Robert L. Folmer, Ph.D.
Oregon Hearing Research Center
Mail Code NRC04
Oregon Health & Science University
3181 SW Sam Jackson Park Road
Portland, OR 97201-3098
Telephone: (503) 494-8032
Fax: (503) 494-5656
email:
folmerr@ohsu.edu
web:
www.dangerousdecibels.org
According to the OSHA?s Occupational Noise Exposure
Standard and Hearing Conservation Amendment (published
in the Federal Register on March 8, 1983), if workers
are exposed to excessive sound levels, "the employer
shall administer a continuing, effective hearing
conservation program."
Children are often exposed to excessive levels of
sound
At some time in their young lives, 97% of 273 third
graders surveyed by Blair et al (1996) had been exposed
to hazardous sound levels. Chermak & Peters-McCarthy
(1991) reported that 43% of the elementary school
students in their study routinely listened to a personal
stereo system or television at a loud volume. Thirty
percent of the students said they sometimes participated
in other noisy activities (such as shooting firearms or
attending auto races); however, only 5.5% of the
students ever used hearing protection while engaged in
these activities. Sources of excessive sound exposure
for children include loud music (Lipscomb, 1972; Meyer-Bisch,
1996), real or toy firearms (Woodford, 1973; Lipscomb,
1974), power tools (Roeser, 1980; Plakke, 1985),
fireworks (Ward & Glorig, 1961; Gupta & Vishwakarma,
1989), loud toys (Axelsson & Jerson, 1985; Hellstrom et
al, 1992); snowmobiles or other loud engines such as jet
skis or motorcycles (Bess & Poynor, 1972).
Noise-Induced Hearing Loss (NIHL) in children
When humans of any age are repeatedly exposed to
hazardous sound levels without using adequate hearing
protection, the common result is noise-induced hearing
loss (NIHL). Several studies have demonstrated that the
prevalence of NIHL among children is increasing
(Woodford & O?Farrell, 1983; Chermak & Peters-McCarthy,
1991; Montgomery & Fujikawa, 1992). Anderson (1967)
reported a surprisingly high prevalence of NIHL in
school-aged children more than 30 years ago. Blair et al
(1996) claimed that 1% of the school age population has
some degree of NIHL. Niskar et al (2001) estimated that
12.5% of all children in the United States aged 6 to 19
years have noise-induced hearing threshold shifts (NITS)
in one or both ears. Studies by Weber et al (1967),
Cozad et al (1974) and Hull et al (1975) all found
relatively large numbers of school boys who failed
hearing screenings at 4000 Hz -- an indicator of NIHL.
Evidence of NIHL was also observed in Swedish (Costa et
al, 1988), Chinese (Morioka et al, 1996) and French
(Meyer-Bisch, 1996) children.
What are the consequences of NIHL in children?
Even though the degree of high frequency hearing loss
detected in these studies was generally mild and usually
not even noticed by the children involved, Lass et al
(1986) warned: "the significance of the problem lies in
the insidious nature of noise-induced hearing loss (NIHL)
as well as the cumulative interaction between this type
of loss and sociocusis. It follows then that a mild
high-frequency hearing loss in a 16-year-old high school
student may well deteriorate to a debilitating degree in
later life. Additionally, there is another factor that
could indicate that damage to the auditory system in
this population is more prevalent and/or significant
than might be believed from results of hearing tests."
Prasher (1998) reiterated the assertion that audiometric
thresholds may be normal despite substantial loss of
outer and inner hair cells.
Children with high frequency hearing loss in Anderson?s
(1967) study had more learning difficulties and
behavioral problems than their classmates who had normal
hearing. Bess et al (1998) reported that, compared to
their classmates with normal hearing, children with
minimal sensorineural hearing loss (MSHL) scored
significantly lower on the Comprehensive Test of Basic
Skills; they also exhibited more behavioral problems and
lower self-esteem. Thirty-seven percent of children in
the study with MSHL failed at least one grade compared
to the school district average of eight percent or less.
What should be done?
In response to this trend of increasing NIHL among
children, numerous experts have recommended the
implementation of hearing conservation education
programs in schools:
"Educating students to the possible consequences of
future vocational and avocational noise exposure, as
well as instructing them in how to protect their hearing
when exposed to noxious noise levels, may prevent
further hearing loss and perhaps extensive communication
problems later in life." (Cozad et al, 1974)
"The findings from this survey certainly suggest the
need for some form of hearing conservation program at
the high school level." (Roeser, 1980)
"Hearing-conservation programs are needed to provide
students with the proper information about hearing and
hearing loss, and about the protective measures to
prevent hearing loss at home, in school (e.g., in
industrial art classes), and at social/recreational
events." (Lass et al, 1987a)
"Education on the hazards of noise is needed at all
levels, and early education is particularly important."
(Florentine, 1990)
"Strategies to prevent damage from sound exposure should
include the use of individual hearing protection
devices, education programs beginning with school-age
children, consumer guidance, increased product noise
labeling, and hearing conservation programs for
occupational settings." (National Institutes of Health
Consensus Development Conference Statement, 1990)
"Due to the rising numbers of children acquiring
noise-induced hearing loss (increasingly in the
elementary school years), education about the impact of
excessive noise on hearing would be a worthwhile
addition to the health curriculum of any school
district. It is only through early and repeated
education that we may reach these young people so that
they may responsibly prevent permanent hearing loss."
(Anderson, 1991)
"Hearing conservation programming should begin no later
than third or fourth grade in order to prevent
noise-induced hearing loss." (Chermak & Peters-McCarthy,
1991)
"Education regarding the potential dangers of high
decibel levels for students should begin in the
elementary grades." (Montgomery & Fujikawa, 1992)
"Comprehensive, age-appropriate educational programs
must be developed for elementary and secondary students
and their parents to acquaint them with potentially
hazardous noise sources in their environment." (Brookhouser
et al, 1992)
"Otolaryngologists should support efforts to provide
information about NIHL as part of health education in
our schools." (Dobie, 1995)
"The percentage of high-frequency hearing losses is
greater in the upper grades, suggesting that hearing
conservation programs should be introduced in the
elementary grades." (Blair et al, 1996)
"Educate the public and especially children to practice
lifetime hearing health with regular audiograms and ear
protection against toxic noise." (Wheeler, 2000)
Even though children are often exposed to excessive
sound levels, there are no policies requiring
hearing conservation practices to be taught in our
nation?s classrooms. In spite of mounting evidence that
the prevalence of NIHL is increasing among children --
and contrary to the recommendations of countless
audiologists and other experts in the field -- basic
hearing conservation information (that could prevent
many cases of NIHL) remains conspicuously absent from
most school curricula.
Why aren?t hearing conservation practices taught in
most schools?
Lack of public awareness about how excessive
sound exposure damages hearing and the consequences of
hearing loss. In general, people tend to take hearing
for granted until their own hearing loss becomes so
severe that it interferes with communication. Because
most teachers, school administrators, and parents are
not aware of the problem, hearing conservation and the
preventability of NIHL are given a low priority if
they are considered at all.
Lack of effective dissemination of existing
hearing conservation programs, curricula, and
materials.
Berger & Royster (1987) made the following statement
about occupational hearing conservation programs: "In
large part, what is needed is not the development of new
solutions, but rather the broad dissemination of
existing techniques plus the education and motivation of
management and labor alike to speed the implementation
of effective programs." If we substitute the words
"administrators, teachers, parents, and students" for
"management and labor," this statement would also apply
to school hearing conservation programs.
The problem is not a lack of hearing conservation
education materials and resources. The problem is not
a lack of agreement among experts about what should be
done. Given the paucity of hearing conservation
instruction that is offered in our nation?s schools, the
problem is a lack of dissemination of this important
information to our children.
- Lack of perpetuation
of hearing conservation
instruction. A relatively small number of teachers,
audiologists, nurses, or trained volunteers have
presented hearing conservation curricula in selected
classrooms across the country. However, if the person
who implemented the program retires, moves, or stops
making such efforts for other reasons, hearing
conservation education in those schools usually
diminishes or ceases completely.
What can be done to address these problems?
- Raise public awareness about hearing; how hearing
can be damaged by excessive sound exposure; the
consequences and permanent nature of sensorineural
hearing loss; how NIHL can and should be prevented.
- Inform teachers and school administrators about
existing hearing conservation programs, curricula, and
materials that can be used in classrooms.
- Persuade teachers and school administrators to
integrate hearing conservation messages into existing
lesson plans on hearing, sound, music, science, math,
and health.
- Seek a mandate from state and local school boards,
and state or federal legislatures to implement and
perpetuate hearing conservation instruction to each
new 1st, 4th, 7th, and 10th grade class of students in
all of the nation?s schools on a continuing basis.
What elements should be included in a hearing
conservation education program for children?
Lass et al (1987a) recommended the following:
Instruction about 1) normal auditory mechanisms; 2)
types of hearing loss and their causes; 3) noise and its
effect on hearing; 4) warning signs of noise-induced
hearing loss; and 5) specific recommendations for
preventing noise-induced hearing loss. Anderson (1991)
added the following topics to the list: Instruction
about consequences of hearing loss and how it can affect
life quality; what kinds of noises or noisy activities
are most dangerous to hearing?
It is not necessary to spend exorbitant amounts of class
time to cover the basics of hearing, hearing loss and
hearing conservation. Teachers should be encouraged to
integrate the information into existing lesson plans on
hearing, sound, music, science, math, and health.
Chermak et al (1996) reported that students who received
the hearing conservation message through an interactive
style of instruction exhibited greater improvement on
post-instruction tests than students who heard it in a
more traditional lecture format. Results from a study by
Bennett & English (1999) agree with this conclusion.
Therefore, a hearing conservation program for children
should be as interactive as possible and utilize a
variety of media and activities.
What resources are available to facilitate hearing
conservation instruction in classrooms?
Table 1 lists twelve organizations that produce or use a
variety of materials in a comprehensive hearing
conservation curriculum for school-age children.
To view Table 1 please
Click Here. (Requires
Adobe Acrobat)
The Crank It Down! curriculum includes
construction of a sound thermometer, spaghetti and Play-doh
model of stereocilia, and demonstrations of proper usage
of hearing protection. The "Know Noise" video and
"Unfair Hearing Test" audiocassette -- a list of 10
common words with high frequencies filtered out to
simulate hearing loss -- (both available from the Sight
and Hearing Association) also are used. Crank It
Down! has been presented by trained guest speakers
to students in second, third, fourth, and fifth grades.
Presentations to students in second and third grades can
be shortened and simplified by leaving out the sound
thermometer and "Unfair Hearing Test" activities.
Crank It Down! materials are available from the
National Hearing Conservation Association.
Dangerous DecibelsTM is a hearing
health education program being developed by the Oregon
Hearing Research Center and the Oregon Museum of Science
and Industry. Program goals are to raise public
awareness about mechanisms of hearing and hearing loss,
and to educate people about sources of, effects of, and
how to protect themselves from hazardous levels of
sound. When completed, the program will include 11
permanent museum exhibits; classroom curricula and
activities for all school-age children; training and
materials for teachers; epidemiological and educational
research components.
HIP Talk was developed by the House Ear Institute
in Los Angeles. The curriculum, originally designed for
fifth- and sixth-graders, includes information about ear
anatomy (illustrations are provided), environmental
noise, hazardous sounds, and ways to protect hearing.
Also included are separate quizzes for elementary,
middle school, and high school students; the "HIP Talk"
video (produced in 1992, 34 minutes); 400 pairs of foam
ear plugs to distribute to students; and a form that
solicits comments about the curriculum from teachers.
The video is a significant component of the curriculum.
Because much of the video consists of a panel discussion
among musicians and a moderator, it will not hold the
attention of most students. However, a brief segment of
the video contains an effective simulation of hearing
loss: the audio portion of a Flintstones cartoon is
filtered to demonstrate mild, moderate, and severe high
frequency hearing loss.
Know Noise is distributed by the Sight and
Hearing Association of St. Paul, Minn. The Know Noise
program includes lesson plans, activities,
illustrations, and transparencies for grades three
through six. Also included are the "Know Noise" video
(produced in 1993, 14 minutes), the "Unfair Hearing
Test" audiocassette, supplemental articles, and teacher
comment forms. The main weakness of this program is the
video. Although it conveys some useful information, the
"Know Noise" video, like many hearing conservation
videos, is dated. This problem is recognized by
producers of educational materials: videos are expensive
to make and they tend to go out of date quickly. If the
fashions, music, and dialogue seem antiquated or "corny"
to an audience of children (especially older children),
these distractions tend to dilute any educational
message contained in the video. However, carefully
selected portions of videos that are less susceptible to
this aging process (and still convey pertinent
information) may be used indefinitely.
Wise Ears, one of the most complete hearing
conservation curricula for children available on the
Internet, is provided by the National Institute on
Deafness and Other Communicative Disorders (NIDCD).
Their web site includes lesson plans and activities for
grades three through six, questions and answers about
hearing, an interactive sound ruler, and three videos.
NIDCD also distributes the video "I Love What I Hear"
(produced in 1992, 8 minutes) to be used in the
classroom.
Table 2 lists seventeen organizations that produce one
or a few types of material (e.g., a video or printed
material) designed for children or which could be
adapted for use in a classroom.
To view Table 2 please
Click Here. (Requires
Adobe Acrobat)
Perry Hanavan?s "Virtual Tour of the Ear" web site
provides a comprehensive list of links to dozens of web
sites that contain a variety of illustrations,
photographs, micrographs, and animations of the outer,
middle, and inner ear as well as auditory structures in
the brain.
To encourage people to protect their ears from hazardous
noise, most hearing conservation programs include some
information about how the ear works and how excessive
sound exposure causes permanent damage to inner ear
structures. One of the fastest and most entertaining
ways to convey this information is to use animations
such as those in "The Hearing Video" produced by the
Workers? Compensation Board of British Columbia, Canada.
Portions of this fast-paced, informative, and
entertaining video can be used with students of all
ages. One negative aspect of "The Hearing Video" is its
relatively high purchase price. A less expensive video
that illustrates auditory system function and damage is
"Quieting the Skies" (available from N.A.S.A. Central
Operation of Resources for Educators). A much more
technical, anatomically accurate and expensive video
series, "Human Hearing," is being produced in four
volumes by Caldwell Publishing Co., in Redmond, Wash.
Most of the other resources listed in Table 2 provide
basic information (booklets, pamphlets, posters, or web
sites) about hearing and the consequences of excessive
sound exposure. For example, Howard Leight Industries
produces posters and leaflets with photomicrographs of a
normal cochlea with the caption "This is your inner
ear," and a cochlea damaged by excessive sound exposure
with the caption "This is your inner ear without plugs.
Any questions?"
How effective are hearing conservation programs for
children?
Numerous studies evaluated the effectiveness of hearing
conservation programs administered in elementary schools
(Chermak & Peters-McCarthy, 1991; Blair et al, 1996;
Chermak et al, 1996; Bennett & English, 1999), middle
schools (Lass et al, 1987b; Knobloch & Broste, 1998),
and high schools (Lewis, 1989; Lerman et al, 1998; Lukes
& Johnson, 1998). All these studies concluded that,
compared to preinstruction responses, students?
performance on hearing knowledge and noise awareness
questionnaires improved significantly after they
participated in hearing conservation programs.
It is much more difficult to assess potential changes in
behavior that might occur as results of these programs.
Knobloch and Broste (1998) reported that 87.5% of
students who received hearing conservation instruction
used hearing protection devices in noisy environments at
least some of the time. Only 45% of students in control
groups who did not receive such training reported using
hearing protection in similarly noisy conditions.
Studies by Lass et al (1987b), Lewis (1989), and Chermak
et al (1996) all reported postinstruction increases,
compared to preinstruction responses, in student
intentions to protect their ears from excessive sounds.
The ultimate goal of hearing conservation education
programs is to reduce the prevalence of noise-induced
hearing loss among children and adults. Even if hearing
conservation instruction began immediately in all of the
nation?s classrooms, it would take years to determine if
such instruction had any effect on the prevalence of
NIHL in the United States. However, every person who can
be spared the debilitating consequences of NIHL
(including communication difficulties, isolation,
frustration, depression, or chronic tinnitus) is worth
the effort.
Conclusion
Hearing conservation should receive attention and
resources similar to those allocated for anti-smoking,
anti-drug, teen pregnancy, and sexually transmitted
disease education programs that are now presented
routinely in public schools. The time is now to
wage a public health campaign against NIHL, a
potentially debilitating condition that, according to
Dobie (1995), "is almost entirely preventable."
___________________________________________________________________
This article was adapted from Folmer RL, Griest SE,
Martin WH. Hearing conservation education programs for
children: a review. Journal of School Health
2002;72(2):51-57.
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