Sensorineural hearing loss imprint on fine motor skills: A pediatric and adolescent innovative study

Abstract

BACKGROUND:

Sensorineural hearing loss is the most common type of permanent hearing impairment and results in balance and motor deficits in children which may affect and/or delay all developmental indicators.

OBJECTIVE:

The purpose of this study was to investigate the consequences of sensorineural hearing loss regarding fine motor skills in children and adolescents.

METHODS:

Two hundred children with an age range between 7 to 18 years and diagnosed with sensorineural hearing loss were selected from the Public School for the Deaf and Hard of Hearing in El-Minia district, Minia governorate, Egypt. The outcome was assessed by the use of Bruininks-Oseretsky Test of Motor Proficiency Second Edition scale (BOT-2) to measure fine motor skills.

RESULTS:

There was a statistically significant difference between the scores of Fine Motor Precision and Fine Motor Integration subtests of each study subgroup and its counterpart subgroup in the control group (normative values according to the scale) which has the same age and gender characteristics where p value equals (0.0008 or less, 0.0009 or less) respectively, with a large effect size less than –0.83.

CONCLUSION:

The findings of this study suggest that children with sensorineural hearing loss have a defect in their fine motor skills when compared to normal children of the same gender and age groups according to Bruininks-Oseretsky scale.

Keywords

Sensorineural hearing loss fine motor skills BOT-2 pediatric

1 Introduction

Hearing impairment in childhood and adolescence is a significant problem in public health and is classified as a common disability (McCormick, 2018). Hearing impairment is one of the most common chronic conditions that cause health complications and handicaps for the patients and is considered overload for their families (Quittner et al., 2010). More than five percent of people around the world –or 466 million people –suffer from hearing impairment (432 million adults and 34 million children). It is supposed that by 2050 more than nine hundred million people –or one in every ten people –will have disabling hearing loss (WHO, 2010). In Egypt, the hearing impairment prevalence in children ranged from 13.8% (Hamid et al. 2010) to 20.9% and was more prevalent with increasing age (Taha et al., 2010).

There are three sorts of hearing loss including conductive hearing loss, mixed hearing loss, and sensorineural hearing loss (SNHL), which is the most common type (Rajendran & Roy, 2011). The main cause of the SNHL may be idiopathic, genetic, prenatally acquired, postnatal acquired, or craniofacial anomalies (Angeles et al., 2006). A recent systematic review confirms that balance and motor impairments were associated with hearing impairment (Rajendran et al., 2013). Furthermore, Rine and colleagues mentioned a progressive motor deficit in children with sensorineural hearing loss (Rine et al., 2000). In line with other researchers, Wiegersma et al. confirmed that deaf children had in general both dynamic balance deficits, and visual-motor incoordination that may affect the fine motor performance of the children with SNHL (Wiegersma & Velde, 1983). They are likely to present with delays in important aspects of non-verbal development such as balance, and motor development which are reflected on their quality of life (QOL) (Squittner et al., 2004). QOL is the person’s awareness of their position in life in the perspective of the culture and value systems in which they live and is affected by the individual’s physical health, psychological condition, individual’s beliefs, and social relations (Roland et al., 2016). Studies mentioned that when QOL was measured in children with hearing loss, they have lower scores when compared with their counterparts with normal hearing (Umansky, 2011). The lower the QOL for pediatric patients with SNHL, the lower the developmental progress of their physical, educational, social, and emotional function (Eliasson et al., 2006).

With normal development in children, fine motor skills develop rapidly during the first years of life with a subsequent refinement throughout childhood and approximate that of adults at the age of six to eight years (Eliasson et al., 2006). There are acquisitions for normal fine motor skills development at an early age which are necessary to accomplish various daily living activities (Gaul & Issartel, 2016). There are elements that are essential for the successful completion of fine motor functions which are precise control of fingers, coordinated hand and arm movements, and visual-motor integration so (Gerber et al., 2010).

A review by Rajendran et al. reported that the Bruininks-Osretsky test of Motor Proficiency scale (BOT-2) can be used as an assessment tool for HI children with motor deficits (Rajendran et al., 2013). It has an appropriate validity and reliability as well as high sensitivity and characteristic in children and can be used to evaluate motor skills (Gharaei et al., 2019) and this result is consistent with studies of the simultaneous validity of the BOT-2 (Vinçon et al., 2017; Schulz et al., 2011).

To the best of our knowledge, there is a lack of information regarding the fine motor skills of children with SNHL. By comparing the fine motor performance of the hearing impaired children with the scores of normal-hearing peers, it may be possible to determine whether retardation of this function is associated with SNHL. Therefore, this study aimed to investigate the effect of sensorineural hearing loss on fine motor skills in children and adolescents with SNHL.

2 Methods

2.1 Subjects

This cross-sectional study was administered over three months from October to December 2019. Two hundred children were recruited from the Public School for the Deaf and Hard of Hearing in El-Minia district, Minia governorate, Egypt, and their ages ranged from 7 to 18 years. Before data collection, the study was approved by the Research Ethical Committee from the Faculty of Medicine, El-Minia University (No. 625-5/2020), informed consent was obtained from the parents of all participants, and assent forms were obtained from all subjects.

The participants were screened to ensure that they met the following inclusion criteria for the study: both boys and girls with a clinical diagnosis of SNHL only, ages between 7 and 18 years, able to understand simple instructions by sign language, and able to use pen and write independently. The exclusion criteria were: any cognitive, physical, visual, or neurological condition (other than SNHI and vestibular impairment), history of previous upper limb fracture/surgical procedure that interfere with fine motor skills, or enrolled in a previous or current physical or occupational therapy program. All of these cases were confirmed by medical records and examined by a physical therapist, pediatrician, and audiologist, as shown in Fig. 1.

Fig. 1

Flowchart.

2.2 Measures

The outcomes were assessed by BOT-2 second edition. BOT-2 is an individually administered test that uses engaging, goal-directed activities to measure motor skills in individuals of ages 4 to 21. It has an appropriate validity and reliability as well as high sensitivity in children and can be used to evaluate motor skills (Gharaei et al., 2019) and this result is consistent with the studies of the simultaneous validity of the BOT-2 (Vinçon et al., 2017; Schulz et al., 2011), as shown in Fig. 2. Both versions are categorized into four composite motor domains each containing two motor subtests, but we only used the Fine Manual Control which contains Fine Motor Precision and Fine Motor Integration.

Fig. 2

BOT-2 fine motor form.

Total motor composite and subtest measures are available as a raw score, standard score, percentile rank, and descriptive category (“well below average”, “below average”, “average”, “above average and “well above average”). Gender-specific norms were used for scoring as the BOT-2 authors reported these as more precise than combined gender norms (Bruininks & Bruininks, 2005).

The BOT-2 uses a subtest and complex structure that reflects motor performance in the wide functional areas of stability, mobility, strength, coordination, and object manipulation. In this study we used the Fine Manual Control composite only which measures control and coordination of the distal musculature of the hands and fingers, especially for grasping, drawing, and cutting through Fine Motor Precision and Fine Motor Integration subtests.

The Fine Motor Precision subtest is a series of activities that require accurate control of fingers and hand movement. The objective is to draw, fold, or cut within a specified boundary. A child’s score is consistent with individuals who generally make no errors when drawing a line through a crooked path (3 mm wide, 20 cm long) and can remain within a boundary 1 cm wide when cutting out a circle.

The Fine Motor Integration subtest requires the examinee to reproduce drawings of many geometric shapes that range in difficulty from a circle to overlapping pencils. The child’s score is consistent with individuals who, when copying from pictures, can precisely draw different geometric figures such as a triangle and a wavy line, as well as more composite designs such as a five-point star and overlapping pencils.

2.3 Statistical analysis

Statistical analysis was performed using SPSS, version 23 for Windows (SPSS Inc., Chicago, IL, USA). Descriptive statistics for patients’ ages and the dependent variable (subset 1, subset 2) were calculated as mean, and standard deviation. The Mann-Whitney U test was conducted for comparison between groups. The effect size statistic for the Mann–Whitney U test (r) was calculated (0.1 to 0.3 is small effect; 0.3 to 0.5 is Medium effect and more than 0.5 is high effect). The alpha level of significance (α) was set less than 0.05.

3 Results

In this study, 200 deaf students participated, who were divided into 8 subgroups according to school stage (KG, primary school, preparatory school, and high school) and gender (male and female). The study group scores of subset 1 (Fine Motor Precision subtest) and subtest 2 (Fine Motor Integration subtest) were compared to the normative fine motor skills scores of children of the same gender and same age according to Bruininks-Oseretsky Test of Motor Proficiency scale, second edition. The mean values of the study group’s age are presented in Table 1.

Table 1
Mean values of age of each subgroup

Variable Gender Number Study group Mean±SD

KG Male 16 7.38±0.46

Female 8 7.34±0.49

Primary school Male 59 10.62±1.03

Female 27 10.51±1.12

Preparatory school Male 31 13.75±0.79

Female 23 13.41±0.89

High school Male 24 16.89±0.86

Female 12 16.92±0.74

Total 200

Variable	Gender	Number	Study group Mean±SD
KG	Male	16	7.38±0.46
	Female	8	7.34±0.49
Primary school	Male	59	10.62±1.03
	Female	27	10.51±1.12
Preparatory school	Male	31	13.75±0.79
	Female	23	13.41±0.89
High school	Male	24	16.89±0.86
	Female	12	16.92±0.74
Total		200

3.1 Results of subset 1 (Fine Motor Precision subtest)

The Mann-Whitney U test revealed that there was a statistically significant difference between the scores of each study subgroup and its counterpart subgroup in the control group (normative values according to the scale) that has the same age and gender characteristics where p-value equals 0.0008 or less with a large effect size less than –0.83, as presentd in Table 2 and Fig. 3.

Table 2
Subset 1 results

Variable Gender Study Control Z value p-value Effect size (r)

Mean±SD Mean±SD

KG Male 9.37±2.16 31.2±2.38 –4.82 < 0.00001 –0.85

Female 12.87±1.64 33.25±1.39 –3.33 0.0008 –0.83

Primary school Male 15.02±2.67 37.88±1.53 –9.43 < 0.00001 –0.87

Female 17.44±1.5 38.59±0.75 –6.46 < 0.00001 –0.88

Preparatory school Male 15.03±2.79 40.06±0.25 –7.14 < 0.00001 –0.91

Female 17.61±1.72 39.08±0.29 –6.11 < 0.00001 –0.9

High school Male 21.75±1.82 41±0.00 –6.35 < 0.00001 –0.92

Female 25.08±1.97 40±0.00 –4.42 0.00001 –0.9

Variable	Gender	Study	Control	Z value	p-value	Effect size (r)
KG	Male	9.37±2.16	31.2±2.38	–4.82	< 0.00001	–0.85
	Female	12.87±1.64	33.25±1.39	–3.33	0.0008	–0.83
Primary school	Male	15.02±2.67	37.88±1.53	–9.43	< 0.00001	–0.87
	Female	17.44±1.5	38.59±0.75	–6.46	< 0.00001	–0.88
Preparatory school	Male	15.03±2.79	40.06±0.25	–7.14	< 0.00001	–0.91
	Female	17.61±1.72	39.08±0.29	–6.11	< 0.00001	–0.9
High school	Male	21.75±1.82	41±0.00	–6.35	< 0.00001	–0.92
	Female	25.08±1.97	40±0.00	–4.42	0.00001	–0.9

Fig. 3

The mean values of subtest 1 scores.

3.2 Results of subset 2 (Fine Motor Integration)

The Mann-Whitney U test revealed that there was a statistically significant difference between the scores of each study subgroup and its counterpart subgroup in the control group (normative values according to the scale) that has the same age and gender characteristics where p-value equals 0.0009 or less with a large effect size less than –0.83, as presented in Table 3 and Fig. 4.

Table 3
Subset 2 results

Variable Gender Study Control Z value p-value Effect size (r)

Mean±SD Mean±SD

KG Male 6.69±1.99 31.68±1.4 –4.83 < 0.00001 –0.85

Female 10±2 34±1.51 –3.32 0.0009 –0.83

Primary school Male 16.89±4.02 37.1±1.33 –9.48 < 0.00001 –0.87

Female 15.07±2.13 37.63±0.63 –6.45 < 0.00001 –0.88

Preparatory school Male 14.03±2.6 38.87±0.49 –6.95 < 0.00001 –0.88

Female 21.96±1.82 38.61±0.49 –5.92 < 0.00001 –0.87

High school Male 20.29±2.23 40±0.00 –6.34 < 0.00001 –0.91

Female 22.83±2.72 39±0.00 –4.41 0.00001 –0.9

Variable	Gender	Study	Control	Z value	p-value	Effect size (r)
KG	Male	6.69±1.99	31.68±1.4	–4.83	< 0.00001	–0.85
	Female	10±2	34±1.51	–3.32	0.0009	–0.83
Primary school	Male	16.89±4.02	37.1±1.33	–9.48	< 0.00001	–0.87
	Female	15.07±2.13	37.63±0.63	–6.45	< 0.00001	–0.88
Preparatory school	Male	14.03±2.6	38.87±0.49	–6.95	< 0.00001	–0.88
	Female	21.96±1.82	38.61±0.49	–5.92	< 0.00001	–0.87
High school	Male	20.29±2.23	40±0.00	–6.34	< 0.00001	–0.91
	Female	22.83±2.72	39±0.00	–4.41	0.00001	–0.9

Fig. 4

The mean values of subtest 2 scores.

4 Discussion

The findings of this study indicate that children with SNHL have an extreme developmental deficits in their fine motor skills which are measured by The Bruininks-Oseretsky Test of Motor Proficiency scale. The results of subset 1 and 2 revealed that there was a statistically significant difference between the scores of each study subgroup and its age and gender-matched control subgroup where p-value equals 0.0008 or less in subset 1 and 0.0009 or less in subset 2 with a large effect size less than –0.83 indicating the control group has greater values than the study group.

The results of this study are in line with the study by Esther et al., who examined 42 deaf children in deaf elementary school children and found that their motor performance was lower than the normative sample that had the same age (Esther et al., 2011). It has also been reported that the performance of deaf persons was affected due to incoordination, clumsiness, and balance deficits (Rajendran & Roy, 2011).

Development and maintenance of postural control are essential for skilled movement performance especially for the acquisition of optimal reaching and grasping behaviors needed (Lobo & Galloway, 2008). Posture stability is essiential for infants to learn successful grasping gradually (Cunha et al., 2013). Deaf handicapped persons who have motor disabilities do not receive any signals, signs, or sounds from the surrounding environment, so they cannot perform a motor task in a different way (Zwierzchowska et al., 2008).

The first explanation for poor fine motor skills may be attributed to reduced dynamic visual acuteness. The children with SNHL may present with poor dynamic visual acuteness as a result of gaze instability due to reduced vestibular function (Martin et al., 2012). Several authors mentioned that children with SNHL are more likely to have an impairment of the vestibular system than normal-hearing children (Zhou et al., 2008). Children with congenital vestibular impairment often display delayed gross motor development, and visual tasks, such as learning how to read,which may be may be problematic for students as a result of impairment of the gaze stabilizing function of the vestibular system (Braswell & Rine, 2006). Motor performance depends on dynamic visual acuteness and severity of the sensorineural hearing loss. The prevalence of reduced dynamic visual acuteness is 15.6% so it is important to assess children with SNHL for the presence of abnormal dynamic visual acuteness as well as motor retardation, as they can have serious implications for the safety, education, and general wellbeing of these children (Martin et al., 2012).

The second explanation for these results may be attributed to late diagnosis of hearing impairment as it is also observed that the rate of delay in developmental domains increased in line with the delay of diagnosis and that children with hearing loss diagnosed before 6 months are found to have a higher rate of “normal” social-personal, language, fine and gross motor field skills than those diagnosed between 6 and 12 months and 12 and 18 months (Sahli, 2019). Similarly, Hitchins and Hogan mentioned that it is useful and very important for all domains of development in children with hearing loss to maintain early diagnosis and intervention programs which are very useful for identifying and monitoring the progression (Hitchins & Hogan, 2018). Moreover, delayed use of hearing aid may be a cause of poor fine motor skills in our study results as Sahli observed in his study that children with hearing loss who were instrumented between 3 and 6 months and started auditory-verbal training before 6 months showed normal development in personal-social, language, fine and gross motor domains, whereas the delay in developmental domains increased in line with the delay in amplification and auditory-verbal training (Sahli, 2019). In contrast, Freja Gheysen and colleagues investigated the effect of a cochlear implant on the motor development of deaf children. The findings of their study showed that it does not matter for deaf children with or without cochlear implantation to perform better in balance and motor skills (Gheysen et al., 2008). In the present study, a small number of female students participated in the study, especially in KG and high school stages. Further analysis in a larger population is recommended.

5 Conclusion

Childhood hearing impairment is a world-wide problem that causes serious limitations for children, as it retards their optimal development in general and especially their fine motor skills. The results of this study support the idea that children with SNHL have fine motor deficits, which justifies the need for early diagnosis and early multidisciplinary intervention.

Author contributions

Roshdy M. Kamel has contributed to acquisition, analysis, and interpretation of the data. Elsayed S. Mehrem has substantially contributed to the conception or design of the manuscript. All authors have drafted the manuscript. Mohamed M. Essa, Samir M. Mounir, Mohamed A. Elbedewy, and Lamyaa A. Fergany critically revised the manuscript. All authors have read and approved the final version of the manuscript.

Footnotes

Acknowledgments

The authors acknowledge all sign language teachers for their help to communicate with deaf students and help them to understand the tasks required.

Conflict of interest

The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. The authors report no involvement in the research by a sponsor that could have influenced the outcome of this work. Furthermore, neither the submitted material nor portions of it have been published previously or are under consideration for publication elsewhere.

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