • Sam: a 9-year-old with learning problems arising from central audi­ tory processing dysfunction • Mary: an adult who has had progressive hearing loss since childhood • Frederick: an adult who suddenly became totally deaf and has par­ tially recovered his hearing • George: an adult with mild occupational noise-induced hearing loss • Don: a victim of occupational hearing loss verging on total deafness.

2.1 JOHN John's deafness was suspected at about 11 months. The family doctor agreed there might be a problem and referred John to a specialist who confirmed , profound deafness. This took about 3 months and in _the next 2 months the family had seen an adviser on deaf children and hac!. aids fitted. John's parents count themselves as fortunate because: 5 • their family doctor was willing to listen • neighbours with a deaf daughter were the first to suggest they see a . doctor about John's hearing • Jo~n was born just before a 'rubella epidemic .when the Depllrtment of Education 'was not under so much pressure'. . The cause of John's deafness was a recessive gene; this was diagnosed at age 22. Early questions about the cause were met' with uncertainty but when John was preparing for marriage the family thought it prudent to establish a cause of deafness. His account follows:

My name is John~ I was born in 1958 and so far as we know I was born with a profound hearing loss. Of course I am not writing this on my own as I do not have sufficient language. We will include a sample of my writing at the end of this paper. I have little memory of my early years in a central North Island village where an adviser called regularly. Our family moved toAuckland so that I could attend Kelston School for the Deaf as a day pupil. ' 'As a 4-year-old a,t school I can only rememper being very quiet, I can clearly remember going to a unit class at a nearby school with other children. The principal thought we were all clever enough but I was not clever at school. Our very good teacher tried hard to help me. I was upset that this school was too hard. for me. I could ,not write and could not talk well.· I was very upset when I had to go back to the School for the Deaf (SFD) after one year. All of my friends stayed at the primary school and I had to start to get some new friends at the SFD again. After a time I settled down enough to concentrate on learning again but asthma ,made me sick many days at school. The work at SFD was easier than at primary school. In Forms I and II some of myfriends from primary school came back to SFD and during these years I often found the work hard and did not understand much of it. I did not have the language to understand maths, English, social studies or reading. I did not have very much, speech. Only my family could understand me, and they had to tell other people what I was' saying and they had to tell me what other people said to me. They always had to change the words many times because I could not. understand all the words people used and I could not lip-read them very well. ' In the fourth form my teacher helped me a lot with speech. I cannot remember doing very much speech work earlier than this. I can remember the speech trainer ear phones hurting my head. We spent hours learning to say's', 'g', and 'h'. Some of us could learn like this but some could not, and many of us .learned some sign language from each other' at 'play time' and lunch time. The older boys would teach us. I think they learned from adults~ My teacher was very good but I was not learning anything. The third form and fourth form were the same and when I went to high school in the fifth form 1 could not follow the work because the language was too hard.

6 I went to the high school for woodwork and technical drawin.g and back to SFD for maths, English and ocher things. Maths in Forms I, II, III, .and IV. was very hard. In the fifth form maths improved except for division. It took a'long time to und~rstand dividing. In the 2nd year fifth form my parents were very upset at ,my poor speech and language and took me to a speech therapist who, in one-and-a-half years of 2 hours per week; improved my speech and English very much. I still cannot read very much. I cannot req,d the newspaper and cannot read my own mail. I have to get my family to tell me what it means. I cannot write a letter very well. I.have to use only easy words. My speech has improved: it is not very good but mostly I can make people understand what 1 say. My wzfe and I both talk to our cat and he knows what we say but he won't take notice of people with ordinary speech. I think it was hopeless at school. I am very disappointed I cannot' read. I went to the technical institute to learn my trade but I cannot get a Trade Certificate because J cannot understand the language. My familY have helped me. but they didn't understand how bad it was at school until I htld nearly left school. At work the men are very good to me but because I have to rely on lip-reading I don't always' know what they say or I don't know what the word means. Sometimes I ask them what that word means and the man will laugh and say 'don't you know what that means, never m{nd' and just keeps on'laughing, leaving me very ashamed and I never find out what he said. lam lucky that now 'one man is learning to sign, some from me arid I help him learn signs from the book and he helps me to learn the meaning of some of the words. . I have some friends. All of them are deaf and we communicate' with signs and lip reading but we only use simple words. We see my family often and i have a few hearing friends but" iti~ very tiring for them' and us but we enjoy being with them. Examples of John's own language: • We can't hear 'the phone • We not know what the TV talking about • We can't hear the car something wrong. We have ask hearing people if the car is alright • Sometime we don'i un.derstand wh'ai the doctor says • Sometime don't understand the mail • Sometime we never heard about milk and petrol on strike • Sometime it very hard to hear knock on door.

7 2.2 DIANA Diana was suspected of being deaf at approximately 9 months. Her mother had a friend nearby who had a baby a little older to compare progress with. Diana was potentially an 'at risk' baby, being the third child of an RH mother. A letter from the Department of Health automatically followed up subse­ quent pregnancies of RH mothers; it would appear that the 'at risk' register worked well in the case of Diana. National Women's Hospital called her in for a check-up every 3 months until she was 5 years old and every year until she was 14. Here is Diana's story: I was born in 1962. I am deaf When I was a baby I was very sick and was in hospital for a long time. As I grew older my mother worried because I did not learn to talk and I cried a lot and got very bad tempered. When I was about four-and-a-half I started at the School for the Deaf We were not allowed to use our hands to sign, we had to try to talk. We were made to sit on our hands, but when we went out to play the older children used to teach us to sign. I was always very sad because it was very difficult for me to learn speech and language without signs. I cried a lot. I hated school. 1 spent 12 years at school and left with very poor language and I cannot read or write. This is very embarrassing because people write things down for me because they think I can read. 1 cannot read the newspapers, recipe books or even my mail. 1 like to knit but have to get someone to read the pattern for me. I was very lonely at home too. Nobody knew how to help me, nobody could understand me, so I used to get very upset and throw tantrums. I used to want to know what my family was talking about or what the TV was saying but was told Wever mind, never mind' or 'Shut up, we can't hear' or '1 will tell you later' but they never told me. When I started work it was terrible. 1 couldn't understand them and they could not understand me. They used to write things down but 1 was too embarrassed to say 1 could not read. Nobody was very nice to me and 1 felt very sad and lonely. 1 left that job. They were pleased that 1 left and the, boss clapped his hands and said he was happy that I was leaving. My second job was quite good and the people were very good to me but there was a big fire. No job. The work I have now is very good and everyone is good to me but they find it hard to talk to me and I find it hard to talk to them,~ut they do try. When 1 met my husband it was a lot better. We were happy together and we talk in sign and understand each other. My husband's family are very good to me and they help me a lot. They always talk to me and help me to understand. I used to get upset sometimes because the children used to pull my leg and 1 didn't understand that they were joking, but I soon learnt that they would not hurt me and they would explain about what they were saying. I spent a lot of time at my husband's home with his family.

8 We did many things together. I.never felt left ·out. They always explain about television and what people are saying. I learnt to cook meals and cakes and bi.scuits. I learnt to knit and many other things. My husband and I have a lot of deaf friends. We sign to each other, we talk too, but more signs really. It is much easier to sign when you do not have enough words. We go out to dinner with our friends and we visit our friends in their homes. Most of them are married now and all of them are married to deaf people. It is much easier to marry a deaf person because hearing people do not under­ stand us very well. It· is very hard to be deaf. It is very lonely. You cannot hear the radio. We often don't understand what is happening on television. We have 10 have special door bells because we cannot hear people knocking on the door and people think we are intellectually handicapped because we sound funny and don't understand. In a crowd it is easier just to be quiet and just smile nicely. Schools seem much better now because the children learn to sign and they have a lot of language and can read and write a lot better. I wish we had learnt with signs. It is much easier. Here are a few things that are a real problem: • Going to the doctor and trying to explain what is wrong without an interpreter • Shopping, asking for things you can't see on the shelf, quantities etc • When people go on strike we never know about it, milkman, petrol etc • Letting the boss know when you are sick and cannot: go to work • Making people understand that we are only deaf, not stupid • . Having to get someone to write our personal letters (or correct what we write ourselves).

2.3 TONY A mother describes her preschooler's history of ear disease and the obstruc­ tive behaviour of her general practitioner: Tony was born in May 1980. Before the age of 10 monihs he had otitis media in his right ear and was on his second course of Amoxil. At 12 months he had a cold with tonsillitis. Every winter he seemed to live on Amoxil and was plagued with persistent colds and sore ears. He attended Plunket in May 1983 for his 3-year check and was referred to the medical officer for her opinion. At the end of May we attended the Otara Ear Clinic and had a tympanogram done which was 'flat'. I was given the result of the test with a covering letter from the clinic to take to my GP for his information and for referring on to a specialist. My GP's opinion was that the test seemed normal and that Tony's ears were not affected. This was approximately one week after the test had been done. Tony

9 complained of sore ears again during the winter months andagam 1 took hzm to my GP with no result. I spoke to my plunket nurse about Tony's bad ears and she referred me again to the clinic., By thi's time the results were norma'. In September I took Tony back to the GP with a cold and sore ears. He said his ears looked normal but zj I was concerned that Tony's hearing was affected 1 should take him to the National Acoustics Centre in Remuera. 1 rang the centre for an appointment and 6 months later I was rung by them and asked to have Tony there by the next morning. * The tests showed he had abnormal hearing and I was once again given a letter to this effect to take to my GP. On vi'siting my GP he finally conceded that Tony should perhaps be referred to a specialist. Two weeks later I took Tony to see the specialist. At this time he was ill, very pale and complaining of sore throat, sore ears and sore stomach. He was examined by the specialist whose verdict was grommets in his ears, adenoids and tonsils out and nose cauterised. This was done in May 1984, 3 years after his first diagnosis olear trouble. Since his operation he 'has not had any bad colds or sore ears. His health has improved one hundred percent com­ pared with the previous three winters.

*Tony's mother was given a cancelled appointment.

2.4 PETER Four-year-old Peter's story is told by his ENT surgeon: Peter's birth was normal and his landmarks unremarkable up to the age of 12 months, by which time he was walking well- but soon after, was noted to be unsteady. He appeared tO',have reached. a plateau and to be slow to move off it. There were personality changes, in that, /rom being a model infant, tractable and cheerful and sleeping right through the night, he started to be wakeful in the early hours. He appeared not to be in pain but was fretful and clinging. Tht's roused the whole family and his father was obliged to move to the other end of the house, so as to be fit for work the next day. Peter'S mother became exhausted and father found himself doing her night-duty in the weekends. The family doctor advised the parents that the child was 'taking over' the home and should be ignored. A sleeping course was recommended. A second general prac­ titioner prescribed sedatives. ' ' Between the ages oftwo and three, while Peter was for most ofthe time reasonably content, he still had the reputation of being the, irritable one of the family. Although his balance was still at times unreliable, his motor coordination in other respects was good. He no, longer grizzled at night.' At routine medical exa,minations he passed without comment. His parents were a bit dismayed by his slow progress, the more so since he came from an academic family. It was assumed that 'they perhaps expected too much of him, as his retarded speech implied a slower intellect than had been hoped. His grandfather, a university' professor, reflected that 'there had to be a dumb one turn up in the family sooner or later.' " '

10 By the time he was nearly four, his mother had begun to suspect a hearing loss and could no longer accept the reassurance of the family doctor. Insisting on further referral, she arrived at the specialists' rooms,somewhat on the defensive, bringing her subdued and wide-eyed son. Impedance audiometry was unnecessary as microscopy revealed bilateral glue ears, their pale colour and high sheen simulating the pearly appearance of the normal drum. Drainage of the glue and insertion of grommets resulted in' a rapid personality change. The night of the operation Peter realised that from his bedroom he could hear his parents talking in the kitchen and came through ex.citedly to tell them that he had 'long ears now'. The resultant improvement in his speech and behaviour caused his kindergarten teacher to realise that his previous failure to participate in preschool games had been due to uncertainty and insecurity. He rapidly became a boisterous participant. With hindsight, one is prompted to wonder how far back this hearing loss might have developed and whether it had been a constant steady reduction in hearing efficiency or whether it'had been relieved by bursts of normality. The consistency of.the glue present in. each middle ear would certainly have reduced his conversational efficiency to a distance of about one' to two metres. Perhaps this fluctuated so that one ear worked briefly, then the other? if so, sounds which he could clearly see should have been coming irom ihe right side would be heard on the left, or vice versa. This would obviously have produced some mental confusion and a sense of inse­ curity. His relation to his environment would have been changing intermittently, the world being sometimes off to one side and sometimes so grossly contracted that people speaking to him from the other end of the table would have been incomprehensible; '. Peter was fortunate in that during his deaf years his mother played and sang to him, unconsciously stimulating his auditory centre at close range, so that he still was able to develop pitch discrimination, even though speech was delayed. Rehabilitation there/ore came speedily, once the normal pathways were re-opened to regular traffic.

2.S MOANA The following three case studies, those of Moana, Josie and'Eruera, have been presented by a medical officer who reports that thl:'!re are 'hundreds more cases like these': Mocma is an 8:.year-old Maori child who, together with a J 7-year-old aunt and two brothers and a sister, lives with her maternal grandmother. Her mother has for some years been 'up north' and has other children to her present partner. A year 'ago the grandmother was paralysed by a stroke and Moana's very young aunt now does most of the household chores and child caring. However both the real mother, who keeps in touch, and thi grandmother have been concerned about Moana's deafness. Moana has been attending the sector office ear clinics for some years with recur­ rent otitis media and increasing deafness.

11 In July 1983 it was noted that her left ear had normal hearing except for a moderate high frequency hearing loss (40 decibel loss at 4kHz), The right ear had a mild hearing loss at the lowerfrequencies, ranging through to a moderate high frequency loss (30,30,35,45 decibels), At that time the right ear drum looked normal and the left itad a healed perforation and the sector medical officer referred her to the ENT specialist who attends tite departmeiual clinic. He con­ firmed sensorineural loss and a ,normal drum in the right .ear. The left ear was discharging at this time. Moana returned twice over the next week for her ear to be swabbed. . ' By October the ear drum was dry and Moana was referred by letter to the advi~er on deaf children. Later the mother, down from Northland, had contacted the sector office as she was worried about Moana's poor school progress and difficult behaviour and concerned that she had not heard from the adviser as expected. In June 1984 Moana returned to the sector clinic. At this time there was a bilateral otitis' media which was subsequently treated. A pure tone audiogram 3 weeks later showed the same picture in the left ear as a year previously. The right ear showed the same mild loss in the lower frequencies but now had severe loss at the high frequencies (65dB loss at 4kHz and 70dB loss at 8kHz). Another appointment was made with tlie ENT specialist who noted atrophy of the drum and again recommended that Moana see the adviser on deaf children. This still has not happened as the adviser is so overloaded. In summary, this deprived child has a high frequency loss in the left ear which recurrently discharges, and increasing deafness in the right ear .. Thus her deaf­ ness is a mixture of conductive and sensorineural loss. Many months after re/er­ ral to the adviser on deaf children she has still not been seen.

2.6 JOSIE The Medical, Officer reports: Josie, a Maori girl of 11 years lives with her mother and stePfather, two pres­ choolers, several older unemployed teenagers, the mother's siblings,and a large uninhibited Alsatian dog. The household is highly disorganised and inadequate in parental supervision and care. In June 1982 Josie's deafness and very poor'speech came to the attention of the public health nurse and arrangements were made for speech therapy. In this area the parent must take the children to the therapist and this did not happen. When the medical officer sa'w Josie a month later both drums were dull cmd retracte4 and she. was referred as a case ofglue ear (OME) for grommet insertion. In November 1982 pure tone audiometry showed moderate bilateral high fre­ quency hearing loss (45 to 60dB loss at 2kHz and 4kHz). As she had clinical OME as well she was referred to Middlemore Hospital but did not attend. Early in 1983 she was again referred to the hospital for assessment and probably grommet insertion, and again to the speech therapist for her barely intelligible speech, but again without parental compliance.

12 In April it was arranged that the visiting teacher would take her for speech therapy and this was continued on a regular basis. Josie's speech began to improve and she seemed a somewhat happier child. In June 1983 the public health nurse took her to the hospital ENT outpatient department. The registrar noted that both drums were scarred and retracted but there was no fluid. Pure tone audiometry again showed bilateral sensorineural loss and the registrar referred Josie 'to the adviser on deaf children for hearing aids to be fitted. In March 1984 the public health nurse noted that Josie had not yet been seen by the adviser. Her school attainment was low and by now she had a severe behaviour problem, was sullen and disobedient and obviously unhappy. Over the past 2 years she had been caught out in many petty thefts and it was known that she was on the street at all hours of the day and night. Her truanting and vandalism was because, as .she said, she hated school. She was also believed to be on the fringe of a gang of addictive glue sniffers. The school noted that neither her mother nor her unemployed stepfather took any interest in her. Josie's non-attendance at school was particularly sad because in the past she had, by every indication, much enjoyed going to school. It was decided that Josie might benefit from a period in a health camp and while there, perhaps, she could learn to use her hearing aids. The adviser on deaf children had made appointments for the mother to attend the school and discuss Josie's ear problems in July and September 1983. On both occasior,zs neither Josie nor her mother came to school to keep the appointment. In February 1984 Josie saw the ENT specialist at Middlemore Hospital, thanks to a lift by the public health nurse. Her bilateral high frequency hearing loss was by now very severe. In March 1984 the adviser took an impression of the left ear at school bu~ otitis externa prevented this being done in the right ear. The medical officer prescribed treatment for this but Josie refused to comply. The public health nurse managed to obtain parental approval for Josie to attend health camp in May and. the headmaster followed this up with a letter complimenting the mother on Josie's selection for camp and making an appointment for the adviser on deaf children to call at the home and discuss Josie's need for hearing. aids . .The adviser called at the appm'nted time but no one was home. In June, several weeks after her admission'to camp, the adviser brought two hearing aids for the left ear for Josie to try. She also managed to take an impres­ sion for the right ear. Thus Josie received a hearing aid for one ear for the first time ever in the fourth week of camp. Up to that time she was a tearful loner, unpopular and distrustful. However staff also noted that she was beginning to take a pride in her appearance and that she could at times be honest, polite and helpful. She twice ran away from camp. There was an amazing change for the betler when Josie got her hearing aid. She became cheerful, friendly and began to enjoy her stay. She gained confidence until the return home was imminent when she again became anxious and fearful.

13" 111, camp she, received no letters and no visitors. No arrangements were made for her to get home at the end of camp . .When the public health nurse drove her home and took her inside the mother's greeting was 'Huh, .so you're home!' whereupon Josie dropped her things and darted .out of th~ house.. As the. paperwork had not been completed by the time camp ended, Josie's hear­ ing aid had to stay at camp and .be sent, bac.k to the adviser on d(/af children. She has now been without an aid fQr 2 weeks but soon the adviser hopes to take aids for both edrs to Josie at school. She has still not been able to meet Josie's mother and talk to her about the care and use of the aids.

2.7 ERUERA The medical officer describes the case of lS-year-old Eruera: Eruera is the seventh child of an islcmd family. The father is an alcoholic and unemployed and does not believe in western medicine. There is extreme health neglect of several. of the children. There are 19 children in the household, six of whom are under 5 years of age. Eru is not the only.one with neglected deafness. The children get severe recurrent impetigo, scabies and lice. Gross overcrowding of the home is compounded by the fact that two large untrained dogs share it with the 21 human occupants. Since 1980 Eru's ears have been monitored by public health nurses. An audi­ ogram at that time showed mild hearing loss in his right ear (30,35,45,50dB) and severe hearing loss in his left ear (70,70, 70, 85dB) . It is known that he has had recurrent discharging ears since that time. The family has not cooperated in allowing Eru to recei~e specialist treatment nor has any advice about any health care been followed. On record are parental letters saying that Eru·'s ears ate not to be treated at school, but that he will be looked after at home. Eru's ears have often copiously discharged at school, to the extent of dripping onto his books. In 1981 the public health nurse referred the case to social welfare and a volunteer worker tried to help the family. For a while there was minimal com­ pliance with health care. The ear record notes several non-attendances at special­ ist ear clinics in 1982 and 1983 and this has continued up to the present time. In 1983 the parents appeared before the children's "board with little result. After years of parental non-compliance, now at 15 years of age, Eru himself refuses the myringoplasties he so greatly needs. " He is unmanageable at school, has made little academic progress even in his work experience class . .other young people are. intimidated by his standover tac­ tics. He sniffs glue, is quite uncontrolled by his parents and there· have been reports of sexual misconduct. He is grossly neglected in appearance, often smells and has infected sores. Years. of untreated deafness and discharging ears, as well as his appallingly neglected fortress-type family, have probably contributed to his extreme antisocial tendencies and mistrust of the world.

14 2.8 SAM Sam's problem is comparatively rare and difficult to diagnose; he has central auditory perceptual dysfJ.1nction. In such cases peripheral hearing is normal so an auditory problem is often denied. These children often have difficulty sorting out information from background noise or from other competing information. Nine-year-old Sam's learning difficulties are described by his mother in a request to the National Acoustics Centre: Sam has acute hearing. I had the usual hearing test done at school, but as you can imagine, it has its limitations. When Sam started school he came home very uptight and complaining about the noise! Even now he cannot concentrate where there is noise. He can only be taught on a one-to-one basis without noise of any description. No school caters for that! Consequently, he can only read a handful of words and his learning pattern is severely impaired because he has a severe central auditory dysfunction. His vocabulary is good. I beg you never to disregard what a mother has to say. I thought that it was an auditory problem when Sam was 6 or 7 years old. I asked my local doctor to make an appointment at the hospital for me. This he did but the pressures put on me within and without the family were too much and ldidn't keep the appointment. I was called some awful names and labelled neurotic. j knew I was right but I didn't at that stage have my husband's backing. I do now. The pressure on my son was noise. He has been labelled dumb, lazy, unruly and was blamed for everything, as the other children really did think he was backward. He is intelligent; if he wasn't, the problem would be easier as we could "all accept the fact that he was naturally backward. The continuing suf­ fering a child goes through at school is extremely cruel and no child should have .to suffer so. . The teachers for the most part are sympathetic but are powerless to help. Nothing is done! .

2.9 MARY Mary is in her thirties and has a progressive hearing loss which began in childhood. The following are excerpts from an autobiographical article: As I began to make my own way in life I became increasingly aware of the ignorance and social stigma associated with deafness. Up until this time I had perceived my hearing loss to be an annoyance and inconvenience to myself only, but it became apparent that I was also an inconvenience and embarrassment to ochers. It was as a teenager I began to experience the loneliness and rejection that a hearing loss imposed . .... To have a degree of hearing loss. is to be neither deaf nor hearing. At times I felt I could accept being totally deaf better than this half-way state-at least I would know where I s~ood in regard to involvementS. What.are the limitations? How does one assess capabilities? Do you just give it a go and find qut? At what cost? I was soon to find out!.! was repeatedly being told by my doctor that I had

IS no problem simply because I appeared to cope, and I never felt that I could make my hearing disability an excuse for 'opting out'. I decided to go for my driver's licence. In presenting myself on the day of examination, I explained my hearing disability to the traffic officer to avoid any confusion of instructions since I would not be able to lip-read him' while driving. He turned his back on me and spoke at the same time. When I asked for a repeat he told me that that was a test and he was sorry but he couldn't take me without my first having got a doctor's clearance. I was shattered and couldn't possibly see what bearing such a 'test' could have on my ability to drive. The doctor was even less understanding when I complained at this discrimination and the problems encountered by the deaf when they do attempt to help themselves. He supported the Traffic Department's regulation and implied that zj I was experiencing these problems I was not very well adjusted. Perhaps I wasn't! Obviously to be deaf is to be daft as well! How­ ever he did give me a medical certificate stating that in spite of a hearing dis­ ability he did not consider it would handicap my ability to drive. Two days later I passed a faultless driving test . .. I was rather reluctant to join the Hearing Association. I was only 22 years old and such organisations were for the 'oldies', I thought. And besides to join up would be making public confession that I had a hearing loss! However, after giving it thought for a year I decided that since there was nothing that medical science could do for me and I had the best that money could buy in a hearing aid, I could learn the skills of lip-reading and that would be another line of defence. I was much impressed with the calibre of the tutors I encountered over the years, but acutely aware of the limitations of the services offered . . " There were times when the children were small that I questioned my adequacy as a mother. I would not hear them cry at night or zj they were out of sight. I wondered what the neighbours thought when on occasions they had had to respond to my child's cries and rescued her from some distressing situation. At nights when my husband was away, I'd sleep with the baby's bassinette pulled up beside the bed and my arm over the side resting on the baby to 'feel' when it woke up ... I had experienced times of frustration because of my hearing difficulties, but I was not prepared for the overwhelming anxiety and depression that engulfed me when for some inexplicable reason I lost all useable hearing in my left ear. This served only to increase my sense of guilt and worthlessness-surely something as 'trivial' as a hearing loss did not justzfy such a distressful reaction? ... It was my good fortune to meet and talk with Dr Bate, Professor of Audiology. at Western Michigan University, at the Hearing Association's national confer­ ence. Although I did not specifically indicate my personal problems, he was perceptive enough to recognise my need and in conjunction with Dr Keith of the National Acoustics Centre arranged for me to come to Auckland for complete audiological assessment, something I had never had done before. This resulted in my being fitted with a more efficient hearing aid that also aided my left side. I was also able to engage in further counsellt'ng sessions with Dr Bate. What took place in therapy is still an on-going process. There will always be adjustments to make according to the degree of hearing loss sustained over the years and the

16 changing circumstances of life. And, although I am just as deaf as ever, I now have a much more positive acceptance of my disability and reordering my life within that framework has become a challenging and at times rewarding experience.

2.10 FREDERICK

Frederick became totally deaf over a 4-month period. His hearing has par­ tially recovered as a result of medical intervention. Frederick's case has been described in the New Zealand Medical Journal and is a rare occurrence of autoimmune sensorineural deafness [5]. He describes the effects of his ordeal: I suspected I was going deaf due to the sensation of my head being blocked up and the feeling of loss of balance. I was isolated in a world of silence and com­ pletely shattered. The only means of attracting my attention was by touching me and then communicating by signs or writing the necessary message. There were many occasions when I felt like throwing everything away and there were times when I felt there was no hope for me. My health deteriorated in such a manner that I was unable to work for 18 months and even when I returned to work I could only manage part-time for another 18 months and then had to retire earlier than I should have. All this was due to side effects from the drugs. * My friends visited me and were a great support to both my wife and myself; they were patient with me (probably sorry for me) and were only able. to com­ municate by signs and notes. They did not frustrate me, but brought some light into my lzfe, but it must have been frustrating for them trying to communicate with me. I got angry with myself and deliberately turned myself off from my wzfe. Looking back now I feel asJiamed of my actions. The sudden and complete loss of my hearing was devastating and while still· in a state of confusion I realised, when I held a transistor radio to my ear, that a small amount of my hearing was returning. This caused emotional confusion as I wondered if my hearing was going to return to normal. Although my hearing disability has now improved from stone deaf to about 65 percent hearing I still rely on my WIfe to fill in for me. My friends invite me to socialise with them but the background noises make it very heavy going. I am able to cope at meal limes mainly because it is on a one-to-one or one-to­ four basis. I hear some voices better than others and am fortunate my wife has a good voice for communication with the hard of hearing. When I was stone deaf I missed the sound of the human voice and the sounds of /zfe which I had taken for granted in the past.

•Frederick was having steroid treatment.

17 2.11 GEORGE George is in his early fifties and has permanent mild occupational noise-induced hearing loss. He has been employed as a fitter in the railways for the whole of his working bje. At work he has some. difficulty communicating by phone and has to ask for information to be repeated. He often doesn't hear the phone ring when others hear it. However, George feels that the worst effects are on his domestic and social life. His wlje and daughters are upset and frustrated by his inability to hear. He feels excluded from family discussions and 'left out of things'. George's hearing loss doesn't stop him going out, but he doesn't mix and can't relax. Unless he concentrates hard he doesn't talk with others much and usually ends up retreat­ ing into his own little world. He is often embarrassed when he gives the wrong answers after mishearing what was said. Note: George was able to benefit from hearing aids.

2.12 DON Don has been employed as aboilermaker for about 40 years. He is in his early sixties and he has permanent profound occupational noise-induced hearing loss verging on total deafness. Don cannot hold any conversation unless it is with one person in quiet surroundings where he can watch the speaker's lips. He is an efficient lip reader but if he takes his glasses off he has difficulty holding a conversation. He has turned down two foreman's jobs because he can't converse by telephone. Don has cut down on his socialbje and he has resigned from being union delegate and given up his sports club. His difficulty with speech discrimination has meant that he .has almost com­ pletely lost the mean,S of communicating verbally. Don. relies on his wife to act as an intermediary when communicating with others. Dan's wife reports that her husband is irritable and tense because of his hearing loss and, most dis­ tressing, is his inability to talk with his grandchildren. Note: Hearing aids were of no help to Don because although they amplified 'Sound he still had difficulty discriminating speech.

Notes and references 1 Guidelines for the practice of language-speech pathology and audiol­ ogy: report of an expert group convened by the Health. Services and Promotion Branch. Ottawa: Health and Welfare, 1982. 2 SCHEIN, Jerome D and DELK, Marcus T.-The deaf population of the United States.-Silver Spring, M4 : National Association of the Deaf, 1974. 18 3 Physical disability : results of a survey in the Wellington Hospital Board area / Avery Jack et al.-Wellington : Management Services and Research Unit, Dept of Health, 1981. (Special report series; no 59). 4 Deafness the invisible handicap: a review of services for persons with hearing disabilities.-Wellington : Advisory Council for the Com­ munity Welfare of Disabled Persons, 1979. 5 WILSON, Roger L K and STEWART, Ian A-'Autoimmune sen­ sorineural deafness', in NZ Med J.-v 94 no 697 (9 Dec 1981) P 414-5.

19 Part 2

Incidence and prevalence of hearing loss and ear dsease 3 '. INTRODUCTION' The main objective of the first stage of the Hearing Research Project was to describe the incidence and prevalence of hearing loss using existing data. New Zealand and overseas information for all age groups was collected and summarised. Although the terms 'incidence' and 'prevalence' are often used interchangeably in the literature, in this report they will be defined as follows: • prevalence is the number of people in a population who are deaf or , hearing impaired at any point in time • incidence is the number of new cases, for example of ear disease, occurring per year. It was decided that New Zealand data would be used' as first choice, with overseas studies being used as a supplement. Although one of the objectives of the study was to highlight areas in which there was inadequate infor­ mation, it was nevertheless frustrating to find either gaps in the information, or studies which were not able to be compared because of the use of differing criteria for measuring hearing loss, for example. The most notable gaps in the New Zealand data were the lack of reliable information on the hearing status of: • preschoolers, particularly the under 3-year-olds • the general population of adults. A theoretical model was drawn up to show the numbers of people who were born deaf, or who later acquired either temporary or permanent hearing impairment. The purpose of the model was to illustrate the movement between the categories of 'hearing' and 'hearing loss'. The category of 'hear­ ing loss' was further divided into 'temporary' and 'permanent' loss for the following reasons: 1 It would enable the model to illustrate the fact, that the pool of per­ manently hearing impaired increases with the ageing process. 2 It would portray fluctuations in hearing loss over time; i.e., hearing to temporary loss and vice versa, temporary to permanent loss and hearing to permanent loss. 3 It would link the first stage of the project with the second stage; provision of services and management of hearing loss would be related to the type, severity and age of onset of the hearing loss. The terms 'sensorineural' and 'conductive' were not used as categories of hear­ ing loss in the model because: • so little definite information was available on the cause of hearing loss • some hearing loss, is 'mixed" i.e., it has both conductive and sensorineural components • conductive loss, although more commonly temporary, can contribute to permanent loss. 23 FIGURE 3a MODEL SHOWING MOVEMENT BETWEEN CATE­ GORIES OF HEARING LOSS AND NO HEARING LOSS AS A FUNCTION OF AGE

Birth Age 1 Age 2

?> ----// -~U --- . ;;. -::: / p >­

Hearing

Permanent loss: This category includes the congenitally deaf and those who acquire permanent deafness. It follows that one cannot move out of this category. Temporary loss: This category includes those with conductive loss, usually as a result of ear disease. If a child suffers from recurrent or chronic ear disease he or she will remain in the 'temporary loss' category. Those who are left with a permanent legacy from ear disease may move into the 'permanent loss' category. Those who return to normal after ear disease will move back into the 'hearing' category. The model as described was collapsed into two categories (hearing loss and no hearing loss) for adults, partly because of the lack of hard data and partly because the category of 'temporary loss' is not as relevant for adults as their hearing loss is more often permanent. For these reasons too, data on children and adults will be presented separately.

24 4 THE PRELINGUALLY DEAF AND SEVERE DEAFNESS ACQUIRED IN CHILDHOOD

The prelingually deaf are those people who were born deaf or who acquired deafness in early childhood thus preventing the acquisition of normal speech and language. Age of onset of deafness is critical and young children with early onset have special needs. ­ F or the purpose of this report we will broaden our definition and add to the· above group those children who, after the acquisition of speech and lan­ guage, become so severely deaf that they require similar educational, social and other support.

4.1 EFFECTS OF EARLY DEAFNESS Some of the effects of severe and profound hearing loss in children, including prelingual loss, are summarised in Table 4.1. Service requirements are also included to emphasize the importance of early assistance for these children and the multidisciplinary nature of the intervention required.

TABLE 4.1 EFFECTS OF SEVERE AND PROFOUND HEARING LOSS IN CHILDREN, AND SERVICE REQUIREMENTS [1] .­

Category of hearing loss Effects of hearing loss Service requirements

S6-70dB (ANSI) Group discussion will be Speech and language can (moderately­ difficult to follow; language be learned through the ear severe) usage and comprehension with amplification; speech may be deficient and con­ and language should be fused; speech can be under­ aided with cues through stood only if it is loud; visual channel; child may speech and language are benefit from regular class delayed; early speech is placement along with unintelligible. special assistance in special classes; may require speech and language training during preschool years; later may require tutorial assistance in academic subjects.

2S Category' of hearing loss Effects of hearing Joss Service requirements 71-90dB (ANSI) Voices are heard only from Speech, language and audi­ (severe) a distance of about one foot tory training are necessary; from the ear; environmen- auditory amplification is tal sounds and vowel sounds necessary; child is consid­ may be discriminated, but ered educationally deaf; many consonants will be enrolment in preschool distorted; speech and lan- programme is necessary; guage will be distorted and needs speech reading; may not develop spontan- special education place.­ eously if the loss is present ment is necessary, with before 1 year. emphasis on speech and language. More than 91dB . May hear some loud Requires special classes; (ANSI) sounds, but is more aware may profit from hearing (profound) of vibrations than tonal pat­ aids to monitor own voice terns; speech and language and to discriminate loud­ are defective and will not ness, inflection, and rhythm develop spontaneously if patterns of other talkers; loss is present before 1 year enrolment in preschool of age. programme is necessary.

4.2 TYPE AND CAUSE OF DEAFNESS It is assumed that the majority of children described in this section would have the type of hearing loss known as sensorineural, which arises because of disorders of the inner ear or the auditory nerve. It prevents the perception of sound by the brain. Such hearing loss is caused by hereditary factors, maternal rubella and other viral infections, meningitis, ototoxic (i.e., deaf­ ness-inducing) drugs, kernicterus, severe asphyxia and prematurity. Such loss is usually permanent. Information on deaf children in New Zealand is piecemeal and has been obtained from notification by advisers on deaf children and audiologists to the Management Services and Research Unit, Department of Health. From these returns, Laugesen [2] and Thomson [3] have reported the following causes of deafness (Table 4.2). It can be seen that approximately 10 percent are deaf as a result of maternal rubella, 40 percent have other known causes and in 50 percent the cause is unknown. This lack of ascertainment of cause is of considerable concern especially when compared with only 15 percent of 'unknowns' quoted in a recent paper by Flint on severe childhood deafness in Glasgow [4]. Causes of deafness in Glasgow children are presented in Table 4.3 for comparison. 26 TABLE 4.2 RELATIVE CONTRIBUTIONS TO CAUSE OF DEAF­ NESS IN NEW ZEALAND CHILDREN

Children born 1973-74 [2] Children born 1973-81 [3] (n 96) (n 441) Cause Percent Cause Percent

Genetic (family history) ...... 9.4 Hereditary...... 10.5 . Prenatal (rubella) ...... 10.4 Rubella...... 7.9 .Perinatal (asphyxia, jaun­ 8.3 Other...... 31.9 dice, prematurity) ...... Postnatal (meningitis) ...... 12.5 Unknown,...... 59.3 Unknown...... 49.7

TABLE 4.3 CAUSES OF PROFOUND DEAFNESS IN GLASGOW CHILDREN*

Cause Percent

Genetically determined...... 32 Prenatally acquired** ...... 14 Perinatally acquired ...... 17 Acquired in childhood+ ...... 22 Unknown ...... :...... :...... 15

TOTA~...... 100

.. adapted from Flint (4) . u congenital rubella accounted for 74 percent of this group (10 percent of total) + meningitis accounted for 43 percent of this group (10 percent of total) in Australian children born between 1949-1980, a history of maternal rubella was reported in 11 percent of cases of deafness. [51

27 4.3 INCIDENCE AND PREVALENCE OF DEAFNESS IN CHILDREN (a) Incidence: how many children are born de'af, or have their deafness newiy detected, each year? Data on the incidence of deafness occurring at or around birth has also been provided by the Management Services and Research Unit, and has been set out in Table 4.4.

TABLE 4.4 INCIDENCE OF DEAFNESS IN THE NEW ZEALAND POPULATION

Year of birth Rate per 1000 Actual number

1959 ...... 1.73 107 1960 ...... 3.15 198 1961 ...... ,. 1.73 113 1962 ...... ~ ...... 1.24 81 1963 ...... 0.91 59 1964 ...... 3.92 246 1965 ...... ­...... 2.16 130 '(1959-65 average) ...... (2.1 ) (133) 1973 ...... 1.0 61 . . Prepared by Laugesen, 1979 [61

Year of birth Rate per 1000 Actual number

1973 ...... 1.45 88 1974 ...... 1.16 . 69 1975 ...... 1.25 71 1976 ...... 1.09 60 (1973-76 average)...... (1.24) 1977 ...... :...... 0.92 50 1978 ...... 25 - 1979 ...... 25 1980 ...... 25 1981 ...... 28 441

Prepared by Thomson, 1983 [31 When averaged over a number of years it appears that the rates per 1000 have dropped from approximately 2 per 1000 in the mild sixties to 1.2 per 1000 in the mid seventies. The incidence rate in Australia, over the period 1949-1980 is 2.6 per 1000.[5]

28 There is no New Zealand information available fonhe years 1966-72. The incidence data in Table 4.4 are inadequate because of haphazard notification procedures and the lack of a deafness register. Available data are incomplete for recent years partly because of late detection of deafness, which is illus­ trated by the two differing rates for 1973 calculcated 4 years apart; and partly because of the lack of recorded information on the deaf. For example, Table 4.4 shows that in 1980 and 1981, 25 and 28 children respectively had their deafness detected, yet in 1983 the Audiology Centre alone detected deafness in 40 children. The lower incidence rate in the most recent years of birth shown in Table 4.4 therefore does not necessarily mean the incidence of prelingual deafness is continuing to drop. (b) Prevalence: how many children are there with either prelingual or later­ acquired severe deafness? It would have been preferable to give separate prevalence rates for both groups (including prelingually deaf adults), but such information was not available. In the absence of national survey data the New Zealand prevalence rates were calculated from the only two sources available: • notifications by audiologists and advisers on deaf children to the Man­ agement Services and Research Unit, for deafness with onset at or around birth, averaged over the 3-year period 1973-76 • all deaf children known to advisers on deaf children in 1982, i.e~, all children whose hearing loss is such that they receive special edu­ cational assistance provided by the Department of Education[7]. Table 4.5 is derived from these two sources. It must be emphasised that there are no definitive diagnostic criteria for inclusion in this table because such data were not available.

TABLE 4.5 PREVALENCE OF DEAFNESS IN CHILDREN BY AGE, ESTIMATED RATES PER 1000 POPULATION

Age Prevalence Prevalence rate Age rate

Birth ...... 1.2 8 ...... 2.5 1...... 1.2 9 ...... 2.6 2...... 1.2-1.5 10 ...... 2.4 3...... 1.2-1.5 11 ...... 2.8 4 ...... 1.2-1.5 12 ...... 3.4 5...... 1.5 13 ...... 2.9 6...... 2.0 14 ...... 3.0 7...... 2.6' 15 ...... 3.1

The range of values shown for ages 2-5 indicates the lack of information on prevalence of deafness between birth and age five. The overall increase in prevalence as a function of age may reflect a variety of factors such as

29 late detection, particularly of children with less severe hearing losses, inclu­ sion of some children with unilateral deafness, and a higher incidence of prelingual deafness in previous years (see Table 4.4). The increase in preva­ lence rates at ages 6, 7 and 12 is probably accounted for by previously unde­ tected deafness picked up at routine new entrant and ll-year-old school screening. To summarise Table 4.5, prevelence rates indicate that approximately one child per 1000 is known to have onset of deafness at or around birth. This rate rises to 3 per 1000 young people known to advisers on deaf children by age IS. To put the New Zealand rates into context, rates from the United States National Census of the Deaf Population (NCDP) have been given in Table 4.6[8]. No large national survey has been done in New Zealand so the rates are not strictly comparable. The NCDP concentrated on the extreme end of the impairment continuum and on those persons whose hearing loss occurred before adulthood, i.e., 'those persons who could not hear and understand speech and who had lost (or never had) that ability prior to 19 years of age'. This group was called the 'prevocationally deaf. The survey also presented rates for slightly less severe hearing loss, described as 'signifi­ cant bilateral impairment' which is defined as a hearing deficit in both ears, the better ear experiencing some difficulty hearing and understanding speech. Table 4.6 presents the rates for both prevocational deafness and significant bilateral impairment in children and young people. The NCDP therefore estimated that in. young people under the age of 25 there were 1.3 per 1000 with prevocational deafness and 6.6 per 1000 with significant bilateral impairment. Hearing loss was more frequent among males than females. If it is assumed that both of the above categories of hearing impairment warrant appropriate special educational provision, and that United States and New Zealand prevalence rates are similar, then it is likely that there are a number of New Zealand children with significant bilateral impairment who are not receiving special assistance, i.e., there were 3 per 1000 New Zealand children at age 15 known to advisers on deaf children in 1982, compared with the 8.5 per 1000 with significant bilateral impair­ ment at age 16 quoted in the NCDP. (c) Degree of hearing loss: how may children are there in the different sever­ ity categories? It has been calculated from Jauhiainen's estimates (see Table 6.4 in a later section on adults) that of children under 15 years of age with hearing loss over 30dB, 77 percent have a hearing loss of 30-45dB, 18 per­ cent of 45-60dB and 5 percent of 60dB and over, i.e., the more severe the loss the fewer the children affected. There are no New Zealand data on the prevalence of the varying degrees of hearing loss in children, but as from 1984, more detailed information on children receiving special education for the deaf has been provided by the principals of the two schools for the deaf. Data on degree of hearing loss are presented in Table 4.7.

30 TABLE 4.6 PREVALENCE RATES FOR PREVOCATIONAL DEAF­ NESS AND SIGNIFICANT BILATERAL IMPAIRMENT IN NON-INSTITUTIONALIZED CHILDREN AND YOUNG PERSONS UNDER 25 YEARS OF AGE, ACCORDING TO AGE AND SEX: UNITED STATES 1971* Rate per 1000 Significant Sex/age Prevocational bilateral Both sexes Under 6 ...... 0.38 2.62 6 to 16 ...... 1.91 8.52 17 to 24...... 1.69 8.62 Total, birth to 24 years ...... 1.33 6.59 Females Under 6 ...... 0.36 2.27 6 to 16 ...... 1.84 7.01 17 to 24 ...... 1.63 5.68 Total, birth to 24 years ...... 1.28 4.99 Males Under 6 ...... 0.39 9.95 6 to 16 ...... 1.98 9.97 17 to 24...... ~ ...... 1.76 11.91 Total, birth to 24 years ...... 1.38 8.28

*adapted from Schein and Delk [81 TABLE 4.7 NUMBER OF CHILDREN RECEIVING SPECIAL EDU­ CATIONAL ASSISTANCE FOR THE DEAF, BY DEGREE OF HEARING LOSS AND DEAF SCHOOL CATCH­ MENT AREAS, AS AT 31 MARCR1984

CentrallSouthern Northern NZ total van Asch & Kelston & resource St All . Auckland All classes Dominics others unics others n n n n n n % Mild (6-40dB) ...... 271 1 119 391 17.6 Moderate (41-55dB) ..... 4 1 228 4 462 699 31.5 Moderate-severe (56-70dB) ...... 16 4 88 14 182 304 13.7 Severe (71-90dB) ...... 33 5 103 41 117 299 13.5 Profound (91 +dB) ...... 102 12 98 '100 110 422 19.0 U nilateraL...... 80 21 101 4.6 TOTAL ...... 155 22 868 . 160 1011 2 216 99.9 * 0.5, I, 2 and 4kHz average in the better ear'· 31

Sip;... The information presented in Table 4.7 shows that special educational assist­ ance is not restricted solely to those children with more extreme forms of deafness, i.e., in terms of the United States NCDP definitions above, children with 'significant bilateral' hearing loss are included as well as the 'prevo­ cationally' deaf. Nearly 50 percent of New Zealand children receiving special educational provision for the deaf have a hearing loss of 55dB or less. When this is compared with Jauhianen's estimate (Table 6.4) that 77 percent of hearing impaired children have mild to moderate loss of 30-45dB, it further supports the contention that there are many more children with mild to moderate hearing loss in the general population who are in need of appro­ priate educational assistance (see 2.5, the case study of Moana).

4.4 RUBELLA Outbreaks of rubella have accounted for the major fluctuations in the inci­ dence of congenital deafness over the years. The high rates of deafness in 1960 and 1964-65 (see Table 4.4) were related to the rubella epidemics of 1959 and 1964. There were small outbreaks of congenital rubella in 1975 and 1981. . Of the 44 cases of laboratory-confirmed congenital rubella in children born during 1980-81 throughout the whole country, 10 are so far known to be deaf [9]. Twelve known cases of rubella deafness were reported in Australia over the equivalent period [10]. Table 4.8 gives the proportion of New Zealand children with laboratory-confirmed rubella, and the proportion of these chil­ dren with known deafness, expressed as rate per 1000 births in each health district.

TABLE 4.8 KNOWN DEAFNESS IN eHILDREN BORN 1980-81 WITH LABORATORY-CONFIRMED RUBELLA AT BIRTH, NUMBER AND RATE PER 1000 BY HEALTH DISTRICT [9] .

Laboratory-confirmed rubella Known deaf Number Rate per /000 Number Rate per 1000

Whangarei...... 1 0.2 . Takapuna ...... 1 0.1 Auckland ...... 1 0.1 South Auckland ...... 7 0.7 6 0.6 Hamilton ...... 3* 0.3 1 0.1 Rotorua ...... 3 0.4 1 0.1 Gisborne ...... :..... 3. 1.2 Napier ...... ,...... 3 0.7 1 0.2 New Plymouth ...... 2* 0.6 Wanganui ...... :...... 2 0.6 Palmerston North...... 1 0.2 32 Laboratory-confirmed rubella Known deaf Number Rate per 1000 Number Rate per 1000

Lower Hutt...... 2 0.3 1 0.1 Wellington .....:...... : ...... 8* 1.3 Nelson ...... 4 1.0 Christchurch ...... 3 0.3 m Timaru...... Dunedin ...... Invercargill ......

TOTAL...... 44 0.4 10 0.09.

.. 1 child since deceased

Of those children with known deafness: • 60 percent were from South Auckland • 60 percent were boys • the breakdown by race was:. 40 percent Europeans, 40 percent Pacific Islanders, no Maoris and 20 percent of unknown race. Of Pacific Island children with laboratory-confirmed rubella at birth, 50 per­ cent were found to be deaf; of European children with laboratory-confirmed rubella, 17 percent were found to be deaf. It is not known how many of the notified rubella cases have been tested for deafness.

4.S REGIONAL DIFFERENCES

The numbers of children known to advisers on deaf children and attached to the two schools for the deaf, Kelslon in Auckland and van Asch in Christ­ church, have been expressed as a proportion of all children of that age group within the two popUlations served by the schools. Children attending St Dominies have been included in the van Asch total. The dividing line between the two school catchment areas lies across the middle of the North Island, approximately New Plymouth to Gisborne.[ll] It must be-pointed out that children attached to the schools for the deaf are not only those who. are attending the residential 'base' schools. Type of specialist assistance can be categorised as fo.Ilows: • children attending the reside'ntial schools / : • children attending resource classes attached to regular schools • children receiving assistance from itinerant teachers of the deaf but not in schools or classes for the hearing impaired • children under the guidance of an adviser on deaf children but not in the above three categories.

33 TABLE 4.9 REGIONAL COMPARISON FOR CHILDREN RECEIV­ ING SPECIAL EDUCATIONAL ASSISTANCE FOR THE DEAF, EXPRESSED AS RATE PER 1000 OF SCHOOL AGE CHILDREN

Kelston population van Asch population (i.e., northern (i.e., central & National Age NZ) southern NZ) total

5...... ,....", ...... 1.6 1.4 1.5 6...... :...... 1.6 2.4 2.0 7...... 2.8 2.3 2.6 8...... "...... 2.7 2.2 2.5 9...... ,...... 2.8 2.5 2.6 10...... :...... " 2.3 2.5 2.4 11 .. "...... ".. ""...... "...".. 3.1 2.6 2.8 12"...... "...... ".".,,;. . 3.7 3.1 3.4 13 ...... """ ...."";"...... "..,,...... ,, 2.8 3.0 2.9 14...""... ".... ".... ".".."".."...... ".. ".. 3.4 2.6 3.0 IS"...... ".. ""...... "" .. .. 3.5 2.8 3.1 TOTAL...... ,.".... "."."...... : 2.8 2.4 2.6

A more detailed version of the above table can be found in Appendix 4a. It can be seen from Table 4.9 that the rates for the northern region are higher than the central/southern regions in 8 out of the 11 age groups quoted. The top half of the North Island therefore has slightly more deaf children receiv­ ing special .educational provision.

4.6 SUMMARY (1) New Zealand data on the pre1ingually deaf, and those who acquire deafness in childhood, are fragmentary and inadequate. (2) The cau~e of deafness is unknown in SO percent of deaf childr~n, compared with 15 percent in a Glasgow study (see Table 4.3). (3) The incidence of deafness with onset at or around birth dropped from approximately 2 per 1000 in the mid sixties to 1.2 per 1000 in the mid seventies. (4) The prevalence of deafness* in children in 1982 (*in the absence of survey data, defined 'as those children receiving special educational provision for the deaf) was 1.5:1000 at age 5 and 3.1:1000 at age 15. (5) Of children born in 1980-81 with laboratory-confirmed rubella at birth, nearly a quarter are so far known to be deaf. (6) There is, a slightly higher proportion of deaf children (defined as above) in the northern half of the North Island.

34 NOles and references 1 NICOLOSI, Lucille, HARRYMAN, Elizabeth, KRESHECK, Janet.-Terminology of communication disorders: speech-Ianguage­ hearing.-2nd ed.-Baltimore, Md : Williams and Wilkins, 1983. 2 NZ Committee on Child Health.-Child health and child health services in New Zealand.-Wellington : Board of Health, 1982. (Report series; no 31) 3 Data received by the Management Services and Research Unit, Department of Health, Wellington. Prepared by George Thomson, 1983. 4 FLINT, Ewen F.-'Severe childhood deafness in Glasgow, 1965­ 1979', in J Laryngol Otol-v 97 (May 1983) p 421-425. 5 UPFOLD, Laurence J and ISEPY, Judy.-'Childhood deafness in Australia : incidence and maternal rubella, 1949-1980', in Med J Aust.-v 2 (2 Oct 1982) p 323-326. 6 Deafness the invisible handicap: a review of services for persons with hearing disabilities.-Wellington : Advisory Council for the Com­ munity Welfare of Disabled Persons, 1979. 7 Information provided by the principals of van Asch College, Christ­ church and Kelston School for the Deaf, Auckland. 8 SCHEIN, Jerome D and DELK, Marcus T.-The deaf population of the United States.-Silver Spring, Md : National Association of the Deaf, 1974. 9 Information provided by the Division of Health Promotion, Depart­ ment of Health, Wellington. 10 Information provided by L J Upfold, Principal Audiologist, National Acoustic Laboratories, Canberra, Australia to W J Keith Principal Audiologist, Audiology Centre, Auckland. 11 A more detailed description of the demarcation line between Kelston and van Asch schools has been provided by the Special Education Officer, Northern Region Office: the line 'starts just south of Gis­ borne, through to Lake Waikaremoana on the Rotorua side, south to take in Taupo and Turangi, across Taumarunui and "thence to Piopio'. 5 OTHER HEARING'IMPAIRMENT IN CHILDHOOD 5.1 TYPE AND CAUSE OF HEARING .LOSS This group is iargely composed of childre,n with conductive hearing loss. This type of loss is mainly caused by disease of the middle ear which prevents the passage of sound vibrations to the inner ear. Such hearing loss is most commonly caused by infections of the middle ear or by perforation of the ear drum. Impacted wax or infections of the ear canal can also cause some degree of deafness. A high percentage of such defects can be remedied or improved by medical or surgical treatment. Middle ear infection (otitis media) is one of the most prevalent medical con­ ditions of childhood. It ranges from acute otitis media which may cause pain and fever to the more chronic forms in which hearing loss is more prominent as a symptom than pain. These more ,chronic forms are commonly known as glue ear and have a variety of medical names: otitis media with effusion (OME) , middle ear effusion (MEE), secretory otitis media (SOM). In children in the Dunedin Multidisciplinary Child Development study cohort there was an increased incidence of chronic OME in conjunction with: • a history of previous acute OM • nasal obstruction (based both on the history !'lnd examination findings) • winter and spring months • younger age group; there was a decline in incidence between ages 5 and 9.[1] . Acute otitis media is often a sequel of a viral respiratory infection and the occurrence of respiratory infections is highest during the cold months of the year[2]. Other overseas studies show a correlation between OME and upper respiratory infections [3,4,5]. Casselbrant et al reported that 32 percent of ears examined during an episode of upper respiratory infection were iden­ tified as having OME, whereas only 7 percent of the ears had OME when the children did not have this condition [3]. Henderson et al have shown a clear association between respiratory syncytial virus, influenza, and adeno­ virus and acute otitis media[6]. These infections impair eustachian tube func­ tion and alter middle ear ventilation; it has been suggested that this epidemiologic observation may provide a due to the cause of otitis media.[7] The relationship between OME and conductive hearing loss, either transitory or permanent, has been well documented in overseas and New Zealand stud­ ies. Even if the hearing loss is only temporary, it may have serious conse­ quences if it occurs at a critical stage in a child's development. The Dunedin Multidisciplinary Child Development Study has documented the link between OME, conductive hearing loss and developmental problems here in New Zealand [8,9,10]. Overseas, Brooks has stated that OME is 'the major cause of auditory dysfunction in preschool and early grade schoolchildren'[ll]. He

36 reviewed a number of studies on the relationship between middle ear effusion and hearing loss and concluded that hearing loss secondary to effusion aver-' aged IS-20dB with a standard deviation of around lOdB. Data from the Dunedin cohort also show an average hearing loss of 1S-20dB. Paradise states that hearing impairment associated with middle ear effusion may range from negligible to as much as SOdB with thresholds in the 20dB range being the rule[12J. A Dunedin ENT specialist reports having seen cases of con­ ductive loss ranging from OdB up to nearly 60dB in extreme cases.[13] The hearing loss described so far in this section may be described as tem­ porary, although not without its short term or long term educational or social sequelae. However, otitis media can contribute to more lasting, or even per­ manent, hearing loss. Fry et al followed up 403 children (93 percent response rate) who had suffered from acute otitis media S-10 years previously[14]. Seventeen percent had a hearing loss of 20dB' or more in at least two fre­ quencies compared with 4.5 percent of matched controls. Fry et al quoted four earlier studies as follows: Neil et al found 20 percent had a hearing loss of more than 20dB in one or more frequencies after 6 months and in 6.S percent this deafness was still present after 3-4 years[14J; Lowe et al reported that 25 percent of their children had 'significant deafness' of 30dB or more 6 months after the attack [14J; Olmstead et al reported a lSdB loss in 12 percent 6 months after an attack of acute otitis media[14J; Reed et aI, in a cohort study of Eskimo children, reported a loss of 2SdB or more in 31 percent after 3-4 years.[14] A reference to the contribution of otitis media to permanent deafness was reported by Murphy[15]. Of deaf children born between 1956-1972 in Vic­ toria, Australia, otitis media accounted for 6.7 percent of the total aetiologies of deafness. These children were all fitted with hearing aids, 89 percent (of the otitis media aetiology group) had a loss of under 60dB and 11 percent had a loss of 61-90dB. In the light of New Zealand and overseas evidence the assumption will be made that some form of hearing loss, either at the time of the attack or as a lasting consequence of it, will be associated with otitis media.

S.2 PREVALENCE OF HEARING LOSS Prevalence rates are dependent upon the criteria used for the classification of hearing loss. The criterion of hearing loss greater than 15dB across four frequencies (0.5, 1, 2 and 4kHz) in either ear was taken as an ideal definition . because it was seen as important to include mild hearing loss. While a hear­ ing loss of 15dB does not usually require medical intervention, it can be strongly argued that it is an educationally significant loss, particularly in a noisy classroom. Unfortunately very little New Zealand information exists on degree or severity of hearing loss in children. The Dunedin Multidisci­ plinary Child Development Study provides the only data on mild hearing loss starting at 15dB, and these will be reported> later.[ 16J Available New Zealand data on the prevalence of hearing loss in children are as follows: 37 (a) School screening results[17] All new entrants (age 5) and Form I pupils (approximately age 11) are rou­ tinely screened for hearing loss by the Department of Health vision hearing testers. The number of children failing the hearing screening test provides us with the only national data on hearing loss. It does not provide infor­ mation on the type of hearing impairment but we can guess that the numbers will largely be composed of those with conductive hearing loss resulting from otitis media with effusion, plus a small proportion with previously undetected sensorineural loss. To pass the screening test, children must be able to hear 20dB at any of the frequencies 1, 2 and 4kHz and 30dB at 0.5kHz. Table 5.1 presents the rate per i 000 of children failing school screening (first test only) averaged across all health districts. The 1982 results are theoretically for the better ear only, that is bilateral loss, although an unknown number of health districts were also recording unilateral loss. The 1983 results are based on the new policy guidelines which request that failure in either ear be recorded, that is both unilateral and bilateral loss. It would therefore be expected that the 1983 prevalence rates would be higher because of the use of a less conservative criterion. TABLE 5.1 PREVALENCE OF CHILDREN FAILING SCHOOL SCREENING*, EXPRESSED AS RATE PER 1000 POPULATION[17] 1982 1983 Preschoolers...... 155 New school entrants ...... 152 192 Form I pupils ...... 65 83 * first test only School screening data have been used in the absence of any other national data, but it must be pointed out that these rates may be unreliable because they are based on individual vision hearing tester returns and not on a uni­ formly conducted study. This topic is further discussed under regional vari­ ation in school screening failure rates (see 5.6). (b) Dunedin Multidisciplinary Child Development Study This study provided data on a birth cohort of approximately 1000 children, at ages five, seven and nine. Its strength, for our purposes, is that it provided objective data on both hearing loss and otitis media with effusion. It must be reiterated, however, that: • it is a Dunedin sample only and consequently under-represents the Maori and Pacific Island population and also lower socio-economic groups[18] • it is an intervention study (it would have been unethical for it to have been otherwise) and the fact that the study cohort was carefully mon­ itored and treated inevitably produced lower prevalence rates

38 • systematic otological data were not collected until age five~ although some information was available for 3-year-olds. Hearing status results from the Dunedin cohort are presented in Table 5.2; rates include both unilateral and bilateral hearing loss. TABLE 5.2 PREVALENCE OF HEARING LOSS IN DUNEDIN COHORT, EXPRESSED AS RATE PER 1000 POPULATION[16]

Age Hearing loss of 20dB+ Hearing loss of 15dB+ 5...... 69 143 7 ...... 54 208 9 ...... 42 164

* same criterion as school screening, i.e., over 30dB at O.5kHz and over 20dB at 1,2 and 4kHz. For reasons explained above it would be expected that the prevalence rate for the Dunedin cohort would be lower than the national rate. If prevalence rates within the Dunedin sample are compared using the two different cut-off points it can be seen that, if hearing loss of greater than ISdB is used as the criterion, the prevalence rates are four times as high at ages seven and nine. (c) South Auckland data[19] Because of the high prevalence of hearing loss and ear disease, and the gross inadequacy of hospital ENT services in South Auckland, a number of studies have been carried out in this area: Maynard and Keith[20], Maynard and Sisley[21], West and Harris[22]. They have been summarised by the district health office who, using the very conservative criterion of a hearing loss of 25dB and functional damage confirmed by impedance testing as lasting more than 12 weeks, estimate that the prevalence of significant and sustained hear­ ing impairment in young children is of the order of 15 percent. In population terms this is approximately 5500 school children in South Auckland. Although there are no precise figures available, it is thought that there is an equivalent number of preschool children with significant and persistent hearing loss. . . (d) Other data Hearing impairment prevalence rates from other New Zealand studies and one Australian study are summarised in Table 5.3. Most of these studies used school screening criteria for assessment purpos.es. TABLE 5.3 PREVALENCE OF HEARING IMPAIRMENT IN SOME SMALL STUDIES Rate per Age group Sample 1000 Category 31/2-5...... A Hun Valley 300 failed first audiometry kindergarten[23] 320 failed first tympanometry (n = 76) 180 failed follow-up audiometry 180 failed follow-up tympanometry 39 Rate per Age group Sample 1000 Category . 10-12 ...... :.. Sydney school 158 hearing loss calculated by children[24] ·NAL method (n = 386) 13 ...... An Auckland girls' 110 failed follow-up audiometry secondary school[25] 20 chronic bilateral loss (n 282) 60 chronic unilateral loss 14-15...... Northland high 90 failed school screening school pupils[26] 17-21...... Auckland 166 pre-existing hearing (approx) apprentices[27] loss (degree not stated) (n 60)

5.3 INCIDENCE AND PREVALENCE OF EAR DISEASE \ In this report the discussion of ear disease will largely be restricted to otitis media and its sequelae because it is experienced by so many children at some stage in their first 7 or 8 years of life. Because of the often fluctuating nature of OM, longitudinal and incidence studies are of most use when attempting to identify an at-risk population. Consequently the report will largely con­ centrate on incidence studies but, ·before beginning, several New Zealand and overseas prevalence studies will be summarised to indicate the extent of the problem at anyone time. (a) Prevalence: in a birth cohort of 879 Dunedin 5-year-olds, 17.1 percent had either unilateral or bilateral OME[8]. Other New Zealand studies, the results of which have been summarised by Clements and Joseph[8], have been based on at-risk populations and mainly reported on the status of the tympanic membrane (ear drum) [29,30,31,32]. In a sample of 492 Tokelauan children under the age of five, living in New Zealand, 21 percent had OM[33]; 14.4 percent of 0 to ll-year-old Northland children had middle ear effu­ sion[32]; a prevalence of 13 percent of all types of ear disease was reported in 13-year-olds attending a large Auckland girls' secondary school.[2S] Overseas, Fiellau-Nikolajsen reported a prevalence rate of middle ear effu­ sion in 10 percent of all ears in a representative popUlation of Danish 3­ year-olds[34]; more recently the same author reported a prevalence of 20 percent in a sample of 3-year-olds.[35] The prevalence of otitis media follows a seasonal distribution which peaks in the winter months and declines in the summer months.[1,2,3,4,36]

(b) Incidence: some recent oversea~ studies of the occurrence of OME in representative popUlations were reported at the Third International Sym­

40 posium on Recent Advances in Otitis Media with Effusion in May 1983. They confirmed earlier studies which indicated that the highest attack rates for otitis media are in the first 2 years of life. In a study based on a population of 147,000 persons in Finland, Pukander et al[2] showed that the highest annual incidence of symptomatic acute otitis media (51.4 percent) was during the second year of life. An even higher rate of 75.5 attacks per 100 child:" years was found in the age group 6-11 months. Large studies in Sweden[37] and the United States[38] have identified a similar age distribution. Using the criterion of B tympanograms, Tos has shown that asymptomatic middle ear effusion peaks in the second year of life, remains high until around the age of 6 or 7 and thereafter falls to low levels by the age of 9 or 10[39]. A similar drop in the occurence of OME is shown in children between the ages of5 and 9 years in the Dunedin cohort[I]. We have no equivalent information on New Zealand prescho'olers, and the lack of population-based data should be cause for considerable concern. The Christchurch Child Development Study provided limited data in the form of recorded visits to general practitioners for otitis media or suspected otitis media[40]. This is a non-intervention follow-up study of 1072 Christchurch children from birth to 5 years of age and it provides the only New Zealand longitudinal data available on middle ear disease in preschoolers. For our purposes, the Christchurch information had the following limitations: • it was based on visits made to the general practitioner for otitis media, i.e., rate of medical consultations for otitis media would be less than the actual occurrence of otitis media • it was a Christchurch-based sample only • the type of otitis media was not specified • there was no information on hearing status. Despite these drawbacks the data were used to study otitis media attack rates for different children across the first 5 years of life. Figure Sa presents the incidence of otitis media expressed as rate per 1000 in the Christchurch study and in a study done by Pukander in Finland[41]. The comparison cannot be carried too far because, as previously explained, the Christchurch data are based on visits to the doctor for any type of otitis media whereas the Finnish data are based on the incidence of acute otitis media over 1 year. Cases of chronic otitis media have been excluded from the Finnish study which may explain why the rates drop rapidly with increas­ ing age. The discrepancy between the two studies in incidence of OM during the first year of life, together with evidence from other overseas studies, suggests that ear infections are not being detected in New Zealand babies during their first year of life. The same information is presented in a different form in Table 5.4 with the addition of data from the Dunedin Multidisciplinary Child Development Study.

41 FIGURE Sa INCIDENCE OF OTITIS MEDIA, CHRISTCHURCH[40] AND FINLAND[41], ESTIMATED RATE PER 1000 POPULATION Rate per 1000 3S0~------~------~ 300

250 Legend Finland

200

ISO

100

50+-----~----~----~----~----~----~------~ Birth-1 1-2 2-3 3-4 4-5 5-6 6-7 __7-8 8-9 Age Range

TA~LE 5.4 INCIDENCE OF OTITIS MEDIA BY AGE, ESTIMATED RATES PER 1000 POPULATION

Incidence over Incidence over I-year period 2-year period Finland Christ- (acute OM Christ- Age church Dunedin only) church Dunedin o < 1...... 226 328 1 < 2: ...... 318 289 2 < 260 250 241 3 < 4...... 250 196 4 < 5...... 248 175 5 < 6...... 136 6 < 7...... 98 7 < 8...... ·.. :...... 81 8 < 9...... 57

42 From the Christchurch data in column 1 it can be seen that approximately 25 percent of children have episodes of otitis media in anyone year between birth and age five. The incidence of ear disease in children in the Dunedin cohort during their third year of life (mothers' reports of ear disease) agrees with the Christchurch data. Because the Dunedin cohort are assessed every 2 years it is not possible to obtain an annual incidence rate; column 5 shows the occurrence of ear disease over the previous 2 years when the children were tested at around their fifth, seventh and ninth birthdays. Where it was possible to calculate the Christchurch data in the same manner at age three to five~ the results are similar (see column 4).

5.4 LONGITUDINAL DATA ON OTITIS MEDIA

(a) Christchurch Child Development Study Data from this study have been used to present more detailed information on the occurence of otitis media. Having longitudinal data means that attack rates for different children across the first 5 years of life can be studied. In an attempt to separate out those children who have recurrent episodes of otitis media from those who have less frequent attacks, arbitrary categories have been constructed in which children may be placed in each year of life. The categories are as follows: 1 disease free: no otitis media recorded in a given year 2 'current OM': otitis media in a given year, no OM recorded in year immediately preceding (although a child may have had an asymptomatic attack) 3 'recurrent' OM: otitis media in a given year and OM in year immediately preceding. Results are set out in Table 5.5, using the above categories.

TABLE 5.5 LONGITUDINAL DATA ON OTITIS MEDIA, CALCU­ LATED FROM DATA PROVIDED BY THE CHRIST­ CHURCH CHILD DEVELOPMENT STUDY

Age 0-1 1-2 2-3 3-4 4-5 % % % % % Disease free ...... 77 68 74 75 75 'Current' OM ...... 23 21 13 14 15 'Recurrent' OM ...... 11 13 11 10

TOTAL...... ~ ...... 100 100 100 100 lOr.

43 U sing the above definition it should be noted that all children experiencing otitis media in their first year of life have been classified as having 'current' OM. In the second year of life 11 percent of the children were classified as 'recurrent', i.e., had had attacks of OM in both the first -and second year of life. An extra 21 percent were experiencing their first attack. By the third year of life the pattern appears to be stabilizing, with approximately 75 per­ cent in the disease free category. Similarly, by the fourth year of life, the relative proportions of children in the two OM categories has settled to a ratio of approximately 1.5:1. Taking the model a step further, the question can be asked: what is the probability of getting OM in a given year when no OM was experienced in the immediately preceding year? This can be called the 'new case' rate. Such probabilities may be estimated by the per­ centages of children in the disease free category who move into the OM category in the following year. More detailed information on new and repeat episodes of OM can be found in Appendix Sa. The 'new case' rate is about 19 percent each year and the 'repeat attack' rate is approximately 40 percent, that is, roughly twice that of the 'new case' rate. This gives further evidence for the concept of 'otitis proneness' put forward by Howie et al[42] and sup­ ported by otl)er overseas studies. It suggests that there is a hard core of children who experience OM many times during many of their early years of life. With these data it is possible to identify such children at age five. Table 5.6 classifies children at 5 years of age as to whether they have had OM in any one, two, three, four or all of their first years of life.

TABLE 5.6. PERCENTAGE OF 5-YEAR-OLDS BY NUMBER OF YEARS WITH AT LEAST ONE ATTACK OF OTITIS MEDIA[40]

Number ofyears in which . Percentage of at least one attack had children occurred o 32 1 29 2 21 3 12 4 5 5 1

It can be seen that only 32 percent had had no OM during these years, that is, 68 percent had visited the doctor for otitis media at some time between birth and age five. As many as 18 percent had OM in at least three of their first 5 years of life. As has been suggested earlier, these rates are conservative because they are based on the rate of medical consultation for otitis media only. .

44 Up to this point the discussion has centred on whether a child had OM in a given year. In fact in any given year a child may have more than one attack (see Figure 5b). FIGURE 5b ESTIMATED NUMBER OF INCIDENTS OF OTITIS MEDIA IN CHILDREN 0-5 YEARS, CHRISTCHURCH DATA Percentage 30~------~

25

20

15 Legend 1 Infection 2 Infections 10 --­ -----3+ Infections

5 --______------_ , -- ... ~ ...... ---- .... -.. ---- ... --- .. -.. -­ ------~------

Birth-lO+------r------~------~------~ f ... 2 2-3 3-4 4-5 Age Range

Figure Sb divides the children as to whether they have had one, two, three or more attacks by each year of life. Of the children who had OM in these years the majority had only one attack while approximately 10 percent (the sum of the two bottom lines) had two or more episodes. Unfortunately there is no additional information on duration of attack. Unless we can assume that children having only one attack have an average duration of attack approximately equal to that of children having more than one attack, it is difficult to say which group of children are more disadvantaged. Theoreti­ cally some children having one attack may be diseased for a whole- year, while some of those having more than one attack may experience short spells of OM, yielding an overall shorter total period with the disease. (b) Dunedin Multidisciplinary Child Development Study This study has presented a longitudinal clinical classification of middle ear status of the cohort between the ages of five and nine years (see Table 5.7). 45 TABLE 5.7 LONGITUDINAL CLASSIFICATION OF OME GROUPS BETWEEN THE AGES OF FIVE AND NINE, DUNEDIN COHORT(l]

Description n % Bilateral tympanostomy tubes on more than one occasion...... 13 1.4 Bilateral tubes on one occasion for hearing loss exceeding 25dB ...... 40 4.2 Bilateral tubes on one occasion without hearing loss exceeding 25dB ...... 30 3.1 Bilateral persistent otitis media with effusion, no tubes ...... 15 1.6 Bilateral transient otitis media with effusion ...... 45 4.7 Unilateral tube ...... 18 1.9 Unilateral persistent otitis media with effusion, no tube ...... 8 0.8 Unilateral transient otitis media with effusion .. .. 73 7.6 Never proven otitis media with effusion, scarred tympanic membrane ...... 138 14.3 Never proven otitis media with effusion, no scar in tympanic membranes, always bilateral A tympanogram when assessed ...... 133 13.8 The remainder (essentially C tympanogram on at least one occasion, never otitis media with effusion or B tympanogram) ...... 449 46.6

Total ...... 962 100.0

Summary of longitudinal data on otitis media 1 . Calculations from ear data provided by the Christchurch Child Develop­ ment Study suggest that: • . OM is a very common and recurrent disease in under 5-year­ aIds • approximately 25 percent of children had at least one episode of OM in anyone year between birth and age five; approxi­ mately 10 percent of these had two or more episodes in a given year • only 32 percent of children in this sample had no visits to the doctor with OM or suspected OM up to the age of 5 years • there is a hard core of children who experience OM many times during many of their early years of life; 18 percent of children in this cohort had OM in at least three of their first five years of life.

46 2 A longitudinal classification of middle ear status in the Dunedin Multi­ disciplinary Child Development Study birth cohort; between the ages of five and nine, showed that: • 13 percent has persistent bilateral or. unilateral OME • 12 percent had transient bilateral or unilateral OME • 14 percent were never observed to have OME, but scar lissue was present in the tympanic membrane (ear drum) • 60 percent were otologically 'normal' (although 47 percent of this group had a C tympanogram on at least one occasion).

S.S SPONTANEOUS IMPROVEMENT AND REGRESSION

(a) New Zealand studies West and Harris conducted a study of 7 and 8-year-olds in a school chosen because it had the highest hearing failure rate for school entrants in South Auckland [22]. One hundred children were tested using audiometry and tym­ panometry every 2-3 weeks throughout the school year, giving 17 testocca­ sions. The results showed that not only was there an average prevalence of any test abnormality (including C tympanograms) in 62 percent but also that the composition of the 'abnormal' group was constantly changing. This study was also able to provide information on the duration of abnormal episodes, the median duration being 3-4 weeks with a mean of6 weeks. Forty-four percent of the children had more than one episode., The changes in the composition of the group having abnormal hearing and middle ear function suggest that school audiometry is too infrequent to detect some children with significant disabilities: Our results showed that many of the children who would have passed the first test would have failed the same audiometric screen at a later time. We found 14 children who had normal audiometry and tym­ panometry tests for both ears on some occasions yet produced bilat­ eral hearing abnormalities of considerable severity later in the year. For example, one child had normal or minor abnormalities on the first five test occasions and severely disturbed patterns thereafter. [22] Additional New Zealand information is available from a South Auckland study by Maynard and Keith which used serial screening on 533 new entrants in nine primary schools(20]. Children were tested using pure tone audiome­ try and· impedance tympanometry and the tests were repeated in not less than 6 weeks. Those children who passed both tests at. the first screening were not tested at the second screeriing, so it is not possible to know how many would have passed from the normal to the abnormal category in the intervening 6 weeks. Twenty-six percent of new entrants failed the first pure tone test and halLof these failed'the second test, ie J 3 percent of the' original group. Seventeen percent failed the first impedance test and 8 percent failed

47 the second test. These results give a conservative failure rate because a num­ ber of children (3 percent of the original sample) were absent on the day of the retest. The major purpose of this study was to refine screening methods and the authors concluded that serial screening, in this case a retest after 6 weeks) approximately halved the failure rate. As has already been mentioned, we have no information on whether hearing or middle ear status deteriorated in those who passed the first screening. Information on spontaneous improvement in children taking part in the Dunedin Multidisciplinary Child Development Study is quoted by Lauge­ sen[43]. Upon re-examination of the 14 percent of 5~year-olds with OME) 5 months later 5.2 percent had improved spontaneously, 4.4 percent had had surgery done or it was required and 4.5 percent were still under observation.

(b) Overseas studies Studies carried out in Scandinavian countries provide the best overseas infor­ mation available on spontaneous improvement in children with otitis media. Fiellau-Nikolajsen investigated the prevalence and spontaneous course of middle ear effusion in 938 healthy 3-year-old Danish children [34]. Tym­ panometric screening was performed over a period of 6 months. Approxi­ mately one third of the ears in these 3-year-olds showed abnormal tympanograms (defined here as B, C -I and C2 tympanograms), including almost 10 percent of type B. One-point-seven percent of ears had type B tympanograms at all four screenings over the 6-month period. After the first month the initial pool of type B had been reduced to 60 percent, after 3 months to 45 percent and after 6 months to 35 percent. Temporary improve­ ments were common and were found in, 33 percent of the ears that showed type B tympanograms at the first as well as the final test. In a recent monograph Fiellau-Nilolajsen presented follow-up data on his sample of 3-year-olds at the age of 6 years[35]. He found that: • one out of every six ears with type B tympanograms at 3 years of age failed pure tone audiometry at 6 years, compared with one out of every 20 equally distributed over the other tympanogram types . • among 3-year-olds with MEE at their first screening, about one-third had effusion in the middle ear also when tested 3 years later • children consistently showing type B tympanograms from test to test at the age of 3 years had the poorest middle ear status at -age six. More than half of them still had MEE, more than a third failed pure tone screening and only one fifth had become normal. Tos also investigated the spontaneous improvement of secretory otitis media in healthy Danish infants and children[39]. In 2-year-old children 28.6 per­ cent of all ears had a type B tympanogram in at least one screening out of four and 1.6 percent had type B at all four investigations over a 9-month period. Fifty percent of all ears changed type every 3 months. Spontaneous improvement over time was as follows: of ears that had type B at the pre­ ceding evaluation, 53 percent improved between the first and second eval­

48 uation, 67 percent between the second and third and 84 percent between the third and fourth. Tos concluded that spontaneous improvement of type

B to type A or C 1 was 70.6 percent from the first to the fourth evaluation, i.e., over a 9-month period. It was not stated, however, how many tympan­ ograms deteriorated to type B over the period of study. Tos et al recently reported a similar study in which the middle ear status of 288 healthy 4­ year-olds was evaluated five times over one year[44]. Evaluations were 3 months apart. Thirty two percent of all ears had a type B tympanogram in at least one screening out of five and 12 percent were type B at all five trials. If those children with grommets are included, 22 percent had either type B tympanograms or grommets at all five evaluations. As with the younger age groups, 50 percent of all ears changed tympanogram type between each investigation, i.e., every 3 months. Tos et al described spontaneous improve­ ment as 'high' because 78-88 percent of type B ears 'changed type' at least once in 1 year, even though many later deteriorated to type B again. Only

49 percent of type Bears changed to types A or C1 at least once during the year. In the 4-year-old children described in this paper improvement of type B was more often to type Cn from where it may have deteriorated to type B and improved again to Cz• In the younger children. described in the pre­ vious paper by Tos, improvement of type B was more often to type A or C 1, and deterioration to type B was less frequent. If we roughly translate the transition from type B to type C2as meaning 'improvement' and type B to types A, or C 1 as meaning 'recovery' then it can be concluded, from the work of Tos et aI, that secretory otitis media has a more protracted course in 4­ year-olds than it does in 2-year-olds. Renvall et al reported a 'high degree of spontaneous normalisation' in Swed­ ish 4-year-olds who had ears with reduced middle ear pressures or flat tym­ panograms[45]. Of the ears exhibiting flat tympanograms 70 percent improved or normalised without treatment over a I-week period, thus 'indicating the need for a more conservative treatment philosophy in ears with serous­ Imucoid otitis media'. A Pittsburgh study showed that during a 12-month follow up of 66 2 to 5­ year-olds, 52 percent of the children had OME in at least one ear for 1 month or longer.[3]

Summary of data on spontaneous improvement of otitis media The majority of studies on spontaneous improvement of ear infection are concerned only with the progress of the 'failures', i.e., a child had to have a middle ear problem to be included in the study sample. The West and Harris study, on the other hand tested all children at all stages and gave information on 'new' cases with hearing loss or middle ear problems as well as the progress of 'old' cases. It is clear from the studies described that: • middle ear status, and presumably degree of hearing loss, fluctuate considerably over long observation periods

49 • the composition of the 'abnormal' group is constantly changing • despite this, there remains a 'hard core' of children with recurrent , and lasting middle ear problems. The Scandinavian writers were enthusiastic about the spontaneous improve­ ment rates because they were advocating a conservative approach to surgical treatment for the problem and 'also expressed their reservations about single impedance screenings of preschool children. , However their observations were much more revealing when we consider the consequences of temporary partial hearing loss on communicative abil­ ities in the critical preschool and early school years. There is an urgent need for further investigation of the effects of transient and partial hearing loss in the early years of life.

5.6 REGIONAL VARIATION IN SCHOOL SCREENING FAILURE RATES

Screening results are recorded as they have been passed on to the Division of Health Promotion, by district offices of the Department of Health. Figure 5c presents screening results for new entrants in all 18 health districts. It can be seen from Figure 5c that in 1982, Gisborne and Whangarei health districts had very high failure rates (over 20 percent). Auckland, South Auck­ land, Rotorua, Napier, Wellington, Dunedin and Invercargill also had high rates (over 15 percent). New Plymouth Health District had the smallest num­ ber of children failing the test. Figures Sd and Se present 1982 and 1983 school screening results, in the form of bar graphs, for new entrants (approximately 5 years of age) and Form I pupils (approximately 11 y~ars of age) in all 18 health districts.

Some of the regional' differences' may be explained as follows: • differing interpretation of screening criteria, i.e., departure from departmental policy • inter-tester error • varying accuracy of reporting results • varying prevalence of respiratory infections • varying prevalence of acute OM,' OME and CSOM • possible influence of socio-economic or racial factors. Many regional and area differences have not been accurately documented, and this is of crucial importance when making a case for equitable, rather than equal, distribution of resources and services. Distribution of services will be discussed in Part 3, Services for the Hearing Impaired. '

50 FIGURE 5c PROPORTION OF 5-YEAR-OLDS FAILING SCREEN­ ING TEST BY HEALTH DISTRICT, 1982

".

RATE PER 1000

o < 50 New Plymouth Ri~j > 50-100

> 100-150

~ > 150-200

III > 200

51 FIGURE 5d PERCENT FAILING HEARING SCREENING TESTS BY HEALTH DISTRICTS, 1982

Whangarei 'i//////////////////h Takapuna 'i////////~ South Auckland 'i////.'if//.'i/////. Auckland 'i//. 'i////. Hamilton 'i/////h ROlorua 'i/. 'if//. 'if//. Gisborne 'if//.'i///////.'i/////////.'i/. Napier 'i//.

New Plymouth 'Z~ Wanganui 'l//////.'i//. PalrnerslOn North 'l., Lower Hutt'i/////. Wellington 'i//. 'i//. Nelson 'l////////_ Legend 'l.,'i//. Christchurch I!!:Zl Form 1 Tirnaru 'l., _ New Entrant Dunedin 'F///////////~ lnvercargilI 'i////////////h Overal1 /'////////­

5 io !'s io is 3'0 3'5 40 Percentage Failing Tests

FIGURE Se PERCENT FAILING HEARING SCREENING TESTS BY HEALTH DISTRICTS, 1983

Whangarei 'i/. 'i/. 'i//. 'i//. '/////. 'if//. Takapuna 7///////////­ South Auckland 'i///.'i//. '///. 'l., Auckland 1/"///////.1": Hamilton 'i//. 'i/. Rotorua 7/////////////////////////, Gisborne '///. 'i//. 'i/, 'i///.'i////. 'if//. '////: '///. Napier I/"//////­ New Plymouth '//. '//: Legend WanganUi 7/////////////////////.1": e:zJ Form 1 _ New Entrants Palrnerslon North '//: Lower Hun 7////////////// Wellington 'l., '//: 'i//: '//: '//: Nelson 7/////.1": Chrislchur~h Timaru Dunedin InvercargilI 7/////////////­ Overall r///.'////.'i//: '//:

o 10 15 20 25 30 35 Percentage Failing Tests 52 5.7 PREVALENCE IN SPECIAL POPULATIONS

5.7.1 Children with speech and language problems In a review of the natural history and morbidity of persistent middle ear effusions, Klein states that 'although no published studies are perfect, the cumulative information suggests that frequent episodes of acute otitis media accompanied by prolonged middle ear effusion are associated with lower scores on speech and language tests administered at age 3 to 7 years'.[46] Results from the Dunedin Multidisciplinary Child Development Study showed that although language and IQ differences between groups with and without OME were no longer significant at age nine, those children who had had bilateral tympanostomy tubes on one or more occasions for OME with hearing loss (n= 52, 5.4 percent of the cohort) were still significantly disadvantaged in speech articulation.[ 10] For these reasons, it seemed likely that children attending speech clinics would have a higher rate of hearing impairment, or a higher frequency of ear and hearing problems in the past. This is not to say that hearing loss inevitably causes speech problems, but it may be a contributing factor. Speech therapists were asked to estimate how many children on their rolls had mild hearing loss, or had had hearing loss in the past[47). Eight out of ten districts responded, representing approximately 14,600 children. Speech therapists were not provided with an audiom~ter or tympanometer so their estimate of mild hearing impairment was largely subjective in the absence of any uniform audiological or otological data. Their overall estimate was 15 percent which was no higher than the proportion of new entrants failing school screening in 1982. It was concluded that either mild hearing impair­ ment is no more common in children attending speech clinics than in chil­ dren in the general population, or that without adequate testing, even speech therapists underestimate the prevalence of mild hearing loss in children. Whichever is the true explanation, and since on theoretical grounds children requiring speech therapy are at special risk, a more rigorous study of their hearing and middle ear status is now called for. Comments received suggest that speech therapists themselves would like to be able to quickly and rou­ tinely rule out hearing loss in their client children. s.7.2 Intellectually handicapped children Because it is difficult to test the intellectually handicapped, systematic audi­ ometric testing is often not done. However the literature indicates that there is a higher rate of hearing impairment in the intellectually handicapped population than in the general population, for example Down's syndrome children exhibit a higher prevalence of middle ear problems.[48,49] The inCidence and prevalence rates will vary as to whether calculations include or exclude untestable persons. Hogan argues that incidence per­ centages should be based upon data obtained from testable persons only.[50]

53 In a socio-medical study of a Norwegian birth cohort at 30 years of age, Kinge and Tonning found that the prevalence of hearing impairment was highest in former pupils of special schools for the educable mentally retarded (33.3 percent) as compared with a 17.5 percent prevalence for the cohort as a whole.[5I] In a recent Australian study of the hearing status of school-aged intellectually handicapped children (n = 128 after untestable children were excluded), 16.6 percent were found to have a 'significant' hearing loss, and an additional 32.5 percent had 'other slight but detectable hearing losses' (SO percent over­ all)[52]. The authors felt that the high prevalence of mild sensorineural and monaural sensorineural loss might be a contributing factor to the degree of intellectual handicap. When one health district tested children in two schools for the intellectually handicapped (n=54), 30 percent failed impedance tympanometry (an additional 4 percent were uncooperative) and 26 percent failed puretone audiometry (an additional 33 percent were uncooperative). If 'uncooperative' subjects were excluded, then nearly 40 percent of the children failed audi­ ometr-y using school screening criteria. Most of the Down's syndrome chil­ dren were found to have middle ear problems. This survey is reported more fully in Appendix 5b.

5.7.3 Children with multiple handicaps In the Wellington study, Physical disability, deafness was the most frequently reported main condition, affecting half of all physically handicapped children.[53] Of deaf children (hearing loss which averaged 50dB or worse in the better ear at the frequencies of 0.5, 1 and 2kHz) enumerated at age eight in an epidemiological study on childhood deafness in the European Economic Community, 29 percent were reported as having associated handicaps[54]. The three major handicaps reported were mental retardation, visual deficits and cerebral dysfunction (including cerebral palsy and epilepsy). Greville and Houghton investigated hearing loss in a multiple-handicapped population served by a New Zealandpsychopaedic hospital[55]. The popu­ lation ranged from the mildly behaviourally retarded to the profoundly intel­ lectually and physically handicapped. Most were cared for by their families with only a few being institutionalised. Of a total of 2360 files, 688 of the most recent records were included in this study; 657 of these persons were born since 1960. The in-patient and out-patient records were scanned for any information on hearing status and it was found that only 25 percent had had a hearing assessment. Of those tested 52 percent had abnormal hearing status which in this case included the categories of mild conductive, unilat­ eral and significant hearing loss. When those with abnormal hearing status were described as a proportion of the total number of records scanned, i.e., untested and tested combined, 13 percent had hearing problems. The percentage rose to 24 percent when those

54 with a recorded history of otitis media were included. When recorded cases of otitis media and unilateral hearing losses were excluded, the remaining hearing losses were described by the authors as significant because in most cases hearing aids were required. Over the whole sample, 7.1 percent had a 'significant' hearing loss as defined above~ f\ further breakdown of the various degrees of 'significant' hearing loss has been presented in Table 5.8.

TABLE 5.8 DEGREES OF 'SIGNIFICANT' HEARING LOSS IN A PSYCHOPAEDIC POPULATION[55]

Degree of loss Number Percentage Mild (not conductive) ...... 2 4.0 Moderate ...... :...... 8 16.3 Moderate-severe...... 4 8.2 Severe...... l3 26.5 Profound ...... 8 16.3 High frequency ...... :...... 2 4.0 Not known ...... 12 24.5 TOTAL ...... 49 99.8

To enable a comparison to be made between the prevalence of hearing loss in a 'psychopaedic population and the general population of children, rates for children aged 5-15 were extracted from the psychopaedic data and com­ pared with parallel information from schools for the deaf. Of all 5 to 15­ year-aids with psychopaedic records scanned in the course of the above sur­ vey (n = 331, both hearing-tested and untested), 6.9 percent had a 'signifi­ cant' hearing loss. In comparison with 5 to 15-year-olds in the general . population, 0.26 percent are receiving education for 'educationally signifi­ cant' hearing impairment. In other words 69 per 1000 school-age children in a psychopaedic population, compared with 2.6 per 1000 in a general popu­ lation, have a significant hearing loss. . It must be pointed out that the prevalence rate of approximately 70 per 1000 in the abo~e psychopaedic population is a very conservative estimate because 75 percent had not even had their hearing assessed.

S.8 SUMMARY (1) Otitis media (OM) is one of the most prevalent medical conditions of childhood. (2) . Overseas studies show that the highest attack rates for acute OM are in the first 2 years of life. .

55 (3) There is inadequate epidemiological information on OM and hearing status in preschoolers. (4) The Christchurch Child Development.Study has recorded. visits to the general practitioner for OM or suspected OM in a birth cohort up to the age of five. In these children it was found that:

• approximately 25 percent had at least one episode of OM in anyone year • 68 percent had been to the doctor with OM at some time during their first 5 years of life • 18 percent had OM in at least 3 of their first 5 years of life.

(5) Analysis of the Christchurch data and evidence from overseas studies indicate there is a hard core of 'otitis prone' children with recurrent middle ear problems. (6) At age five, 17 percent of the Dunedin Multidisciplinary Child Development Study birth cohort had either unilateral or bilateral otitis media with effusion (OME). (7) Longitudinal clinical data from the Dunedin cohort (over 900 chil­ dren) showed that, between the ages of five and nine, only 60 percent of the cohort could be regarded as otologically 'normal'. (8) The link between OME and conductive hearing loss has been well documented in overseas studies and the Dunedin study. (9) In 1983, 16 percent of preschoolers, 19 percent of new school entrants and 8 percent of Form I pupils (approximately age 11) failed school hearing screening, i.e., failed to hear 30dB at 0.5kHz and 20dB at 1, 2 and 4kHz in one or both ears on a first test. (10) There is considerable regional variation in the proportion of children failing school screening; in 1982, New Plymouth had a failure rate of 5 percent and Gisborne and Whangarei had failure rates of over 25 percent. (11) In the Dunedin cohort, the prevalence of hearing loss of ISdB and over was:

• 14 percent in 5-year-olds • 21 percent in 7-year-olds • 16 percent in 9-year-olds. (12) In South Auckland it is conservatively estimated that significant and sustained hearing impairment in school children is of the order of 15 percent. (13) Theoretically, children receiving speech therapy may have had a his­ tory of ear and hearing problems; an audiological and otological sur­ vey of such children is required.

56 (14) There is a higher prevalence of hearing impairment and ear prob­ lems in intellectually handicapped children and children with mul­ tiple handicaps. Acknowledgments 5.1 Mr Ian Stewart, ENT specialist, Dunedin . 5.3,5.4 Ms Lucy Carpenter, Hearing Research Project statistician Notes and references 1 'Some factors of possible etiologic significance related to otitis media with effusion' / Ian Stewart et aI, in Recent advances in otitis media with effusion: proceedings of the Third International Symposium / edited by David J Lim et at.-Philadelphia : Decker, 1984. p 25-27. ) 2 PUKANDER, Juhani, SIPILA, Markku and KARMA, Pekka.­ 'Occurrence of and risk factors in acute otitis media' (see ref 1) p 25-27. 3 'Prevalence and incidence of otitis media in a group of preschool children in the United States' / Margaretha L Casselbrant et ai, in (see ref 1) p 16-19. . 4 VAN CAUWENBERGE, Paul Band KLUYSKENS, Paul M.­ 'Some predisposing factors in otitis media with effusion' in (see ref 1) p 28-32. 5 'Incidence of secretory otitis media after acute inflammation of the middle ear cleft and upper respiratory tract' / Y Kaneko et ai, in (see ref 1). p 34-36. 6 'A longitudinal study of respiratory viruses and bacteria in the etiol­ ogy of acute otitis media with effusion' I F W Henderson et ai, in N Engl J Med.-v 306 (1982) p 1377-1383. 7 GIEBINK, G Scott.-'Epidemiology and natural history of otitis media' in (see ref 1) p 5-9. 8 'Some developmental and behavioural problems associated with bilat­ eral otitis media with effusion' / Phil A Silva et ai, in J Learn Dis­ abil.-v.I5 no 7 (Aug/Sept 1982) p 417-421. 9 SILVA, Phil A et al.-How impaired are children who experience persistent bilateral otitis media with effusion? Paper presented to the International Study Group on Special Educational Needs Research and Develoment Seminar, July 18-22 1983, Mayo Clinic, Rochester, NY. . 10 'Some developmental characteristics associated with otitis media with effusion' / Ian Stewart et ai, in (see ref 1) p 329-331. 11 BROOKS, Denzil N.-'Otitis media and child development: design factors in the identification and assessment of hearing loss', in Ann Otol Rhinol Laryngol.-v 88 5 Pt 2 Suppl. 60 (Sept/Oct 1979) p 29­ 47.

57 12 PARADISE, Jack L.-'Otitis media during early life: how hazardous to development? A critical review of the evidence', in Paediatrics.­ v 68 no 6 (6 Dec 1981) p 869-873. 13 STEWART, Ian.-Personal communication, 1984. 14 'The outcome of acute otitis media: a report to the Medical Research Council' /John Fry et aI, in Br J Prev Soc Med.-v 23 (1969) P 205­ 209. ' 15 MURPHY, P.A.-'Etiologies of childhood deafness in Victoria', 'in J Otolaryngol Soc Aust.-v 4 no 2 (1977) p 108-111. 16 Dunedin Multidisciplinary Child Development Study Team.­ Personal communication, 1983. 17 Information provided by the Division of Health Promotion, Dept of Health, Wellington. 18 McGEE, Rob and SILVA, Phil A.-A thousand New Zealand chil­ dren : their health and development from birth to seven: report from the Dunedin Multidisciplinary Child Development Study.-Dunedin : University of Otago, Medical Research Council of New Zealand, 1982. (Special report series; no 8). 19 Information provided 'by South Auckland District Office, Dept of Health. 20 MAYNARD, E J and KEITH, W J-Hearing screening amongst new scho,?l entrants-':'-South Auckland : District Office, Dept of Health 1981. (Unpublished), 21 MAYNARD, E J and SISLEY, D.-Hearing screening amongst new school entrants, addendum : otoscopy.-South Auckland : District Office, Dept of Health 1981. (Unpublished). 22 WEST, S Rae and HARRIS, Barbara J.-'Audiometry and tympan­ ometry in children throughout one school year', in NZ Med J.-v 96 no 737 (10 Aug 1983) p 603-605. 23 Information provided by Lower Hutt District Office, Dept of Health. 24 Hearing levels of 10-12 year old Sydney school children I N L Carter et al.-Canberra : National Acoustic Laboratories, Dept of Health, 1978. (Report; no 70). 2S MACREADY, M E, SOLOMON, N and YOUNG, S L.-Ear dis­ ease amongst third form girls: the results of a study in a large Auck­ land secondary school undertaken in the first school term, 1981.­ Auckland: District Office, Dept of Health 1981. (Unpublished). 26 FLIGHT, R J, McKENZIE-POLLOCK, M and HAMILTON, M.­ Northland fourth form student survey.-Whangarei : Northland Health. Services Advisory Committee, Dept of Health, 1981. (Unpublished). 27 Information provided by Auckland District Office, Dept of Health.

58 28 CLEMENTS, C J and JOSEPH, J G.---:-'Hearing impairment: causes, effects and prevention', in NZ Health 'Review no 1 (1981) p 15-19. 29 ASHER, M I and SHORT, D P-Child health survey: Ruatoki Family Health Clinic. Paper presented to the Annual Meeting of the Paediatric Society of New Zealand, 1978. (Unpublished). 30 'Ear disease in rural New Zealand school children' rJ M Stanhope et aI, in NZ Med J.-v88 n 615 (12 July 1978) p 5-8. 31· 'A survey of child healtl-i in Te Teko, Bay of Plenty' / K Downer et ai, in Research and development projects 1979, 5th year class in Community Health. -Wellington: Dept of Community Health,' Clinical School of Medicine, 1979. 32 HAMILTON, Mary A and McKENZIE-POLLOCK, M.-'Aural health in 227 Northland school and preschool children', in NZ Med . J .-v 91 (1980) P 59-62. 33 TONKIN, Shirley L.-'Tokelau Island children's study: common diseases' in Migration and health in New Zealand and the Pacific ledited by J Stanhope.-Wellingtan : Wellington Hospital Epide-. miology Unit, 1977. 34 ,FIELLAU-NIKOLAJSEN, M.-'Tympanometry in three-year-old . . children : prevalence and spontaneous course of MEE', in Ann Otal Rhinol Laryngol .-v 89 3 Pt 2 Suppl 68 (May-June 1980) p 223­ 227. . 35 FIELLAU-NIKOLAJSEN, M.-'Epidemiology of secretory otitis media: a descriptive study cohort', in Ann Otal Rhinal Laryngol.­ v 92 (1983) p 172-177. 36 'Natural history of acute and serous otitis media during the first two years of life' j Juliette Thompson et aI, in (see ref 1) p 324-326. ·37 INGVARSSON, Leif, LUNDGREN Kaj and OLOFSSON, Ber­ til.-'Epidemiology of acute otitis media in children: a cohort study in an urban population' in (see ref 1) p 19-22. 38 TEELE, D W, KLEIN, J 0 and ROSNER, B.-'Middle ear disease and the practice of paediatrics', in JAMA.-v 249 (1983) p 1026­ 1029. 39 TOS, Mirko.-'Spontaneous improvement of secretory otitis and impedance screening', in Arch Otolaryngol.-v 106 (June 1980) p 345-349. . 40 FERGUSSON, David.-Personal communication, 1983. 41 'Incidence of acute otitis media' I J Pukander el ai, in Acta Otolar­ yngol.-v 93 (1982) p 447-453. 42 HOWIE, V M, PLOUSSARD, J Hand SLOYER J.-'The "otitis­ prone" condition', in Am J Dis Child.-v 129 (June 1975) pi 676­ 678. . , .

59 43 NZ Committee on Cl}ild Health.-Child health and child health services in New Zealand. -Wellington: Board of Health, 1982. (Board

of Health report series ; no 31) < 44 'Spontaneous course and frequency of secretory otitis in 4-year-old children' / Mirko Tos et ai, in Arch Otolaryngol.-v 108 (Jan 1982) p 4-10. 45 RENVALL, Ulf, ANIANSSON, Gunnar and LIDEN, Gunnar.­ 'Spontaneous improvement in ears with middle ear disease', in Int J Pediatr Otorhinolaryngol.-v 4 (1982) p 245-250. 46 KLEIN, Jerome O.-'Persistent middle ear effusions: natural history and morbidity', in Paediatric infectious disease. Williams and Wilkins~ 1982. 47 Data collected for the Hearing Research Project. 48 STROME, Marshall.-'Down's syndrome: a modern otorhinolar­ yngological perspective', in Laryngoscope.-VXCI no 10 (October 1981) p 1581-94. 49 WHITE, Benjamin LeM, DOYLE, William J and BLUESTONE, Charles D,-'Eustachian tube function in infants and children with Down's syndrome' in (see ref 1) p 62-66. 50 HOGAN, Donald D. 'Errors in computation of incidence of hearing loss in studies of large populations', in Ment Retard.-v 11 (April 1973) p 15-17. 51 KINGE, F 0 and TONNING, F.-'Hearing impairment; preva­ lence and relation to school background, intellectual ability and encephalopathy: a sociomedical study of a birth-cohort from Bergen', in Scand Audiol.-v 6 (1977) P 225-231. 52 JITTS, Stephe and KEYES, Carrie.-'Incidence of hearing loss 'in a population of school-aged intellectually handicapped children', in Aust J Audiol.-v 5 no 2 (1983) p 71-75. 53 Physical disability : results of a survey in the Wellington Hospital Board area! Avery Jack et al.-Wellington : Management Services and Research Unit, Dept of Health, 1981 (Special report series; no 59). ' 54 'Childhood deafness iQ the European Community' I JAM Martin et ai, in Scand Audiol.-v 10 (1981) p 165-174. 55 Data collected by Anne Greville and Janet Houghton, Audiologists, . Audiology Centre, for the Hearing Research Project.

60 6 HEARING IMPAIRMENT IN ADULTS

6.1 TYPE AND CAUSE OF HEARING LOSS

As with children, there are two major types of hearing loss, conductive and sensorineural. Sensorineural loss is more common in adults and can be class­ ified in several ways: noise-induced, presbyacusis, sociocusis or due to birth defects, congenital problems, disease, injury or drugs.

Noise-induced hearing loss (NIHL) is also known as noise-induced permanent threshold shift (NIPTS), and is a permanent shift in the hearing threshold (a lowering of the sensitivity) of the ears due to exposure to noise[l]. It can result from either a single exposure to high intensity impulsive noise, such as blasts or explosions, or to longer exposure to lower, but still damaging noise levels. Typically, hearing loss due to noise exposure occurs first at the higher frequencies, particularly around the 4kHz level (3kHz-6kHz).

Presbyacusis is hearing loss associated with increasing age. It is most marked at higher frequencies especially those above 3kHz. The causes of presbyacusis are believed to be deterioration of the central nervous system and changes in the auditory system.[l]

Sociocusis is noise-induced hearing loss attributed to environmental (non­ occupational) noise. It is difficult to separate sociocusis from hearing loss due to ageing or to occupational noise exposure. Exposure to high levels of envi­ ronmental noise" may accelerate loss normally due to ageing[l]. 'The effects of noise exposure on hearing may be considered to represent certain aspects of premature presbyacusis' .[2] In a voluntary testing programme for office workers in one health district the factors which most strongly distinguished those who failed the hearing test were: • having experienced a head injury, with unconsciousness • service in "the armed forces • previous work in a noisy environment • hearing difficulty in the past.[3] A breakdown of cause of hearing loss in a random sample of 206 Danish males aged 49-69 is presented in Table 6.1. The aetiological diagnosis is based on a combination of otoscopy, pure tone auditory thresholds, audi­ ogram shape and patients' accounts of their medical history.

61 /. TABLE 6.1 CAUSE OF HEARING LOSS IN DANISH MALES AGED 49-69* Number of Aetiological diagnosis subjects % Bilateral noise-induced hearing loss...... 77 37.4 Monaural noise-induced hearing loss...... 12 5.8 Otosclerosis...... 3 1.5 Chronic otitis media ...... ,...... 5 2.4 Inherited hearing loss ...... 2 1.0 Normal hearing** (both ears)...... 32 15.5 Unknown cause...... 57 27.7 Asymmetrical s~nsorineural hearing loss (symptom)...... 18 8.7

TOTAL...... 2'06 100.0

* adapted from Parving et al. (41 ** 'abnormal' hearing was based on' the criterion of an audiometric pure tone threshold averaged over 0.5,1,2 and 4kHz greater than or equal to 25dB HL.

6.2 PREVALENCE ESTIMATES The brief for the Hearing Research Project was to work from existing data, which highlighted the fact that there are no audometric data on the general adult population in New Zealand. We turned to data from other countries, making the assumption that the prevalence of hearing impairment in New Zealand would be similar to that found in British, North American and Scan­ dinavian countries. In the past, hearing loss prevalence data rarely included frequencies over 2 kHz because high frequency loss was not seen as significant. However, 'in most languages,good high-frequency hearing is important for speech intel­ ligibility, especially when listening conditions are imperfect owing to back­ ground noise'[S]. For this reason it is important to include hearing loss at 4 kHz when presenting prevalence estimates in the general popUlation rather than restricting it to the presentation of data on noise-induced hearing loss. A working definition of hearing loss agreed upon by the Committee on Hear­ ing was 'loss exceeding 2SdB at any of the four frequencies, O.S, 1, 2 and 4kHz, in one or both ears'. Overseas data collected during the early stages of the project have since been updated with more recent information from Britain and the United States. The following two large overseas studies have been used: (1) National Health and Nutrition Examination Survey (HANES I), USA [6] HANES'I was conducted in the United States from 1971-197S. Over this period a sample of 6913 persons was examined, representing the civilian non- .• institutionalized popUlation of 2S-74 years of age.

62 (a) Pure tone air conduction findings: an advantage of the HANES I data over the earlier Health Examination Survey (HES, 1960-62) data is that they provide rates for hearing loss at 4kHz.· Unfortunately, however, this study does not provide us with an overall rate; the results are presented separately for each of the four frequencies (0.5, 1, 2, and 4kHz) and not as a three;. frequency or four-frequency average. Table 6.2 presents audiometric test findings for pure tone air conduction for the right ear. A less conservative cut-off (21 +dB) and a more conservative cut-off (31 +dB) have been included because they straddle our definition of 'hearing loss exceeding 25dB'.

TABLE 6.2 PREVALENCE OF HEARING LOSS ACROSS FOUR FREQUENCIES BY AGE, RATE PER )000, USA 1971­ 75[6]

Frequency Age 500Hz 1000Hz 2000 Hz 4000Hz group 2JdB+ 31dB+ 21dB+ 3JdB+ 21dB+ 31dB+ 2JdB+ 31dB+ 25-34 ...... 40 15 35 11 44 17 121 76 35-44 ...... 60 26' 65 20 102 47 254 168 45-54 ...... 117 55 124 57 187 99 409 282 55-64 ...... 200 81 236 98 362 196 608 431 65-74 ...... 272 153 364 198 555 332 784 598 All ages ...... 123 55 137 61 207 112 381 268

It can be seen from Table 6.2 that the prevalence of some degree of hearing handicap that would interfere with understanding sp~ech (defined in the HANES I report as ahearing level of 21dB or more above audiometric zero, ANSI 1969) in the right ear ranges from 12.3 .pe·rcent to 20.7 percent at the pure tone frequencies often considered most important for understanding speech, i.e., 0.5, 1 and 2kHz. At 4kHz the prevalence .rate for this degree of hearing handicap is 38.1 percent ranging from 12.1 percent for persons 25­ 34 years of age to 78.4 percent for those 65-74 years of age. . Two main points emerge from these prevalence rates: • the high prevalence of hearing loss at 4kHz, a frequency wpich was not even taken into account in earlier sur~eys" . • an apparent increase in the prevalence of hearing impairment over a 10-year period; in 1960-62 (HES) the overall prevalence rate for hearing loss of 26dB and over for ages 18-79 was 7.3 percent, using the criterion of better-ear-average over 0.5, 1 and 2kHz; in 1971-75 (HANES I) the prevalence of hearing loss of 21dBand over for ages :25.,..74 was 12.3 percent at 0.5kHz, 13.7 percent at lkHz,.20.7percent at 2kHz and 38.1.percent at 4kHz. . .

63 Sig. 6 (b) Speech reception hearing levels: HANES I also carried out speech recep­ tion testing, obtaining data on the examinee's ability to identify speech and the relationship of this ability to pure tone air conduction hearing thresholds. Each subject was asked to repeat lists of 10 sentences, each list containing 50 key words. If the examinees missed six key words or more, the next list was presented at a level IOdB higher. Testing was continued in this way, in the right ear only, until the subject missed five key words or less or until the ear had been tested at 80dE. A summary of the HANES I speech reception findings is presented in Table 6.3. .

TABLE 6.3 PREVALENCE OF SPEECH RECEPTION DIFFICUL­ TIES BY LEVEL OF AMPLIFICATION REQUIRED TO MISS NO MORE THAN FIVE WORDS FROM LISTS OF • SENTENCES: BY AGE, RATES PER 1000, USA 1971-75[6]

Presentation level in decibels Age group . 30dB+ SOdB+ 80dB+ 25-34 ...... 86 7 4 35-44...... 167 26 4 45-54 ...... 299 28 5 55-64.,...... ,...... 437 71 7 65-74...... 667 185 35 All ages ...... 286 so 9

An estimated 28;6 percent of adults 25-74 years of age could not hear or understand everyday speech presented at 30dB, i.e., missed six or more words from one of ten SO-word lists of Revised Central Institute for the Deaf (RCID) sentences. Five percent of adults would have been unable to understand speech presented at 50dB, and 0.9 percent at 80dE. Put another way, the percentage of adults meeting the speech reception test criterion at 20dB (the criterion used in the HANES I summary discussion) decreases with age from 91.4 percent at 25-34' years to 33.2 percent at 65-74 years.[6 p3] (2) Medical Research Council National Study of Hearing (NSH), United Kingdom[7,8,9,1O]: The objectives of the NSH are to document the prevalence, causes, descrip­ tion, understanding and consequences of hearing disorders in the adult popu­ lation[9]. The study, which began in 1978 and is still in progress, has a two tier design: a questionnaire tier followed by a sub-sampled clinical tier. In the first phase a random selection of the adult British population aged 17 years and over was taken by sampling from the electoral rolls in Cardiff, Glasgow, Nottingham and Southampton. A total of 11,740 individuals were sent a postal questionnaire enquiring about their hearing status, of which 9607 (82 percent) were returned. The sample was stratified on the basis of

64 these replies and a total of 2396 individuals were invited to attend for a full ototogical and audiometric assessment. In all, 759 (32 percent) individuals . were tested at this second tier. No substantial differences between attenders and non-attenders were found with respect to the measures reported here.[lO] An advantage of the NSH data for our purposes is that it not only provides reliable up-to-date prevalence rates, but also information on type of hearing . loss. Data on the prevalence of hearing defects in the British adult population are. summarised in Figures 6a, 6b and 6c and more detailed information can be found in Appendix 6a.

FIGURE 6a PREVALENCE OF HEARING DEFECTS OVER ALL AGES, BY TYPE OF HEARING LOSS, BRITISH ADULT POPULATION

81 IBetter Ear I

68 IWorse Ear I

Legend D Normal I22'J Conductive lIIJ Mixed _ Sensorineural

o 10 20 30 40 50 60 70 Percentage

65 FIGURE 6b PREVALENCE OF HEARING DEFECTS, BY AGE GROUP AND TYPE OF HEARING LOSS, BRITISH ADULT POPULATION, BETTER HEARING EAR

Percentage

Z1

73 60 86 96

Legend CJ Normal I'ZJ ConductivelMixed _ Sensorineural

.15-30 31-50 51-70 71+ Age Range

Major findings from the NSH are: '. the prevalence of hearing disorders in the adult British population is considerably higher than previous estimates • ' the prevalence of hearing defects is 19 percent in the better ear and 32 percent in the poorer hearing ear, using the criterion of 2SdBHL averaged across 0.S-4kHz , • if these rates are applied to the New Zealand adult population (15 years and over), approximately 430,000 persons will have hearing loss in their better hearing ear " • ' the majority of defects are of a sensorineural type and become increasingly common with age; however, hearing loss 'is by no means a disease of old age' as 9 percent of 31 to SO-year-oIds had a mean sensorineural loss greater than 2SdB in their poorer hearing ear[IO] • noise was by far the most important factor identified in the aetiology of sensorineural defects

66 • conductive defects do not become more common with age; it must be pointed out that if ENT services are functioning well, the preva­ lence of conductive hearing loss will be underestimated because these people will have beep successfully treated.

FIGURE 6c PREVALENCE OF HEARING DEFECTS, BY AGE GROUP AND TYPE OF HEARING LOSS, BRITISH ADULT POPULATION, WORSE HEARING EAR ' Percentage

25

56 72 86 Legend CJ Normal 40 12'21 Conductive/Mixed _ Sensorineural

20

15-30 31-50 51-70 71+ Age Range

A summary of three major overseas studies on prevalence of hearing loss in adults is presented in Figure 6d: It includes the United States HANES I data, United Kingdom NSH data, as welL as Jauhiainen's estimates for com­ parison[ll]. The hearing measurement criteria for the data presented in Fig­ ure 6d are as follows: . 1 HANES I : adults who couid not hear or un.derstand everyday speech' at 30dB amplification (see Table 6.3) 2 NSH : adults with hearing loss at 0.5, 1, 2 and 4kHz greater than or equal to 25dB (see Figures 6b, 6c and Appendix 6a) 3 Jauhiainen, quoted in Deafness the invisible handicap, p46 : hearing loss greater than or equal to 30dB at 0.5, 1 and 2kHz; 4kHz has not been included.

67 FIGURE 6d HEARING IMPAIRMENT IN ADULTS ACROSS AGE GROUPS, COMBINED OVERSEAS DATA

Percentage 80~------'

70

60 Legend USA UK (beuer&_ 50 UK(w

30

20

10 __=.I....------~ O~--~~~~--~------r_----~------~----~--~--~ 10 20 30 40 50 . 60 70 80 Age

6.3 SEVERITY OF HEARING LOSS Having obtained some idea of the quantity of the problem, we turn now to the qu~lity or degree of the hearing loss experienced. This information is even more scarce than simple prevalence data. The only comprehensive work which has looked at severity of loss across age is that by Jauhiainen in Fin­ land[ll]. His model, based on British, North American, and Finnish studies, was applied to the New Zealand population in Deafness the invisible hand­ icap[12]; it does not include hearing loss at 4kHz so will therefore be an underestimate. A summary of Jauhiainen's data for hearing loss of over 30dB is presented in Table 6.4. We may look simply at what he predicts in terms of the relative percentages in different severity categories for hearing losses over 30dB ('mild' 30-45 dB, 'moderate' 45-60dB, 'severe' over 60dB) by age. It is clear that with increas­ ing age the relative percentage of severe hearing losses also increases; for example from 5 percent to 16 percent for losses over 60dB. Thus it appears

68 · that not only is the prevalence of hearing loss related to age but that the severity of that loss is also related to age. Both of these factors are particularly relevant in the face of an ageing population, where we must expect not only an increasing percentage of our population to have a significant hearing loss but also an increasing percentage of more severe hearing losses. In other words, we can expect a change in the quantity and quality of the hearing loss .problem. Additional NSH data received from the Institute of Hearing Research, Not­ tingham, has provided prevalence rates for 'severe, profound and total' deaf­ ness in adults and these have been applied to the New Zealand population (see Table 6.5).[13]

TABLE 6.4 SEVERITY OF HEARING LOSS, ESTIMATED PER­ CENTAGE IN DIFFERENT SEVERITY CATEGORIES, BY AGE GROUP*

Hearing Age group loss (dB) -14 15-24 25-44 45-64 65-75 75+ 30-45 ...... 77 76 71 65 60 58 45-60 ...... 18 19 20 24 26 26 60+ ...... 5 5 9 11 14 16

* adapted from Jauhiainen [II)

TABLE 6.5 ESTIMATED PREVALENCE OF SEVERE, PROFOUND AND TOTAL DEAFNESS IN THE NEW ZEALAND ADULT POPULATION, 15 YEARS AND OVER, EXTRAPOLATED FROM THE BRITISH NATIONAL STUDY OF HEARING*

Better ear hearing level average 65dB 85dB 95 dB across 0.5, 1, 2, 4kHz Prevalence rate per 1000, UK ...... 11.23 2.28 0.54 Estimated number in NZ population...... 25 800 5 500 1 200

* adapted from Davis (13)

The above figures are higher than those presented in· Deafness the invisible handicap which were derived from Jauhiainen's model: NSH estimate: 32,500 persons with hearing loss greater than 65dB. Deafness the invisible handicap estimate: 21,700 persons with hearing loss of 60dB or more.[12] .

69 6.4 NOISE-INDUCED HEARING LOSS

6.4.1 Criteria for notification The World Health Organisation executive summary Noise points out that noise-induced hearing. handicap has been traditionally assessed by measuring hearing acuity at 0.5, 1 and 2kHz. 'However, this procedure is restrictive and the frequencies 3 and 4kHz have recently been included in damage- risk formulae of an increasing number of countries' .[5] . A recent paper from Norway points out that a sensorineural dip on an audi­ ogram in the 4-6kHz area is most commonly caused by exposure to high noise levels.[14] . In New Zealand the Accident Compensation Corporation's criterion for assessing degree of hearing loss for compensation uses the Australian National Acoustics Laboratory (NAL) system of calculating percent loss of hearing (PLH). Details of this method can be obtained from the authors or the Acci­ dent Compensation Corporation. The Department of Health criterion for notification of occupational hearing loss applies 'when two audiograms show a loss of hearing at 4kHz in either ear equal to or exceeding 35dB at age 45 or less, or a loss of 50dB at any age'[IS]. It is also stated that the two audiograms should be taken after a period of at least 16 hours without expo­ sure to noise and must not be taken on the same day. The criteria for notification used in Victoria, Australia are similar to New Zealand's, but go further towards early detection. They apply: • when an employee has a hearing threshold level at 4kHz which equals or exceeds 25dB at 30 years or less, or 3SdB at 45 or less, or SOdB at any age . • when a difference in hearing level between audiograms of any employee, taken at two-year intervals or less, exceeds I5dB at 3, 4 or 6 kHz[16]. The first criterion makes provision for intervening at an earlier age and lesser degree of los~ and the second allows for close monitoring of any hearing deterioration. 6.4.2 Prevalence Just as we have no NewZealand data on the hearing status of the general population of adults, so we do not know what proportion of the-population has noise-induced hearing loss. Some questions which require answers are: • what is the extent of severe high frequency hearing loss? • what proportion of hearing loss at or around 4kHz is the result of exposure to noise? • what proportion of the work force is exposed to potentially hazardous noise? 70 • what proportion of the population is experiencing the early signs of NIHL? • what proportion of the population has moderate or severe NIHL? • what proportion of NIHL results from exposure to noise at work, as against sociocusis, for example? At this stage we do not have the answers to many of these questions. In the absence of hard data, a number of estimates will be provided: 1 . Estimated number of persons with 'notifiable' deafness, from whatever cause (see Table 6.6).

2 Estimated number in workforce exposed to noise, i.e., at risk of NIHL, by age (see Table 6.7). .

3 Estimated number in workforce exposed to noise, by type of industry (see Table 6.8).

TABLE 6.6 PERCENT DISTRIBUTION OF HEARING LOSS EXCEEDING SOdB AT 4kHz, RIGHT EAR ONLY (HANES '1) APPLIED TO CORRESPONDING AGE GROUPS IN THE NEW ZEALAND POPULATION*

% with SOdB Estimated number in Age group loss at 4kHz NZ popn. affecte~ Total 25-74 ...... 11.9** 191 206 25-34 ...... 2.8 13 328 35-44 ...... 6.5 23425 45-54 ...... 13.6 40995 55-64 ...... 18.7 51 010 '. 65-74...... ;...... 31.4 62448

* New Zealand census of population and dwellings 1981 Bulletin 11. National Summary. ** age-adjusted.

Approximately 190,000 people have high frequency loss of such severity as to be notifiable had it been caused by exposure to noise in the workplace: Presbyacusis and exposure to noise will account for most of the above hearing loss. The estimate of 190,000 is a conservative one because it does not include the other category of potential 'notifiables', that is those under the age of 46 with Ii hearing loss of 35dB at 4kHz. An estimated 200,000-400,000 full-time workers are exposed to potentially hazardous noise at work. The lower figure is a very conservative estimate. (T'able 6.7). .

71 TABLE 6.7 NEW ZEALAND FULL-TIME WORKFORCE BY AGE GROUP*, ESTIMATED NUMBER EXPOSED TO POTENTIALLY HAZARDOUS NOISE

Estimated number exposed to noise If 15% If 30% Age of workforce of workforce . 15-19...... 24439 48878 20-24 ...... 31 396 62792 25-34 ...... 49284 98 568 35-44 ...... 40457 80914 45-54 ...... :.. 32947 65894 55-64...... 18 618 37 236 65+ ...... 2 708 5416 TOTAL...... 199 849 399699

* New Zealand census 0/ f!

TABLE 6.8 NEW ZEALAND FULL-TIME WORKFORCE BY TYPE OF INDUSTRY,* ESTIMATED NUMBER EXPOSED TO POTENTIALLY HAZARDOUS NOISE

Total number Estimated no. Type of industry of persons exposed to noise

Potentially high noise levels If 60% of workforce Agriculture, hunting (i.e., shooting) for­ estry, fishing ...... :...... :...... 144 252 .. Mining and quarrying ...... 4659 Manufacturing ...... 311 133 Electricity, gas and water ...... 15 123 Building and construction ...... 85 737 Subtotal .....·...... 560904 . 336 542 .Potentially lower noise levels If 10% of workforce Wholesale, retail, restaurant ...... 218 439 Transport, storage, communication ...... 107 826 Finance, insurance, property ...... 91 638 Community, social, personaL ...... 307 575 Inadequately defined ...... 4S 963 Subtotal ...... 771 441 77 144 TOTAL...... 1 332 345 413 686

* New Zealand census 0/ population and dwellings 1981. Bulletin 11. National Summary p 27

72 Table 6.8 estimates that 42 percent of the full-time workforce are employed in noisy industries. A breakdown of the workforce by type of occupation (given in Appendix 6b) gives a similar rate of 45 percent in potentially noisy . occupations. If an estimated 60 percent of workers in noisy occupations and 10 percent of workers in less noisy occupations are exposed to potentially hazardous noise levels, then 400,000 workers at:e at risk. American data on noisy manufacturing industries give the following percentage of workers exposed to noise above 85dBA: wood products-94 percent [17] textile-75 percent [18]. petroleum-50 percent [19] paper-..:..40 percent [20] chemical-23 percent [19]

What proportion of the workforce is experiencing the early stages ofNIHL? Exist­ ing data do not provide an answer to this, however possible clues are that: 1 Twelve percent of the US population aged 25-34 and 25 percent of those aged 35-44 are experiencing hearing loss greater than 20dE at 4kHz (HANES I, see Table 6.2).

2 Information from the British NSH suggests that noise is by far the most important aetiology of sensorineural defects in adults[ 10]. If individuals. had had the equivalent of lifetime exposure to noise greater than 90dBA, they had significantly higher thresholds, that is more hearing loss, at 2kHz and above.

3 In a recent survey of hearing acuity in a Norwegian standard popUlation of 1474 men and women aged 20-80 years, Molvaer et al found a marked dip in the audiograms at 6kHz, even in the youngest age group[14]. Mean pure tone thresholds for both ears combined are Presented as audiogram curves in Figures 6e and 6f. . Molvaer et al believe that the described dip may be a result of exposure to noise, and quote several studies which discuss the occurrence of NIHL in young pe

4 In a sample of Danish males aged 49-69 with hearing loss greater than or equal to 25dB averaged across 0.5,1,2 and 4kHz, 37 percent had per­ manent bilateral noise-induced hearing impairment and an additional 6 per­ cent had monaural noise-induced hearing loss (see Table 6.1).

5 It is possible that hearing loss at 6kHz is an early sign of NIHL. Thirty­ five percent of employees in a New Zealand paper mill (75 percent of those tested) had high frequency hearing loss of 25d~ and over (see Table 6.10), and most of this loss was either at 6kHz or at both 4 and 6kHz (see Table 6.9),

73 FIGURE 6e MEAN HEARING LEVELS FOR BOTH EARS COM­ BINED IN MEN, NORWAY[14]

0

~':::-- , I~~-"""';;::,o • Age 20-29 30-39 20 .--..---.:::::::. " .'"0.~// 0_. o~_ '\..". • 40-49 ~ ~/ --- '", :~ ~ 0 50-59 ;;; 40 co . \'~I (') 60-69 0 "'- ',,:/0 ~ 60 \ ..'" 70-80 m '''''./' ~" 80 .... I

100

0.25 0.5 2 3 4 6 8

Frequency (kHz)

FIGURE 6f MEAN HEARING LEVELS FOR BOTH EARS COM­ BINED IN WOMEN, NORWA Y[14]

I ,

o

,::::::::::::::1' =~._.,~..-==-'=1:::::::: Age 20-29/30-39 .~ 40-49 20 .-.--.--...... " . .--.--- /':0 50-59 "-. '--.-...... "":1 ...... \ '" 40 -0-- " ",,, . 60-69 <0 " ./ o'" /I) '",/. 60 • 70-80

.... 80 I

100

"

0.25 0.5 2 3 4 6 8

Frequency (kHz)

74 TABLE 6.9 _HIGH FREQUENCY HEARING LOSS GREATER THAN 25dB IN PAPER MILL EMPLOYEES (AGED 18-65), BY FREQUENCY (Hz)[21]

Frequency Number Percent

4kHz only ...... ;...... 89 6 6kHz only ...... :...... 820 56 4 and 611Hz ...... 545 38 . Total with high frequency loss ...... 1 454 100

. 6.4.3 Occupational data Although some audiometric testing is being carried out by the Department of Health and occupational health personnel in some large firms, .data are rarely presented in a systematic manner. Table 6.10 presents a summary of the rather fragmentary data that were collected in the time available. More work 'is required in this area.

TABLE 6.10 . PREVALENCE OF HEARING LOSS IN THE WORK· FORCE, SOME NEW ZEALAND DATA[21]

Rate per Rate per No. in 1000 of 1000 of Source of work­ No. Criteria used! work. those dala force tested degree of loss force tested

Paper mill 4200 1942 Loss of 25dB or 350 750 (a) (46% . more at either of work 4kHz, 6kHz or force) both frequencies (See Table 6.9) Building 2 502 871 (l) hearing loss 119 343 supplies (35% of (2) notifiable 48 138 manufac­ work deafness turer (b) force) (subcategory of hearing loss) Wanganui 911 285 Notifiable deaf­ 95 305 District (31% of ness Office (c) . work force) Manukau 524 (1) failed test 430 District Health (no definition) Office (d) 50 (2) failed test 600 (no definition) Ministry 197 197 Slight hearing 147 625 of Works (100% of / loss programme workforce) Moderate hearing 229 (e) loss Severe hearing 249 loss . )no definition)

75 Rate per Rate per No. in 1000 of 1000 of Source of work- No. Criteria used! work- those data force tested degree of loss force tested

Food pro- 172 Hearing loss 285 cessing (no definition) plant (I) Auckland 60 Pre-existing 166 District Health hearing loss Office (g) (degree not stated) Dunedin 51 . Hearing loss, 333 District slight, moderate Health severe (no Office definition)

Additional notes to Table 6.10 (c) Wanganui District Health Office: the 9.5 percent (n=87) of the workforce (n=911) who had notifiable deafness was composed of 2 percent (n= 18) aged 45 or less who had a loss of 35dB or greater and 7.5 percent (n=69) of all ages· who had a loss of 50dB or greater. (d) Manukau District Health Office: the first rate given refers to high noise areas in private industry and the second, higher rate, refers to the railway workshops. (e) Ministry of Works programme: the total workforce tested in this group was composed of 84 office-based workers and 113 field workers. Of the total group, 66 (33 percent) were exposed to hazardous noise levels. (I) Food processing plant: further information on biographical characteristics is presented in Table .6.10(a). . (g) Auckland District Health Office: these data pertain to a group of 60 apprentices aged approxi­ mately 17-21 years. .

TABLE 6.10 (a) BIOGRPHICAL CHARACTERISTICS OF THOSE WITH HEARING LOSS IN A FOOD PROCESSING PLANT[21]

Total group (n=172) Those with hearing loss (n=49) n % n %

Sex:.: ...... male 114 66 28 57 female 58 34 21 43 Age: ...... 18-45 114 66 17 35 46+ 58 34 32 65 Race: ...... Eur. 113 66 29 59 Maori 50 29 18 37 Pac. Is. 9 5 2 4

76 6.S THE ELDERLY There have been no New Zealand audiometric studies on a representative sample of the elderly, as far as is known. Non-audiometric information was available from two surveys of residential homes, one from Auckland and one from Christchurch.

1 Auckland Hearing Association rest home survey[22]: Sample Total surveyed 1 014 Total 65 years and older 890 "Measurement criterion self report (series of eight questions) . Results 54 percent of those 65 years or older in residential care had a significant hearing problem and 15 percent had been provided with hearing aids.

2 Christchurch Hearing Association report Survey of needs for elderly people with impaired hearing and the institutions which care for them[23] Sample 2003 residents of 60 institutions Measurement criterion estimate of number of deaf residents by matron or person in charge of the institution. It is likely that numbers would be underestimated especially in the larger institutions where the matron would 'not have a lot of personal contact with the residents and there­ fore would probably not notice a hearing impairment unless it was severe'[20 pl0]. Results 26 percent (n = 510) had a hearing impairment suf­ ficient to be noticed by the person running the institution 8 percent (n = 157) of the total number wore hearing aids successfully 5 percent (n = 91) of the total number had hearing aids but did not wear them. Both these surveys provide a very conservative estimate of the prevalence of hearing impairment in the elderly when compared with overseas audiometric data. A summary of recent overseas data, for both rest home residents and elderly people living in their own homes, is given in Table 6.11. It can be seen from Table 6.11 that by the age of about 65 we can expect approximately 60 percent of those living in their own homes and 80 percent of those in residential homes to have hearing problems. With the number of elderly increasing as a proportion of the total population (those born in 1946, the beginning of the post-war baby boom, will be 65 years old in 2011) the number of people requiring aural rehabilition will increase.

77 TABLE 6.11 PREVALENCE OF HEARING LOSS IN THE ELDERLY, RECENT OVERSEAS AUDIOMETRIC DATA

Rate per 1000 Age Popn. rt.ear I. ear Degree of loss 60+ residential 826 840 Over 26dB in years home either ear avo (a) own home 635 636 over the 7 freq. combined 680 720 0.2S-8kHz. (n=4967) 65+ residential 820 26dB and over years home in better ear (b) (n=202) avo over 3 freq. 0.5-2kHz. 70+ own home 600 35dB and over years (n=253) in better ear (c) avo over 3 freq. I-4kHz.

(a) Schallenkamp et al USAI24J (b) Schow and Nerbonne USAI25j (c) Herbst and Humphrey UK[26)

6.6 SPECIAL POPULATIONS OF ADULTS

6.6.1 Armed forces The armed forces were considered as a special population not representative of the general population because: I The rate of hearing loss is likely to be higher than normal as those exposed to weapon fire are at greater risk of hearing loss and hearing protection is not always adequate. 2 The rate of hearing loss is likely to be lower than normal as: • those with hearing loss are not recruited in the first place· • . the early retirement system results in the older age groups being under~represented. . The Defence Department provided data on hearing status in the armed forces over the period May 1982-May 1983[27]. Hearing status is ranked from first degree (HI, very good hearing) to eighth degree (H8; unfit for service) and each level is defined audiometrically. Those with hearing levels of H3 and over are considered to have hearing impairment and are channelled into appropriate jobs within the forces. The audiometric definition of H3 is 'no

78 loss to exceed in each ear, 30dB at l.and 2kHz, 40dB at 3kHz and SO dB at 4kHz'. Levels H4 to H7 indicate a progressively greater hearing loss. Table 6.12 presents hearing levels of H3 to H7 in the three armed forces.

TABLE 6.12 HEARING LOSS IN THE ARMED FORCES, RATE PER 1000[27]

Armed force Hearing level H3-H7 Rate per J000 Army...... 707 129 Air Force ...... 263 60 Navy...... 121 43

All Forces...... 1 091 86

Figure 6g shows hearing loss in the armed forces broken down by category of armed force and age group.

FIGURE 6g HEARING LOSS IN THE NZ ARMED FORCES, BY CATEGORY OF FORCE AND AGE GROUP

Percentage 60~------~------~

50 Legend IZZJ Navy • Airforce . Ii:::SI Army 40

30

1 .

17-24 25-34 ·35-44 45-54 55-64 Age Range

79 Sig.l The higher prevalence of hearing impairment in the army -is largely the result of noise from weapon-fire. The difference between the army and the other forces is not as great in the 55-64 age group because many of the group who experience marked hearing loss have been transferred from the infantry to the navy or airforce as 'general hands'. Figure 6h presents the percentage of personnel with -hearing loss in all forces combined.

FIGURE 6h HEARING LOSS IN THE NZ ARMED FORCES BY AGE GROUP, ALL FORCES COMBINED

Percentage 50~------~

40

30

20

. 10

17-24 25-34 35-44 45-54 55-64 Age Range

The rate of increase in hearing loss in the older age group is not as great as would be expected in the general population as this group is under-rep­ resented, i.e., in May 1983 only 6 percent of armed forces personnel were aged 45 years and over. Unfortunately the hearing measurement criteria used in the forces do not make it possible to compare these data with the standard population data presented previously (see 6.2). However it is likely that many of those per­ sonnel with hearing levels of H4 and over would have notifiable hearing loss.

80 6.6.2 Psychiatric hospital patients In the course of a survey of psychiatric services for the deaf in the Wellington region, fifth year medical students, in a community health course at the Wellington Clinical School, investigated the prevalence of deafness at Pori­ rua Hospital[28]. A total of 116 patients in two acute admission wards and two long stay wards were tested. The expected number of severely and pro­ foundly deaf people in the sample examined was just over one person. The actual number found was four and could be considered as six as two of the untestabIe patients were so deaf that the testers were not able to make them­ selves understood clearly enough to carry out a hearing test. In other words, there were five times more deaf people than expected. A Christchurch audiologist carried out an audiological survey at Sunnyside· Psychiatric Hospital for the Hearing Research Project[29]. Of a total popu­ lation of approximately 650 patients, 109 were assessed representing the majority of patients in three 'villas' and one clinic. They were as follows: • acute to medium-term mixed ward • intellectually handicapped • alcohol-related illness • psychogeriatric The age of the patients tested ranged from 18 to 80 years: Results are pre­ sented in Table 6.13.

TABLE 6.13 PERCENT HEARING LOSS IN A PSYCHIATRIC POPULATION GREATER THAN 25dB IN THE BET­ TER EAR, AVERAGED ACROSS 0.5-4kHz, BY AGE

% of age group Age group N. teSled N. with hearing loss with hearing loss n % n %

16-25 ...... 18 16.5 1 2.9 5.5 26-35 ...... :...... 16 14.7 1 2.9 6.3 36-45 ...... 16 14.7 2 5.7 12.5 46-55 ...... 16 14.7 5 14.3 31.3 56-65 ...... 13 11.9 7 20.0 53.8 66-75 ...... 23 21.1 12 34.3 52.2 76-85 ...... 7 6.4 7 20.0 100.0 TOTAL ...... 109 100.0 35 100.1 32.1

Thirty-two percent of those tested had hearing loss of more than 25dB in their better hearing ear, which is considerably higher than the prevalence . of 19 percent (NSH, UK) found in the general population using the same measurement criteria .. Looked at from a different perspective, 27 percent of the sample (the majority of whom are included in the 32 percent quoted above) had high frequency loss in their better ear of such severity as to be

81 notifiable had it been caused by noise in the workplace (SOdB at 4kHz). ·If subjects under the age of 25 and over the age of 74 were excluded to give comparability with the HANES I data (see Table 6.6), then 18 percent had notifiable loss compared with the 12 percent expected in the general populati~n. . . . Additional points noted by the audiologist carrying out the survey were: • only one person tested had, and regularly used, a hearing aid • a young profoundly deaf person had spent some years in the intel­ lectually handicapped villa because of behaviour and management problems • staff were often aware that a patient was 'deaf, but formal hearing assessment was rarely undertaken, presumably because the psychi­ atric problem was the main focus of attention. 6.6.3 . Intellectually handicapped adults Eighty-three adults in one Auckland IHC centre were examined for hearing defects[30]. The sample was fairly representative of all ages although some centres have more young people. The findings are as follows: • 54 percent had significant hearing loss, 'most of which was reme­ diable or amenable to treatment' • 34 percent had wax in one or both ears, often hard and impacted • 9 percent had pathology in addition to wax, e.g., otitis externa, cho­ lesteatoma, secretory otitis media. 6.6.4. Prison inmates Bowers, in Auckland, assessed 100 European and 100 Maori young male prisoners for hearing impairment, ear disease and adverse social history[31]. Audiometric results were analysed using: • average decibel loss over 0.5, 1 and 2kHz • the National Acoustics Laboratory (NAL) scale in which a normal ear does not score and a disability of five percent or above is regarded as eligibkfor compensation. Average decibel loss by race, for the better and worse hearing ear, is shown in Table 6.14 TABLE 6.14 PERCENT HEARING LOSS IN PRISON INMATES, AVERAGED ACROSS THE FREQUENCIES OF 0.5-2 kHz, BY RACE*

Maori European Average dB loss % better ear % worse ear % better ear % worse ear Less than ISdB...... ; 40 17 63 46 15dB to 29dB...... 57 72 37 51 30dB and greater ...... 3 11 3

.. adapted from Bowers[31[ 82 Sixty percent of the Maori prisoners and 37 percent of the European pris­ oners had a hearing loss of ISdB or greater in their,better ear (48.5 percent combined). Eighty-three percent of the Maoris and 54 percent of the Euro­ peans had a hearing loss of ISdB or greater in their poorer ear (68.5 percent combined). Bowers points out that if Jauhiainen's model for hearing impair­ ment is used as a prediction for the age group 15-24 years, 6.7 percent would be expected to havt; a loss of 15dB and over. In the age group 15-25 years in the prison inmates she assessed, 48.5 percent (better ear only) had a hear­ ing loss of 15dB or greater; more than seven times greater than predicted. Table 6.15 presents the audiometric results in a different form; as NAL scores. TABLE 6.15 OVERALL PERCENTAGE HEARING DISABILITY IN PRISON INMATES REGISTERED ON THE NAL SCALE, BY RACE*

NAL Scores Maori European % % %

No score...... 6 27 0.1-4.9 ...... 67 .66 5.0 and greateL...... ,.. 27 7

* adapted from Bowers[31)

Twenty-seven percent of Maori prisoners and seven percent of Europeans scored more than five percent, indicating that they had a hearing disability such as to entitle them to compensation had their loss resulted from accident rather than disease.

6.7 SUMMARY (1) There are no· New Zealand data on hearing status in the general adult popUlation. (2) A 1971-75 survey of the US standard popUlation '(aged 25-74) esti­ mated that the prevalence of hearing loss of over 20dB was 12.3­ 20.7 percent across the frequencies often considered most important for understanding speech (0.5-2kHz) and 38.1 percent for high fre­ quency loss (4kHz). (3) The same study also found that the percentage of adults able to hear and understand everyday speech at 20dB presentation level, decreases with age from 91.4 percent at 25-34 years to 33.2 percent ~t 65-74 years. (4) A large British survey (NSH) still in progress has found that the prevalence of hearing disorders in adults is considerably higher than previous estimates.

83 (5) The NSH found the prevalence of hearing loss of 2SdB and over (averaged across the four frequencies 0.S-4kHz) was 19 percent in the better hearing ear and 32 percent in the worse hearing ear. (6) Extrapolating from NSH data, it is estimated that there are approxi­ mately 430,000 New Zealanders with mild to moderate hearing loss in their better hearing ear (2SdB and over), 25,800 with severe hear­ ing loss (greater than 6SdB) and 6,700 with profound hearing loss (greater than 8S dB). (7) Not only does the prevalence of hearing impairment increase with increasing age, but the severity of the impairment also increases with age; this has wide-ranging implications in the face of an ageing population. (8) The NSH and Scandinavian studies show that noise is a far greater contributor to sensorineural hearing defects in adults than previously thought. (9) It is not known what proportion of the New Zealand popUlation has noise-induced hearing loss and data on occupational noise-induced hearing loss are fragmentary. (10) Approximately 190,000 persons are estimated to have high frequency hearing loss of such severity as to. be notifiable had it been caused by exposure to noise in the workplace, i.e., greater than SOdB at 4 kHz. (11) Forty-two to forty-five percent of the workforce are employed in potentially noisy occupations. (12) Ifit is assumed that 30 percent of the workforce are exposed to poten­ tially hazardous noise levels, then approximately 400,000 persons are at risk. (13) Overseas data indicate that as many as 60 percent of elderly people living in their own homes, and 80 percent in 'residential homes, are likely to be hearing impaired. (14) The prevalence of hearing impairment is higher in the psychiatric and intellectually handicapped popUlations. (IS) In young prison inmates hearing impairment was seven times greater than would be expected in the general population.

Acknowledgments 6.2, 6.3 Ms Lucy Carpenter, 'Hearing Research Project statistician

Notes and references 1 US Environmental Protection Agency.-Noise effects handbook: a desk reference to health .and welfare effects of noise.-Springfield, Va : National Technical Information Service, 1981. '

84 2 CORSO, John F.-'Age correction factor in noise-induced hearing loss: aquantitative model', in Audiology.--:v 19 no 3 (1980) p 221­ 223. 3 ROUTLEDGE, Mary L.-'Hearing conservation programme for office workers', in NZ Occup Health Nurs.-(Spring 1983) p 19-21. 4 'Epidemiology of hearing impairment in male adult subjects at 49­ 69 years of age' / A Parving et aI, in Sc;.and Audiol.-v 12 (1983) P 191-196. 5 Noise: executive summary.-Geneva : World Health Organisation, 1980. (Environmental health criteria; no 12). 6 Basic data on hearing levels of adults 25-74 years: United States, 1971-75 : Vital and Health Statistics, series 11 no 215.-Hyattsville, Md : National Center for Health Statistics, 1980 (DHEW publication; no 80-1663). 7 HAGGARD, Mark, GATEHOUSE, Stuart and DAVIS, Adrian.­ 'The -high prevalence of hearing disorders and its implications for services in the UK', in Br J Audiol.-v 15 (1981) p 241-251. 8 GATEHOUSE, Stuart, HAGGARD, Mark and DAVIS, Adrian.­ Implications of a population study of hearing thresholds and noise exposure. Paper presented to the Acoustical Society of America, Nov 1982, Orlando, Fla. 9 DAVIS, Adrian C.-'Hearing disorders in the population; first phase findings of the MRC National Study of Hearing', in Hearing science and hearing disorders / edited by ME Lutman and MP Haggard.­ London: Academic Press, 1983. 10 BROWNING, G G and DAVIS A C.-'Clinical characteristization of the hearing of the adult British population', in Adv Otorhinolar­ yngol.-v 31 (1983) p 217-223. 11 JAUHIAINEN, Tapani.-'A model of the assessment of the inci­ dence of hearing impairments in a population', in J Laryngol Otol.­ v 8 (1968) P 1109-1117. 12 Deafness the invisible handicap: a review of services for persons with hearing disabilities.-Wellington : Advisory Council for the Com­ munity Welfare of Disabled Persons, 1979. 13 DAVIS, Adrian- C.-Characteristics of the adult population in Great Britian with severe hearing impairment. Paper presented to the IVth British Conference on Audiology, Sept 6 1983. 14 'Hearing acuity in a Norwegian standard population / 0 I Molvaer et aI, in Scand Audiol.-v 12 (1983) p 229-236. 15 NZ Department of Health criteria for noise-induced hearing loss. 16 GOATER, lan.-'Noise induced hearing loss and the general prac­ titioner', in Aust Fam Physician.-v 9 (Feb 1980) p 120-124.

85 17 MILLER, Richard K, MONTONE, Wayne V and OVIATT, Mark D.-Noise control solutions for the wood products industry.-Atlanta, Ga : Fairmont Press, 1980. 18 MILLER, Richard K, MONTONE, Wayne V and OVIATT, Mark D.-Noise control solutions for the textile industry.-Atlanta, Ga : Fairmont Press, 1980. 19 MILLER, Richard K, MONTONE, Wayne V and OVIATT, Mark D.-Noise control solutions for the chemical and petroleum indus­ try.-Atlanta, Ga : Fairmont Press, 1980. . 20 MILLER, Richard K, MONTONE, Wayne V and OVIATT, Mark D.-Noise control solutions for the paper products industry.-Atlanta, Ga : Fairmont Press, 1980. 21 Data provided for the Hearing Research Project. 22 Data provided by the Audiology Centre (formerly National Acoustics Centre), Dept of Health, Auckland. 23 Data· provided by the Christchurch branch of the Hearing Associa­ tion : a study carried out by Paula Roberts from May 1977 to Novem­ ber 1979. 24 'Incidence of hearing loss among the elderly' I Kay K Schallenkamp et aI, in Hearing Aid J.-v 10 (Jan 1980) p 48-49. 25 SCHOW, Ronald Land NERBONNE, Michael A,-'Hearing levels among elderly nursing home residents', in J Speech Hear Disord.­ v 45 no 1 (Feb 1980) p 124-132. 26 HERBST, Katia and HUMPHREY, Charlotte.-'Prevalence of hear­ ing impairment in the elderly living at home', in J Col1.Gen Pract.­ v 31 no 224 (March 1981) p 155-160. 27 Data provided by the Defence Department for the Hearing Research Project. 28 'Psychiatric services for the deaf in the Wellington region' I L Car­ penter et aI, in Research and development projects 1983 5th year class in Community Health.-Wellington : Dept of Community Health, Clinical School Medicine, 1983. 29 Data provided by Beth Kempen, Audiologist, Christchurch, for the Hearing Research Project. 30 MACDONALD, Mark.-Hearing loss in the intellectually handi­ capped. Paper presented to the Australian and New Zealand Society for Epidemiological Research and Community Health (ANZ­ SERCH), May 1984, Dunedin. (Unpublished). 31 BOWERS, Mary.-Hearing impairment in prisoners.-Auckland Deafness Research Foundation, 1982. (Unpublished).

86 Part 3

Services. for the hearing mpaired 7 OVERVIEW OF SERVICES Information gathered on services for the hearing impaired has been grouped into the four major areas of need: • services for the prelingually deaf • services for children with ear disease • services for adults with acquired hearing loss • services related to noise-induced hearing loss. Aspects of hearing services which are relevant to all of the above groups, su~h as public and professional education, are discussed in a final chapter. Before beginning with services for the prelingually deaf, a listing of all services· for the hearing impaired will be given. At this stage the services have simply been listed, with no indication as to their adequacy or number and distri­ bution of personnel involved. Following this, available data on general services pertaining to hearing loss and ear disease are summarised, with more detailed information presented as appendices.

7.1 LISTING OF HEARING SERVICES IN NEW ZEALAND DEPARTMENT OF HEALTH Audiology Centre (formerly National Acoustics Centre): • hearing assessment and diagnostic testing • training courses • advice and resource centre Vision hearing testers: • screen hearing of all new entrants and Form I pupils • screen school children on request • screen some preschoolers • screen children in special classes and some special schools Occupational health nurses: • screen for occupational hearing loss in government workshops and some private industries • fit hearing protectors and provide hearing conservation advice Public health nurses: • surveillance of all school-age children with continuing hearing defects or ear problems • treat chronic suppurative otitis media in areas of need • evaluate hearing of some babies Medical officers: • support services for vision hearing testers and public health nurses • intermediaries for further medical referral 89 Inspectors of health: • survey noise levels Regional noise control officers: • advisory role and backup for inspectors of health • function under the new Noise Control Act HOSPITAL ·BOARDS (funded by the Department of Health) Neonatal screening: • hearing screening of high risk infants Ear, nose and throat (ENT) clinics: • public sector ENT specialist diagnostic testing and surgery • referrals from general practitioners • approval 01 hearing aid subsidy requests Audiology clz'nics: • associated with ENT clinics • hearing measurement, diagnosis and hearing aid fitting • administration of hearing aict subsidy • hearing investigation of high risk infants in some hospitals • rehabilitation PRIVATE MEDICAL SERVICES' General practitioners/practice nurses: • treat ear disease and symptomatic deafness • carry out some infant hearing screening • refer patients to ENT and audiology clinics o refer patients to privateENT specialists Private ENT specialists: • diagnosis, medical and surgical treatment DEPARTMENT OF EDUCATION Schools for deaf children: • Kelston School for Deaf Children, Auckland • van Asch College, Christchurch • St Dominies School for the Deaf, Feilding (integrated school) Classes/units for deaf children in regular schools Advisers on deaf children: • educational management of hearing impaired children • guidance to parents • hearing testing and hearing aid fitting • assistance to teachers in ordinary classrooms 90 Visiting/resource teachers of the deaf: • itinerant teaching Auckland and Christchurch Teachers' Colleges: • training of advisers on deaf children and 'teachers of the deaf Financial grants: • to the Hearing Association : payment of salaries and travel subsidie's of tutors • to the New Zealand Association of the Deaf: supports one field officer' in Auckland DEPARTMENT OF SOCIAL WELFARE· Field offices for the deaf: • working with New Zealand Association for the Deaf, funds offices in Auckland, Wellington and Christchurch War pensions: • funding of hearing aids for war pensioners

DEPARTMENT OF LABOUR Factory inspectors: • responsible for the protection of workers against hazardous noise in work places • required to enforce the provisions of the relevant. legislation which puts the onus on the employer to reduce noise at source or provide hearing protection devices OTHER SERVICES Plunket nurses: • referral of infants with suspected deafness Occupational health nurses in private industry: • hearing screening, fitting of hearing protectors and hearing conser­ vation education Hearing aid dealers: • retail hearing aids to the public Hearing Association: • voluntary association with financial assistance from the Department of Education for· speech-reading tutors . • members are mainly adults with acquired hearing loss • holds free hearing testing days • provides advice and foHow-up to people fitted with hearing aids • '. Auckland branch operates an audiology/hearing aid clinic 91 New Zealand Association of the Deaf and local deaf societies: • voluntary associations • provide social and welfare services • work with Department of Social Welfare in administering field offices New Zealand Federation for Deaf Children and local groups of parents of deaf children: • voluntary associations • provide services for deaf children and support for parents of deaf children and lobby for better services on their behalf Combined New Zealand Societies for the Deaf • represents and coordinates the activities of the major voluntary organisations working with and for deaf people New Zealand Deaf Communications Network: • organises the setting up of teleprinter answering services and the printing of a directory Accident Compensation' Corporation: • provides for compensation and treatment costs for proven occupa­ tional noise-induced deafness and deafness resulting from accident • has an obligation to promote occupational safety, including hearing conservation Deafness Research Foundation: • funds medical research into causes and treatment of deafness.

7.2 AVAILABLE DATA ON GENERAL SERVICES PERTAINING TO HEARING LOSS AND EAR DISEASE A full· version of the following tables can be found in the appendices indi­ cated for each section. ­

7.2.1 Number and distribution or'ear, nose and throat (ENT) specialists The number of ENT specialists (persons, rather than full-time equivalents) can be found in Appendix 7a. The table is set out by hospital board areas in regional groupings. Unofficial data indicate there were 41 practising ENT specialists in March 1984, giving a ratio of 1:77,000. The number of ENT specialists has fallen from 47 in 1982 and this drop is largely accounted for by the retirement of older ENT specialists. In 1982 eleven registrars were in recognized postgraduate training for otolaryngology, accounting -for only 2 percent of the total number of registrars in training. The only specialities with fewer registrars in training were community medicine, dermatology and oncology. As at March 1984, the -number of registrars in training had only

92 increased by one, that is, to twelve (Appendix 7a). The appendix table also . sets out the number and location of otolaryngologists required if a conserv­ ative formula of 1:50,000 population is used (a total of 63) and if a liberal formula of 1:35,000 is used (a total of 90). The ratio is 1:25,000 in Scan­ dinavia. It was argued by one ENT surgeon interviewed that 'if the job was to be done properly, that is, ongoing care for deaf people, prevention of hearing deterioration where possible, provision of good medical diagnostic services, then 1:35,000 ENT specialists would be required'. Applying the latter formula to an area of known need, for example Auckland, would mean that an increase from 14 to 23 ENT specialists would be required. For fur­ ther examples from other areas see -Appendix 7a.

7.2.2 N umber and distribution of audiologists The number of audiologists (full-time equivalents) set out by hospital boards in regional groupings can be found in Appendix 7b. There were 34.4 full­ time equivalent audiologists in March 1984, giving a ratio of 1:92,300 popu­ lation. As With otolaryngologists, the number required is between 63, if a ratio of 1:50,000 is used and 90, if a ratio of 1:35,000 is used.

7.2.3 Number and distribution of vision hearing testers The number of vision hearing testers' per health district is set out in Appen­ dix 7c. There were 5l.49 full-time .equivalent vision hearing testers in December 1983. There is an average of 3000 children to every vision hearing tester, ranging from approximately 1:1500 in Dunedin to 1:6000 in Auckland Health Dis­ trict. The increased ratio in Dunedin was specifically to cover the pilot impedance screening programme which also incorporates serial testing of 3, 5 and 7-year-olds as well as special groups. The above ratios are based on children requiring routine screening only, i.e., 3, 5 and II-year-olds. Additional demands on vision hearing testers include requests for testing, follow-up testing, serial testing where it has been introduced, screening of children in special classes and special schools, and in some cases, industrial audiometry. . The Department of Health has announced that six more vision hearing test­ ers will be employed as from the end of 1984.

7.2.4 Admissions to public hospitals for diseases of the ear Appendix 7d provides data on all diseases of the ear and mastoid process admitted to public hospitals in 1982. The data are broken down by age and race. It will be seen that admission rates for 0 to I-year-olds are much higher than for 15 to 6-year-olds (the difference is statistically significant). There are proportionately more Maori children and adults admitted than other races and the difference is also statistically highly significant.

93 7.2.5 Ear operations carried oudn public and private hospitals All ear operations carried out in public and private hospitals in 1982 are set out in Appendix 7e. They are listed by type of operation. Over 9000 ear operations were carried out in 1982 and slightly over half (56 percent) took place in public hospitals. Myringotomies accounted for by far the greatest number of operations (64 percent). 7.2.6 Waiting lists for ENT surgery The most recent data available show that there were 8417 people awaiting surgery in 1982. A detailed surgical wiliting .list, by hospital board, is pre­ sented in Appendix 7f. Apart from orthopaedic surgery, more people were waiting for ENT surgery than any other type of surgery. . 7.2.7 Public/private working time of ENT specialists An analysis of ENT specialist working time is presented in Appendix 7g. Although it would appear from this information that just under half the ENT work is being paid for by the public hospital system, in reality it may be only one~third. Calculations are based on a normal working week but if surgeons are being consulted 70 hours per week, for example, which is known to be the case with many younger surgeons in Auckland, then it is possible that up to two-thirds of ENT work is being done privately. 7.2.8 Notifications of occupational deafness to the Department of Health Official notifications of occupational deafness for the years 1978-1983 are given in Appendix 7h. Although notifications are increasing as awareness of the problem increases, i.e., 174 cases in 1980 to 679 in 1983, these cases clearly represent only the tip of the iceberg. 7.2.9 Occupational hearing loss compensated by the Accident Com­ pensation Corporation (ACC) The number of people receiving compensation for occupational hearing loss over the past 4 years is given in Appendix 7j. As with deafness notifications, the number of compensated cases is increasing, rising from 411 cases in 1980 to 862 in 1983. Over $3,800,000 was paid out in· claims over that 4-year period. In Appendix 7j the compensated cases are set out by region, and the fact that 44 percent of all occupational deafness claims paid out during the period 1980-1983 have gone to Canterbury cases indicates that Christchurch has a more advanced system for dealing with occupational hearing loss. As other regions become more competent and organised in the field of noise­ induced hearing loss it is predicted that many more compensation claims. will be made.

94 8 SERVICES FOR THE PRELINGUALLY DEAF

8.1 SCREENING SERVICES

8.1.1 Neonatal screening To date there is no ideal proven method for mass neonatal screening of hearing. More research is needed on the use of the automatic cradle for screening, with the possibility of implementation if the procedure proves satisfactory. However even mass neonatal screening will miss babies with mild to moderate hearing loss and babies whose deafness occurs subsequent to discharge from hospital, e.g., meningitis, rubella deafness with late onset, and other progressive deafness. Some hospitals use Auditory Brainstem Response (ABR) audiometry at present for the screening of high risk infants. In June 1980, hospitals were asked to identify all 'high risk' infants so that their hearing would be investigated within the first year of life. A list of high risk factors for pre lingual deafness is as follows: • family history of deafness from birth • rubella (including contact with rubella) or other congenital infection (such as cytomegalovirus, herpes, toxoplasmosis) • birthweight less than 1500 grams • malformation of cranium or face • hyperbilirubinaemia (jaundice) exceeding levels for exchange transfusion • severe asphyxia at birth Apgar score 0-3 at birth, or failure to breathe spontaneously by 10 minutes, or hypotonia persisting till 2 hours of age • meningitis.[I ] Referral for full hearing assessment by· an audiologist is recommended if there is a risk factor present. Of hospital boards serving popUlations of more than 35,000, twelve out of eighteen boards employ audiologists. It is not known how many hospitals adhere to the above criteria. It is sus­ pected that inadequate audiometric techniques are still being used in some hospitals without audiologists.

8.1.2 Infant screening Screening of high risk infants can be done at a few months of age instead of within the neonatal period. All high risk infants not tested- prior to leaving hospital should be referred to an otologist or audiologist within their first year of life. The Department of Health is concerned about the use of 'dis­ 95 traction' testing by nurses and general practitioners. Their lack of audiome-" tric experience and facilities means that deaf babies are missed and their ultimate detection is delayed. Worried parents can be falsely reassured. This raises the issue of professional education and community education and awareness (see 12.1). General practitioners are key people in a smoothly operating hearing service, yet submissions on the subject of hearing problems made to the committee which reviewed primary medical services did not rate a mention in the body of the report.[2J ." 8.1.3 Screening of children with multiple handicaps Approximately 30 percent of deaf children have additional handicaps such as mental retardation, visual deficits and cerebral dysfunction (see 5.7.3). Audiometric screening of children in psychopaedic hospitals is not done rou­ tinely, for example, information on hearing status was recorded for only 25 percent of inpatients and outpatients at one psychopaedic hospital surveyed, although assessment" of new referrals is now more thorough. Investigation for hearing impairment should be mandatory given the fact that such a popu­ lation is highly at risk for deafness (see 5.7.3).

8.2 MEDICAL AND AUDIOLOGICAL SERVICES

8.2.1 Preventive services In order to prevent deafness resulting from maternal rubella the Department of Health introduced rubella immunisation in 1970 and widespread rubella epidemics, such as seen in the sixties, disappeared. However, the lower levels of immunisation achieved in the mid-seventies were followed by small outbreaks of congenital rubella in 1975 and 1980­ 1981. Rubella was confirmed as the cause of deafness in 8 percent of deaf children born from 1973 to 1981. . Currently a high level of rubella immunisation is being achieved in school girls: 98 percent of Form I girls in 1983. Immunisation programmes for women who have not been immunised at school have been publicized, and the cost of testing and immunising such women by family doctors is now reimbursed by the Department of Health. However, recent statistics derived from the H661 birth notification forms, which include a question on rubella immunity, show that: • only 75 percent of women were reported as having their rubella status measured during pregnancy[3] • of the total notifications of rubella status, 93 percent were rubella immune[4J. • only 62percent of those women. known to be susceptible to rubella are immunised after the birth of their child.[4J More recent data, from January to March 1984, show a slight improvement.

96 8.2.2 Audiological services Services provided by audiologists include hearing assessment and hearing aid fitting in conjunction with advisers on deaf children and ENT specialists. It is also necessary for hearing to be retested and hearing aids to be reviewed at regular intervals by an audiologist, adviser on deaf children, or both. The number of audiologists is slowly being increased and has reached 34.4 full-time equivalents. Ifa minimum of one audiologist per 50,000 population is accepted as an appropriate ratio, then over 60 full-time equivalent audiol~ ogists would be required to provide adequate services for all ages (see Appen­ dix 7b).' . Although clinics try to avoid waiting list delays for children with known hearing problems, waiting times are still far too lengthy. In the Auckland region, hospitals with long waiting lists often refer infants and children to the .Audiology Centre which had a waiting list of 561 in March 1984 with referrals dating back seven-and-a-half-months. Included in this total were 128 infants with referrals dating back to July 1983 and 100 preschoolers with referrals from August 1983. It is essential that services for deaf children be supplemented by the appoint­ ment of paediatric 'amplification' audiologists. This was recommended by the Committee on Hearing as early as 1981. Such audiologists would spec­ ialise in the fitting and monitoring of hearing aids to optimise the use of any residual hearing in hearing impaired children. Advisers on deaf children and hospital audiologists are generally not sufficiently skilled in this area to be certain of providing the most effective hearing aid fitting for individual deaf children. The employment of paediatric audiologists should free the advisers on deaf children to spend more time providing guidance, especially to preschoolers and children,now being placed in mainstream classes. Although deaf children are entitled to free hearing aids until they leave school, the system of funding is unnecessarily complex. The hearing aid subsidy of $81 ,per aid (last reviewed on September 1, 1982) covers approxi­ mately one-third of the aid and claim then has to be made for the remainder, through the schools for the deaf, to the special aid fund administered by the Audiology Centre. For FM radio aids, funding comes from three sources: the subsidy and special aid fund as above, plus application to the Welfare Services Distribution Committee of the Lotteries Board. The Department of Social Welfare is currently investigating ways in which the provision of these aids could be undertaken more efficiently. "

8.2.3 Medical services Concern about the use of 'distraction' testing resulting in false reassurance to parents has already been mentioned in the section on screening for pre­ lingual deafness. Ear, nose and throat surgeons are responsible for the otological monitoring of deaf children. In many cases only the most basic services are provided

97 because there are insufficient ENT surgeons and they are not distributed equally or equitably. For example, in 1983 Middlemore hospital was allo­ cated 0.9 ENT full-time equivalents to serve a population of approximately 300,000. If one ENT specialist per 35,000 population is an ideal ratio as suggested by one ENT specialist, then 90 ENT specialists would be required; 41 specialists and 12 registrars are currently practising (see Appendix 7a). Of considerable cause for concern is the fact that in about 50 percent of cases of pre lingual deafness the cause is reported as unknown, yet it is pos­ sible for modern medical tests, including genetic investigations, to provide a diagnosis in. many of these children. Successful diagnosis can assist in the detection of related problems, in prevention of deterioration in certain cases, and in genetic counselling, as well as providing a better data base for the prevention of deafness. Many parents receive inadequate and incorrect genetic counselling. As a result of this some parents then go on to have a second deaf child without being aware of the risk involved.[5] It is clear that a more thorough diagnostic evaluation service is required, followed by time spent with parents providing comprehensive information with a written summary of the information given. There is a need for genetic counselling for the parents and later for school leavers and deaf. adults. It is essential that children with significant sensorineural deafness receive regular monitoring for conditions causing an overlay of conductive deafness. In those areas 'where regular monitoring does not take place at present, oto­ logical resources should be increased so that a satisfactory standard can be achieved. 8.2.4 Age of detection of deafness Early detection of deafness is vital so that early intervention, in the form of hearing aids and special education, can promote language development and the ability to communicate. It is possible for hearing aids to be fitted in the first month or two of life. Although the proportion of deaf children who have their deafness detected by the age of 1 yelir has improved, it is still inadequate. There is need for, a higher level of awareness by professionals in contact with infants, and for greater credence to be given to parents' reports. Some professionals fail to act on parental suspicion of deafness and give false reassurance. Of deaf children born in 1973-1974, only 11 percent had their deafness detected by the age of one year and 45 percent were still undetected by the age of three. Recent information provided by advisers on deaf children in the Central and Southern Region Education Districts (responsible for the education of approximately half the deaf children in New Zealand) shows that over the period February 1982 to February 1983,29 percent of referred preschoolers had their deafness detected by age one. Policies involving follow-up of high risk babies and public and professional education in all aspects of hearing impairment need to be pursued even more vigorously to obtain a further improvement in the early detection rate: .

98 8.2.S Notification of deaf children An improved method for recording information about deaf children is now in use by advisers on deaf children and audiologists. A copy of the form now in use can be found in Appendix 8a. Such a register of young deaf people will be maintained by the National Health Statistics Centre. An annual sum­ mary of these data is necessary to inform planners and providers of services.

8.2.6 Psychiatric services for deaf adults[6] Psychiatric services for the deaf are sparse or non-existent. Psychiatric assess­ ment depends upon communication, and misunderstanding can invalidate diagnostic assessment and render treatment useless. In the absence of psy­ chiatrists skilled in sign language, a competent interpreter should be present when a therapist undertakes work with a severely or profoundly deaf person. This will not only provide word-for-word interpreting but also help both parties to understand underlying concepts. A knowledge of the behavioural effects of deafness and experience with deaf people is essential. It is likely that there are deaf people in psychiatric institutions who have been diagnosed as retarded, for example, when they may be untaught profoundly deaf persons.

8.3 EDUCATIONAL SERVICES The Department of Education provides the following types of special edu­ cational assistance for deaf children: • advisers on deaf children • special classes/special schools. The three residential schools are: Kel­ ston School for Deaf Children, Auckland; van Asch College, Christ­ church; St Dominics School for the Deaf, Feilding . • resource/itinerant teachers of the deaf • teacher aides • tutor hours • supplementary teaching • speech therapy • psychological services. A child may receive assistance from more than one of these sources. The number of deaf children receiving the above types of educational assistance can be found in Appendix 8b. The numbers of deaf children aged 0-19 receiving special educational pro­ vision in 1982 were aggregated into four age groups and presented as a rate per 1000 of the total age group (Table 8.1).

99 TABLE 8.1 NUMBER OF HEARING IMPAIRED CHILDREN AND YOUNG PEOPLE RECEIVING SPECIAL EDUCA­ TIONAL PROVISIONI EXPRESSED AS RATE PER 1000 OF SPECIFIED AGE GROUPS

Total Age group Number pop u lation 2 Rate per 1000

0-4...... 172 252 642 0.7 5-9...... 634 290 067 2.2 10-14...... 903 305 868 3.0 15-19...... 570 307 917 1.9

I 1982 data 2 Figures obtained from 1981 census data

It can be seen from Table 8.1 that the small proportion of preschoolers receiving assistance, i.e., 0.7:1000, is lower than the estimated rate of 1.2:1000 for deafness at or around birth and 1.5: 1000 at age five (see Table 4.5). This is probably an expression of the fact that not all cases of deafness have been diagnosed in this age group. A Danish report on audiological services, written 8 years ago[7], estimated that the need for teaching services for deaf children under 5 years is 1.4:1000 per year. Data' available as from March 1984 shows an increase in the number of preschoolers receiving special educational assistance. This information (Table 8.2) is organised by schooling level rather than by age group~

TABLE 8.2 NUMBER OF HEARING IMPAIRED CHILDREN AND YOUNG PEOPLE RECEIVING SPECIAL EDUCA­ TIONAL ASSISTANCE, BY SCHOOLING LEVEL AND DEAF SCHOOL CATCHMENT AREA, AS AT 31 MARCH 1984

Cenlral/Souchern Northern NZ total

vanAsch & St Kelston & Schooling resource Domi­ All Auckland All level classes niCS others Total units others Total

Preschool...... 87 87 ISS ISS 242 Primary ...... 18 17 354 389 .76 420 496 885 Intermediate ...... 24 5 114 143 22 123 145 288 Secondary ...... 72 275 347 51 298 349 696 Tertiary/transition .: ... 41 38 79 II 17 28 107

.TOTAL...... ISS 22 868 1045 160 I 013 I 173 2 218

100 In the course of gathering data for the Hearing Research Project it became clear that there was considerable disenchantment with the system of edu­ cating deaf children and young people. There has been a call. by consumers for a complete review and reorganisation of deaf education and the Depart­ ment of Education has begun a review of this. If deaf children are to be maintained in ordinary schools then they will need much more support from trained itinerant teachers of the deaf. The survey· One hundred deaf children reported that 40 percent of deaf children in nor­ mal schools and preschools did not receive specialist teaching from an itin­ erant teacher of the deaf or a remedial teacher[8]. Whereas children with a moderate hearing loss may cope well without specialist teaching providing they were detected early, had good hearing aids which they used constantly and were under the attention of an adviser on deaf children, over half the children in the above group had a hearing loss of greater than SSdB. The Department of Education reports that the situation has improved since the above 1981 survey. Deaf Maori children are even worse off than deaf European children, but such differences may be as much socio-economic as racial. VandenBerg[9] in her study of the written language of deaf children, found that the Maori children in schools for the deaf had a greater language deficit than European children even though their hearing loss was often not as severe, i.e., con­ ductive loss resulting from middle ear disease rather than sensorineural loss. Three out of four of the Maori children had not been enrolled in a school for the deaf before the age of five-and-a-half, and one-third not until they were at least 7 years of age. A far higher proportion of European children had obtained instruction as preschoolers. . Just as there are serious deficiencies in the education of deaf preschoolers, both Maori and European, so there is a limited continuing education struc­ ture in place for young deaf people after the age of 18, and sooner in many cases (see Table 8.2). There are limited opportunities for apprenticeship qualifications and a lack of interpreters for students attending tertiary insti­ tutions, to name but two spheres in which young deaf adults are disadvan­ taged. Services are slowly developing in some·polytechnics and technical institutes. A recent New Zealand survey of the parents of disabled and non-disabled Form IV students to ascertain to what extent physical and/or sensory disa­ bility influenced expectation for further education reported that: Many deaf youngsters are having to take work below their intelli­ gence because of needing to gain information from lip-reading. Lan­ guage is well below average level, thus by the time the child has reached secondary age it is more difficult than ever to lip-read words never before encountered and which of course have no meaning. Even to obtain an apprenticeship a fair amount of theory is essential. School teachers haven't the. time to spend with the deaf pupil. More deaf trained teachers' aides are essential and preferably those who

101 can use sign language as well. These people should be available to deaf students wanting to go on to community colleges, technical insti­ tutes etc. [10 p30]

8.4 REHABILITATIVE AND SOCIAL SERVICES For the born deaf and those who become deaf at an early age, services required would be more accurately described as habilitative rather than rehabilitative as such deaf persons cannot return to the 'normal' hearing state they have never experienced, but require every assistance to cope in a hearing world. 8.4.1 Voluntary groups With the exception of audiological services provided by hospital boards and field offices for the deaf which are partially funded by the Departments of Social Welfare and Education, any post-school services for the deaf have been provided by voluntary agencies. There are local groups of parents of deaf children and local deaf societies. The national organisations are: • New Zealand Federation for Deaf Children. • New Zealand Association of the Deaf (NZAD) • Combined New Zealand Societies for the Deaf • New Zealand Deaf Communications Network. There are no rehabilitative/habilitative services for deaf adults and young people in the following areas: • accredited interpreter services • counselling services • employment assistance • child care services. 8.4.2 Field offices At the time of writing, there were field offices for the deaf situated in Auck­ land (two field officers), Wellington (one field officer) and Christchurch (one field officer). Some of the field officers are themselves deaf, and each office has an assistant whose position is now funded on a permanent basis by the Department of Social Welfare. . The purpose of the field offices is to provide practical assistance for the deaf according to their needs, for example help with obtaining employment; find­ ing accommodation and advice on personal problems. In the absence of any official interpreter system in New Zealand, field office staff are often called upon. to act as unofficial interpreters for their deaf clients. Currently the NZAD receives a grant towards the salaries of the field officers and their assistants but the running costs of the field office, for example rent and the office car, still have to be met by the NZAD from money raised nationally and locally.

102 It is clear that the services provided by field offices are meeting an important need. The Wellington Field Officer has noted that a high proportion of Maori hearing impaired use the service: According to the evidence from the Wellington and Auckland Field Office records, the ratio of Maori to pakeha clients is 1:2 (Wellington) and 1:1 (Auckland), while in predominantly pakeha Christchurch the number of Maori clients is negligible. The nature of the cases, as well as the numbers, indicate that in areas with a substantial Maori population hearing impaired Maoris will form a disproportionate part of field office work.[Il] In a month-long survey of the Wellington Field Office, reported more fully in Appendix 8c, it was found that there was a core of regular clients who required help from the Field Officer or her assistant several times a month. More than half the clients were between the ages of 15 and 30 years and there was a very high proportion of Maori clients. As well as giving immed­ iate practical assistance and advice to deaf clients and helping them with employment problems, a considerable amount of the Field Officer and her assistant's time was spent on field office administration and answering requests for information. Clients required immediate practical assistance with such tasks as letter writing, filling in forms, preparation for appointments and finding accommodation.

8.4.3 Hearing aids Once a deaf young person leaves school they are no longer eligible for a free hearing aid. A subsidy of $81 per aid is available for adults and covers an average of one-third of the cost. Hearing aid subsidies are not inflation-linked and the most recent hearing aid subsidy review was in September 1982. In some areas audiologists spend considerable time and effort raising the balance of the hearing aid cost for those on low incomes. The 6-year-long 'saga' of a congenitally deaf woman reported in Appendix 8d· is an example of this. An audiology technician reports on the case of Cynthia G., aged 23, a severely deaf solo mother on the Domestic Purposes Benefit: Up until the age of 18 her aids, which are crucial in her ability to communicate, were paid for by the government through the school for the deaf. Now, at age 23, the aid has broken down and she faces a bill of approximately $150 for a replacement. She is in no position to pay this amount. The Departments of Maori Affairs and Social Welfare will not assist and the hospital will only provide the $81 subsidy which has already been deducted from the previously men­ tioned sum. The full price of an aid is $200-$280. We now have to approach serviee groups, like the Lions, to get her aid paid for. This puts Cynthia in the stressful position of not know­ ing if we can get the aid paid for. She cannot do without it; all communication would be by pen and paper.

103 8.S CONSUMERS OF THE SERVICES

8.5.1 Findings from a report on physical disability[12] Researcher Jan Dowland reported that: In talking with deaf people in the course of our study we discovered there was considerable unmet need for some type of social or psy­ chiatric support service. Evidence of this need came not from direct comments as such. No one specifically stated they needed a social worker or psychiatric help. However there was considerable evidence which suggested that the psychological and social problems associated with deafness were too frequently neglected and that many indi­ viduals and families were suffering the consequences.[13] Problems and difficulties experienced by deaf people surveyed in the above study fell into three main areas: Social life and relationships : 'one woman said she felt diffident and doubted herself in social situations, and another said that meeting people caused embarrassment and that seemed to make her hearing even worse. One man said that as an adolescent and even now as an adult he found approaches to women extremely difficult.'[13] Employment: 'we spoke to a 36-year-old carpenter who wanted to be a commercial fisherman but could not because he was not able to use the radio equipment-he did not seem reconciled to the fact that he was not doing what he really wanted to do.'[13] Child care difficulties: 'one deaf woman with children aged two, five and seven said she had problems when the children were fighting because she did not know what was going on and could not intervene fairly. She also commented that the children talked behind her back and took advantage of her deafness.'[13]

8.5.2 A statement from the New Zealand Federation for Deaf Children The Federation was asked to comment on services for the hearing impaired in New Zealand. Areas of concern were summarized and divided into five sections corresponding to ages and stages of a hearing-handicapped child's progress. The stages are: 1 Identification of hearing handicap and initial support. 2 Preschool stage and early guidance. 3 Schooling years and middle childhood. 4 Young adults and adulthood. S General. For the sake of clarity and brevity each area of concern is outlined only briefly, but the reasons and rationale for each can be supplied more fully by the Executive of the New Zealand Federation for Deaf Children, if required. 104 An asterisk denotes areas in which the Federation feels some improvement is being made. 1 Identification of hearing handicap and initial support: • prevention of rubella deafness .* development of infant hearing screening procedures • identifying deafness early-before 1 year where possible • attitude of medical profession (i.e., referring patients to audiologists where justified and being sympathetic, informa-. tive and supportive to parents of diagnosed deaf child) .* appointment of paediatric audiologists • availability of audiology service in provincial and country areas • team approach between medical profession, audiologists, advisers on deaf children and other professionals and therapists • absolute lack of printed information leaflets on services available .* time lost between detection of deafness and support and help to parents. 2 Preschool stage and early guidance: • trained preschool teachers of the deaf should be available to all deaf preschoolers in some way or other • advisers on deaf children should have the time to give maxi~ mum support and guidance at this stage • availability of Total Communication training in many forms, weekly classes, weekend workshops, home videotapes for loan, public TV programmes, etc • support services for parents need to be coordinated • Department of Education's Psychological Service needs a special section for deaf children . • counselJing services for parents and families of deaf children, both psychological and psychiatric counselling. 3 Schooling years and middle childhood: .* parental choice in type of schooling, local or residential 0* support services for deaf children in ordinary schools .* training of ordinary teachers and principals to accept and cope with deaf children in ordinary schools,' with back-up of sup­ . port services • re-thinking of general classroom acoustic standards in the . building and equipping of schools • standards of noise levels in school classrooms for benefit of partially deaf children lOS • , some deaf teachers of the deaf, as role models, particularly in schqols for the deaf • schools for the deaf to become major resource centres for teaching deaf children in ~rdinary schools over the whole country • ways must be found to alleviate social isolation of deaf children • encouragement and subsidising of sport for deaf children. 4 Young adults and adulthood: • interpreters available at schools, universities and other edu· cational institutions and in health and legal situations • general availability of social workers and counsellors-not just in the three main centres, • resource centre for a psychiatric service for the deaf • speech therapy available after school leaving age • leadership training • employment opportunities. / 5 General: .* public awareness of the handicap of deafness • at Department of Education policy making level there should be a committee (like a high school board) including parents of deaf children, deaf adults, and teachers of the deaf to advise the Minister of Education and senior departmental officials. It should be there as of right, and not just give opinions if . and when asked • liaison between groups involved with, and representing, the deaf. Note: The opinions of parents of deaf children were canvassed at the con­ clusion of their 1983 annual conference and these findings can be found in Appendix 8e.

8.5.3 A statement of the priorities of the New Zealand Association of the Deaf (NZAD) 1 The introduction of a professional interpreter service: • people with severe or profound hearing loss require com­ munication access to the wider community • they have the right to an equal footing in situations where they interact with hearing people who are not familiar with the problems of the deaf, for example law courts, medical examinations, psychiatric treatment,' business transactions, further education and driving tests

106 • in the past and at present these needs have been partly but inadequately met by the services of voluntary interpreters, often family members with very limited ability to commu­ nicate with the deaf • there is an urgent need for trained, salaried interpreters with professional standards who would be available to facilitate communication in a wide variety of situations and with all classes of deaf people, from the illiterate born deaf who need to have language paraphrased, to those who became deaf in later life and only need speech they can lip-read, or the writ­ ten word • it was hoped that the government would agree to a pilot stage of four interpreters, however the Department of Social Wel­ fare has given approval for the training and employment of two interpreters to begin withj practical details are still to be . worked out. 2 Total funding and extension of the field offices for the deaf: • the role of the field officers is to interview and assess deaf clients and identify their needs, so that they can be referred, and if necessary accompanied, to the appropriate sources of help, which may be a government department, voluntary agency, or a specialist in some field such as marriage guid­ ance, vocational training, or a lawyer, doctor, the police or a psychiatrist (see 8.4.2) • during the first three years of the field office operation, costs were met by the NZAD through grants, donations, fund-rais- . ing efforts and by grants from the Welfare Services Distri­ bution Committee of the Lotteries Board • it was hoped that the government would agree to permanent funding of the existing three field offices and an extension of the service to Manawatu/Hawke's Bay, Dunedin/Otago, Nelson, Whangarei and Waikato/Taranakij it was estimated the cost would be $131,000 per annum (1983 values) • in October 1983 the Department of Social Welfare instituted permanent partial funding which ensures the survival of the field offices and confers official status and approval on the operation; the NZAD still has to find approximately $45,000 a year to provide the balance for salarie~, office running costs, telephones and .essential cars. 3 Education and continuing educati!>n: • many. of the personal and social problems of the born deaf and prelingually profoundly deaf are traceable to the inade­ . quacy of their education; many are illiterate or semi-literate and have little of the general knowledge needed to enable them to function in today's world 107 • the work of the field' offices has provided proof of this view; field officers are called upon to assist with all kinds of doc­ umentation, from applications for benefits and passports to explaining business letters and answering personal letters • NZAD urges the government to review the appropriateness and effectiveness of the current provisions for deaf children; NZAD sees the need for all-round improvement and a change of attitude in schools and units for the deaf, with higher expectations and a more work-orientated atmosphere; over­ seas evidence indicates that deaf children can respond to higher standards of teaching • NZAD has established a Scholarship Fund (supported mainly by donations from the McKenzie Trust) which is supporting one severely deaf student at Gallaudet CoUege • there are other deaf young people who might benefit from higher education who are deterred by the lack of facilities in New Zealand; a report published in 1983 by the New Zealand University Students' Association indicated that the seven New Zealand universities regard hearing impaired students as more difficult to accommodate than any other category of disabled students, except the multiple handicapped.[14] 4 Leadership training: • a report on the condition of the deaf in New Zealand pre­ pared by Gallaudet College staff after visiting this country stressed the importance of deaf leadership training and the need for the initiative to come from the deaf themselves • already heavily committed to the field office operation and the Scholarship Fund, NZAD has been unable to take the practical step of either sending selected persons to Gallaudet for training or providing for Gallaudet trainers to come to New Zealand • this impasse has been partially resolved by an offer from Gal­ laudet to provide free accommodation and instruction for three persons (two deaf, one hearing) for one month from mid-June 1984; 'they will explore' the possibilities in leadership 'and interpreter training. S Special psychiatric service for the deaf: • it is a matter of concern to NZAD that there appears to be no practising psychologist* or psychiatrist in New Zealand with a knowledge of the psychology of the deaf or any ability to communicate directly with deaf patients (see 8.2.6). * It has been drawn to the attention of the authors that there is currently one psy­ chologist in Dunedin who has a special interest in the problems of the deaf and who is fluent in sign language,

108 • at the request of the Wellington Field Officer, fifth-year medical students from the Wellington Clinical School under­ took to investigate the need for psychiatric services for the deaf as part of their community health course (see 6.6.2). As a result of this limited but intensive investigation it was recommended: . that far more, if not all, health professionals be edu­ cated about just how severe a handicap deafness is that special psychiatrists be trained in Total Com­ munication to iilcrease the effectiveness of patient management, and that TC possibly be incorporated into the nursing programme that all admissions to a psychiatric hospital be accom­ panied by a mandatory audiometric hearing test. In this way not only would- the hearing limitations of the \ individual be understood from the outset but also fur­ ther 'studies could be undertaken to establish the prevalence of deafness in the psychiatric community on a more concrete basis t1).at more attention be directed towards preventing the development of psychiatric disorders in the deaf in those cases where their deafness plays a significant aetiological role • the third recommendation is highly relevant to the concern felt by NZAD for people who may have been wrongly com­ mitted to a psychiatric hospital when in fact they were deaf and further afflicted by lack of education, lack of commu­ nication and possibly family rejection and hostility; it is feared that in the past people may have been wrongly committed at a young age and may have become institutionalised and una­ ble to emerge into the community without intensive rehabilitatiqn.

Acknowledgments 8.3 Ms Mary Roberts, Special Education Officer, Department of Education Mr Alan Young, Principal, Kelston School for Deaf Children Mr Sefton Bartlett, Principal, van Asch College

Notes and references 1 Recording child health and development : a handbook for profes­ sionals using the 'Health and development record book' I written and edited for the Division of Health Promotion by Dr Murray Lauge­ sen.-Wellington: Dept of Health, 1984. . 2 Report ofthe Committee to Review Primary Medical Services.-Wel­ lington : Dept of Health, 1982.:

109 3 REID, Stewart.-'Rubella immunisation [letter)', in NZ Fam Phy­ sician.-v 11 no 1 (Summer 1984) p 54. 4 Data for January-December 1983, provided by National Health Sta­ tistics Centre, Dept of Health, Wellington. 5 KEITH, W J and SENANAYAKE S M S.-'Prelingual deafness (let­ ter]" in NZ Med J.-v 97 no 7':'9 (8 Feb 1984) p 91-92. 6 'Psychiatric services for the deaf in the Wellington Region' I LCar­ penter et' ai, in Research and development projects 1983, 5th year class in Community Health.-Wellington : Dept of Community Health, Clinical School of Medicine, 1983. 7 Danish audiology: 1951-1976 I edited by 0 Bentzen, H W Ewertsen and G Salmon-Kobenhavn : Nyt Nordisk Forlag Arnold Busck, 1976. 8 One hundred deaf children : a survey of the hearing assessment and guidance service for deaf children in New Zealand I complied by Coralie Kirkland.-Wellington : New Zealand Federation for Deaf Children, 1981. 9 VANDENBERG, D Marjorie.-The written language of orally-taught deaf children : a comparative study.-Wellington : New Zealand Council for Educational Research, 1971 ~ 10 NEALE, Jenny.-Where next? : a survey of the parents of disabled and non-dis'abled Form 4 students to ascertain to what e~tent physical and/or sensory disability influenced expectation for further educa­ tion-Wellington : Further Education for the Disabled Group, New Zealand University Students' Association, 1984. 11 DUGDALE, Pat.-The Maori hearing-impaired.-Wellington: New Zealand Association of the Deaf, 1982. (Unpublished) 12 Physical disability : results of a survey in the Wellington Hospital Board area I Avery Jack et al.-Wellington : Management Services and Research Unit, Dept of Health, 198 ~ (Special report series ; no 59). 13 DOWLAND, Jan.-Personal communication, 1983. 14 ALEXANDER, Martin and,BRIDGEMAN, Christopher.-Further education for disabled people: a New Zealand survey.-Wellington : New Zealand University Students' Association, 1983.

110 9 SERVICES FOR' CHILDREN WITH EAR DISEASE AND ASSOCIATED HEARING LOSS

9.1 SCREENING SERVICES It is recommended thitt children be checked at 6 weeks, 9 months and 3 , years by either general practitioners, medical officers, Plunket nurses or pub­ , lic health nurses. However the system falls down in many ways as parents do not always bring their children to be checked and, in the majority of' cases; health professionals do not have the time, training' or equipment to carry out adequate otological examinations or measure hearing status; neither do they often have the equipment to conduct an objective test of middle ear status, as in impedance tympanometry. Exceptions to this are some practices which have hearing testing equipment. Recent overseas studies confirm that the highest attack rates for acute otitis media are iri the first 2 years of life (see section 5.3). It is thought that , children having episodes of OME in their first year of life later become 'otitis prone,' so it is important to monitor this population in case medical or edu- ' cational intervention is required. ' Apart from the experimental use of impedance tympanometry at age three, to be described in section 9.1.1, no objective screening techniques for detect­ ing middle ear problems are in general use and only a small proportion of children have their hearing screened during their first 5 years of life (see section 9.1.2). It is clear that the screening and monitoring of preschoolers deserves more attention and action. A newly available instrument, the acous­ ,tic otoscope, has,some potential for monitoring children in a general practice. 9.1.1 Impedance screening Impedance tympanometry gives a quick, fairly reliable test of the presence of fluid in the middle ear, requires only the minimum of client cooperation, is non-invasive and may be administered by a person with minimal training. It does not test hearing. In the hope of developing a more effective screening programme, particularly for younger children, pilot impedance tympano­ metry screening programmes for children aged three, five and seven have been undertaken in Christchurch, Timaru and Dunedin and are currently being evaluated. A comprehensive and literature-based statement on the sub­ ject of impedance screening has been prepared by the Impedance Screening Subcommittee of the Committee on Hearing. , 9.1.2 Pure tone screening Vision hearing 'testers of the Department of Health are required to test the hearing of preschoolers (3-4 years), new entrants (5-6 years) and Form I pupils (approximately 'II -years) using pure tone audiometry. Because pure tone hearing tests are difficult and time-consuming in noisy preschools, and

111 because of other demands on vision hearing testers' time, only about a quarter of New Zealand preschoolers had their hearing tested in 1982. Vision hear­ ing tester returns for 1983 show an overall improvement in the proportion of preschoolers screened nationally although these data are not always con­ sistent or reliable. There is still scope for improvement and there remains, as in previous years, a marked regional variation in the coverage of pre­ schoolers as can be seen in Table 9.1. The data presented in this table are not restricted to pure tone screening, e.g., impedance screening is carried out in three health districts. With the exception of data from the pilot imped­ ance screening programmes, too much weight should not be placed on the information presented in Table 9.1. TABLE 9.1 PRESCHOOLERS SCREENED BY VISION HEARING TESTERS AS A PROPORTION OF 4-YEAR-OLDS WITHIN EACH HEALTH DISTRICT, 1983

Health Total 4- Total no. tested district year-old popn. I (J st test}2

n % Whangarei...... 1 857 232 12.5 Takapuna,.....:...... 4440 2 836 63.9 Auckland...... 4 329 1072 24.8 South Auckland ...... 4869 Hamilton...... 5 018 3 180 63.4 Rotorua ...... :...... ' 3 545 737 20.8 Gisborne...... ;·... 1 232 616 50.0 Napier...... :..:...... :...... :...... 2 050 1 370 66.8 New Plymouth ...... :.....:...... 1 741 668 38.4 Wanganui ...... ;...... ;...... :...... 1 561 734 47.0 Palmerston North...... 2 359 1 372 58.2 Lower Hutt ...... 3 259 743 22.8 Wellington ...... :...... 3 189 690 21.6 Nelson ...... :...... l 979 1 699 85.9 Christchurch ...... ::...... 4 821 4941 57.0* Timaru ...... :...:....:...... 1 665 858 50.0* Dunedin ...... 2 314 80.0* bivercargill ...... 1 985 86 4.3 TOTAL...... 52 213 21 834 . 41.8

, Estimated population of 4-year-olds is derived from number of live births in 1979 (Table 2, p 9. Fetal and infant deaths 1979, National Health Statistics Centre).

2 Annual vision hearing tester returns, 1983 : Division of Health Promotion. * Pilot impedance screening programme : inform~tion provided by Dr Anne Simpson, Dunedin. The majority of new.entrants and Form I pupils have their hearing screened. Screening· ages are under review because it is known that OME is ·most prevalent in the first 8 or 9 years of life. In a study in Dunedin, screening

112 at age 11 detected few new cases of hearing impairment. However, even if routine screening of II-year-olds was abandoned, there would still be a need for the screening of special populations such as disadvantaged children and those in conflict with the law, for example. It is hoped that the South Island pilot screening programme (which includes both impedance and pure tone screening) will produce useful informati()fl on appropriate ages for screening.

9.1.3 Screening of special populations (1) Children in psychopaedic hospitals: these children may be in-patients or out-patients. They are usually multiply-handicapped and range from the mildly behaviourally retarded to the profoundly intellec­ tually and physically handicapped. There is no routine monitoring of hearing and middle ear status in this population, despite the fact that it is more highly at risk for deafness and middle ear infection than the general population (see 5.7.3). In one New Zealand psy­ chopaedic hospital, records of children born since 1960 were scanned for any information on hearing status and it was found that only 25 percent· had had a hearing assessment. Of those tested, over 50 per­ cent had abnormal hearing status (see 5.7.3). In the light of this evi= dence, psychopaedic hospitals will need to review their hearing and otological services. (2) Children in special schools or special classes for the intellectually handi­ capped: as with the above popUlation there is a higher risk of hearing loss[I,2] and middle ear problems, for example in Down's syndrome children[3,4]. The importance of determining the presence of hearing impairment in such a popUlation is emphasized by Kinge and Tonning[l] when they point out that the practical consequences of hearing loss are not only dependent upon the degree of the impairment, but also on other factors such as 'mental capacity': In general, it may be assumed that the lower the. mental capacity the more difficult it will be for a person to compen­ sate for his hearing impairment ... Even a sli'ght hearing impairment may have serious consequences for the mentally retarded ... Corrective measures must start as early in life as possible. Although Department of Health vision hearing testers are required to test the hearing of children in special schools and special classes 'as for other children and at more frequent intervals at the discretion of the medical officer', this is often not done because it is time-con­ suming and difficult. For example, one vision hearing tester has attempted, over a period of 3 years, to enlist support through accepted official channels to initiate assessment in one school for the intel­ lectually handicapped in a deprived area which she feels isparticu­ lady neglected. To date, no action has been taken.

113 . Clearly, the monitoring of hearing and middle ear starus bf children in special schools and special classes is not within the capabilities of the service as it is currently organised, as a great deal of expert time is required to test such children. Increased resources will be necessary . before adequate services can be provided in this area., (3)' Children attending speech clinics:' an investigation of the need for a more thorough hearing and otological assessment and monitoring of children recommended to attend speech clinics is urgently required (see 5.7.1). Any history of middle ear or hearing problems is not always known to speech therapists, and there is often difficulty in obtaining hearing assessments for children attending their clinics. (4) Children in social wei/are homes:. a hearing screening programme for all children in Department of Social Welfare care was instituted in mid, 1983. During the course of a medical examination a quick but crude check of hearing is made using ahand-held audiometer, which screens at 30dB at the frequencies of 1 and 4kHz. An informal assess­ ment of this programme. is underway. . 9.2 MEDICAL AND AUDIOLOGICAL SERVICES FIGURE 9a REFERRAL SYSTEM FOR CHILDREN FAILING PRE­ SCHOOL OR SCHOOL SCREENING

Vision hearing tester

,- --- '1 (-- - - -i Medical officer I

,..J

Parents r ------,

I Public health' nurse ~

,-______~~=______~~,_G_e_n_e_ra_l_p_r_ac_t_it_io_n_e_r__ ~__~~~~~

Public hospital: ENT Private ENT and audiology clinic specialist

~:~ -­ .- ­ - - ­ ...... , Public ENT surgery Private ENT surgery

114 9.2.1 Referral system This section outlines the referral system for children failing preschool or school hearing screening and' notes some problems with service de.1ivery. A description of a special system, which has overcome some of the referral problems, can be found in Appendix 9a.

Problems for vision hearing testers: • low status and professional isolation • lac;:k of credibility arising out of the above; parents and general prac­ titioners often reluctant to act upon screening results • lack of refresher courses and supervision • impracticable workload, e.g., the testing of preschoolers as, well as all new entrants, Form I pupils, children in special classes and some industrial testing , • poor back-up by Department of Health medical officers in some districts • lack of cooperation in some schools • difficulty in obtaining a quiet place for pure tone screening • frustration at seeing the same children failing repeatedly because of inadequate treatment and delays in treatment • lack of feedback from general practitioners and, ENTspecialists. ',.­ A list of suggestions for improving vision hearing screening in schools, pre­ sented by a vision hearing tester, can be found in Appendix 9b.

Problems for parents: • lack information about hearing screening • may lack awareness of educational and social implications of 'the invisible handicap', even if it is only temporary and partial • are reluctant to admit their child could be affected • may be worried about the short-term and long-term implications of surgical intervention for their child.

Problems for general practitioners: • not.all children failing screening are taken to their doctor; in a Christchurch study 16 percent did not see their family doctor • with a simple otoscope many doctors can only reliably diagnose wax, perforations and acute infections; pneumatic otoscopy may increase the reliability of diagnosing middle ear effusions • most general practitioners do not have equipment for testing hearing, i.e., an audiometer, so hearing loss cannot be ruled out

115 • despite the above, general practitioners may not refer children to an ENT specialist and are usually precluded from direct access to an audiologist; in a Christchurch study 40 percent of the children_saw their doctor only • in some cases lack of referral may be justified as many middle ear problems are self limiting or responsive to treatment, for example with antibiotics • if they refer children to a hospital clinic they are aware that there will be· an unacceptable waiting time • they are aware that in .underprivileged areas the wait is even longer • they are also aware that not all parents will be able to afford a con" sultation with a private ENT specialist and surgery in a private hospital • there are only two private audiologists to whom they could have direct access.

Problems for public hospital ENT and audiology clinics: • clinics are generally overwhelmed by the demand for services • there is an unacceptable waiting time for appointments because of the shortage and maldistribution of ENT surgeons and audiologists, e.g., in 1983, Middlemore hospital had an allocation of 0.9 of a specialist (two parHime ENT surgeons) to a population of approxi­ mately 300,000 • not all hospitals have audiologists, e.g., Southland • - patients may fail to arrive for an appointment • patients may find travelling to clinics difficult and expensive, e.g., many people in South Auckland have to be directed further afield than Middlemore Hospital; patients visiting the Dunedin Hospital may have up to a SOO-mile round trip.

Problems for private ENT specialists: • patients may find consultation costs, and possible future surgical costs, a problem • patients may find travelling to consultations difficult and expensive, e.g., in Auckland the majority of private ENT consulting rooms are in Remuera.

Problems with public ENT surgery: • in general, hospital boards give ENT services a low pfiority and do not fund them adequately; there is also a reluctance to fund ENT positions • there is an unacceptable waiting time for surgical treatment because of the shortage and mal distribution of ENT surgeons.

116 •. there can be deleterious effects on children's education if essential surgery is delayed; at Middlemore hospital the delay between referral and surgery can be up to 3 years • there are disparities in length of hospital stay for myringotomies which consequently affect waiting lists; in some parts of the country chil­ dren are keptin hospital for several days while for others it is a day stay. Problems with private ENT surgery: • private hospital costs are a consideration, particularly for low-income families.

9.2.2 Treatment for otitis media (1) Acute otitis media : acute middle ear infection responds to treatment with antibiotics and is the responsibility of the general practitioner. The Department of Health has introduced a publicity campaign to raise public awareness' about the need for treatment for ear infections., Anecdotal evidence suggests that parents often check out the possibility of an ear infection in their child with their Plunket or public health nurse before committing themselves to a doctor's visit. (2) Chronic suppurative otitis media (CSOM) : discharging ear is usually due to previously untreated middle ear infection resulting in perforation of the ear drum. If 'running' ear is left untreated it can result in severe hearing loss and educational disadvantage. A chronically discharging ear may also be due to cholesteatoma which is potentially life-threatening. There are still no reliable national data on discharging ear and perforations of the ear drum. In the past, the highest prevalence of discharging ear was thought to be in those rural areas of the North Island where there was a high proportion of Maori children. Mobile ear clinics housed in caravans were introduced in some parts of the North Island to cope with this problem. Although it appears to be accepted that CSOM is now less prevalent in New Zealand, there is a paucity of hard data on the subject. In 1983, 4.8 percent of school entrants in Takapuna Health District had discharging ears ot perforated ear drums[S]. Mobile ear clinics are now often immobilised in urban areas to compensate for the lack of hospital ENT clinics in outlying city suburbs. Public health nurses have been equipped with otoscopes for examining ears and some are able to perform 'aural toilets', thus providing a first-line treat­ ment for discharging ears. For cases which require referral to an ENT specialist, there is often a delay in obtaining clinic. appointments or long distances to travel. It is hoped that by 1985, data on the prevalence of chronic problems at 5 years of age will be available from public health nurse returns for new entrants' health assessment. (3) Otitis media with effusion (OME): otitis media with effusion, also known as secretory otitis meqia, middle ear effusion and glue ear, is much more common than previously thought. It consists of an accumulation of fluid in ~ 117 the middle ear which may be thick and glue-like, and it is the most frequent cause of hearing loss in children in developed countries. It is likely that the majority of children failing school screening tests are experiencing conduc­ tive hearing loss resulting from OME. There is now evidence from controlled trials that in many' cases OME responds to initial therapy of an extended (four~week) antibiotic course. [6] , In a survey of patients attending all Wellington Hospital Board ENT clinics over a one-month period, 38 percent were under 15 years of age. If only those attending for ear or hearing problems were included; i.e., 'nose and, throat' patients were excluded, then 57 percent of patients were under 15 years. In this survey, 29 percent of all ENT patients were diagnosed as having OME and the majority of these were children. If 'nose' and 'throat' patients were excluded then 44 percent of patients attending for ear and hearing problems were diagnosed as having OME.[7] . Surgery for OME usually involves the insertion of a ventilation tube in the ear drum (myringotomy) which aerates the middle ear and brings about an immediate restoration of hearing. Under normal circumstances the tube (,grommet') is eventually rejected and the. ear drum heals over. The number of myringotomies performed in public and private hospitals in 1982, by age and sex, can be found in Appendix 9c.· It,can be seen from these tables that more than half of the myringotomies were carried out in private hospitals. Half of the private hospital myringotomies were performed . on preschoolers whereas only a quarter of public hospital myringotomies were on this same age group. The decision to intervene surgically has to take into account educational as well as health implications; although there" is always the possibility of overtreating a self-limiting condition. The dis­ advantages of hospital treatment, anaesthesia and possible damage to the ear drum (usually a minor problem) need to be weighed againsuhe advantage of restored hearing for a child when most needed in the critical learning years.

9.2.3 Diagnosis of central auditory perceptual dysfunction [8,9] Central auditory perceptual dysfunction is a specialised type of problem which is difficult to diagnose due to lack of simple standardised tests. Its prevalence in New Zealand is not known. Although children with this problem would pass a test of peripheral hearing, they have a form of 'central' deafness which results in learning difficulties (see 2.8, the case history of Sam). Such chil­ dren have trouble sorting out important information from background noise or from other competing information; some have a problem with short-term auditory memory, i.e., they cannot remember spoken information well unless it is presented in small segments. . ' At the beginning of March 1984, there were 23 children awaiting testing at the Centre who were suspected of having 'central' deafness.

118 9.3 EDUCATIONAL SERVICES

9.3.1 . Developmental effects of conductive hearing disorders[10] • children with early sensory deprivation have difficulty learning to listen, paying attention and making auditory discriminations; -inability to concentrate is evident where hearing impairment fluctuates • as they mature, such children may not have the foundation to develop implicit speech or thought. This in turn may lead to inadequate development of higher order abstraction and conceptualisation • the onset of middle ear infections during the critical years of lan­ guage development, as well as the number of infections, play an important role in the impairment of speech and language development • vocabulary tends to be below average in children who have had slight deafness for some years as they do not discriminate words as well as those whose hearing impairment was equally severe but of short duration • reading may be affected (research does not give a clear answer on this topic, and some research provides negative evidence) • superficially the child may appear to be functioning normally. Authors' note: bright children may become under-achievers, i.e., they are not conspicuous because they are achieving at an average level but they may be capable of much more. 9.3.2 Preschool provision_ In the light of the above statements and the fact that OME is mpst common in the early years, it is clear that much needs,to be done before children enter the primary school system. Currently there is no official education provision for preschoolers whose hearing loss ,is not sufficiently gross or of the type to benefit from a hearing aid. 9.3.3 Classroom provision In Dunedin children examined when they started school, 25 percent had a hearing loss of 16dB or more (19 percent unilateral, 6 percent bilateral) and 17 percent had OME in one or both ears. Rates are likely to be higher in such areas as Auckland, North Auckland and Gisborne. In South Auckland alone, it is estimated that there are approximately 5500 young school chil­ dren in this category and probably as many preschoolers. Only about 300 of these children are eligible to be seen by advisers on deaf children, so it may be that some other type of educational provision is needed for the remainder, for example classroom teachers may need help from advisers on deaf children. As with preschoolers, there is no provision for children with mild hearing loss who do not qualify for assistance from advisers on deaf children. The needs of children with temporary hearing loss may be better dealt with by educational intervention than surgical intervention; even if surgery is required,

119 the teacher still has to cope with the intervening waiting period. The class­ room teacher receives little or no training to deal with conductive hearing loss, partly because the extent of the problem has been recognised only com­ paratively recently. The needs of hearing impaired children in ordinary class­ rooms are often unrecognised as the impairment may be unilateral or bilateral, fluctuating in presence and degree and associated with varying distortions of sound. For example, a child may have difficulty hearing in the presence of background noise. The Department of Education recently called together a group of health and education professionals and representatives from community groups to dis­ cuss the educational implications of the effects of mild to moderate hearing impairment in ordinary classrooms.

9.3.4, Intervention studies The most comprehensive study of the association between OME and learning problems is the Dunedin Multidisciplinary Child Development Study[llJ. It is an intervention study in the sense that the health of the cohort was care­ fully monitored and treated when required. The study showed that children with severe OME were significantly disad­ vantaged in terms of language, IQ, verbal comprehension and expression and speech articulation. These differences were maximal in assessments carried out at the age of 3 and 5 years and, thereafter, tended to diminish. It is possible that part of the improvement can be accounted for by the fact that the more severe cases of OME had surgical treatment in their fifth and sixth years of life. A more recent controlled intervention study[11] has been unable to demonstrate any educational advantage from ventilation tubes over a one­ year period, even though hearing improved in the treatment group. As an alternative to surgical treatment West et al[12] used classroom inter­ ventions to augment the hearing of 76 7-year-olds in a South Auckland school. The interventions used over a one-year period consisted of: • acoustic treatment of the classrooms with carpet • amplification of the teacher's voice by radio microphone and multiple loud' speakers • teacher education· on methods of teaching the hearing impaired. The children with partial or intermittent hearing impairment showed a greater improvement in a post-intervention test of listening comprehension than did either those who were not hearing impaired or those who were more severely impaired. As measured by the Test oj language development (TOLD) more of the severely hearing impaired children had improved after the interven­ tion. The researchers were unable to distinguish between the effects of the three interventions. However, they felt that test results provided evidence that moderately hearing impaired children benefited from the use of carpet in classrooms and teaching techniques recommended by advisers ,on deaf children; the use of amplification had been proved effective overseas and

120 should be considered for use in some circumstances. A great deal more research is needed, both in the education of children with OME and dis­ orders of central auditory perception.

9.3.S Information services There is some information available but it takes time and motivation to seek it out. The schools for the deaf and advisers on deaf children provide infor­ mation on conductive hearing loss and suggestions for parents and teachers as to how to help with hearing loss at home and at school. However, there is a need for more widely-targeted parent and teacher education on the extent of the problem, how to recognise it and what to do about it.[13]

Acknowledgments 9.1 Mr Ian Stewart, ENT specialist, Dunedin Hospital.

Notes and references 1 KINGE, F 0 and TONNING, F.-'Hearing impairment; preva­ lence and relation to school background, intellectual ability and encephalopathy: a sociomedical study of a birth-cohort from Bergen', in Scand Audiol.-v 6 (1977) p 225-231. 2 JlTTS, Stephe and KEYES, Carrie.-'Incidence of hearing loss in a population of school-aged intellectually handicapped children', in Aust J Audiology.-v 5 no 2 (1983) p 71-75. 3 STROME, Marshall. - 'Down's syndrome: a modern otorhinolaryn-' gological perspective', in Laryngoscope.-v XCI no 10 (Oct 1981) p 1581-1594. . 4 WHIT'E, Benjamin- LeM, DOYLE, William J and BLUESTONE, Charles D.-'Eustachian tube function in infants and children with Down's syndrome' in Recent advances in otitis media with effusion / edited by David J Lim et al.-Philadelphia : Decker, 1984. 5 Information supplied to the Division of Health Promotion, Dept of Health, Wellington by the Takapuna District Health Office. 6 STEWART, Ian.-Personal communication, 1984. 7 Data collected for the Hearing Research Project. 8 Central audiotory and language disorders in children I edited by R W Keith.-Houston : College-Hill Press, 1981. 9 Handbook of clinical audiology / edited by Jack Katz.-2nd ed­ Baltimore : William and Wilkins, 1978. 10 Helping the child with conductive deafness at home and at school / Michael Parsons et al.-Christchurch : van Asch College, 1975? (U npublished).

121 11 'Some developmental characteristics associated with otitis media with effusion' / Ian Stewart et ai, in Recent advances in otitis media with effusion / edited by David J Lim et al.-Philadelphia : Decker, 1984. 12 'Classroom interventions for children with hearing impairment' / S Rae West et a1. A paper presented at the Third International Sym­ posium on Recent Advances in Otitis Media with Effusion, May 17­ 20 1983, Fort Lauderdale, Florida. (Unpublished). 13 BOSWELL, Kathleen.-'Perhaps they just can't hear you: how to help children with impaired hearing in the classroom', in National Education.-v 66 no 2 (Apr 1984) p 52;..55.

122 10 SERVICES 'FOR ADULTS WITH ACQUIRED HEARING L9SS

10.1 SCREENING SERVICES

10.1.1 Pre-employment and employment screening The extent of pre-employment screening is unknown. Any that is done is carried out by occupational health personnel employed by large firms ,or organisations. Pre-employment (or prior to school leaving) screening would enable the hearing status of individuals to be monitored and would provide baseline data to be used in estimating the allocation of services and calcu­ lating compensation payments, for example. The extent of employment screening is also unknown. The public sector provides a limited number of public health nurses and vision hearing testers who are required to test all government workshops and are available to test in private industries which are known to have high noise levels. Coverage of these groups is incomplete and varies greatly between health districts. In the private sector large firms often employ their own occupational per­ sonnel who carry out audiometric testing as one of their duties. Some large public sector organisations, for example New Zealand Railways, employ their own occupational health staff. Small organisations and self-employed groups, for example farmers, are not covered. 10.1.2 Screening of the general population and the elderly The only screening service is offered by the Hearing Association which runs a number of free testing days throughout the year. Public health nurses working in occupational audiometry are sometimes approached with requests for hearing tests from the public and from general practitioners .. 10.1.3 Screening of special populations There is no routine screening of special popUlations of adults such as those in prisons, psychiatric hospitals, centres for the intellectually handicapped, or homes for the elderly. An Auckland prison study showed that hearing loss was seven times greater than would be expected in a group of 15 to 25-year­ olds (see 6.6.4). Audiometric surveys conducted at Porirua and Sunnyside· hospitals showed that there was a higher prevalence of hearing impairment in a psychi!1tric population than in the general popUlation (see 6.6.2). In a survey of middle ear and hearing status at one Auckland centre for intel­ lectually handicapped adults, over 50 percent were found to have a signifi­ cant hearing loss. Over 30 percent of these adults required the removal of hard impacted wax before their hearing could be tested. Studies in Britain and North America revealed a higher rate of hearing loss in the elderly in residential institutions than in those living in their own ,homes (see Table 6.11).

123 10.2 MEDICAL AND AUDIOLOGICAL SERVICES

10.2.1 Referral system , The referral system for adults is set out diagramatically, followed by notes on aspects of service delivery. As hearing loss in adults is largely sensori­ neural and not remediable by surgery the diagram reflects the referral system for sensorineural loss. In cases of remediable conductive loss an additional stage of public or private surgery would need to be added.

FIGURE lOa REFERRAL SYSTEM FOR ADULTS WITH SENSORI­ NEURAL HEARING LOSS

Occupational" Self referral audiometry

General practitioner

Private ENT specialist

Public hospital Hearing aid audiology clinic salespeople

General practitioners: " As mentioned in earlier sections on prelingual deafness and children with ear disease, general practitioners are an important part of the referral system. Unfortunately they can sometimes be instrumental in blocking ~he system by 'not referring their patients for expert assessment for example, and by underestimating the day-io-day effects of a hearing disability[l]. This lack of awareness is commented on by Dr Harold Bate, Professor of Audiology at Western Michigan University, an 'authority on rehabilitation of the hearing impaired: ' There needs to be a change in the laissez-faire and uninformed atti­ tude of many general practitioners regarding hearing loss. Misinfor­ mation and disregard of the seriousness of the complaint is impinging

124 on people's lives, careers and marriages. This is unacceptable. The advice it happens to all of us, learn to live with it, is no longer (and never has been) adequate.

Public hospital ENT clinics: Treatment at these clinics is free but there are unacceptably long waiting times for appointments for non-urgent cases. These clinics deal with prob­ lems of the nose and throat as well as hearing problems. Non-urgent cases may suffer when urgent cases are dealt with. ENT clinics carry out otological examinations, diagnosis and both surgical and nonsurgical treatment. Many patients with ear disease require regular follow-up and treatment on a long-term basis. Public hospital clinics, espe­ cially in conjunction with the medical schools, are responsible for the train­ ing of junior specialists (registrars) and other doctors. They also provide a range of emergency services, e.g., for sudden hearing loss and other severe ear diseases. An ENT specialist must certify that a hearing aid is appropriate for a patient before a government subsidy is payable. .

Private ENT specialists: Services are the same as for public hospital clinics. In general waiting time is less and fees are charged. If clients require hearing aids they are referred either to private sector hear­ ing aid salespeople, with subsequent expense and likely hearing aid diffi­ culties, or to public sector audiology clinics with less expense, more expertise but lengthy waiting times. .

Public hospital audiology clt'nics: These clinics carry out diagnostic tests for patients with hearing problems, in conjunction with ENT specialists. Audiology clinics provide hearing assessment services for infants and children. Once a patient has been ade­ quately assessed and diagnosed by audiologist and otologist, clinics are responsible for the rehabilitation of patients whose problems are not amen­ able to medical or surgical treatment; the majority of adults with hearing problems fall into this category. The major rehabilitative services provided .are evaluation and fitting of hearing aids, and ongoing management of hear­ ing aid problems. Counselling of patients with hearing problems is also an important' role of audiology clinics. Pressure on public hospital audiology clinics has also resulted in long waiting lists. An indication of the proportion of hearing aid work done in an audiology clinic (excluding diagnosis and assessment) is as follows: of all attendances at the Wellington hospital audiology clinic over a one-month period, approxi­ mately 16 percent were for hearing aid evaluation, 12 percent for hearing aid fitting and 5 percent were for hearing aid follow-up.[2]

125 A hearing aid fitting usually requires a number of appointments. Keith notes that the Australian National Acoustic Laboratories have developed a protocol involving five appointments which incorporate hearing aid assessment, hear­ ing aid evaluation and instruction and guidance. The five appointments involve a total time of 3 hours per client.[3] It is clear that most patients with a sensorineural loss require considerably more of an audiologist's time than an ENT specialist's. Hearing aid salespeople: Hearing aid salespeople are not required to be registered and range from the conscientious to the unscrupulous. The New Zealand Audiological Society and the Otolaryngological Society have expressed their concern about hear­ ing aid agents. Criticisms of agents who work through chemists' shops are: • some hearing aid dealers use misleading advertising, by implying that hearing aids are equivalent to contact lenses • some people are fitted with hearing aids without a proper assessment of their hearing; often all that is done is a simple audiogram and this is not done in a sound-treated room • some people are not being allowed a home trial of the aid before purchasing it • some people are not told of the government subsidy on hearing aids • some people are fitted with aids without having seen an ENT specialist • some people have experienced difficulty in obtaining a refund if the aid proves to be of no help • some people have experienced difficulty' in obtaining after-sales service. There will be a further discussion of hearing aids in the section following.

10.2.2' Hearing aids and hearing aid services. It is obvious from the preceding section thin many adults with acquired hear­ ing loss experience difficulties in obtaining appropriate hearing aids. A case study illustrating this point, but one !\'ith a successful outcome, ,is presented in Appendix lOa. The following section reports excerpts from a recent article by Dr Bill Keith; Principal Audiologist, Audiology Centre.[3] .

Hearing aids: • hearing aids come 'in three basic types: body-worn, behind-the-ear (including spectacle aids) and in-the-ear (including canal aids) • hearing aids with the microphone at head level are acoustically better than body-:worn aids, but require more manual dexterity to mariage

126 • behind-the-ear aids are the most commonly fitted type, though in the United States sales of in-the-ear hearing aids have almost equalled sales of behind-the-~ar aids.

Hearing aid fitting: • while it is true that hearing aids cannot restore normal hearing, they have far more potential for improving hearing ability than is often assumed • the crucial factor in determining whether that potential is achieved is not the cost or brand of the aid but the expertise with which it is fitted. Authors' note: in the Wellington study of Physical disability approximately 45 percent of all those with hearing aids found them unsatisfactory, and the proportion was even higher among those over age 75 • monaural fittings give about as much assistance to persons with bilat­ eral hearing impairment as do monocles to persons with bilateral visual impairment.

Hearing aid services: • in 1984 hearing aid services were free to children, and adults were entitled to a subsidy of $81 per aid on hearing aids • the subsidy is payable on the authority of an otologist. The approval of an audiologist also is required in the case of custom-made in-the­ ear aids • there is no qualifying restriction on the degree of hearing loss, and new subsidies may be paid whenever patients' existing hearing aids are considered inadequate • a double subsidy is paid for binaural hearing aid fittings • hospitals in New Zealand stock a wide range of imported hearing aids" on a consignment basis; the aids are issued at direct wholesale cost ' • in 1984 prices per aid obtained through hospitals ranged from $73, , to approximately $350 for custom-made in-the-ear aids; the majority of aids fitted were priced in the range from $200 to $300 ' • most hospital boards employ audiologists and are equipped to carry out sound field testing of hearing aids • private hearing aid dealers charge retail prices for hearing aids; prices are variable but range up to $900 per aid • few dealers have sound-treated premises or sound field equipment; many operate from chemist shops • dealers offer a more limited choice of hearing aid brands than hos­ pital clinics.

127

Si~, 10 Role of the general practitioner: The general practitioner can encourage accountability in hearing aid fitting, whether done by a private dealer or a public agency by: • checking that hearing aid fittings include the three components of aided tone detection tests to measure real-ear gain, speech discrim­ ination and home trial • checking patient satisfaCtion with the fitting • encouraging patients .to return the hearing aids and request their money back if they are not satisfied.

10.3 REHABILITATIVE (POST -HEARING AID} SERVICES The fitting of hearing aids is only one part of the treatment and rehabilitation that a hearing impaired person requires. There is a need for careful instruc­ tion in the use of hearing aids, advice about other aids, instruction in com­ munication tactics and individual counselling. 10.3.1 Audiologists Audiologists are required to fit hearing aids and provide a follow-up service. Despite their training in rehabilitative techniques they often do not have the time to put these skills into practice because of more urgent priorities and excessive waiting lists. As a result of the demands for hearing testing it is not uncommon for trained audiologists to be asked to carry out screening and monitoring which audiometric technicians.are better emplQyed doing. 10.3.2 Hearing Association The Hearing Association (known before 1976 as the League for the Hard of Hearing), a voluntary organisation, provides the only rehabilitative services for adults with acquired hearing loss. The Department of Education pays the salary of Hearing Association speech-reading tutors. Up until recently this has represented a rather limited type of rehabilitative service and has not always met the needs of the 'hard of hearing'. In the hope of widening the scope of its rehabilitation services and broad­ ening the training of its tutors, the Hearing Association has twice brought to New Zealand Dr Harold Bate, Professor of Audiology, Western Michigan University. During his 1983 visit he suggested that a good rehabilitative service needs the following components from which individuals can choose to meet their current needs: • provision of information • traditional speech/lip-reading training • auditory and listening training • speech conservation training

128 • manual communication • hearing aid orientation and guidance • personal adjustment counselling • family and other counselling. For the young hearing impaired adult there is often nowhere to turn because the Hearing Association is perceived as catering mainly for the elderly hear­ ing impaired. More detail on the Hearing Association can be found in a later section on 'consumers of the services'. At the time of writing the Auckland branch of the Hearing Association had established its own audiology clinic. The Asso­ ciation has employed a private audiologist and will primarily provide a hear- . ing aid service. 10.3.3 Technological advances This section has been taken from an article by Dr Bill Keith: The most recent development in the continuing trend toward mini­ aturisation of hearing aids is the introduction of canal aids, hearing. aids which fit entirely in the external auditory canal. The output of . miniature hearing aids is less easily controlled and modified to suit individual hearing losses than the output of behind-the-ear hearing . aids. Thu~ fitting is more of a hit-and-miss procedure, but location of the microphone in the ear is acoustically advantageous and the cosmetic appeal of inconspicuous aids is strong. That there are still . many people who could benefit from hearing aids but who are reluc-· tant to wear them for reasons of cosmetic and social acceptability was evidenced by the doubling of hearing aid sales in the United States following the recent announcement by the White House that Pres­ ident Reagan has been fitted with a canal hearing aid. The impact of computers has been felt in most areas of science and medicine. In the hearing aid domain computers lend themselves. to the task of fitting. They can store ·data. on many hearing aids and, given appropriate input data on a patient'S hearing loss, can calculate. required gain and select a number of aids for trial. But this appli­ cation uses computers simply for filing and arithmetic. Far more sig­ nificant is the use of digital technology to process speech signals before they are delivered to the ear. A body-worn digital processor that con­ nects to a behind-the-ear hearing aid has already been released in prototype form. This type of processor will open avenues for more precise control of such parameters as output level, compression ratio, and frequency.response in hearing aids, and provide active processing capability· to enable features such as suppression of background noise and prevention of acoustic feedback. Hearing aids, though, are not the only for:m in which technology can benefit the hearing impaired. There are several devices to make tele­ phone communication mote accessible including portable telephone 129 amplifiers, and teletype. telecommunication devices. Flashing light alarms are available to signal when, a door-bell is ringing or a baby crying. And a new world of enjoyment and access to news and current affairs has been opened up with the introduction in some countries of closed captioned television. Closed captioning enables television receivers incorporating an appropriate decoder to receive a display caption on pre-captioned programmes. Captioning is due to be intro­ duced in New Zealand in January 1984. A major research thrust at present is in the development of cochlear ,implants. Well over 100 subjects have received implants already throughout the world, with positive results. Multiple electrode implants, of the type being developed at the University of Melbourne, appear to offer more promise than single electrode implants. But at present benefit is still confined mainly to profoundly deaf subjects who derive no help from hearing aids.[3]

10.4 CONSUMERS OF THE, SERVICES

10.4.1 Hearing news survey results The journal of the Hearing Association asked readers to say what they most needed from the government, from hospital audiology clinics and from the Association itself. The responses (representing 120 replies) are listed below.

Top priority ranking was given to three areas: • while-you-wait hearing aid repair service from audiology clinics • subsidies from government on special listening devices • information from the Hearing Association on hearing aids; how they work; how to get best help from hearing aids,

Close behind in priority were: • appointments to audiology clinics on request without the need for a general practitioner referral • a fund to provide free hearing aids to the needy • information from the Hearing Association on listening devices for, television, and other listening aids • introduction of elocution lessons for school children

Lowest priority was given to: • home visits by tutors • transport to Hearing Association rooms • increased number of lipreading lessons

130 Several readers contributed suggestions: • introduction of a universal sign language. This should be part of the school curriculum to encourage acceptance and understanding of hearing impaired people • government assistance to finance Hearing news so that its content can be expanded and its distribution extended to doctors, teachers, trade unionists and others • employment of more deaf people by the government • louder pedestrian crossing buzzers • reduction of background music on TV • publication of a circular urging doctors, especially ENT specialists, not to disregard slight hearing losses • a publicity campaign to educate those dealing with the' public (in banks, shops, etc, etc.), as to how to communicate with hearing impaired people • from audiology clinics a clear explanation of the results of hearing tests so that the person understands the implications of the hearing loss • from doctors and audiologists: a more caring attitude. A smile" and welcome from the receptiqnists. 10.4.2 A statement from a Hearing Association tutor The following points are made by a Hearing Association tutor who is herself deaf. A complete version of her statement can be found in Appendix lOb: • there is a need for a greater understanding of hearing impairment which requires education of the general public, general practitioners and school-age children • the expansion of audiological services is most welcome but geograph- . icallocation, the 'red tape involved in referral' and the 'clinical set­ ting within a hospital' are still a deterrent for some people, especially the elderly • the practices of some hearing aid dealers are very questionable • the Hearing Association has the structure and personnel to carry out· comprehensive rehabilitation services, but this is currently hampered by administrative and funding arrangements, i.e., the number of 'students' attending Hearing Association weekly group sessions dic­ tates the number of full-time or part-time tutors employed by the Department ofEducation. Such 'students' constitute only about one­ third of a tutor's workload but to maintain roll numbers, and hence her job, the tutor must cut back on work with individuals such as counselling, and helping with hearing aids and special cases • there is a need for closer coordination of all services for the hearing impaired, 'ministering to the total wellbeing of the person not just the hearing loss'. 131 Acknowledgments 10.2, 10.3 Dr Bill Keith, Principal Audiologist, Audiology Centre (for­ merly National Acoustics Centre) .

Notes and references 1 TANAKA, M M.-'The general practitioner and the hearing­ . impaired, [letter]" in NZ Med J.-v 97 no 751 (14 Mar 1984) p 164. 2 Data colleCted for the Hearing Research Project. 3 KEITH, William J.-'Hearing aids: current status and future direc­ tions', in Patient Management.-v 13 no 6 (June 1984) p 87-104.

132 11 SERVICES RELATED 'TO NOISE­ INDUCED HEARING LOSS

11.1 INTRODUCTION Because noise-induced hearing loss is permanent, yet preventable, it 'is vital for it to be recognised as one of the major areas in which preventive medicine and health education can be practised. Deafness prevention at work is one of the priority programmes of the Bureau of Public Health and Environ­ mental Protection of the Department of Health. The progress of the pro­ gramme to date represents a small but significant start in tackling the immense problem of noise-induced hearing loss (NIHL) (see 6.4).' ' To reiterate information presented in section 6.4: • 42-45 percent of the workforce are employed in potentially noisy occupations • an estimated 200,000-400,000 persons in the workforce are at risk for NIHL • an estimated 190,000 persons have hearing loss greater than SOdB at 4kHz which would be notifiable had it been caused by exposure to noise in the workplace. The objectives of the Bureau of Public Health's priority programme are as follows: • the measuring of noise levels in all undertakings in districts where it is expected that noise levels may be above 85dBA • ensuring advice is available to assist in reduction of noise, at source or in isolating noise sources, and that adequate hearing protective devices are available where necessary • the implementation of an adequate hearing conservation education programme • carrying out occupational audiometry where necessary. Responses from health districts give an indication of the progress of the programme during 1983 to 1984[1]:

Target I-each district office is to produce a district plan based on local conditions and in consultation with other organisations. Copies of this plan are to be distributed to all involved by 1 November 1983 , ' . Result-seven out of 18 district offices achieved this by November 1983.

Target 2-district offices are to list all undertakings suspected of having noise levels in excess of 8SdBA by 1 May 1983 Result-sixteen district offices submitted this list by May 1983.

133 Target 3-noise measurements of undertakings listed aboye should be com­ pleted as follows: • 50 percent by 1 September 1983 • 75 percent by 1 March 1984 • 100 percent by 2 September 1984 Result-three district offices had carried out noise measurements in 50 per­ cent of suspected noisy undertakings by the target date. Some districts, such as Auckland, that have a high concentration of noisy undertakings experi­ enced particular difficulty in reaching the target. Thus the 75 percent target has been extended to September 1984. Target 4-procedures for implementing a hearing conservation programme including noise control advice, health education, and occupational audi­ ometry should be completed by 1 July 1983 ­ Result-nine district offices achieved this target by the date set. The health education programme that resulted was supported by a 'noise kit' produced by the Health Education and Information Unit of the Department of Health. From approximate figures submitted by 78 percent of the districts at 8 March 1984 it transpires that the total number of people exposed to the noise kits up to that date was 16,546. Extrapolating from this figure gives an approxi­ mately 1 percent exposure rate over the whole country. Target 5-a third advanced noise measurement and assessment course for inspectors ofhealth is to be arranged by Head Office by 1 July 1983. Result-this course has been run. Target 6-Head Office is to arrange a third advanced hearing conservation course for public health nurses by 1 July 1983 . Result-this course has been run. Target 7-in conjunction with the Audiology Centre, Head Office will arrange eight training courses in audiometry by 31 March 1984. These will be pri­ marily for non-departmental staff Result-nine such courses were run in 1983 in Auckland, Hamilton, Gis­ borne, Palmerston North, Wellington, Christchurch, Dunedin. A total of eight are planned for 1984. ­ Given the estimated number of people exposed to potentially hazardous noise in the workplace (see Tables 6.7 and 6.8) and given that an estimated 38 percent ·of the population have hearing loss of over 25dB at 4kHz (see Table 6.2) it is unlikely that the current allocation of resources and pex:sonnel to the area of occupational deafness prevention will do little more than scratch the surface.

134 11.2 PREVENTIVE SERVICES

11.2.1 Control of noise and recording of noise levels • the law requires that noise be controlled at the source in the first instance; constraiius operating in this area include lack of expertise in the field of noise control by Department of Labour inspectors. However there are expert consultants available to advise industry. Consultants that are available are perceived to be very expensive, both because of their charge-out rate (which can be half that of lawyers or other professionals) and because their recommendations may involve further cost • the Australian Council of Trade Unions (ACTU), and Victorian Trades Hall Council (VTHC) Occupational Health and Safety Unit have put forward the following suggestions for tackling noise at source, to be achieved 'in descending order of priority': 1 designing new plant and equipment in a manner which results in less noise emission 2 substituting noisy plant machinery and tools by equipment that produces less noise 3 proper maintenance of equipment 4 modification of equipment and work processes 5 the control of noise transmission through the use of shields and barriers, sound absorbers, and sound insulating enclo­ sures [2 p57] • the Factories and Commercial Premises Act, which came into force in February 1982, has put the onus for noise control into the hands of management; it is up to managers to arrange this themselves or call in others • Department of Labour inspectors carry out screening noise surveys only to identify possible hazardous situations. If impact noise is pres­ ent, or other difficulties arise, the Department of Health· may be asked to assist; noise levels had been measured in approximately 50 percent of suspected noisy work places in only three health districts by September 1983 (see Target 3 above) • each health district has at least one inspector of health who has com­ pleted an advanced course in noise measurement and assessment. This person has the ability to carry out in-depth studies into noise at work using special equipment, and to report on this in detai1ja constraint in this area is the lack of equipment for all he~lth districts. It is hoped that this problem will be overcome by 1985 when planned spending and orders now being processed become available • regional noise control officers provide expert back-up to inspectors of health

135 • despite the improvements which are beginning to be implemented, cases with noise-induced hearing loss are regularly presenting to general practitioners and ENT specialists from establishments where no monitoring of noise hazard has been carried out. 11.2.2 Hearing protection • the extent to which hearing protection devices are issued and worn in the workforce at large is not known; during the course of surveys carried out in 1983, inspectors estimated that approximately 44 per­ cent of those working in noise levels of over 8SdBA were wearing hearing protection devices[l] . • it is the management's responsibility to provide protective devices for workers in hazard areas; the Department of Health provides infor­ mation on the maximum permissible daily noise exposure for indi­ viduals not wearing personal hearing protection[3] • appropriate hearing protection devices, e.g., ear muffs, are recom­ mended by the Department of Health[4] • if ear plugs are the recommended device, a public health nurse, staff­ ing resources permitting, visits the premises and fits workers in the hazard areas • it can be argued that personal protection,such as ear muffs and plugs, is not an effective long-term noise control option, but rather an interim measure until noise levels are reduced. 'Hearing protectors do not solve the noise problem; they only treat the symptoms of the problem' (US Environmental Protection Agency)[S] • at high noise levels, removing the protectors for a short time can lead to the noise limit for the day being exceeded. For example, in a jet engine room at 117dBA, taking the protectors off for just one minute would give a noise dose in excess of the recommended level of 8SdBA for 8 hours. 11.2.3 Hearing conservation programmes • • the extent and content of hearing conservation programmes run by occupational health personnel in the private sector is not known. There were 414 hearing conservation programmes initiated by the Department of Health in 1983[1] • at least one public health nurse in each health district has received training in hearing conservation programmes and audiometry • there is a risk that industries may use hearing conservation pro­ grammes to over-emphasize the use of personal hearing protectors and give less emphasis to the control of noise at source • making the wearing of hearing protection a condition of employment is unsound for it effectively transfers the onus of responsibility for providing a safe working environment from management to

136 employees. This is not to say that hearing protection should not be worn, but rather that it is only a temporary solution which itself poses problems. However there. will remain tasks where no other option but hearing protection is available, for example panel-beating. 11.2.4 Public education • . most health districts have been involved in education programmes involving public displays, media coverage, field days and approaches . to individual industries • health districts have met requests from schools and colleges for back­ ground material· on hearing conservation • the effectiveness of the Department of Health's hearing education programmes in industry are being evaluated in a .sample of work sites; a report on this topic will be completed in 1985 • . the theme of hearing conservation at work was extended in 1984 with the goal of reaching the homehandyman. A pre-campaign survey has been conducted to determine the level of awareness and knowledge about types of equipment likely to cause damage to hearing, attitudes towards the wearing of hearing protectors at home, and the propor­ tion of respondents already owning hearing protectors; another sur­ vey will be conducted at the conclusion of the campaign to evaluate its effectiveness. 11.3 SCREENING SERVICES The Factories and Commercial Premises Act requires the control of noise and the provision of hearing protection in circumstances where it is not possible to lower the noise levels. Bureau of Public Health priorities are in the areas of noise assessment and hearing conservation, with hearing screen­ ing ranking lower in order of priority. This can be justified, as audiometric screening is not strictly a preventive. strategy. However, its uses are as a long­ term check on the effectiveness of noise control measures, as a means of identifying individuals at risk for hearing loss, and as a tool for educating and monitoring workers to protect their hearing. It will be difficult to carry out a long-term evaluation of the effectiveness of the deafness prevention programme if there are no baseline data to measure improvements against. The current state of screening services is as follows: • . district health offices are required to survey the hearing of employees in government departments and industries; this is a priority in those departments which cannot carry out the. surveys themselves. The extent to which this is carried out is not accurately known • . the Department of Labour has no information on the hearing status of the 24,766 apprentices in training between March 1982 and March 1983. When a group of 60 apprentices aged approximately 17-21 were tested in one health district, 16 percent were found to have a pre-existing hearing loss (Table 6.10) 137 • the extent of pre-employment screening is unknown.Pre-employ­ ment screening, or screening at age IS prior to school leaving, would enable individuals to monitor their hearing status and take appro­ priate action if they choose to do so. Record keeping would need to be more effective, however. After a young person leaves school, there is no use made of hearing status data recorded on school progress cards • the Australian Council of Trade Unions points out that pre-employ­ ment screening can be used to deny employment to those who may have impaired hearing or to those at special risk from developing hearing loss. The Health and Safety Bulletin suggests that pre­ employment screening be replaced by a routine audiometric exam­ ination within the first month of employment[2] • the extent of employment screening is also unknown, but given the small number of" Department of Health personnel involved, for example a ratio of 1:71,000 workforce population in the Wellington health district, it can be assumed that a very small proportion of people working in noisy occupations have their hearing monitored.

Acknowledgments 11.1, 11.2 Dr John Stoke, Mr Lyall Mortimer, Bureau of Public Health and Environmental Protection, Department of Health, Wellington. Ms Diane Reed, Division of Nursing, Department of Health, Wellington. Mrs MabelYarrell, Health Education and Information Unit, Department of Health, Wellington.

Notes and references 1 Information provided by the Bureau of Public Healih and Environ­ mental Protection, Dept of Health, Wellington. 2 Iiealth and safety bulletin : guidelines for the control of noise at work I edited by John Mathews and Nick Calabrese.-Carlton"South, Victoria: ACTU -VTHC Occupational Health and Safety Unit, 1983. 3" Hearing conservation : damage-risk criteria and hearing protection grades for continuous and intermittent noise.-Wellington : Dept of Health, 1982. (Unpublished). " 4 Hearing protection devices: a list of devices approved by the Direc­ tor-General of Health for use by workers exposed to noise.-Wel­ lington : Dept of Health, 1982. (Unpublished). 5 US Environmental Protection Agency.-Noise effects handbook: a desk reference to health and welfare effects of noise.-Springfield, Va. : National Technical Information Service, 1981.

138 12 OTHER ASPECTS OF HEARING SERVICES

12.1 COMMUNITY EDUCATION AND AWARENESS Publicity and education are considered separately because they can be seen as different stages in a learning process. Publicity can be used to disseminate inform'ation, which may then be absorbed as knowledge, which may provide insights, which may bring about some action or change. In other words; it is unlikely that learning or education will take place unless the information can be satisfactorily internalized and practised.

12.1.1 Publicity All forms of the media, for example radio 'spots', television 'commercials', can be used to dispel public ignorance about deafness and hearing impair­ ment. Regular public funding is needed for such programmes which are likely. to be more effective if they are targeted at specific groups. A practical option is for public awareness programmes to be administered by relevant voluntary agencies, with public funding and appropriate help from govern­ ment and other agencies. Known causes of deafness require publicity as part of a preventive pro­ gramme and the Department of Health has already run publicity campaigns in the following areas: • the need for rubella immunisation in women of child-bearing age • the need for medical treatment of ear disease • the potential danger of noise and the need to conserve existing hearing. ' The availability of services for the hearing impaired needs to be publicized, for example hearing aid services and aids for hearing in public buildings such as loop systems in movie theatres. The study of Physical disability recommended: That organisations for the deaf make themselves better known, give more information about the effectiveness of hearing aids, endeavour to reduce the stigma associated with the wearing of aids and inform the public of available facilities.[l p 231]

12.1.2 Education The Physical disability study also r~commended: That there be a public education programme to make better known the problems experienced by deaf persons and the ways in which other people can alleviate these problems.[1 p 231]

139 A practical example of this is the suggestion that when speaking to a hearing impaired person one faces him or her and speaks clearly rather than shouting. Other forms of community education, which may begin with publicity but need to be followed up at a more personal level to be effective, are: • hearing conservation education for children; if such education is left until adulthood it is of!en too late • availability of classes teaching Total CommuniCation to improve communication with the deaf • parent education on the educational and behavioural significance of ear disease • the production and regular updating of a directory of all services for the hearing impaired.

12.2 PROFESSIONAL EDUCATION

12.2.1 Training of professionals (1) Trat'ning of medt'cal professionals: from the point of view of consumers of the services, some of the basic skills required of medical profes­ sionals are: • a deeper understanding of the implications of deafness • the ability to listen and give credence to complaints of.hear­ ing impairment • skills'to communicate with the. deaf • knowledge of support services • provision of inJormatiori; there are many examples where adequate information has not been given or the hearing impaired person has not heard properly, for example a young woman with otosclerosis did not realize the possibility of the disease progressing during pregnancy and she had lost her hearing in both ears by the time her baby was 3 weeks old • an understanding of the importance of rehabilitation for the deaf • counselling skills • an awareness of the educational and behavioural implications of ear disease. Despite recommendations in Deafness the invisible handicap there are still gross inadequacies in undergraduate, postgraduate and nursing training[2]. Three recommendations from Deafness the invisible handicap on the subject of care of the deaf in medical and nursing school curricula were referred to the Committee on Hearing:

140 Recommendation 22 That medical schools include in undergraduate courses more training in the care of the deaf (indeed in the care. of all disabled)

Recommendation 23 That hospital staff be alerted to the communication problems of the hearing impaired and take steps to ensure that deaf people's needs are readily identified

Recommendation 36 . That all trained professionals working with deaf people be made aware during their training period of the importance of total rehabilitation. The Committee on Hearing approached medical schools, technical institute schools of nursing and hospital board schools of nursing and found that teaching in the care of the deaf was far from adequate. A summary of the responses to this survey can be found in Appendix 12a. (2) Training of education professionals: the introduction of Total Com­ munication in the education of the deaf course at Christchurch Teachers' College in 1979 represented a major pedagogical shift and broke the oral-aural monopoly. If consumers are calling for an over­ haul of the deaf education system it is inevitable that more changes will be required. Because of the large numbers of children with mild and fluctuating hearing loss in ordinary schools, classroom teachers will require more training in recognising and coping with hearing impairment. (3) Continuing education for professionals: all professionals working in the fields of otology, audiology, education and rehabilitation of the hear­ ing impaired require ongoing education to keep abreast of the latest developments.

12.2.2 Establishment of an otolaryngology and audiology unit There is no academic and research focus concerned with hearing in New Zealand. Because of its specialist role the Audiology Centre is thrust into an academic leadership role by default, in additiort to carrying out its service role. However, because of the fact that it is part of a government department, it is not always acceptable to the private medical sector. Some research is funded privately by the Deafness Research Foundation. There is a pressing need for art academic base tei provide:

e undergraduate teaching and advanced training in otolaryngology

e training in audiology; this would mean that' audiologists would not need to go to Melbourne for training .

e a research programme, including multidisciplinary research

e, public education and the dissemination of research findings.'

141 12.3 ORGANISATIONAL ASPECTS It is suggested that if the Committee on Hearing breaks into four working parties, consideration be given to the following topic areas:

12.3.1 Goals and priorities

(1) State goal~ first: what are realistic goals for an efficient service in the light of what is now known about the prevalence of that type of hearing impairment? (2) Choose priorities once the goals are set: these will vary according to the type of hearing impairment. (3) Arrange consultation between those providing the services and those receiving them. For example, for the working party on prelingual deafness it would be vital to draw on the skills and expertise of the successful deaf and those hearing people who have grown up in deaf families. Goals and priorities may be modified as a result of such consultation. (4) Arrange consultation amongst professionals providing services, for example, Departments of Health, Education, Social Welfare and Labour. (5) Arrange consultation with voluntary agencies and the private sector.

12.3.2 Distribution of resources (1) The deployment of the workforce and material resources will need to be related back to goals and priorities. The current situation is that: • the workforce providing services is insufficient • the workforce is not distributed according to need and popu­ lation size .• waiting lists are. too long. (2) Accessibility of services: • the two most affected groups,. .children (often of low socio­ economic status) and the elderly, find the services the most inaccessible, for example in South Auckland • there are often transport difficulties for those in rural areas and outlying suburbs, for example travelling from outer Auckland to clinics at the new children's hospital will be expensive and inconvenient. (3) Types of services: consideration will need to be given to the different services appropriate to the type of hearing loss: • prevention • diagnosis/detection

142 • treatment, for example with.O¥E there..is disagreement among the experts over when to intervene and the method of treatment • follow-up servic'es: may help prevent further deterio'ration of hearing. ' , (4) , Knowledge about existing, services and aid{available: the,re is a need for a regularly up-dated directory of services and aids for the hearing impaired. (5) Cost ofservices. 12.3.3 Alternative' patterns or strategies (I) How can the delivery of services be streamlined? The referral system for, those with hearing loss or ear disease has already been described. The system, if envisaged as a channel, is sometimes blocked by general practitioners and severely constricted by ENT and audiology waiting lists. Even the lengths of waiting lists do not give the whole picture as in an area like South Auckland many general practitioners send children out of the area for ENTservices rather than add to the Middlemore hospital waiting list. (2) How can the gaps in service delivery be remedied? Known inadequacies in relation to children are: • .' services for preschoolers • services for children with mild hearing loss • diagnosis and' assessment of multiply-handicapped .children. This has two' facets: services for' deaf children with other handicaps; and hearing and otological' assessment of handi­ capped children ' • services for young deaf adults. (3) How can .communication and coordination between organisations pro­ viding services be improved and overlap avoided? An example of a move in this direction' is coopenition between the Dep~rtments of Health and Education on the fitting of.h~aring aids to, deaf children: ,Traditionally hearing aids have b~enfitted to deaf children in New Zealand by the advisers on deaf children butthe recent developments in audiological services have brought new hear­ ing aid fitting techniques and facilities to, some regions. Ide­ ally a team approach combining the, expertise of the otologist, the adviser on deaf children and the hospital board audiol­ ogist should occur in the audiological management of deaf children. (Circular letter no. hosp 1982/119)' ' The circular letter then goes on to set outdetaiis of how this should occur. Although this is the ideal,' it cto~s not aiways occur in practice. Specific cases of decisions being taken 'without the consultation of all parties invoJved~ and consequent mismanagement of resources, are:

143 Sig, II • audiologists riot consulted about plans for an audiology suite in a hospital • ENT specialists' advice not taken over a brand of ENT equipment purchased by a hospital • access to ABR machine difficult for audiologists because it is housed in the neurophysiology department. There is also a need for closer cooperation between government departments and voluntary agencies providing services for the hearing impaired. Examples where this is occurring are between the Audiology Centre and the Hearing Association and between the Department of Social Welfare and the New Zealand Association of the Deaf. (4) . Can the job structure of professionals delivering the services be improvear This is an extension of the previous discussion in (3). Practical factors which require recognition are: . . • the hierarchical nature of the medical profession, as with other professions, which makes it difficult for 'new' professions like audiology to fit into the structure • the lack of status, recognition and credibility of non-medical people' working in a perceived medical field; vision hearing testers are in an unenviable position • the presence of ambiguous, and sometimes conflicting, role expectations. Examples are the relationship between audiol­ ogists and audiometric technicians; the role of specialist pae­ diatric 'amplification' audiologists; the role of itinerant teachers of the deaf visiting deaf children in ordinary schools; the within-role conflict for advisers on deaf children, i.e., teaching deaf children, advising their parents, fitting and monitoring of hearing aids, working with itinerant teachers of the deaf and advising classroom teachers. (5) What is the ideal balance between the public and private sector? ENT surgeons who work in both sectors .suggest that there is a need for . greater efficiency, better coordination and better support services in public hospitals. Up until recently all audiologists were employed in the public sector, but there are now two private audiologists, one employed by a group of ENT surgeons and the other by the Hearing Association. The public and private fitting of hearing aids is another problematic area. (6) How can information be gathered so that it is useable and useful? The matters of data-gathering and record-keeping may require extensive overhaul. There is no use made of hearing status data recorded on school progress cards once a young person leaves school. The result can be that those who have had a history of ear and hearing problems may enter noisy occupations and experience further hearing

144 deterioration without being aware of the risks involved. The Depart­ ment of Health plans to phase in a health record card for school pupils. In the area of noise-induced hearing loss baseline data are not always gathered, or if collected they are not presented in a useable form, so there is no way of measuring the long term success of an intervention programme, for example a hearing conservation programme. (7) How will changing expectations affect future needs? • it is possible that deaf children will be better educated and therefore require appropriate services at the tertiary education level • there will be a higher proportion of elderly people in the popUlation and more of them will be educated and insist upon better rehabilitative services • more people will become aware of the hazards of noise • there will be a greater demand for technological aids.

12.3.4 Implications It will be necessary to ascertain the implications of these alternative patterns and strategies for: • the coordination of service delivery • professional training and continuing education • public/community education • expenditure.

Notes and references 1 Physical disability : results of a survey in the Wellington Hospital Board area / Avery Jack et al.-Wellington : Management Services and Research Unit, Dept of Health, 1981. (Special report series; no 59) 2 Deafness the invisible handicap: a review of services for persons with hearing disabilities.-Wellington : Advisory Council for the Com­ munity Welfare of Disabled Persons, 1979.

145 , ~J • . C/),c· ..

ic CD E E . ~. a: 13 BACKGROUND

The committee found that in many important respects data on hearing loss in New Zealand were absent, deficient or incomplete. This applies even to such fundamental questions as the number of profoundly deaf people in New Zealand, the age-specific incidence and prevalence rates of otitis media with effusion (OME), the hearing ability of persons entering or leaving the work force, the degree and distribution of hearing impairment in older people, and hearing impairment in a wide range of different groups (differing by race, socio-economic class or occupation) or in different geographical areas or institutions. There are few data available about which people do or do not use health, social welfare, or other services for reasons related to their hearing· impairment. The major reliable sources of data on children have been the two child development studies and the Department of Health deafness notification sta­ tistics, but these are necessarily limited. There are no comparable sources of data for other age groups. For conditions as common as hearing impairment and for disabilities of this level of importance this is a disturbing lack of information. The committee finds it difficult to assign responsibility for these gaps but suggests that the Departments of Health, Social Welfare and Labour, the Accident Compensation Corporation, the universities and the relevant vol­ untary associations must aU bear some of the responsibility. One reason for this has been the lack of a focus at the national level. . Because of the limitations of local data it has been necessary to use infor­ mation from other countries to estimate the New Zealand situation. Had resources permitted, the committee would have liked to have carried out an in-depth evaluation of services rather than simply documenting them. Nonetheless many deficiencies are apparent without the need for extensive research. The committee has been aware that the health aspects of hearing impairment are only one part of the problem. Hearing impairment results in educational, occupational, economic, social and psychological disabilities. These effects have far-reaching consequences extending beyond the scope of the health services and must involve other groups and society as a whole. The committee also came to appreciate the difficulty in considering hearing impairment as a single entity. A series of quite distinct and different events lead to deafness, or various degrees of temporary and permanent hearing impairment, at different ages and in different circumstances and with dif­ ferent consequences. Although these various causes all lead to changes in hearing, their prevention or treatment requires a quite separate appreciation of their different causes. For this reason the committee decided to divide the topic of hearing impairment into four sub-topics. They are:

149 1 Congenital. and pre lingual deafness. 2 Other hearing impairment in childhood. 3, Acquired hearing impairment in adults. 4 Noise~induced hearing loss. . The committee proposed that each sub-topic should be considered individu­ ally,if the committee's work proceeds to a second stage of preparation of detailed recommendations. D.uring its term the. committee considered several urgent policy matters. SpeCific recommendations were ~ade concerning the need for the appoint­ ment of paediatriC audiologists to schools for deaf children and concerning the need for the training of more otologists. Advice was provided to the Department of Health on neonatal hearing screening policy, in particular with respect to the pilot study carried out at Middlemore Hospital, and on the pilot impedance screening programme being carried out on school chil­ dren in selected South Island centres. The committee also highlighted the urgent need for increased social arid interpreter services for prelingually deaf adults. The Department of Social Welfare· is taking action in response to this need. In December- 1983 the committee also presented an interim report to the Minister of Health.

150 14 PRINCIPAL RECOMMENDATIONS

The committee has id~ntified the major areas of concern with' respect to hearing services in New Zealand and general recommendations on these are presehted in this section. The committee considers however that four special­ ist working groups should be established for a time-limited period to study the four previously mentioned sub~topics in greater depth and provide more detailed recommendations. A coordinating committee, which need not meet frequently, should monitor the work of the subcommittees and promote the implementation of their recommendations. The Committee on Hearing has some misgivings about whether a Board of Health Committee is a sufficiently broad forum to deal with a handicap which leads to consequences in inter­ personal and social relationships,' education,' employment and many other respects. The breadth of the problem and its implications complicate the development of policy and its implementation; There is an urgent need for a broad mechanism by which various departments and voluntary. agencies can reach a common appreciation of the needs and can agree upon means to initiate appropriate action. The Committee on Hearing therefore recommends: That four subcommittees be established for a time-limited period to pro­ vide detailed recommendations in the areas of: .' Congenital and prelingual deafness Other hearing impairment in childhood . Acquired hearing impairment in adults Noise-induced hearing loss, and that a coordinating committee be established to monitor the progress of the above groups and to promote the implementation of their recom­ mendations. (Recommendation /) While hearing services can be usefully considered under these headings there are two extremely important themes which are common to all four areas. The first is the inadequate level of public and professional awareness of hear­ ing loss and its effects. The second is the lack of an academic and research department to provide a national focus and leadership in the field of hearing and deafness in New Zealand. 'Both of these points will be considered in turn.

14.1 PUBLIC AND PROFESSIONAL AWARENESS Available services could be better utilised, some of the effects of hearing loss mitigated and the incidence of deafness -reduced, if there was better public and professional awareness of both the effects of deafness and available services. For example, awareness is an important prerequisite for effective occupational hearing coriservation which in turn has the potential to prevent hearing loss in thousands of persons exposed to hazardous noise. Awareness

151 is a major factor in the early detection of prelingual hearing loss. Awareness by professionals of the necessity for careful diagnosis of the cause of pre lin­ gual deafness can prevent incorrect genetic counselling which in turn can affect the incidence of prelingual deafness. Public awareness of the effects of deafness can ease some of the difficulties of the hearing impaired. These are but a few examples of the need for greater community and profes­ sional education to dispel ignorance about deafness. The Committee on Hearing considers that public awareness and education programmes could be run most effectively and economically by voluntary organisations, given financial grants and technical assistance where necessary from appropriate government or other agencies. The committee. therefore recommends:

That financial grants and technical assistance be given to appropriate voluntary organisations to administer multi-media education pro­ grammes to improve public knowledge concerning hearing handicap. (Recommendation 2) Improving professional knowledge and ability is more difficult but it is an essential element in improving services for the hearing impaired. At present there are an excessive number of reports of poor understanding of deafness by professionals and cases in which hearing impaired persons or parents of suspected deaf children are thwarted in their attempts to obtain expert assess- _ ment and treatment. The main target groups for education are general prac­ titioners and nurses but otologists and audiologists also do not always exhibit sufficient understanding of the problems resulting from hearing impairment. In medical school curricula, teaching concerning the effects of deafness is mainly covered within the time allocated to otolaryngology which itself is already inadequately covered. In audiological training there is a basic prob­ lem in that the diploma course on which New Zealand trainees are sent is only one year long. Within the nursing profession there are several different groups requiring differing knowledge and skills. For example, Plunket and public health nurses require skills in deafness detection in infants and in usil1g otoscopes. Occupational health nurses need skills in hearing conser­ vation, audiometry and otoscopy. Practice nurses, hospital nurses and com­ munity health nurses need a broad knowledge of deafness, its effects, and its detection and treatment. As well as the need for improvements in basic professional training there is a need for training to improve the skills of presently practising professionals. Knowledge should be updated regularly through continuing education. In addition some special skills, practised by some nurses and general practi­ tioners, for example, otoscopy and audiometry, might be best maintained by accreditation and subsequent regular review. The committee believes that a concerted effort should be made to improve the basic training and continuing education of medical practitioners in par­ ticular, and to a lesser extent other professionals, in the area of deafness.

152 The committee therefore recommends: That schools ofmedicine, schools of nursing, the Royal College ofGeneral Practitioners, the Division of Nursing of the Depariment of Health and the Plunket Society improve basic and continuing education concerning deafness. (Recommendation 3)

14.2 A NATIONAL ACADEMIC AND RESEARCH FOCUS The committee's investigations have highlighted the fact that there is no university department in New Zealand concerned primarily with hearing and deafness. This lack of a national academic and research focus explains in part the paucity of data on hearing impairment in New Zealand. Otolar­ yngology is taught in New Zealand but without the benefit of a full university department. Audiologists are sent overseas for training. The Deafness Research Foundation employs two researchers within the Pathology Depart­ ment at the University of Auckland School of Medicine. The only other research efforts in the field are carried out part-time and are scattered throughout the country. It is the committee's opinion that the establishment of a multidisciplinary academic and research group within a university is an essential need in New Zealand. The unit should be an independent department with its own chair in a university medical school. The functions of such a department would include the following: 1 Research ranging from descriptive epidemiological studies of hearing loss in the adult population, otitis media and its treatment, and neo­ natal hearing deficits, through to multidisciplinary studies of hearing impairment and its educational, social and occupational consequences. 2 Collation of relevant information from New Zealand and overseas. 3 Teaching for health professionals including otolaryngologists,audiol­ ogists and others concerned with hearing impairment. 4 Public education where that is the principal area of advancement" in any aspect of hearing intervention, such as noise-induced deafness. 5 Maintenance of close connections with other university departments, government departments, the Accident Compensation Corporation, many health and social professions, voluntary agencies and the public. The committee therefore recommends: That an academic department concerned with hearing and deafness be established within a university medical school. (Recommendation 4)

153 IS GENERAL RECOMMENDATIONS

General comments of the committee on the four areas of concern are reported in this section. There are comments on both achievements and deficiencies followed by general recommendations. In most cases the agencies most . responsible are identified. The recommendations are intended as an interim guide both to appropriate agencies as a guide for future policy planning, and to the anticipated new working groups. A few of the recommendations are already receiving attention. However the working groups should be required to prepare' mo're .detailed recommendations and to specify objectives and expected outcomes.

15.1 CONGENITAL AND PRELINGUAL DEAFNESS Description This group includes the congenitally deaf and those acquiring deafness in early childhood such as to prevent the acquisition of normal speech and language. To this group must be added those persons who, after the acqui­ sition of speech and language, become so severely deaf that they require similar social, educational and other support.' . More than one child in every 1000 is born deaf. Of New Zealand children born between 1973 and 1981, approximately 10 percent were deaf as a result of maternal rubella, 40 percent had other known causes, and the cause was unknown in the remainder. The total number of profoundly deaf persons in New Zealand is' unknown but an estimate of over 6000 based on a recent . British study makes them possibly the biggest group in New Zealand with severe communication difficulties.

Deficiencies in services Currently, less than 30 percent of deaf children have their deafness detected within the fust year of life reflecting a poor level of awareness of the need to detect prelirigual deafness early. The cause of deafness is only ascertained in about 50 percent of these children leading to less than adequate treatment and inadequate genetic counselling in many cases. There are too few Depart­ ment of Education advisers on deaf children to provide frequent support to all deaf children and their families. Hearing aid fitting standards for deaf children are not uniformly high and there are no audiologists in New Zealand who are specialists in this area. Education services for the deaf and the levels of literacy achieved by some deaf children are much criticised by some parents and education researchers. Support 'services for deaf school-Ieavers and deaf adults are inadequate. There are too few field officers, there are no fully-trained and accredited inter­ preters, and there are few, if any, specialised counselling and psychiatric

154 services for the deaf. There is increasing, though still insufficient, specialised vocational guidance arid training for the deaf. . The economic cost of deafness is high, both through restriction of career choice and advancement, and because of direct costs for hearing aids and other special technological aids. ,

Recent developments The Departmeht of Health has been active in promoting both early: detection and prevention of deafness with the result that the proportion of deaf chil­ dren detected within the first year of ,life appears to be increasing. There have been some increases in the numbers of field officers and advisers on deaf children and the need for an interpreter service has been recognised by the Department of Social Welfare. There is a growing awareness of the special needs ()f deaf people.

Recommendations CO'fj cern'ing .congenital and prelingualdeafness Thatthe Department of Health continues efforts to prevent deafness where possible and otherwise ensures that it is detected early, that the cause is diagnosed correctly, and that appropriqte genetic counselling is made available to parents of deaf children and to deaf persons. (RecommendationS)

That the Department of Education activates a wider committee to .review the whole area of educational and vocational training services for the deaf. (Recommendation 6) .

. That the Department of Social Welfare urgently implements a system for the training, accreditation and employment of interpreters on a suf­ ficient scale ,to meet .the needs of the deaf population of New Zealand. (Recommendation 7)

That the Department of Social Welfare further increases the provision for field officers for the deaf in order to provide adequate national cov­ erage. (Recommendation 8)

That the Departments of Health, Education and Social Welfare take action to promote the availability of specialised counselling and psychi­ atric services for the deaf. (Recommendation 9)

That the Departments of Health and/or Social Welfare increase the levels of assistance available to deaf and hearing impaired people through sub­ sidieson hearing aids and other appropriate technological devices, and consider indexing these to cost of living increases. (Recommendation 10)

155 15.2 OTHER HEARING IMPAIRMENT IN CHILDHOOD

Description This group is comprised mainly of the many children who suffer temporary or persistent hearing loss due to acute and chronic forms of otitis media. Within this group, otitis media with effusion (OME) is the dominant con­ dition and problem. The total group includes in addition those children with less severe sensorineural hearing disorders, those with hearing losses due to other middle and external ear conditions, and those with central auditory perceptual disabilities. The incidence of otitis media peaks within the first 2 years of life and declines during later childhood. In Ch.ristchurch 68 percent of children in one study attended the general practitioner for otitis media at some time during the first 5 years of life. In Dunedin 17 percent of children were found to have middle ear effusion around their fifth birthdays. In one South Auckland school 37 percent of 5-year-olds failed pure tone. screening audiometry on their better ear. Otitis media incidence is higher among children with certain other handicaps. It is also thought to be higher in Maoris and Pacific Island­ ers in New Zealand. Among the many children who ·experience otitis media at some time are a proportion of otitis-prone children who suffer recurrent acute problems. Otitis media adversely affects speech and language development as well as having deleterious educational and behavioural effects. Deficiencies in services There are many difficulties with the detection and treatment of OME not least of which is the sheer magnitude of the problem. The role of screening is controversial and there are difficulties both with screening methods and in distinguishing between transitory and chronic or recurrent cases. Screen­ ing programmes do not provide adequate coverage of preschool and handi­ capped children. Once detected, children with OME face long waits for consultation and treat­ ment. Available treatments are themselves controversial though myringo­ tomy with insertion of ventilation tubes at 5000 operations per year in New Zealand is one of the most frequently performed surgical procedures. There is a lack of awareness by parents and teachers of partial and inter­ mittent deafness in children in .the home and classroom, and there is a lack of recognition of the deleterious developmental, behavioural and educational effects of OME. Recent developments The incidence of chronic suppurative otitis media has declined. OME inter­ vention studies have been carried out in Dunedin and Auckland, though

156 more research is necessary. The Department of Health has introduced serial testing (retesting of initial failures after 2-3 months) to reduce referrals of transitory cases and is running pilot impedance screening programmes in the South Island.

Recommendations concerning other hearing impairment in children That the Minister ofHealth sets up a group under an independent chair­ person including otologists, audiologists, general practitioners, hospitals boards and Department of Health· representatives to consider ways in which the present waiting time for both consultation and treatment and the present maldistribution of services can be rapidly corrected. (Recommendation 1J)

That the Minister of Health explores methods to reduce the financial barriers to treatment by both general practitioners and specialists for otitis media and its complications. (Recommendation 12)

That the Department of Health completes its field trials of screening programmes and urgently evaluates these. (Recommendation 13)

That the Department of Education institutes programmes for teachers, at both the pre-service and in-service levels, concerning the educational effects of intermittent hearing loss. (Recommendation 14)

That the Department of Health and hospital boards improve staffing and servic(is for the detection of OME in special groups, including pre­ lingually deaf children, children in special schools and classes, children in psychopaedic and similar institutions, and preschool children. (Recommendation 15)

That more research into the prevalence, detection and treatment ofOME in New Zealand be carried out. (Recommendation 16) . . That it be brought to the atteniion of the Maori and Pacific Island com­ munities that their children in particular are educationally and socially at risk as a result of untreated otitis media. (Recommendation 17)

15.3 ACQUIRED HEARING IMPAIRMENT IN ADULTS

Description The term 'acquired hearing impairment' refers lO hearing losses which are not congenital or prelingual in· origin. The major cause of acquired hearing impairment in adults is presbyacusis, i.e., deafness associated with increasing age. The second major cause is exposure to excessive noise. Noise-induced

157 hearing loss is discussed as a separate category. in Section 15.4. Other causes are disease, inju'ry, and ototoxic drugs. Based on overseas estimates, 15 percent of acquired hearing losses in adults are medically or surgically remediable. The other 85 percent of persons are hearing aid candidates. According to overseas figures more than 60 percent of persons aged 65 years and over suffer from hearing loss.

Deficiencies in services A major problem is that the incidence and prevalance of acquired hearing impairment in adults in New Zealand are not known. There are also prob­ lems'with hearing aid services. In many centres there are long waits for access to audiology clinics. Hearing aid fitting standards are often poor. The Wellington study, Physical disability, fourid a 45 percent dissatisfaction with hearing aid fittings. The value of the hearing aid subsidy has been eroded from 100 percent to about one-third of ·the value of hearing aids. Some private hearing aid dispensers charge exceedingly high prices and lack fitting expertise. Many persons' are unaware that alternative services are available through hospitals. Some are aware but have difficulty obtaining access to appropriate services because of the reluctance of general practitioners to refer, or unac­ ceptably long waiting lists. In many centres general practitioners'do not have direct access to hospital audiological'servkes; this is an issue which has yet to be resolved. . . '. Attitudes. of hearing impaired people themselves can compound the prob­ lems. Most sufferers of hearing impairment do not seek treatment as early as they should if they are to avoid many of its adverse effects. Of those who are fitted with hearing aids, many are not made aware of, or do not avail themselves of, rehabilitative services offered by the Hearing Association. The association has not been as effective at assisting younger hearing impaired persons as it has been with the elderly. With all these obstacles the number of hearing impaired persons receiving good hearing aid treatment and follow­ up is probably a minority. There is as yet no cochlear implant programme in New Zealand. Recent dev,elopments . The quality of hearing aids is steadily improving and other amplification and technological aids for the hearing impaired are becoming increasingly avail­ able. There has also been a steady increase in numbers of audiologists trained and employed in recent years though such growth is unlikely to continue with termination of the Department of Health's subsidised training scheme in 1984.,

Recommendations concerning acquired hearing impairment in adults , That the Ministe.r ofHealth sets up a group under an independent chair­ person including representation from otology, audiology, general practice,

158 hospital boards and the Department of Health to consider the question of access by general practitioners to. audio.Io.gical services: This. could be the same gro.up as' that appointed to.. examine the. maldistribution .o.f services: see under reco.mme.ndations concerning .ot~er hearing impair­ ment in children. (Recommendation 18) That the Department of Health, through ho.spital boards, impro.VeS ihe level and distribution of otological and audio.lo.gical services to decrease . unacceptable waiting times. (Recommendation 19); .' . That the Department of Health undertakes regular revisio.n of,the hearing aid subsidy in line with hearing aid Co.St increases. (Recommendation 20) That the Department o.f Health implements the registration ofhearing aid salespersons. (Recommendation 21) , That the Department o.f Health considers the development 'and imple­ mentation o.f a screening programme for hearing lo.SS in adults, including in particular rest-home residents and the elderly in the co.mmunity. (Recommendation 22) ..,', . . .•'" ., ". That the Department of Health encourages the development' 'and implementatio.n o.f a self-testing, hearing screening proc.edure;' (Recommendation 23) , . That a cochlear implant programme be implemented thro.ugh existing agencies. {Recommendation 24). ,

15.4· .NOISE-INDUCED~EARING LOSS Description Noise-induced hearing loss can be caused by a,single exposure to excessive noise or, more commonly, by long-term exposure at work or at leisure. It is permanent but preventable. .,'.,

There is a paucity of descriptive data on the prevalence of noise~induced deafness in New Zealand, but it is estimated that .400,000' New Zealanders may be exposed to excessive noise in their work environment (Table 6.7). Extrapolation from American figures suggests that 190,000 persons in New Zealand may have hearing losses in excess of SO decibels in the high fre­ quencies (Table 6.6) and a Danish study suggests that noise inhe cause of hearing loss in up to 43 percent of older hearing impaired males (Table 6.1). Based on these figures it can be estimated that there are 86,000 persons with noise-induced deafness in New Zealand. If less severe high frequency hear­ ing loss is included, i.e., SO decibels and less, the prevalence may be more than twice this number. 159 Deficiencies in services Abetter description of the problem is urgently required. Available data, e.g., from district health offices, are uncoordinated and of little use on their own. However they do suggest rates of noise-induced hearing loss that should be of major concern, particularly as this is the most easily preventable form of hearing loss. The data' also suggest that hearing screening resources are inadequate and probably reach only a small proportion of exposed persons and school-leavers entering the workforce. The penetration of hearing conservation pro-, grammes into the workforce is also inadequate especially in small and medium sized industries. Lack of awareness of the long-term effects of noise on hear­ ing, and the implications of deafness, remain a major p,roblem.

Recent developments The Departments of Health and Labour accord a high priority to the prob­ lem of noise-induced hearing loss. They are surveying noisy industries, have increased the number of basic hearing conservation courses held annually, have held advanced courses for health inspectors and occupational health nurses, have developed a system of testing and grading hearing protectors, have developed a hearing conservation education kit and made it widely available, and have held public education programmes including television advertising. These are all welcome developments and have undoubtedly helped to improve awareness. The problem is that the level of hearing con­ servation activity is still inadequate.

Recommendations concerning noise-induced hearing loss That the Departments of Health and Labour take steps to make hearing screening mandatory in noisy industries. (Recommendation 25) That the Health Services Research Committee, Departments of Health and Labour and the Accident Compensation Corporation take steps to obtain more accurate information on the prevalence of noise-induced hearing loss in New Zealand and on the numbers of persons exposed to excessive noise in their occupations. (Recommendation 26) That the Departments of Health and Labour and the Accident Com­ pensation Corporation increase existing services for occupational and pre­ employment hearing screening and provision of hearing conservation programmes. (Recommendation 27)

That the adoption ofstronger measures to control hazardous occupational noise at its source be explored by the Department of Labour in consul­ tation with employees and employer organisations and other interested parties. (Recommendation 28)

160 16 COMPLETE LIST OF RECOMMENDATIONS

Summary of principal recommendations X That four subcommittees be established for a time-limited period to provide detailed recommendations in the areas of: Congenital and prelingual deafness Other hearing impairment in childhood Acquired hearing impairment in adults Noise-induced hearing loss, and that a coordinating committee be established to monitor the progress of the above groups and to promote the implementation of their recommen­ dations. (Recommendation 1) If That financial grants and technical assistance be given to appro­ priate voluntary organisations to administer" multi-media education pro­ grammes to improve public knowledge concerning hearing handicap. (Recommendation 2) That schools of medicine, schools of nursing, the Royal College of General 7 Practitioners, the Division of Nursing of the Department of Health and the Plunket Society improve basic and continuing education concerning deaf­ ness. (Recommendation 3) (jl.... That an academic department concerned with hearing and deafness be estab­ £.AJ-lished within a university medical school. (Recommendation 4)

Recommendations concerning congenital and prelingual deafness That the Department of Health continues efforts to prevent deafness where ~~ possible and otherwise ensures that it is detected early, thin the cause is +l"p./ /diagnosed correctly, and that appropriate genetic counselling is made avail­ ;;:::.,. able to parents of deaf children and to deaf persons. (Recommendation 5)

That the Department of Education activates a wider committee to review v the whole area of educational and vocational training services for the deaf. " (Recommendation 6) That the Department of Social Welfare urgently implements a system for ();"..J the training, accreditation and employment of interpreters on a sufficient " scale to meet the needs of the deaf population of New Zealand. ~/ (Recommendation 7)

That the Department of Social Welfare further increases the provision for)" ') field officers for the deaf in order to provide adequate national coverage. ' ~f~;~ecommendation 8) ~;~ 161 That the Departments of Health, Education and Social Welfare take action to promote the availability of specialised counselling and psychiatric services Y for [the deaf. (Recommendation 9),: . That the Departments of Health andlor Social Welfare increase the levels of assistance available to deaf and hearing impaired people through subsidies on hearing' aids and other appropriate technological devices, and consider y indexing these to cost of living increases. (Recommendation 10)

Recommendations concerning othe~ hearing impairment in children That the Minister of Health sets up a group under an independent chair­ . person including otologists, audiologists, general practitioners, hospitals boards ~qand Department of Health representatives to consider ways in which the ~. (AI"', ytY present waiting time for both cons.ultation and treatment and the present ~~ mal distribution of services can be rapidly corrected. (Recommendation 11) "';:aJ r That the Minister of Health explores methods to reduce the financial barriers F to treatment.by both general practitioners and specialists for otitis media and 0/ its complications. (Recommendation 12) . That the Department of Health completes its field trials of screening pro­ -f' grammes and urgently evaluates these. (Recommendatio1J. 13) That t):le Deparimentof Education institutes programmes for teachers, at . ~ both· the pre~service and in-service levels, concerning the educational effects i of intermittent hearing loss. (Recommendation 14) That the Department of Health 'anci hospital boards improve staffing and ~ services for the detection of OME in special groups, induding prelingually deaf children, children in special schools and classes, childrel) in psycho­ paedic and similar institutions, and preschool children. (Recommendation 15) ..{That more research into t~e prevalence, detection and treatment of OME in New Zealand be cat:ried out. (Recommendation 16) ,

/That it be brought to the ittte'ntion of the Maori and PaCific Island com­ munities that their children in particular are educationally and socially at risk aS"a result, of uptreated otitis media. (Recommendation 17) . "",' .'

Recommendations concerning acquired hearing impairment in, adults , . That the Minister of Health sets' up a group under an independent chair­ person including representation from otology, audiology,general practice, hospital boards and the Department of Health to consider the question of access by general practitioners to audiological services. This could be the same group as that appointed, to examine the maldistribution of services: see under recommendations concerning other hearing impairment in children. (Recommendation 18)

162 , That the Department of Health, through hospital boards, improves the level )( and distribution of otological and audiological services to decrease unac­ ceptable waiting times. (Recommendation 19) That the Department of Health undertakes regular revision of the hearing laid subsidy in 'line with hearing aid cost increases. (Recomme~dation 20) ,That the Department of Health implements the registration of hearing aid 'salespersons. (Recommendation 21) That the Department of Health considers the development and implemen­ Itation of a screening programme for hearing loss in adults, including ~ in particular rest-home residents and the elderly in the community. (Recommendation 22) LThat the Department of Health encourages the development and imple­ mentation of a self-testing hearing screening procedure. (Recommendation 23)

/That a cochlear implant programme be implemented through existing agen­ cies. (Recommendation 24)

Recommendations concerning noise-induced hearing loss ! That the Departments of Health and Labour take steps to make hearing screening mandatory in noisy industries. (Recommendation 25) That the Health Services Research Committee, Departments of Health and Labour and the Accident Compensation Corporation take steps to obtain more accurate information on the prevalence of noise-induced hearing loss Yin New Zealand and on the numbers of persons exposed to excessive noise in their occupations. (Recommendation 26)

That the Departments of Health and Lapour and the Accident Compensa­ tion Corporation increase existing services for occupational and pre-employ­ 'I ment hearing screening and provision of hearing conservation programmes. (Recommendation 27) That the adoption of stronger measures to control hazardous occupational foise at its source be explored by the Department of Labour in consultation with employees and employer organisations and other interested parties., (Recommendation 28)

163 UJ Q) .­C,.,) '"'C c: (].) Q... c...

DEAF CHILDREN· AGED 5-15 RECEIVING SPECIAL EDUCA­ TIONAL PROVISION (1982)1 EXPRESSED ASA PERCENTAGE OF TOTAL NEW'ZEALAND SCHOOL-AGE CHILDREN2, BY AGE AND REGION .. Kelston 'catchment' area' van Asch. 'catchment' area" National total Age Total Total Total (J982J­ popn. % Deaf popn. % Deaf popn. % Deaf

·5 ...... 25 589 0.16 27439 0;14 53 028 0.15 6 ...... 26 102 0.16 26600 0.24 52 702 0.20 7...... ;...... 27 502 0.28 28 180 0.23 ,5.5 682 0.26 8 ...... :... :: 28623 Oj7 30 127 0.22 "58' 750 0.25 9 ...... 29921 0.28 30 508 0.25 60429 0.26 10 ...... 30 267 .0.23 33 f55 0.25. 63 422 0.24 11 ...... 28964 0.31 34707 0.26 63 671 0.28 12 ...... 28409 (U7 33485 0.31 61 894 0.34 . 13 ...... is 821 '0.2:8 32 693 0.30 61 514 . 0.29 14 ...... 28677 0.,34 31 551 0,?6 60 228 0.30 15 ...... 25 831 0.35 28642 0;28 54473 0.31

TOTAL ... 308 706 0.28 358 866 0.2~ 645 793 0.26

1 Figures obtained from the principals of the two schools for the deaf. 2 Figures as at July 1, 1982, obtained from Statistics Division, Department of Education. 3 Northern Region Education District and Gisborne Education Office. 4 Southern and Central Regions, excluding Gisborne Education Office.

167 Appendix Sa

NEW AND REPEAT EPISODES OF OTITIS MEDIA: longitudinal data* What is the probability of getting OM in a given year when no OM was experienced in the immediately preceding year? This can be called the 'new case' rate. Such probabilities may be estimated by the percentages of chi.1dren in the disease free category who move into the OM category in the following year. The 'new case' rate can be seen in Figure' 1, expressed as a dotted line. Repeat attack rates are also shown in Figure 1.

FIGURE 1 NEW CASE RATE AND REPEAT ATTACK RATE OF OM Age

0-1 1-2 2-3 3-4 4-5 % % % % %

Disease free '. E1 El...... • '. E1 ...... " '. 27...... 19 1~ '~' .. 'Current' OM [!2] ·E~ 0 ... '.... ' ...... '", ...... 47 37 39 38 ''II. " " 'Recurrent' OM -X-47-:B-x-46-X~Q-X-45'X~@

ALL OM CASES...... 23 32 26 25 25 ...... 'new case' rate ••••••• 'repeat' attack .rate ·x-x·x· 'repeat·repeat' attack fate

It can be seen that the 'new case' rate remains steady at about 19 percent. It is worth pointing out that by the third year of life some children may be disease free in a given year, but may have had OM ip an earlier year of life. Using the same procedure as for presenting 'new case' rates, the attack rate for those children who did experience some OM in a given year· can be calculated. Given the distinction between the 'current' and 'recurrent' cate­

168 gories it is possible to further refine the repeat attack rate into a purely 'repeat' attack rate (shown as ------in Figure 1) and a 'repeat-repeat' attack rate (shown as -x-x-x- in Figure 1). It can be seen that the attack rate for the 'current' OM group is consistently lower than that for the 'recurrent' OM group. If this distinction is ignored then an overall consecutive year repeat attack rate of 40 percent is obtained, ie roughly twice that of the 'new case' rate. This gives further evidence for the concept of 'otitis proneness' and suggests that there is a hard core of children who experience OM during many of their early years of life. * This section was prepared by Lucy Carpenter, Hearing Research Project statistician, from data pro­ vided by David Fergusson, Christchurch Child Development Study.

169 Appendix Sb

HEARING TESTING AT TWO SCHOOLS FOR THE INTELLEC­ TUALLY HANDICAPPED: report from a district health office In this health district the testing of intellectually handicapped children has only been carried out spasmodically, usually at the request of teachers through the public health nurses. Although vision hearing testers have not been trained to test these children, most intellectually handicapped children respond very well to the methods used in the testing of preschool children, unless they are particularly severely handicapped. It was considered that more emphasis should be made on having hearing assessments carried out at all handicapped children's centres in our area, preferably with a medical officer present. This year hearing clinics were held at two primary schools for the intellectually handicapped. Ages of the chil­ dren ranged from 5 to 14 years. The parents of these children were invited to be present and many expressed their thanks for the opportunity. It is desirable for parents to attend these clinics so that the nature of the problem, and the need for subsequent supervision, can be explained. The following assessment techniques were used: • audiometry: pure tone testing carried out by the vision hearing tester • otoscopy and tympanometry: carried out by the medical officer present. I t is necessary for a pure tone test to be done on each child at these clinics to help with the identification of the hearing loss and also to pick up any sensorineural deafness which is not found with tympanometry a~one. Quite a number of the children tested at School A appeared fearful, but at the smaller School B all, except the very young ones, were confident and eager to be tested. Most Down's Syndrome children were found to have some middle ear problem. ALL children who passed audiometry, also passed tympanometry: Results of testing:

TYMPANOMETRY

Number Uncooperative IHC school tested Pass Fail

n % n % n % n % School A ...... 41 31 8 2 School B ...... 13 5 8 TOTAL...... 54 100.0 36 66.7 16 29.6 2 3.7

170 AUDIOMETRY

Number Uncooperative IHC school tested Pass Fail

n % n %' n .,% n % School A...... 41 20 7 14* School B ...... 13 2 7 4**

TOTAL...... 54 100.0 22 40.7 14 25.9 . 18' 33.3

* Of the 14 uncooperative for audiometry at School A, three failed tympanometry and two were uncoop­ erative for tympanometry. It should not be overlooked that although nine pupils passed tympanometry, they could still have a sensorineural hearing loss. A. pass in tympanometry means that the middle ear is functioning normally. ** The four pupils who were unable to be tested with audiometry at School B were 5 to 6-year-olds and unable to respond accurately; two failed tympanometry and two passed tympanometry. Otoscopy and tympanometry findings were referred on to the child's general practitioner by the medical officer. All pupils who failed the test are to be retested at the next cliniC. . Note: in a second testing session at School B, of the 11 children tested, seven failed tympanometry and 10 failed audiometry.

171 Appendix 6a

PREVALENCE OF HEARING DEFECTS IN THE ADULT BRITISH POPULATION IN THE BETTER (BE) AND WORSE (WE) HEARING EAR, BY AGE GROUP, EXPRESSED AS RATE PER 1000

All hearing Age group in years Sensorineural' Conductive' Mixed' loss 15-30 BE 5 20 10 35 WE 10 120 130 31-50 BE 40 90 130 WE 90 170 20 280 51-70 BE 170 60 30 260 WE 230 120 80 430 70+ BE 620 90 710 . WE 560 30 150 740 ALL AGES BE 110 60 20 190 WE 140 130 50 320

I Sensorineural mean air conduction at 0.5, I, 2 and 4 kHz greater than or equal to 25 dB; no conductive defect present. 2 Conductive = mean air-bone gap greater than IS dB at 0.5, 1, 2 kHz. 3 Mixed = as for 'conductive' with mean bone conduction greater than or equal to 20 dB. (after Browning and Davis 1983)

172 Appendix 6b

NEW ZEALAND FULL-TIME WORKFORCE BY TYPE OF OCCU­ PATION,* NUMBER IN POTENTIALLY NOISY OCCUPATIONS

Type of occupation Total number of persons

Potentially high noise levels Agriculture, forestry, fishing ...... ".. "." .. ".,"""""", .. ,.... ,... ". 146 295 Production, transport, labouring ...... ".. ""."."" ...... ""."",, .. ,,",," 457 935 SUBTOTAL,,,,,,,, ...,,,,.,,.,,..,,,, .. ,,.,,.,,",,... ,,,,... ,,,,...... ,,.,,.,,...... ".," .....". 604230 Potentially lower noise levels Professional, technical ...... ,...... ,.. ,...... ,...... ,...... ,..... ,...... ,...... 183 966 Administrative, managerial ...... ""."...... ,...... ""."". 45,993 Clerical and related ...... ".""..."",,...... c...... 214 761 Sales...... "...... ".. 127 101 Service ..c.· ...... · ...... ·•·•··•·...... 106629 New workers seeking work .."...... ".....".. "...... "...... 8 559 Inadequately described .. ,...... ,...... "....."...... :...... 9 213 Not reporting any occupation "." .. "." .....".."...... 31 890 SUBTOTAL...... :...... ;...... 728 112

TOTAL """"""""""""""""""""""""""" ...... 1 332 342

* New Zealand census 0/ population and dwellings 1981. Bulletin 11. National Summary p 32 Note: 45 percent of the full-time workforce are in potentially noisy occupations.

173 Appendix 7a

NUMBER OF ENT SPECIA~ISTS BY LOCATION, HOSPITAL BOARD AREAS IN REGIONAL GROUPINGS; 1982-1984, ACTUAU AND REQUIRED; .

No 0/ ENT specialists (persons) No required (FTE) Hospital Board 1982 . 1983 1984 1/1:50,000 1/1:35,000

Northland ...... :...... c...... 1 1 2 . 2.3 3.3 Auckland ...... :...... 16 19 14 16.6 ' 23.7 Thames ...... 0.7 . .1.0

Subtotal ...... 17 20 16 19.6 28.0

Tauranga...... 1 1 1.5 2.1 Bay of Plenty ...... 0.9 1.3 Waikato ...... 5 5 4 6.5 9.4 Taumarunui......

Subtotal ...... 6 6 5 .9.2* 13.2*

Cook...... 1 1 1 0.8 1.2 Hawke's Bay ...... 2 2 2 2.5 3.6 Waiapu...... ~...... Dannevirke ...... Palmerston North ...... 3 3 2 2.6 3.7 Wanganui...... 1 . 1 1.5 2.1 Taranaki ...... ~ ...... ~ ...... 2 2 2 2.0 2.8

Subtotal ...... 9 9 7 10.0* 14.3*

Wairarapa...... 0.9 1.3 Wellington...... 4 4 3 6.8 9.7 Nelson...... 1 1 1 1.3 1.9 Marlborough ......

Subtotal ...... 5 5 4 9.7* 13.8* West Coast ...... North Canterbury ...... 5 5 5 6.8 9.8 Ashburton ...... South Canterbury ...... 1 1 1.2 1.7

Subtotal ...... 6 .6 6 9.2* 13.2*

174 No of ENT specialists (persons) No required (FTE) Hospital Board 1982 1983 1984 If 1:50,000 If 1:35,000 Waitaki...... Maniototo...... Otago ...... 3 2 2 2.5 3.5 Vincent...... South Otago ...... Southland...... 1 1 1 2.3 3.3 Subtotal ...... 4 3 3 5.8* 8.3*

TOTAL ...... 47 49 41 63.5 90.8

1982 data are from New Zealand medical manpower statistics 1981 and 1982. Data supplement, Man­ agement Services and Research Unit, Department of Health, Wellington 1983. 1983 data are from New Zealand medical manpower sraristics 1983. Blue book no 21. 1984 data were provided by Mr R Goodey, ENT specialist. * The subtotals add up to more than their component parts. This is because boards serving· areas with a population of less than 35,000 have not been allocated an otolaryngologist FTE, for purposes of this table, but the population served by these smaller boards is still included in the regional subtotals. Note: (a) The above table does not take teaching and research into account. Additional ENT specialists would be required to fulfil these obligations adequately. . (b) The table does not show the inequitable distribution of ENT specialists within the Auckland Hospital Board. Although Greenlane, Auckland and Middlemore hospitals serve a population of approximately 300,000 each, in 1983 Middlemore hospital was allocated only 0.9 full-time equivalent ENT specialists. Because the delay between referral alld surgery at Middlemore can be up to 3 years, many general practition'ers in South Auckland refer children to other areas. NUMBER OF ENT REGISTRARS BY HOSPITAL BOARD AREA 1982­ 1984 1982 1983 1984 Auckland ...... 6 3 5 Waikato ...... 1 1 Palmerston North...... 1 Wellington ...... 1 1 2 North Canterbury...... 2 2 2 Otago...... 2 2 '2 All others ...... 1

TOTAL...... 11* 11** 12

* 9 out of 11 were New Zealand graduates: ** 10 out of 11 were New Zealand graduates. 1982 and 1983 data are taken from New Zealand medical manpower statistics, Management Services. and Research Unit. . 1984 data are provided by Mr R Goodey, ENT specialist.

Sig. 13 Appendix 7b

NUMBER OF AUDIOLOGISTS BY LOCATION, HOSPITAL BOARD AREAS WITHIN REGIONAL GROUPINGS, MARCH 1984, ACTUAU AND REQUIRED

No 01 practising Population served audiologists No required (FTE) Hospital board by region (FTE) If 1:50,000

Northland ...... 1 . 2.3 Auckland ...... 5.4. 16.6 Thames ...... "." .....,.... 0.7 Subtotal...... 979 329 6.4 19.6 Tauranga...... 1 1.5 Bay of Plenty ...... 0.9 Waikato...... 2 6.5 Taumarunui...... Subtotal...... ::.. 461 049 3.0 9.2*

Cook...... 0.8 Hawke's Bay ...... 1 2.5 Waiapu...... : Waipawa ...... Dannevirke ...... Palmerston North ...... 2.5 2.6 Wanganui ...... 1.5 Taranaki ...... 2 . 2.0 Subtotal...... 499 296 5.5 10.0* Wairarapa...... ,...... , 0.9 Wellington...... 3.5 6.8 Nelson...... 1 1.3 Marlborough ......

Subtotal...... 483687 4.5 9.7 West Coast ...... North Canterbury ...... 4 6.8 Ashburton ...... South Canterbury ...... 1 1.2

Subtotal...... ~ ...... 460 530 5.0 ·9.2*

176 No 01 practising Population served audiologists ' No required (FTE) Hospital board by region (FTE) if 1:50,000 Waitaki...... Maniototo...... Otago ...... 2 2.5 Vincent...... South Otago...... Southland...... 2.3

Subtotal...... 291 852 2 5.8* National Acoustics Centre ...... 8

TOTAL...... 34.4 63.5

Data provided by Dr W Keith, Principal Audiologist, Audiology Centre. * The subtotals add up to more than their component parts. This is because boards serving areas with a population of less than 35,000 have not been allocated an audiologist FTE, for purposes of this table, but the population served' b¥ these smaller boards is still included in the regional subtotals: Note: Four audiologists were being trained under the Department of Health training scheme. .

177 Appendix 7c ESTIMATED POPULATION SERVED BY VISION HEARING TEST­ ERS, DECEMBER 1983

No of children per VH lesler (rouline No of VH firsl Eslimaled populalion 10 be screened, leslers screenings Heallh dislriC! by heallh dislricl, 1983 (FTE)' only)'

Age 31 Age 52 Age IP Total Whangarei ...... 1 851 1 815 2 461 6 127 3 2 042 Takapuna ...... 4 295 4 228 5 734 14 257 3.5 4073 Auckland ...... 4043 4 225 3 987 12 255 2** 6 127 South Auckland ...... 4 794 4 555 5 967 15 316 4** 3 829 Hamilton ...... ;..... 4760 4611 5 835 15 506 4** 3 876 Rotorua...... 3 452 3527 4 159 11 138 2.2** 5 062 Gisborne ...... 1 219 1 152 1 388 3 759 2 1 879 Napier...... 2 059 2 085 2 621 6765 2* 3 382 New Plymouth ...... 1 574 1 721 1 970 5 265 1.5* 3 510 Wanganui...... 1 560 1 514 1 736 4810 1.5* 3 206 Palmerston North .... 2 331 2 359 2 786 7476 2 3 738 Lower Hutt ...... 3 149 3 103 3 714 9966 4 2 491 Wellington...... 3 041 3 052 3 199 9292 4* 2 323 Nelson...... 1 845 1 916 2 545 6306 2.29 2 753 Christch urch ...... 4643 4864 6 105 15 612 5.5 2 838 Timaru ...... 1 582 1 634 2 080 5 296 1 5 296 Dunedin...... 2 270 2 243 2674 7 187 4.5+ 1 597 Invercargill...... :..... 2 003 2 038 2 206 6 247 2.5 2 498 TOTAL ...... 50471 50942 61 167 162 580 51.49 3 157

Estimated population of 3-year-olds is derived from number of live births in 1980 (Table 2 p 10 Fetal and infant dealhs 1980, National Health Statistics Centre). 2 Estimated population of 5-year-olds is derived from number of live births in 1978 (Table 6a p 24 Fetal and infanl deaths 1978, NHSC). 3 Information on 1972 births was not available grouped by health district so an estimate was derived from 1981 Census data by taking one-fifth of the 10-14 age group (total = 61,167). This provides a conservative estimate of the number of l-year-olds as there were 63,215 live births in 1972 (see p 10 Monthly abslracl of slalistics, NO'llember-December 1980). 4 Data provided by Division of Health Promotion, Department of Health. 5 This column gives estimated numbers per VH tester of preschoolers, new entrants and Form I pupils requiring routine screenings only. Additional demands on VH testers include requests for testing, follow-up testing, serial testing where it has been introduced,' screening of children in special classes and special schools, and in some cases, occupational audiometry. * An additional 0.5 FTE vision hearing tester will be employed as from the end of 1984. ** An additional 1 FTE vision hearing tester will be employed as from the end of 1984. + 0.5 FTE of the Dunedin allocation is a research commitment and the tester is not available for routine testing. 178 Appendix 7d

ADMISSIONS TO PUBLIC HOSPITALS FOR DISEASES OF THE EAR AND MASTOID PROCESS, 1982, BY RACE AND AGE GROUP

Age group 0-14 15-64 Total (all ages)

NZ Maori l No. admitted ...... 1 136 288 1 424 Popn. In. t h'IS age groupZ' ...... 111 654 161 094 272 789 0/0 of popn...... 1.01 0.17 0.52 Pacific Island l No. admitted ...... ,...... 294 46 340 Popn. in this age groupZ ...... 36 837 51 456 88 293 0/0 of popn ...... 0.79 0.09 0.38 Other l No. admitted ...... 2 570 1 161 3 731 Popn. in this age group2 ...... 700062 1 798 464 2 498 526 0/0 of popn...... :...... 0.36 0.06 0.15

TOTAL (all races) No. admitted' ...... ,...... 4000 1 495 5 495 3 Popn. in this age group2 ...... 848 553 2011 014 2 859 567 0/0 of popn ...... 0.47 0.07 0.19

I Data from Hospital and selected morbidity data, 1982, National Health Statistics Centre. 2 Data from 1981 Census, by hospital board district. 3 An additional 249 patients 65 years,and over were admitted, giving a total of 5744. They have been excluded from this table as no breakdown by race was provided,

179 Appendix 7e

ALL EAR OPERATIONS CARRIED OUT IN PUBLIC AND PRIVATE HOSPITALS, 1982

Public Privale Type of operation hospital hospital Total

Incision of external ear ...... 54 6 60 Excision/destruction lesion, external ear ...... 328 146 474 Other excision of external ear ...... 15 15 Suture of external ear...... 40 4 44 Correction of prominent ear ...... 126 120 246 Reconstruction of external auditory canal ...... 38 11 49 Other repair of external ear ...... 35 20 S5 Other operations on external ear ...... 16 1 17 Stapes mobilization ...... 3 6 9 Stapedectomy ...... 204 129 333 Revision of stapedectomy ...... 36 5. 41 Other operations on ossicular chain ...... 46 8 54 Myringoplasty...... 908 248 1 156 Other tympanoplasty ...... 43 8 51 Revision of tympanoplasty ...... 17 17 Other repair of middle ear ...... 17 1 18 Myringotomy ...... :...... 2 812 3 171 5 983 Removal of tympanostomy tube ...... 49 42 9 Incision of mastoid and middle ear ...... 54 15 69 Mastoidectomy...... 171 29 200 Other excision of middle ear ...... 146 9 155 Incision and destruction, inner ear ...... 12 7 19 Other operations, middle and mner ear ...... 37 87 124 Fenestration of inner ear ...... 1 1

TOTAL ...... 5 207 4074 9 281

Data from Hospital and selected morbidity data, 1982, National Health Statistics Centre

180 ·Appendix 7f WAITING LISTS FOR ENT SURGERY AS AT 31 MARCH 1982

Hospital board 1980 /98/ 1982

Northland ...... 281 221 213 Auckland ...... 2 367 2666 2456 Thames ...... :.. . 34 . 54 21 Waikato ...... 1 405 1 537 1 580 Tauranga...... 195 163 196 Bay of Plenty ...... 14 53 69 Waiapu ...... 5 Cook...... :...... 44 68 49 Hawkes Bay...... ·...... 689 721 667 Waipawa ...... 3 5 4 Dannevirke ...... 6 20 7 Taumarunui...... 11 14 5 Taranaki ...... 368 212 249 Wanganui...... 182 l32 129 Palmerston North ...... 430 501 626 Wellington...... 749 751 674 Wairarapa...... 70 76 21 Marlborough ...... 11 8 3 Nelson ...... 38 64 243 West Coast ...... 6 9 North Canterbury ...... 802 693 603 Ashburton...... South Canterbury...... 205 218 209 WaitakL...... Maniototo ...... ,' ...... Otago ...... 115 225 278 South Otago...... 3 1 6 Southland ...... S5 70 104 TOTAL ...... 8083 8482 8417

Data from Hospital management data: year ended 3/ March 1982, National Health Statistics Centre

181 Appendix 7g

PUBLIC/PRIVATE WORKING TIME OF ENT SPECIALISTS

Persons involved Full-time equivalent Activity 1982 1983 1982 1983 Private specialist practice ...... 45 45 22.9 22.7 Public. hospital (non·administrative) ...... 43 45 19.4 ·21.6 Teaching...... 15 16 1.9 2.0 Research...... 5 5 0.5 0.5 Primary medical care/general practice ...... 2 1 0.4 0.1 Administration ...... 2 2 0.4 0.4 TOTAL ...... :...... 47 49 45.5 47.2

Data from New Zealand medical manPower statistics, Management Services and Research Unit

182 Appendix 7h

NOTIFICATIONS OF OCCUPATIONAL DEAFNESS TO THE DEPARTMENT OF HEALTH*

Number 0/ Year notified cases

1978...... 143 1979...... 385 1980...... 174 1981 ...... 348 1982...... 347' 1983 ...... 679 ()' * Data from Department of Health annual reports and the Occupational Health section of the Bureau of Public Health and Environmental Protection, Department of Health.

183 Appendix 7j

NUMBER OF OCCUPATIONAL HEARING LOSS CASES COMPEN­ SATED BY THE ACCIDENT COMPENSATION COMMISSION, BY REGION

Year Region 1980 1981 1982 1983 Total Northland-Auckland...... 64 73 97 148 382 Waikato...... 22 13, 49 85 169 Bay of Plenty ...... 5 10 13 30 58 Hawke's Bay-Poverty Bay ...... 17 16 10 10 53 Taranaki-Wanganui- Manawatu ...... 15 15 20 12 62 Wellington-Wairarapa- N elson-Marlborough- Westland ...... 54 50 108 182 394 Canterbury ...... 180 244 289 358 1 071 Otago ...... 41 39 68 28 176 Southland...... 3 2 7 3 15 Other...... 10 6 26 6 48 TOTAL ...... 411 468 687 862 2 428

184 Appendix 8a FORM FOR NOTIFICATION OF DEAF PERSONS

H627

IMPORTANT ­ CONSENT IlEQUIRED rOR COMPLETION BY ADVISERS ON DEAl' CHILDREIN AND AUDIOIIXISTS. SEE OVllR See reverse side before answering questions 7, 8, 9 and JO. NOTIFICATION OF DEAF PERSONS

under 18 years, wi.th congenital hearing losses and any hearing losses arising before the age of 5 years which are not remedi.able by medJ.cal or surgi.cal means .. and wh:i.ch requJ.re heari.ng aids and/or special educational .intervention.

unilateral' deafness and losses under 30 dB should not be notJ.tied.

This does not imply tbat such deafness maV not requi.re II hearlng aid or cause educati.onal difficult.ies.

16 11 1 Family name of person I I I 1 I 'lr Reg No 2 First given name

3 Other given names

4 Person I a present address

Day Hth Yr 2 5 Date of birth I 27 6 Hospital of birth <~ 7 Probable cause of deafness :if known ! •

31 S Any other serious problems/handicaps? 1 Hth Yr 32 9 When was deafness first suspected? 1 ! Month • Year 36

sy wbom. 1 37 First confirmed? 1 -.th Year 411 By whom:

State the main factors that accelerated and/or retarded speed of confirmation;

10 Hearing loss (four frequency average) JO-S5dB 56-S5dB 86+dB III 1 I I Tick appropriate box 1.1 I I I 42i Best ear averaqe loss

11 Is a hearing aid (aids) necessary, Yes No For NAC use only 12 Name of otol09iat or paediatrician from whom further diagnostic ~nformatJ.on may be aVA,llable I

Name of person completing form Signature ______Address Date ______

Thank. !IOU for completing this form. Even if some information is missing send thi.s foem now to: The principal Aud.iologist, National Acoustics Centre, 98 Remuera Road, AUCKLAND.

185 CHOOSE YOUR ANSWERS FROM THE CATEGORIES BELOW: QUestion Number 7 Probable oause of deafness if known Code Cause 1 Family history of deafness from birth 2 Rubella or contact with rubella during pregnancy 3 Other congenital infection (such as cytomegalovirus, herpes, toxoplasmosis) 4 Birth weight less than 1500 grams 5 Malformation of the otolaryngeal system (ear, nose, throat, lip, palate, etc) 6 Hyperbilirubinaemia (jaundice) 7 Severe asphyxia at birth 8 Meningitis 9 Other - please specify. Include ototoxio drugs or severe neonatal sepsis here 10 Unknown 8 Any other serious problems/handioaps? Code Problem/Handicap 1 Intellectual handicap 2 Blindness 3 Cerebral palsy 4 Heart defeot 5 Multiple handioap (specify) 6 Other (specify) 7 Do not know 9 First suspected and confirmed, by whom? Code Person suspecting and confirming deafness (two entries required) 1 Parent 2 Paediatrioian 3 General practitioner 4 Plunket nurse 5 Public health nurse 6 Otologist 7 Audiologist 8 Other (state) 9 Unknown 10 Use the average of thresholds for 500 Hz, 1 KHz, 2 KHz, 4 KHz. Code Best ear loss level 1 30-55 dB 2 56-85 dB 3 86+ dB Hospital of birth to be coded using NHSC Code List A NOTE FOR PARENTS AND GUARDIANS 1 The information collected here is of great value in planning services for ohildren with hearing disabilities, and improving our knowledge of causes and prevention. Confidentiality will be observed and the name of your son/daughter will not be used.

I consent to this Eorm being completed~and sent to the Department of Health for the use stated. Signature ______Date ______

2 Do you wish your name to go to the Federation Eor Deaf Children so that you can be offered support and guidance? Signature ______Yes/NO ~

186 Appendix 8b

TYPES OF ASSISTANCE RECEIVED BY HEARING IMPAIRED STUDENTS ON THE ROLLS OF ADVISERS ON DEAF CHILDREN*, AS AT 31 MARCH 1984**

Central! Type of assistance Southern Northern NZ total

Adviser ...... ,...... 868 1 002 1 870 Speech therapist ...... 165 210 375 Resource teacher ...... 296 145 441 Supplementary teaching ...... 28 69 97 Teacher aide ...... :...... 49 42 91 Remedial teacher ...... 19 27 46 Audiological...... :...... 467 145 612 Special education ...... 73 120 193 Tutor hours ...... 25 59 84 . Hearing aids: Ear level aid ...... 712 804 1 516 Body aid ...... ~...... ;...... 16 49 65 ·FM ...... ,..... ,...... , 141 85 226 .. * Excludes children enrolled at Kelston Schoo! for the Deaf and van Asch College and associated . resource classes/units, *'" Information provided by the principals of the schools for the d.eaf. Appendix 8c

A SURVEY OF SERVICES PROVIDED BY THE WELLINGTON FIELD OFFICE FOR THE DEAF, OVER THE PERIOD OF ONE MONTH: a report to the Wellington Field Office . This survey was undertaken as part of a wider survey of services for the hearing impaired in the Wellington area. It transpired that the month ran­ domly chosen for collecting data was atypical as the Field Officer was over­ seas for three of the four weeks. However, the office was kept going by her assistant. The Field Officer was asked to include all visits from June 1-30 inclusive, including consultations by hearing people requiring information. Where more than one visit per client occured during the month, that was noted.

TABLE 1 CLIENTS SEEN BY THE WELLINGTON FIELD OFFICE FOR THE DEAF JUNE 1983

Type 0/ client Number

New deaf client ...... :...... 2 Return visits from deaf clients ...... 56 Visits to do with Field office or NZAD administrative matters ...... 23 Visitors and those seeking information ...... 21

TOTAL ...... 102

Biographical details of deaf clients are set out in Table 2. This information is for the number of deaf clients (n = 22) for the month, rather than the number of visits made.

TABLE 2 BIOGRAPHICAL CHARACTERISTICS OF DEAF CLIENTS (n = 22)

Characteristics Number.

Age in years ...... 15-30 12 31-45 8 46-64 2 Sex...... :...... female 11 male 11 Race ...... European l3 Maori 9 Hearing loss ...... severe 12 profound 10

188 Table 3 lists the location of the consultation with the Field Officer or assistant. TABLE 3 PLACE OF CONSULTATION WITH CLIENT

Place Number

Field office...... 88 Home of client...... 4 Social services...... '3 General practitioner ...... 2 Work...... :...... 2 Hospital...... 1 School...... 1 Prison ...... 1 TOTAL...... 103*

* One client was seen in two places. Reasons for the visit or consultation are given in Table 4. TABLE 4 REASONS FOR VISIT

Reason Number 0/ consullations

Practical assistance ...... 20 Seeking information ...... 19 Employment problems...... 18 Interpreting' service ...... 5 Personal and interpersonal problems ...... 5 Field office administration...... 23 Miscellaneous ...... 10

TOTAL...... 105*

* Three clients consulted for more than one reason. 'Practical assistance' involved such tasks as letter writing, filling in forms, explanation of documents, preparation for appointments and finding accommodation. Of a total of 105 consu'ltations or requests, 99 were dealt with by the Field Officer or her assistant and six were referred to another agency, usually the Department of Social Welfare. Summary 1 There ~ppears to be a core of regular clients who visit the Wellington Field Office several times a month. 2 More than half of the clients are between 15 and 30 years of age.

189 3 There is a very high proportion of Maori clients. 4 As well as giving immediate practical assistance and advice to deaf clients and helping them with employment problems, a considerable amount of the Field Officer's and her assistant's time is spent on field office administration and answering requests for information. Note: There are three field offices (Auckland, Wellington and Christchurch) run by four field officers and three. assistants to hnswer some of the needs of New Zealand's adult deaf population. Acknowledgments: I would like to thank Pat Dugdale and Dorothy Szarecki for completing the survey and Winifred Lamb for collating the data.

Kathleen Boswell Research Investigator Hearing Research Project Department of Community Health Wellington Clinical School

190 Appendix 8d OBTAINING NEW HEARING AIDS AND OTHER TECHNOLOGI­ CAL AIDS TO HEARING: a case history of a disadv'antaged, congenitally deaf adult November 1977.' Hiria first comes -to the attention of the hospital audiology' clinic. March 1978: Audiologist writes to Social Welfare for finan~ial ;:I.ssistance. May 1978: Social Welfare declines assistance. October 1978: Audiologist writes again to Social Welfare and makes several phone calls to bring their attention to the letter., November 1978: Audiologist writes to Telephone Services for an amplified headset. Payment received from Social Welfare but no covering letter. , June 1980: Hiria comes to the clinic for new ear moulds and she is not charged for them. September 1982: Hiria's aids are faulty and her hearing has deteriorated. The clinic has new moulds made and tries new high-powered aids. Audiologist writes to Social Welfare requesting payment for new aids. Social Welfare requests letter from hospital board to say they provide no assistance. October 1982: Audiologist phones hospital board social welfare officer requesting letter. December 1982: Audiologist writes to above, requesting letter. Letter received and is for­ warded to Social Welfare Department. . Social Welfare writes to say payment will be made and requests account. January 1983: Audiology clinic sends account. May 1983: Audiologist rings and writes to Social Welfare requesting them to assist in purchase of hearing aid batteries. July 1983: Social Welfare advises that increase has been granted. The audiologist expects this saga to continue whenever Hiria M. requires new ear moulds or hearing aids. 191

Si~. 14 Appendix 8e

NEW ZEALAND FEDERATION FOR DEAF CHILDREN SURVEY The opinions of parents of deaf children were canvassed by a member of the Federation at the conclusion of their 1983 annual conference. Thirty­ eight parents and two specialist teachers completed questionnaires; the num­ ber of questionnaires distributed was not stated. The 38 parents represented 44 deaf children and 34 of these children were profoundly deaf. The question What are your three most important problems to do with your deaf child at present? produced the following responses:

Frequency Item of response

Need for family and parental counselling .... "...... "." ..""..."...... 17 Insufficient educational support at school for child or teacher...... 11 Social isolation of deaf child ...... 9 Lack of information and support from adviser...... 7 Total communication not available for deaf child...... 5 Unsatisfactory hearing aid fittings ...... 5 Employment problems ...... "....."....."...."...... 5

Subsequent questions and responses are listed.

How best can the Federation help you?

Item Frequency

Increasing educational support for my deaf child in school...... 7 Carrying forward our complaints, areas of concern and ideas for improvement to the appropriate authorities ..:..""""""" ... "",,.. ,,...... 5 Communicating to us the latest news and information concerning deaf children ...... :...... 5

In your opinion, what are the Federation's strengths?

Item Frequency

They provide a united voice to government and those people who provide services for our children ...... 14 They provide effective assistance and information to parents of deaf children ...... 7 They provide a forum for uniting parents, bringing them together to share experiences ...... ,...... ,'...... 6

192 In your opinion, what are the Federation's weaknesses

Item Frequency

The lack of finance to do more ...... 6 None ...... :...... 5 Not able to cover all areas· of the country ...... :... 4 Lack of Maori and Polynesian parents involved...... 4

More general comments from a member of the Federation on the subject of services were: . • lack of awareness it:! the medical professions • lack of audiologists and ENT'specialists • lack of enough support at preschool level. • changing nature of education systems and lack of enough support • lack of psychiatric services for the deaf • lack of Social Welfare services accessible tQ the deaf outside of Auck­ land, Wellington and Christchurch • lack of interpreters for medical and legal needs of the deaf, e.g., court appearances • lack of deaf role models and leadership training among the deaf.

193 Appendix 9a

A DESCRIPTION OF A SPECIAL REFERRAL SYSTEM IN A DIS-. TRICT HEALTH OFFICE The medical officer was interviewed and asked to describe the 'hearing assessment clinics' which were run by this particular District Office. 1 Origin: the setting up of these clinics arose out of the frustration of the vision hearing testers. They were identifying children with hear­ ing problems but nothing was being done about it. 2 Procedure: the assessment clinics follow up children who have been identified by the VH testers using' puretone audiometry. The VH testers do the follow-up and organise a clinic when the need arises. They have secretarial help with this. The system has been operating since 1980. 3 Personnel involved: the VH tester was seen as the key person, backed up by the medical officer because of the importance of a medical input. The public health nurse has a supportive role and parents are involved u well and are asked to provide the child's history. 4 Assessment methods: a combination of the following is used-pure tone audiometry, otoscopy, impedance tympanometry and child's history. 5 Position of the general practitioner: the clinic notifies the child's G P of its findings and sends the child's audiograms and tympanograms with interpretations and explanatory notes. GP education is conse­ quently taking place and the majority found the system an acceptable alternative to attending educational meetings. 6 Position of the parents: parents are present for the assessment and are asked to give the child's history. The VRtester or the doctor spends at least five minutes explaining what is being done, drawing a simple diagram of the ear as they proceed, so that when parents see the tympanogram, for example, they will understand its meaning. 7 Importance offollow-up: one is not dealing with a static situation. For example a type B tympanogram indicates an ongoing problem and G Ps were informed of this. A number of children tend to drop out from the ENT out-patient follow-up. The medical officer ascertained that at least 10 percent of glue ears relapse so the assessment clinic often saw chiidren again even after they had been to the specialist. An example given was a kindergarten child aged nearly three who had a speech delay. Impedance testing showed glue ear. She was sent to her GP then sent to a specialist who removed tonsils and adenoids. Six months later the child still had glue ear and 2 years later glue ear and speech retardation were still present.

194 8 Preschool clz:nics.; for children referred-from Plunket clinics or public health nurses. It was thought that more expansion in the preschool area was needed. As similar ear problems were often found within families, the younger siblings of clients were checked whenever the opportunity was available. 9 Organisational aspects: it was suggested that each health district needed one or two medical officers who were responsible fOf',the area of hearing. Public health nurses did not have sufficient training, used inadequate btoscopes and did not have credibility with GPs. The . clinics had elevated the lowly status of the VH testers because they were responsible for arranging the clinics when required, and for . secretarial assistance with the paper work involved in the follow-ups. They related well to parents and worked under the direction of the medical officer. Because the children were still referred through their GP it was important for the clinic to maintain good relationships. The reaction of the two ENT specialists at the time of the interview was mixed, one was favourable and the other was not so favourable. 10 Summary of urgent priorities for childhood hearing problems (as seen by the medical officer of this District Office): better organisation of the referral procedures; education of parents; education of GPs; con­ stant follow-up by VH testers; expansion into the preschool ,area.

195 Appendix 9b

SUGGESTIONS FOR IMPROVING VISION HEARING TESTING IN SCHOOLS: comments from a vision hearing tester

1 Upgrading of the vision hearing testers' position This is a responsible public health position and there should be certain requirements and standards necessary to meet tJ'te position. At the present time a tester can be employed with no relevant background or proven ability to handle children. An early accurate assessment of each child is essential and certain skills are necessary in testing the hearing of young children in particular.

2 Training courses for vision hearing testers There are still testers employed who are not given the opportunity of attend­ ing a training course before commencing duty. I found the four-day Intro­ ductory Course conducted by the NAC in Auckland very interesting and informative. However it was disappointing that more time was not spent on practical testing, specially preschoolers, as the most important part of our work is being able to conduct vision and hearing tests accurately. There was not enough time for all testers present to be supervised whilst conducting a test. The three-day course which I attended in Christchurch, was excellent and much experience was gained in the different techniques used in the testing of hearing in preschoolers.

3 Refresher courses As there are many hundreds of children to test during a year it is very easy to fall into incorrect testing patterns:

o in a noisy school one tends to test too fast to get through the children whilst there is a quieter time in between the noise • perhaps a flick of the eye each time the tone button is 'on' • hand movements able to be seen. A discerning child soon detects these bad habits, although the tester may be oblivious to them. Many children try to please the tester, and watch for signs and respond accordingly. Practical refresher courses should be available for testers and should be held arinually. These courses could be conducted by an audiologist or the adviser on deaf children in each area. The transport and accommodation expense of sending testers to Auckland is unnecessary when we have experienced audiologists and AODC's in each district. These courses would be beneficial in ensuring that the standard of testing does not deteriorate.

196 It must be remembered that when the tester passes a S-year-old at the first screening test at school and places a 'Satisfactory' stamp or an 'A' on the child's record card, that .child will not be screened again until the Form I level. If the child has been incorrectly assessed, schooling will suffer and the child could become a behaviour problem. There have been many cases of children with hearing problems slipping through the first test, and being assessed as normal. Therefore adequate training of a tester and a quiet area to test in is essential. Public health nurses have many study days and courses to attend throughout the year and I consider hearing to be just as important as other health aspects.

4 Periodic supervision in each health district There should be periodic supervision of the vision hearing testers' work in schools as well as checking on school records to ensure that the cards are being filled in correctly and that no children are being missed. At the pJ:'esent time there is no check on testing in schools.

5 Annual personal reports As the major part of. the vision hearing tester's day is spent in schools, it must therefore be difficult for a tester to be accurately assessed by a public . health clerk who is never in the field.

6 Errzployment of school dental nurses to carry out vision testing Last year we were asked for our comments on the feasibility of dental nurses taking over all vision testing. I consider this to be a good suggestion for the following reasons: • this would relieve pressure on the vision hearing tester and allow more time for the testing of hearini which requires a more special­ . ised assessment / • the vision test IS only a screening test and proper testing procedures and follow-up testing required is very simple • clinics are usually spacious and well-lit which would eliminate the difficulties found by testers in some schools of trying to find an ade­ quate room to test in. Often it is difficult to find a room of the correct length andJight enough. Even in schools which have been recently built, medical rooms have little natural light, patterned wallpaper and a coloured light shade • dental nurses have access to record cards to record vision results and also have a preschool dental card on which they could record the vision result. Mothers accompany preschoolers for their dental check­ up and the vision record could then be noted in the new Health and development record booklet • public health nurses are involved in many other areas; soine are test­ ing vision at tpe S-year-old check and at secondary school colour . vision testing is carried out in Form IV.

197

I~ 7 Testing hearing in noisy school situations The high ambient noise levels are a recurring problem. Is there some way in which audiometer earphones could be modified to reduce outside noise during testing in schools? " 8 Referral to hospital audiology clinics for hearing assessment General practitioners need to be aware of the fact that if they refer a child for an audiological assessment they are screened by a technician unless it is stated in the referral letter that he or she wishes the child to be assessed by an audiologist. Busy general practitioners can overlook this when referring. We have had cases during the last year where children have been passed as normal by a technician and after going through the system again have sub­ sequently been seen by ari audiologist, or the adviser on deaf children, and have been fou"nd to have a definite hearing loss. . Parents become confused at conflicting results. 9 Coordination of hearing services At the present time there appears to be some confusion with general prac­ titioners about where to refer children who are suspected of having a hearing loss. Some doctors refer these children either to: • the audiology department of the hospital • hearing testers of the Department of Health • their. own practice nurses. There should be a general training area for all those who test children's hearing because of the current inconsistencies. Testing methods are often inappropriate for testing children, particularly preschoolers, for example. Some still use the 'yes', 'no' method, and children usually try to please the tester.

198 Appendix 9c

NUMBER OF MYRINGOTOMIES CARRIED OUT IN PUBLIC AND PRIVATE HOSPITALS COMBINED, 1982, BY AGE AND SEX

Females Males Age group n % n % Total

Under 1 ...... 56 (32.9) 114 (67.1) 170 1-4 ...... 905 (41..7) 1 265 (58.3) 2 170 5-14...... 1 494 (46.4) 1 724 (53.6) 3 218 15+ ...... 218 (51.3) 207 (48.7) 425 TOTAL ...... 2673 (44.7) 3 310 (55.3) 5 983

AGE AT WHICH MYRINGOTOMIES CARRIED OUT, PUBLIC AND PRIVATE HOSPITALS, 1982

Public Private Age group n % n % Total

Under 1 ...... :...... 45 (26.5) 125 (73.5) 170 1-4 ...... 692 (31.9) 1 478 (68.1) 2 170 5-14.....;...... 1 808 (56.2) 1 410 (43.8) 3218 15+ ...... 267 (62.8) 158 (37.2) 425

TOTAL ...... 2 812 (47.0) 3 171 (53.0) 5983

Compiled from Hospital and selected morbidity data, 1982, National Health Statistics Centre.

199 Appendix lOa OBTAINING HEARING AIDS: a case history of an adult. with acquired hearing loss . . Mr M, a retired managing director aged 70 years; was referred to the National Acoustics Centre by a Hearing Association hearing tutor in March 1983. He had presented to his general practitioner with hearing difficulty. He was tested by tuning fork and told that he did not require hearing aids. A second general practitioner also advised against hearing aids. A neighbour arranged a referral to an otologist with whom he was friendly. The otologist referred Mr M to a private hearing aid firm. Mr M was fitted with a BICROS hearing aid which was intolerably loud. He returned twice to the dealer to complain but did not get past the receptionist. With the consent of the otologist an assessment and hearing aid evaluation were undertaken at the National Acoustics Centre. The results showed a moderate bilateral sensorineural hearing loss, worse in the high frequencies. The hearing aid, which Mr M was wearing at a low gain setting because the output was otherwise intolerably loud, was providing only SdB of gain at 2kHz only. It was fitted to the ear with the worse speech discrimination. Following evaluation and home trial, Mr M was issued with binaural Siemens 22W AGC-PC hearing aids, which incorporate both compression and peak limiting. The aids were fitted using custom-made earmoulds incorporating flared diameter (horn) sound tubes to smooth and extend the frequency response of the aids. Mr M reported that the new aids sounded 'marvellous', and was still delighted with them 6 months later. He has tried using only one hearing aid but finds that, without two aids, sounds appear 'lopsided' and 'unnatural'. With two aids he hears speech more clearly, can appreciate music better, and can local­ ise sounds. His only major remaining difficulty is hearing in noisy situations with several competing speakers.

200 Appendix 1Db

ASTATEMENT FROM A HEARING ASSOCIATION TUTOR The following statement on services for tpe hearing impaired has been pro­ vided by a Hearing Association tutor who is herself deaf. Understanding hearing loss There is a real need for greater understanding of hearing impairment gener­ ally. Degrees of hearing loss and the social, psychological and emotional implications of acquired loss in youth and/or adulthood are not as readily understood as total deafness. These people are in a kind of limbo, neither hearing nor deaf, and require sensitive and perceptive handling to ensure the best possible adjustment is made. Education is therefore important. 1 " Education" of the public generally. Both the hearing and hearing impaired need education to promote understanding of the ramifi­ cations and to offset the stigma so often associated with hearing loss. Lack of understanding is often the reason that people will not seek or accept help for a hearing problem. 2 Education ofgeneral practitioners. Since they are often the first person the hearing impaired individual mentions his/her problem to, the way he/she is received will often determine how positive they will be about accepting help. The tendency here has often been to disregard the problem as of no significance since the individual appears to cope reasonably adequately in a one to one situation; or hearing loss is fobbed off as a part of growing old, and so the.individual is denied proper hearing assessment and generally builds up negative attitudes, puts up with it or blames everyone else for his/her difficulty 'because the doctor said there was nothing wrong with my hearing' or 'it's the "way people mumble these days'! 3 Education of school-age children. An understanding of deafness pre­ vention and the need for dear speech is important. Services 1 AudiologylENT. This has been upgraded considerably in recent years with the increase in the number of audiologists and better equipping of hospital audiology clinics. However, there is still difficulty of access . for many people due to geographic location or the clinic's situation within a large hospital complex. These factors combined with the red tape involved in referral, lengthy delays befqre and during service can be very off-putting for some people, particularly the elderly. Nor is the clinical setting within a hospital very conducive to promoting positive attitudes-only a very small percentage of hearing problems in adults can be helped surgically. The majority require good audiol­ ogical assessment, hearing aid evaluation, fitting, counselling and'

201 guidance in coping with the adjustments that may be necessary in adapting to a hearing problem and/or aid. The setting up of suitably styled Hearing Centres incorporating all the necessary services including rehabilitation would be much more congenial and effective I would think. (Plans of this nature are· under way at the Auckland Branch of The Hearing Association). The procedure for acquiring a hearing aid within the existing struc­ ture of hospital clinics is much too involved and takes too long, espe­ cially when an urgent replacement aid is required. In many cases there needs to be closer liaison with the Hearing Asso­ ciation for pre and post fitting of aids to ensure better adjustment. Generally there needs to be better coordination of the services avail­ able, working in the best interests of the individual rather than each just performing his/her particular discipline. 2 Private dealers. There are undoubtedly some very reputable ones resi­ dent in the cities, but the practice of travelling salesme,n setting up shop for a few brief hours in a chemist shop in small towns and selling off hearing aids at exorbitant prices, is in my opinion very questionable. My experience with hearing impaired people, particu­ larly the elderly, clearly indicates that they need both pre and post orientation to ensure a more positive acceptance and understanding of the use of hearing aids. Those who purchase aids from a dealer (who has placed a most. inviting and often misleading advertisement in the local paper) are often not aware that they can get them much cheaper through a hospital clinic. I have had personal experience of acquiring aids through both mediums and whilst it may be more convenient and less hassle to purchase an aid from a dealer, I believe hearing impaired people need a more comprehensive and continuing service. The practices of some dealers have been very questionable indeed. For these reasons there is a need for more publicity and education of the public and medical people about acquiring hearing aids, and the improved procedures available in hospital clinics. 3 Hearing Association. I believe this organisation has the structure and personnel to carry out very comprehensive rehabilitation services and is doing so in some areas. Professor Harold Bate in his two visits to this country, has suggested a broader range of services that could be offered (see section 10.3.2). A number of individual tutors have endeavoured to implement them and it is hoped that more will do so now since his 1983 visit. There is also a need for such wider­ ranging services to be incorporated in the training curriculum of new· tutors. The upgrading of tutor training, a tutor's handbook/manual and tutors' relationships within the branches are currently being discussed. . Hopefully the image of the Hearing Association is changing from the previously conceived notion of 'a social club for the elderly deaf

202 which teaches lip-reading, to a recognised centre capable of carrying out comprehensive rehabilitation services for adventitiously deafened adults of all ages. Unfortunately, the present structure under which tutors must work imposes severe limitations on the scope and effectiveness of carrying out their broadened role. Many of them just cannot cope through sheer weight of numbers alone. Under the Department of Education policy 'numbers on the roll', i.e., the number of people who attend weekly group sessions (commonly referred to as 'students' and who in fact constitute only about one-third of the workload) is still the criterion for justifying the appointme'nt of a tutor part-time or full­ time. Therefore,in order to keep up these numbers to justify her job, the tutor must cut back on the time-consuming individual work of counselling, hearing aids work, special cases etc, thus limiting the services she is now trained to give. The existing structure needs to be reviewed now that the role. of the tutor is changing and broad­ ening. The job also needs to be much more professionally recognised and structured. We need increased numbers of tutors and hours, as well as suitably qualified tutors in higher paid positions of respon­ sibility. At present there is no salary scale,incentive system or finan­ cial. recognition of positions of seniority or increased responsibility. Much of the foregoing is under discussion with government depart­ ments by ~ur National Board of Governors. Conclusion New Zealand, I believe, has the potential for being a world leader in hearing rehabilitation-an observation also expressed by Professor Bate-because of the basic structure of the system nationwide. With attention to the issues raised here and those already being worked on, that potential could in time be realised. When I look back over the many years of my involvement in. the Hearing Association and of having had a hearing impairment, services l1ave been considerably improved upon. This is thanks, in no small part, to Dr Bill Keith and his efforts in many areas. With time I would also hope that there would be a closer coordination of all services for the hearing impaired, ministering to the total well-being of the person not just the hearing loss, and that the Hearing Association would be the dispensing vehicle for these services.

203 Appendix 12a

THE SUBJECT OF HEARING IMPAIRMENT AND CARE OF THE HEARING IMPAIRED IN MEDICAL AND NURSING SCHOOL CURRICULA ANALYSIS OF AVAILABLE DATA

Medical Schools (four replies out of four) Three schools provided a specific programme but teaching was inadequate because of lack in curriculum time and lack of qualified staff. Specific infor­ mation on programmes from the other school was not forwarded.

Technical Institute Schools of Nursing (nine replies out of eleven) 1 Basic comprehensive nursing programmes: of the nine technical insti­ tutes only five provided a full and comprehensive programme cov­ erage. None of these basic programmes specified the length of time allotted per student to cover this area. 2 Post basic nursing programmes: three schools provided post basic courses but only one provided a fulr programme coverage in their post basic curriculum. None of these programmes specified the length of teachingllearning time required to cover this area.

Hospital Board Schools of Nursing (twenty-two replies out of twenty-six) 1 General and obstetric nursing programmes: of the data received from 16 general and obstetric nursing programmes, only seven schools pro­ vided specific programmes and only some of these provided a full to comprehensive cover. . Ten of these schools did not specify the length of student time required to cover this area, while the other six indicated a range of 1 to 12 hours was required. 2 Enrolment nursing programmes: of the 12 enrolment programmes only four provided specified programme coverage and only three indicated the time required for this coverage. (Committee on Hearing working paper, February 1983)

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