The Child with Cognitive, Sensory, or Communication Impairment

Communication: Development of verbal skills is often delayed more than development of other physical skills. Speech requires adequate hearing and interpretation of sounds (receptive skills) and facial muscle coordination (expressive skills). Both receptive and expressive skills may be significantly impaired, so frequent audiometric testing should be conducted, and hearing aids should be provided to children with hearing difficulties. Other children may require training in controlling their facial muscles. For example, some children may need tongue exercises to correct tongue thrust or gentle reminders to keep the lips closed.

For some of these children, nonverbal methods of communication should be employed. The choice of an assistive device often depends on the child’s cognitive level and physical abilities. For the child without associated physical disabilities, a talking picture board is helpful. For children with physical limitations, several adaptations to and types of communication devices are available to facilitate selection of the appropriate picture or word. Some children may learn sign language or Blissymbolics, a system of graphic symbols representing words, ideas, and concepts. The symbols are typically arranged on a board, and the individual points or uses a selector to communicate a message.

Discipline: Discipline must begin early. Limit-setting measures must be simple, consistent, and appropriate for the child’s mental age. Control measures are based primarily on teaching a specific behavior, rather than on developing an understanding of the reasons behind it. Stressing moral lessons is of little value to a child who lacks the cognitive skills to learn from self-criticism and evaluation of previous mistakes. Behavior modification, especially reinforcement of desired actions and the use of time-out procedures, is an appropriate form of behavior control. (See Chapter 3.) Avoid aversive strategies.

Socialization: Acquisition of social skills is complex. Active rehearsal (with role playing and practice sessions) and positive reinforcement for desired behavior are successful approaches. Encourage parents early to teach their child socially acceptable behavior: waving good-bye, saying hello and thank you, responding to his or her name, and greeting visitors. The teaching of socially acceptable sexual behavior is especially important to minimize sexual exploitation. Parents also need to expose the child to strangers so that manners can be practiced, since transfer of learning from one situation to another is not automatic.

Social acceptance and self-esteem are enhanced when a child is appropriately dressed and well-groomed. Clean, stylish, well-fitting clothing that has self-adhering fasteners and elastic openings facilitates self-dressing and social acceptance.

Opportunities for social interaction and training should begin at an early age. Encourage parents to enroll their child in infant stimulation programs and other appropriate preschool programs as soon as possible. These programs provide education, training, and opportunities for social interaction with other children and adults.

As children grow older, they should have peer experiences similar to those of other children, including participation in group outings, sports, and organized activities such as scouts and Special Olympics. These children often enjoy participating in developmentally appropriate peer activities such as dance and karate classes (American Academy of Pediatrics, 2004; Rehm and Bradley, 2006; Shapiro and Batshaw, 2007). A close relationship with a best friend can be encouraged. Vacations, family outings, dances, and dating are important social opportunities.

Sexuality: Adolescence may be a particularly difficult time for parents, especially in terms of the child’s sexual behavior, possibility of pregnancy, future plans to marry, and ability to be independent. Often, minimal anticipatory guidance is available to parents to prepare the child for physical and sexual maturation, and the degree of the adolescent’s interest in and experience with sex has been underestimated.

The question of contraceptive protection for female adolescents is often a parental concern. Permanent contraception through sterilization is a special dilemma because of moral and ethical questions, as well as psychologic effects on the adolescent. State laws vary; some allow no sterilization, whereas others permit review of requests. Intramuscular injection of medroxyprogesterone acetate (Depo-Provera) is a contraceptive choice that provides long-term protection, requires little compliance, and often produces amenorrhea.

Parents of these adolescents are often concerned about the advisability of marriage between two individuals with significant CI. There is no conclusive answer; each situation must be judged individually. In many instances marriage would help the couple achieve a mutually satisfying and supportive relationship, meaningful companionship, and a more normal social and sexual adjustment. Under the Fourteenth Amendment to the Constitution, every individual has the right to marry and have a family, regardless of his or her mental capacity (Silber and Batshaw, 2004). The nurse should discuss this topic with parents and with the prospective couple, stressing the need for suitable living accommodations and use of appropriate contraceptive methods to prevent pregnancy. If children are conceived, these parents require specialized assistance and guidance in learning to meet the needs of their offspring (Johnson and Walker, 2006; Silber and Batshaw, 2004).

Nurses can help in this area by providing parents with information about sex education that is geared to the child’s developmental level. For example, the adolescent female needs a simple explanation of menstruation and instructions on personal hygiene during the menstrual cycle.*

These adolescents also need practical sexual information regarding anatomy, physical development, and conception. Because they are easy to persuade and lack judgment, they need a well-defined, concrete code of conduct with specific instructions for handling certain situations. Girls should know never to go alone anywhere with any person they do not know well. Boys should be warned of intimate advances from other males. Sexual assault of a cognitively impaired adolescent should be treated and investigated by law enforcement personnel (Eastgate, 2005).

Play and Exercise: Children who are cognitively impaired have the same need for play as any other children. Exercise is beneficial for development of coordination, cardiovascular fitness, and weight management. Because of the child’s slower development, however, parents may be less aware of the need to provide for such activities. They may also feel inadequate in playing with the child because the usual reciprocal interaction and resulting satisfaction between child and parent may be slower in developing.

In addition, children who are cognitively impaired may not be able to initiate appropriate play activities on their own. They may resort to self-stimulatory behavior, such as rocking, twirling, masturbating, or finger sucking, and self-injurious behaviors, such as head banging or biting, hitting, or scratching themselves (Murray, 2003; Shapiro and Batshaw, 2007). The nurse should inquire as to what precipitates the behaviors and review the parent’s techniques used to manage the behaviors (Johnson and Walker, 2006). The nurse may also guide parents toward selection of suitable toys and interactive activities (Fig. 24-2).

The type of play is based on the child’s developmental age, although the need for sensorimotor play may be prolonged. Parents should use every opportunity to expose the child to as many different sounds, sights, and sensations as possible. Appropriate toys include musical mobiles, stuffed toys, floating toys, a rocking chair or horse, a swing, bells, and rattles. The child should be taken on outings, such as trips to the grocery store or shopping center. Other people should visit in the home, and individuals should relate directly to the child, through such means as cuddling, holding, and talking to the child in the face-to-face position.

Parents should select toys for their recreational and educational value. For example, a large inflatable beach ball is a good water toy; encourages interactive play; and can be used to learn motor skills such as balance, rocking, kicking, and throwing. Attractive toys encourage a child to reach, thus assisting in the development of motor skills (Fig. 24-3). Musical toys that mimic animal sounds or respond with social phrases are excellent ways of encouraging speech. A doll with removable clothes and different types of closures can help the child learn dressing skills. Toys should be simple in design so that the child can learn to manipulate them without help. For children with severe cognitive or physical impairment, electronic switches can be used to allow them to operate toys (Fig. 24-4).

Suitable physical activity is based on the child’s size, coordination, physical fitness and maturity, motivation, and health. Some children may have physical problems that prevent participation in certain sports, such as atlantoaxial instability in children with Down syndrome. Children with CI often have greater success in individual and dual sports than in team sports and enjoy themselves most with children of the same developmental level. The Special Olympics* provides a unique competitive opportunity.

Safety is a major consideration in selecting recreational and exercise activities. Some toys that may be appropriate developmentally may present dangers to a child who is strong enough to break them or use them incorrectly.

Feeding: Self-feeding is the first major self-help skill that children learn. It involves the integration of fine and gross motor skills and visual perception. Most parents take for granted that they will be successful in teaching their children to feed themselves. Therefore the nurse and other team members must be especially sensitive to the needs of the parent, as well as the child, if assistance is offered.

Before beginning a self-feeding program, the nurse and parent should do a task analysis, breaking the process of feeding into its smallest components (see Box 24-4). It is important to observe the child in an eating situation to determine whether he or she has mastered any self-feeding skills.

Along with a task analysis, the nurse assesses a number of other factors, such as the shape of the child’s mouth and the child’s control of mouth, lip, and tongue movements (whether the tongue moves forward and backward or from side to side, whether there are rotary movements). The presence of teeth determines the textures and consistencies of foods that the child can eat. The child’s developmental readiness for self-feeding, such as the ability to maintain head and trunk support and to sit without support, the level of eye-hand coordination, the firmness of the grasp, and the ability to reach for an object, hold it, and release it, is examined. If the child has any physical impairments that interfere with holding or grasping the utensil, specially designed utensils can be substituted or homemade modifications can be used. For example, the handle can be built up with a sponge or piece of wood or bent to accommodate arm movement.

The nurse obtains further data from the parent by asking specifically about the family’s approach to feeding. For example, who feeds the child regularly? Is the child fed when hungry or according to a prescribed schedule? What are the child’s appetite patterns? Does the parent know when the child is full? What foods does the child like? How long does feeding take? A short feeding time, such as 10 minutes, might indicate that the child is being deprived of sensory experiences or appropriate interactions; a long time might indicate frustration and fatigue on the parent’s part. Is the feeding environment described as quiet and nondistracting? The nurse also helps determine the best time to begin teaching this new task. If the family is going on vacation, if someone is visiting, or if there has been a major stress in the family, this may not be the ideal time to begin a teaching program.

Also consider preparation for the feeding activity, such as proper placement of the child at the table and protection of the area against spills. Feeding should fit in with family life. (See Chapter 22.) For example, the child is fed in the kitchen, at the table, or in a high chair in a sitting position, and with other family members whenever possible. Food should be offered in separate servings, not pureed or mixed together; should be served at the appropriate temperature; and should be of sufficient variety and texture from each of the basic food groups.

Once the feeding program begins, the nurse is in an important position to give parents supportive feedback. The nurse acknowledges the parents’ observational skills and their ability to share observations, keep records of the child’s progress, and establish goals that are appropriate and realistic for both the child and the parents.

Toileting: Independent toileting is another major self-help skill that parents can teach using behavior modification principles. It usually begins after self-feeding because this is the normal sequence of development. Plans for a toileting program begin by assessing the child’s physical and psychologic readiness. (See Chapter 14.) Because of physical or developmental limitations, certain signals may not be possible. For example, children who cannot walk can be trained once they are able to sit with good balance, and children with poor speech may need to rely on hand gestures to signal their toileting needs.

Interview parents regarding their readiness to pursue a toilet-training program. Readiness is characterized by a positive, consistent, individualized, nonpunitive, nonpressured style of teaching. It is important to explore with parents the time they have to invest in the program, the advantages they see, the inconveniences that toilet training may cause them, the reason they wish to start, and whether this is the best time for both the parents and the child to begin.

Review any past attempts at toilet training the child: When and why did the parents start training? What methods did they use? Did they experience frustration, indifference, or discomfort? How long did they attempt training, and what were their reasons for discontinuing training efforts? Were their efforts consistent? Looking back, how did they view the experience for themselves and the child? If the parents acknowledge using punishment in any form, including spanking, scolding, withholding privileges, using suppositories, withholding fluid, or getting the child up in the middle of the night, the nurse offers positive alternatives.

As part of the procedure for determining the readiness of both parents and child to become involved in a successful toilet-training program, ask parents to keep detailed records for 7 days. They should discontinue record keeping if the child becomes ill or if fluid intake is changed. Record keeping includes documentation of:

If possible, a toilet-training program should begin after such records are completed because they show how parents are responding to the child’s behaviors and at what times the child is most likely to eliminate.

The objective of any toilet-training program is to help the child achieve small goals and experience comfort and success and to help the parents simultaneously experience feelings of adequacy, minimum tension, and success. Parents should understand that they will be capitalizing on the times the child is most likely to eliminate and that they should respond immediately to any cues indicating this need.

A task analysis for toileting includes the same type of discrete steps as outlined for feeding (see Box 24-4). A positive and relaxed attitude toward toilet training is important and differs little from the approach used with other children. (See Chapter 14.)

Dressing: Although dressing skills develop without special instruction in most children, special training is necessary to promote this skill in children with CI. Factors that interfere with spontaneous learning include immature motor skills, lack of motivation, physical impairments, and lack of opportunity.

The level of independence in dressing varies according to the degree of CI. Children with mild to moderate CI and no accompanying physical limitations can become independent in all dressing skills, except for more complex tasks such as color coordination. Those who have moderate CI can master most dressing skills, except fastening complicated closures such as buttons or ties. Those who have profound CI are usually able to assist in undressing and dressing but achieve no independent skills.

Children are considered developmentally ready for dressing training if they can sit quietly for 3 to 5 minutes while working on a task; can watch what they are doing while working on a task; can follow physical gestures or cues; can follow verbal commands; and can relate clothing to the appropriate body part, such as socks to feet. As with other self-help skills, the child may not be able to master every task but should be evaluated for evidence of willingness to participate at his or her level of readiness. The use of teaching devices, such as dolls with clothing with mock closures, and reinforcement for success in managing the fasteners can increase the child’s manipulative skills, which may be transferred to ready-to-wear clothing.

Grooming: The child usually learns self-grooming along with other independence-promoting skills, such as washing hands during toilet training. As with self-dressing, a major factor in learning independent grooming is the opportunity to practice the skills.

Dental hygiene is especially important. An odor-free mouth and clean teeth are essential in promoting a positive image. In addition, healthy teeth are necessary for proper chewing and speech. Missing teeth interfere with proper tongue positioning for clear speech. Most dental problems are preventable with the dental hygiene practices discussed in Chapter 14.

If the child has physical impairments that limit the ability to brush, special devices may be necessary, such as a larger-handled or curved toothbrush, to reach all surfaces of the teeth. Any strategies that help motivate the child to brush are used. For example, the parent can place a special calendar on the wall and mark each date with stars to represent the number of brushings per day. After earning a specified number of stars, the child can receive a special reward.

The child should routinely see a dentist. It is important to prepare the child for such visits, because it is much more difficult to change an unsatisfactory experience than to prevent one. The nurse can assist families by locating dentists who are familiar with treating children with CI and by discussing with parents procedures for preparing the child for the visit.

Intelligence—Mental capacity varies from severe CI to low-average intelligence but is generally within the mild to moderate range of CI and may be related to parental intelligence (National Down Syndrome Society, 2009a). Initial development may appear near normal. Although abilities can vary considerably, relative strengths often occur in visual over auditory processing, with relative weaknesses in grammar and expressive language and delays in motor development (National Down Syndrome Society, 2009a; Shapiro and Batshaw, 2007).

Social development—Development may be 2 to 3 years beyond the mental age, especially during early childhood. Temperamental characteristics show the same range as those found in unaffected peers. However, there is a relative strength in sociability (American Academy of Pediatrics, 2001a; Johnson and Walker, 2006) and a trend toward the easy-child pattern that may facilitate parent-child attachment and assist in integration with peers at school and in the community.

Congenital anomalies—About 40% to 45% have congenital heart disease (CHD), especially septal defects. Other structural defects include renal agenesis, duodenal atresia, Hirschsprung disease, and tracheoesophageal fistula. Skeletal defects include patella dislocation, hip subluxation, and atlantoaxial instability (instability of the first and second cervical vertebrae) in some children.

Sensory problems—Ocular problems include strabismus, nystagmus, astigmatism, myopia, hyperopia, head tilt, excessive tearing, and cataracts. Hearing loss occurs in a large percentage of children with Down syndrome. Conductive, sensorineural, and mixed losses each account for approximately one third of the diagnoses. Frequent otitis media, narrow canals, and impacted cerumen may contribute to the hearing problems.

Other physical disorders—These children have altered immune function, which contributes to numerous other conditions (Rittey, 2003). Respiratory tract infections are prevalent; when combined with cardiac anomalies, they are the chief cause of death, particularly during the first year. Because a high incidence of CHD is associated with trisomy 21, echocardiography is recommended at the time of initial diagnosis (American Academy of Pediatrics, 2001a; Bernstein, 2007). The incidence of leukemia is several times more frequent than expected in the general population, and in about half of the cases the type is acute megakaryoblastic leukemia. Thyroid dysfunction, including Graves disease, goiter, chronic lymphocytic thyroiditis, and hypothyroidism, is common. Acquired thyroid dysfunction also occurs frequently.

Growth—Growth in both height and weight is reduced, but weight gain is more rapid than growth in stature, which often results in overweight by 36 months of age. Deficient growth is most marked during infancy and adolescence. Growth of children with moderate or severe CHD is more affected than growth of those with mild or no CHD.

Sexual development—Development may be delayed, incomplete, or both. Male genitalia and secondary sexual characteristics such as facial hair may be underdeveloped. Breast development in females is mild to moderate. Menstruation usually occurs at the average age, and postpubertal women can be fertile; a small number have had offspring, the majority of whom were born with some type of abnormality. Men with Down syndrome have significantly lower overall fertility rate than other men of comparable ages (Descartes and Carroll, 2007; National Down Syndrome Society, 2009b).

Prognosis: Life expectancy for those with Down syndrome has significantly increased in recent years but remains lower than for the general population (Wiseman, Alford, Tybulewicz, et al, 2009). More than 80% of individuals with Down syndrome survive to age 55 years and beyond. As the prognosis continues to improve for these individuals, it will be important to provide for their long-term health care, social, and leisure needs.

Support the Family at the Time of Diagnosis: Because of the distinctive physical characteristics, the infant with Down syndrome is usually diagnosed at birth. Generally parents wish to know the diagnosis as soon as possible. Most parents prefer that both of them be present during the informing interview so they can support each other emotionally.

Parental responses to the child may greatly influence decisions regarding future care (see Cultural Competence box). Whereas some families willingly plan to take the child home, others consider foster care or adoption. Institutionalization is no longer an option. The nurse must answer questions regarding developmental potential carefully, since the responses may influence the parents’ decision. It is obvious from ranges such as those given in Table 24-3 that the potential for developmental achievement varies greatly. Therefore it would be inaccurate and unfair to predict the child’s intellectual capacity at birth. It is important to stress that a decision regarding placement will affect all of the family members’ lives and need not be made at the time of diagnosis (see Critical Thinking Exercise). The nurse should emphasize every available source of assistance, such as parent groups, professional counseling, and literature, to help the family learn about Down syndrome and deal with childrearing problems.*

Assist the Family in Preventing Physical Problems: Many of the physical characteristics of Down syndrome present challenges. The hypotonicity of muscles and hyperextensibility of joints complicate positioning. The limp, flaccid extremities resemble the posture of a rag doll; as a result, holding the infant is difficult and cumbersome. Sometimes parents perceive this lack of molding to their bodies as evidence of inadequate parenting. The extended body position promotes heat loss because more surface area is exposed to the environment. Encourage parents to swaddle the infant (wrap him or her tightly in a blanket) before picking up the infant to provide security and warmth. The nurse also discusses with parents their feelings concerning attachment to the child, emphasizing that the child’s lack of clinging or molding is a physical characteristic, not a sign of detachment or rejection.

Critical Thinking Exercise—Down Syndrome

Decreased muscle tone compromises respiratory expansion. In addition, the underdeveloped nasal bone causes a chronic problem of inadequate drainage of mucus. The constant stuffy nose forces the child to breathe by mouth, which dries the oropharyngeal membranes and thus increases the susceptibility to upper respiratory tract and ear infections. Measures to lessen infection include clearing the nose with a bulb-type syringe, rinsing the mouth with water after feedings, increasing fluid intake and using a cool-mist vaporizer to keep the mucous membranes moist and the nasal secretions liquefied, changing the child’s position frequently, and practicing good hand-washing technique. If antibiotics are ordered, the importance of completing the full course of therapy for successful eradication of the infection and prevention of growth of resistant organisms is stressed. Because hearing impairment is common and can interfere with development, the nurse should emphasize the importance of auditory testing.

Feeding difficulties may occur. The large, protruding tongue and hypotonia interfere with breast-feeding, bottle-feeding, and introduction of solid foods. Parents need to know that the tongue thrust does not indicate refusal to feed but is a physiologic response. Advise parents to use a small but long, straight-handled spoon to push the food toward the back and side of the mouth. If food is thrust out, it should be refed. At times the family may require the assistance of a specially trained individual, such as a lactation expert or occupational therapist, to guide them in dealing with feeding problems.

Dietary intake, especially of solid foods, needs supervision. Decreased muscle tone affects gastric motility, predisposing the child to constipation. Dietary measures such as increased fiber and fluid intake promote evacuation. The child’s eating habits need careful monitoring to prevent obesity. Obtain height and weight measurements on a serial basis and plot them on specialized growth charts, especially during infancy, because excessive weight gain can impede motor development. The child should receive calories in accordance with height and weight, not chronologic age.

During infancy the child’s skin is pliable and soft. However, it gradually becomes rough and dry and is prone to cracking and infection. Skin care involves minimum use of soap and application of lubricants. Apply lip balm to the lips, especially when the child is outdoors, to prevent excessive chapping.

Promote the Child’s Developmental Progress: Hypotonicity affects muscular development. Supporting skills, such as rolling over, sitting up, standing, or pulling oneself to a sitting or standing position, may be delayed. These children should be involved in an early stimulation program that provides physical therapy to help them learn motor skills.

Assess the child’s developmental progress at regular intervals, and encourage therapeutic adherence to a stimulation program. Developmental screening tests are inadequate to evaluate indications of progress such as increased strength, balance, coordination, or muscle tone. Therefore keep detailed written records of the child’s motor abilities to distinguish subtle changes in functioning. Periodic formal testing should also occur.

Parents can investigate appropriate daycare programs for the child as soon as possible. They should also investigate the public school system for special education classes, including early intervention programs and preschools. The nurse should give attention to preventing the problem of overprotection and including family members, especially the father and siblings, in the caring role.

Assist in Prenatal Diagnosis and Genetic Counseling: Prenatal diagnosis of Down syndrome is possible through chorionic villus sampling and amniocentesis, since chromosomal analysis of fetal cells can detect the presence of trisomy or translocation. Sporadic cases occur in young mothers that are not identified because there is no indication for prenatal testing. However, maternal testing for low serum α-fetoprotein levels, high chorionic gonadotropin levels, and low unconjugated estriol levels may identify potential cases, and these women can then undergo amniocentesis (Descartes and Carroll, 2007; Hall, 2007).

Offer prenatal testing and genetic counseling to women of advanced maternal age or those with a family history of Down syndrome. Although many women elect to have testing, some do not. If testing is conducted and the fetus is affected, the nurse must allow the parents to express their feelings concerning elective abortion and support their decision to terminate or proceed with the pregnancy. It is important for nurses to be aware of their own attitudes regarding testing and related decisions.

Prognosis: Individuals with fragile X syndrome are expected to live a normal life span. Their CI may improve with behavioral and educational interventions, which should begin in preschool. Newborn inexpensive screening methods for fragile X syndrome is being researched in the United States, in line with the broadening of newborn screening criteria to include neurodevelopmental disorders that would benefit from early intervention (Bailey, Beskow, Davis, et al, 2006; Tassone, Pan, Amiri, et al, 2008). The availability of this test will likely facilitate expansion of the newborn screening in other high-risk populations (Hagerman, Berry-Kravis, Kaufmann, et al, 2009).

Etiology: A number of prenatal and postnatal conditions can cause hearing loss. It is often associated with a family history of childhood hearing impairment, anatomic malformations of the head or neck, low birth weight, severe perinatal asphyxia, perinatal infection (cytomegalovirus, rubella, herpes, syphilis, toxoplasmosis, and bacterial meningitis), maternal prenatal substance abuse, chronic ear infection, cerebral palsy, Down syndrome, or administration of ototoxic drugs (Haddad, 2007; Smith, Bale, and White, 2005). In addition, high-risk neonates who survive once-fatal prenatal or perinatal conditions may be susceptible to hearing loss from the disorder or its treatment. For example, sensorineural hearing loss may result from exposure to the continuous humming noises or high noise levels associated with incubators, oxygen hoods, or intensive care units, especially when combined with the use of potentially ototoxic antibiotics.

Environmental noise is a special concern. Sounds loud enough to damage sensitive hair cells of the inner ear can produce irreversible hearing loss. Very loud, brief noise, such as gunfire, can cause immediate, severe, and permanent loss of hearing. Longer exposure to less intense but still hazardous sounds, such as loud persistent music via headphones, sound systems, concerts, or industrial noises, can also produce hearing loss (Daniel, 2007; Holte, 2003; Kenna, 2004). The exact sound level that produces hearing loss is unknown.

Pathology: Disorders of hearing are categorized according to the location of the defect. Conductive or middle ear hearing loss results from interference with transmission of sound to or by the middle ear. It is the most common of all types of hearing loss and most frequently is a result of recurrent serous otitis media. Conductive hearing impairment mainly involves interference with the loudness of sound.

Sensorineural hearing loss involves damage to the inner ear structures or the auditory nerve. The most common causes are congenital defects of inner ear structures and consequences of acquired conditions, such as kernicterus, infection, administration of ototoxic drugs, or exposure to excessive noise. Sensorineural hearing loss results in distortion of sound and problems in auditory discrimination. Although the child hears some of everything going on around him or her, the sounds are distorted, which severely affects discrimination and comprehension.

Mixed conductive-sensorineural hearing loss results from interference with transmission of sound in the middle ear and along neural pathways. It frequently results from recurrent otitis media and its complications.

Central auditory imperception includes all hearing losses for which defects in the conductive or sensorineural structures are not demonstrated. They are usually divided into organic and functional losses. In the organic type of central auditory imperception, the defect involves the reception of auditory stimuli along the central pathways and the processing of the message into meaningful communication. Examples are aphasia, the inability to express ideas in written or verbal form; agnosia, the inability to interpret sound correctly; and dysacusis, difficulty in processing details of sound or in discriminating among sounds. The functional type of hearing loss has no organic lesion to explain a central auditory loss. A functional hearing loss may occur in conversion disorder (an unconscious withdrawal from hearing to block remembrance of a traumatic event).

Symptom Severity: Hearing impairment is expressed in terms of the decibel (dB), a unit of loudness (Table 24-4). It is measured at various sound frequencies, such as 500, 1000, and 2000 cycles/sec, the critical listening range for speech. Hearing impairment can be classified according to hearing level (the individual’s hearing threshold as measured by an audiometer) and the degree of symptom severity as it affects speech (Table 24-5). These classifications offer only general guidelines regarding the effect of the impairment on any individual child, because children differ greatly in their ability to use residual hearing.

Assess for Hearing Concerns: Assessment of children for hearing impairment is a critical nursing responsibility. Identification of a hearing loss within the first 3 to 6 months of life is essential to facilitate language and educational development for children with hearing impairments (Bradham and Bess, 2004; Kenna, 2004; Tierney and Brown, 2008). Assessment involves (1) identifying those children who by virtue of their history are at risk (Box 24-7), (2) observing for behaviors that indicate a hearing loss, and (3) screening all children for auditory function. This discussion focuses on the development and behavior associated with hearing impairment. There is controversy regarding which children should be assessed and when they should be assessed. The Joint Committee on Infant Hearing (2000) issued guidelines on auditory screening of newborns and infants to detect early hearing loss and implement intervention programs.

Promote the Communication Process: The nurse’s initial role in rehabilitation is to encourage the family to participate in an auditory training program.* Rehabilitation training provides assistance in learning appropriate methods for improving communication, such as use of hearing aids, lipreading, sign language, and speech and language therapy.

Support the Child and Family: Once the diagnosis of hearing impairment is made, parents may need extensive support to adjust to the shock of learning about their child’s disability and an opportunity to realize the extent of the hearing loss. If the hearing loss occurs during childhood, the child also requires sensitive, supportive care during the long and often difficult adjustment to this sensory loss. Early rehabilitation is one of the best strategies for fostering adjustment. Progress in learning communication may not always coincide with emotional adjustment, however. Depression or anger is common, and such feelings are a normal part of the grieving process. Parent support groups are often helpful because other parents have dealt with the same issues and can offer practical advice and emotional support.† (See Chapter 22 for an extensive discussion of the emotional support of the child and family.)

Care for the Child During Hospitalization: The needs of the hospitalized child with a hearing impairment are the same as those of any other child, but the disability presents special challenges to the nurse (see Critical Thinking Exercise). For example, verbal explanations must be supplemented using tactile and visual aids, such as books or actual demonstration and practice. Children’s understanding of the explanation needs to be constantly reassessed. If their verbal skills are poorly developed, they can answer questions through drawing, writing, or gesturing. For example, if the nurse is attempting to clarify where a spinal tap is done, ask the child to point to where the procedure will be done on the body. Because hearing impaired children often need more time to grasp the full meaning of an explanation, the nurse needs to be patient, allowing ample time for understanding.

When communicating with the child, the nurse should use the same principles as those outlined for facilitating lipreading. Ideally nurses without foreign accents should be assigned to care for the child. The child’s hearing aid is checked to ensure that it is working properly. If it is necessary to awaken the child at night, the nurse should gently shake the child or turn on the hearing aid before waking the child. The nurse should always make certain that the child can see him or her before any procedures, even routine ones such as changing a diaper or regulating an infusion. It is important to remember that the child may not be aware of the nurse’s presence until alerted through visual or tactile cues.

Ideally parents should room with the child. However, the nurse must convey to them that this is not done for the nurse’s convenience but for the child’s benefit. Although the parents’ aid can be enlisted in familiarizing the child with the hospital and explaining procedures, the nurse should also talk directly to the youngster, encouraging expression of feelings about the experience. If the child’s speech is difficult to understand, try to become familiar with his or her pronunciation of words. Parents often can help by explaining the child’s usual speech habits. Nonverbal communication devices that employ pictures or words to which the child can point are also available. The nurse can also make boards by drawing pictures or writing on cardboard the words representing common needs, such as parent, food, water, and toilet.

The nurse has a special role as child advocate for the hearing impaired and is in a strategic position to alert other health care team members and other patients to the child’s special needs regarding communication. For example, the nurse should accompany other practitioners on visits to the child’s room to ensure that they speak to the child and that the child understands what is said. Not infrequently, caregivers forget that the child has the ability to perceive and learn despite a hearing loss, and consequently they communicate only with the parents. As a result, the child’s needs and feelings remain unrecognized and unaddressed.

Because children with hearing impairment may have difficulty forming social relationships with other children, introduce the child to roommates and encourage them to play. The hospital setting can provide growth-promoting opportunities for social relationships. With the assistance of a child life specialist, the child can learn new recreational activities, experiment with group games, and engage in therapeutic play. Playing with puppets or dollhouses, role playing with dress-up clothes, building with a hammer and nails, finger painting, playing with syringes, and participating in water play can help the child express feelings that previously were suppressed.

Assist in Measures to Prevent Hearing Impairment: A primary nursing role is prevention of hearing loss. Because the most common cause of impaired hearing is chronic otitis media, it is essential to institute appropriate measures to treat existing infections and prevent recurrences. (See Chapter 32.) Children with a history of ear or respiratory tract infections or any other condition known to increase the risk of hearing impairment should receive periodic auditory testing.

To prevent the causes of hearing loss that begin prenatally and perinatally, pregnant women need counseling regarding the necessity for early prenatal care, including genetic counseling regarding known familial disorders; avoidance of all ototoxic drugs, especially during the first trimester; testing to rule out syphilis, rubella, and blood incompatibility; medical management of maternal diabetes; strict control of alcoholism; and adequate dietary intake. Stress the need for routine immunization during childhood to eliminate the possibility of acquired sensorineural loss from rubella, mumps, or measles (encephalitis).

Exposure to excessive noise pollution is a well-established cause of sensorineural hearing loss. The nurse should routinely assess the possibility of environmental noise pollution and advise children and parents of the potential danger. When individuals engage in activities associated with high-intensity noise, such as model airplane flying, target shooting, or snowmobiling, they should wear ear protection such as earmuffs or earplugs—not ordinary dry cotton, although any protection is better than none. Even common household equipment, such as lawn mowers and power vacuum cleaners, can be harmful.