May 1, 2013 Features

Sonic Youth

Protecting ourselves from noise-induced hearing loss should begin in childhood. What can audiologists do to convince kids—and their teachers and parents—to protect their hearing?

When Pete Townshend, guitarist and songwriter of the classic rock group The Who, penned the song "Tommy Can You Hear Me?" in the late 1960s, he probably didn't realize how ironically prescient his song title was. Townshend now suffers from significant hearing loss and tinnitus that resulted from his exposure to loud music during decades of rehearsing and performing.


The association between loud noise exposure and hearing loss has been apparent for centuries. Italian physician Bernardino Ramazzini reported cases of "coppersmith's deafness" in 1713. In 1830, British scientist and physician John Fosbroke coined the term "blacksmith's deafness." In 1882, physician E.E. Holt described "boiler-maker's deafness" in the journal Transactions of the American Otological Society. The assault on our hearing by modern machines, music and firearms continues today.

There's only one way to prevent noise-induced hearing loss, and that's by protecting yourself from exposure to loud sounds. That protection should—but often doesn't—start when children are young.

Townshend is not alone

Loud workplaces, recreational activities and military service can all contribute to the prevalence of hearing loss in adults.

  • Occupational hearing loss is the most common work-related injury in the United States, according to the National Institute for Occupational Safety and Health: "Approximately 22 million U.S. workers are exposed to hazardous noise levels at work ... An estimated $242 million is spent annually on worker's compensation for hearing loss disability".
  • Hearing loss and tinnitus are the two most prevalent service-connected disabilities among all U.S. military veterans, including those who served most recently in Iraq and Afghanistan. Although all U.S. military branches have hearing conservation programs, compliance is problematic. Service members' exposure to loud sounds during training, combat and occupational and recreational activities contributes to the audiologic symptoms many of them experience immediately or later in their lives.
  • About 15 percent of Americans between the ages of 20 and 69—or 26 million Americans—have high-frequency hearing loss "that may have been caused by exposure to loud sounds or noise at work or in leisure activities," claims the National Institute on Deafness and Other Communication Disorders. Like most published estimates of hearing loss prevalence, this figure surely understates the scope of the problem.

The consequences of noise-induced hearing loss are familiar to millions of patients and the clinicians who work with them. Problems associated with NIHL include communication difficulties (especially understanding conversations in background noise), tinnitus, and hyperacusis or loudness recruitment. Patients who experience these symptoms often feel isolated, frustrated, anxious or depressed, resulting in reduced quality of life.

Effects on kids

Although many people think of NIHL as a condition that emerges later in life, children are not immune to the effects of loud sounds. When humans of any age are exposed repeatedly to hazardous sound levels without using adequate hearing protection, the common result is NIHL.

In an article in American Journal of Diseases in Children in 1967—more than 45 years ago—Ursula Anderson reported a relatively high prevalence of NIHL in school-age children. Other studies have found:

  • One percent of the U.S. school-age population has some degree of NIHL.
  • An estimated 12.5 percent of all U.S. children age 6–19 have noise-induced hearing threshold shifts in one or both ears.
  • Children studied by researchers in Sweden, China, France, Australia and the United States have NIHL. Many of these studies concluded that listening to loud music for extended periods of time contributed to the children's hearing loss.
  • The degree of high-frequency hearing loss detected in these studies was generally mild and usually unnoticed by the children involved, but researchers warn that audiometric thresholds may be normal or nearly normal in individuals who exhibit substantial damage to cochlear hair cells. Other studies concluded that excessive noise exposure early in life can accelerate hearing loss progression in later years.

Children with high-frequency hearing loss in Anderson's study had more learning difficulties and behavioral problems than their classmates with normal hearing. In a 1998 article in Ear and Hearing, Fred Bess and his colleagues reported that children with minimal sensorineural hearing loss scored significantly lower on the Comprehensive Test of Basic Skills, and exhibited more behavioral problems and lower self-esteem than classmates with normal hearing. Thirty-seven percent of children in the study with minimal sensorineural hearing loss failed at least one grade, compared to the school district average of eight percent or less, indicating that even a small degree of hearing loss can adversely affect children's development and academic performance.

Strategies for reducing NIHL

Numerous experts have recommended implementing hearing conservation education programs in schools. Many of these recommendations from such high-profile agencies as the National Institutes of Health and the World Health Organization—made during the last 40 years—are listed in my 2002 AudiologyOnline article, "Why aren't hearing conservation practices taught in schools?".

Contrary to these recommendations, however, basic instruction on hearing protection—which could prevent many cases of NIHL—remains conspicuously absent from the curricula in U.S. schools. Reasons for this omission include:

  • Little public awareness about how excessive sound exposure damages hearing, the consequences of hearing loss and the preventability of NIHL.
  • Low priority of NIHL compared to the potential life-and-death consequences related to other health topics—such as smoking, drugs, alcohol, sex and personal safety—emphasized in schools.
  • Ineffective dissemination of hearing loss prevention programs and materials. In some areas throughout the country, dedicated individuals visit schools to present information about hearing loss to students. Although these efforts are important, the total number of students who receive such instruction annually is minuscule when compared to the number of children in our country who should hear these messages as part of their health education.
  • Lack of a mandate. No policies require hearing loss prevention practices be taught in the nation's classrooms. Occupational Safety and Health Administration noise exposure requirements apply to workers on the job, but not to children attending school. A survey of middle school and high school industrial arts classes revealed that hearing loss prevention practices often are not implemented, even in these noisy environments.

Call for action in schools

In October 2006, the first international conference on NIHL in children was held in Covington, Ky. One conference outcome was the publication of 18 articles (14 in Seminars in Hearing and four in the American Journal of Audiology) on NIHL and its prevention. Two years later, the Centers for Disease Control and Prevention carried out the second outcome when it added noise-induced hearing loss to its list of health topics in the Division of Adolescent and School Health.

The CDC's School Health website calls for schools to step up to the plate, emphasizing research indicating that people who are educated about noise-induced hearing loss and hearing loss prevention are more likely to use hearing protection devices in future occupational and recreational settings. However, school districts, municipalities and state boards of education are under no obligation to implement these recommendations.

What can audiologists, speech-language pathologists and other professionals do to bring these concepts to the nation's children?

  • Raise public awareness about hearing, how hearing can be damaged by excessive sound exposure, the consequences and permanent nature of hearing loss, and how and why NIHL can and should be prevented. Encourage parents to implement hearing conservation practices at home and to communicate the importance of these precautions to children.
  • Inform teachers and school administrators about existing hearing conservation programs, curricula and materials that can be used in classrooms.
  • Encourage teachers to integrate hearing loss prevention messages into lesson plans on hearing, sound, music, science, math and health. The National Association for Music Education calls on music educators to recognize that noise-induced hearing loss is a widespread and serious public health issue and to help resolve this problem by monitoring and controlling the intensity of music.
  • Volunteer as a guest speaker on hearing conservation in classrooms.
  • Seek a mandate from state and local school boards and state or federal legislatures for hearing loss prevention instruction to students in grades 1, 4, 7 and 10 in all of the nation's schools every year.

A model program

Dangerous Decibels™, a hearing health education program for children, demonstrates how the ear works, how and why hearing loss occurs, and how it affects people. Developed by Oregon Health & Science University and the Oregon Museum of Science and Industry, the program operated from 2002 to 2011 with a series of 11 exhibits housed at the museum. Today, the program is online ( and includes a virtual exhibit of interactive activities based on the original museum modules; classroom curricula and activities; training and materials for teachers; and epidemiological and educational research components. A study by the Dangerous Decibels team, however, concluded that teacher-led classroom instruction was more effective than web-based activities for conveying hearing loss prevention information to students.

At the minimum, children should understand and follow these three simple protective strategies:

  1. Turn down the volume of music if it is too loud (that is, > 80 dB SPL).
  2. Move away from the source of loud sounds.
  3. If you must be exposed to loud sounds, wear earplugs or ear muffs.

It's not difficult to increase students' knowledge about hearing loss and the preventability of NIHL, but it's much more challenging to change participants' attitudes about noise exposure and motivate them to implement protective behaviors. But research shows some promising outcomes:

  • In a 2012 article in Noise Health, Shawna Dell and Alice Holmes reported a statistically significant reduction in pro-noise attitudes among the adolescents who participated in a hearing conservation education program.
  • Three studies show postinstruction increases in student intentions to protect their ears from loud sound.
  • Three other studies found increased posteducation implementation of hearing protection strategies by children and adolescents who received instruction on these concepts.

Hearing loss prevention principles should be taught regularly to children in our nation's schools. However, even if this instruction began immediately, it would take years to determine if the programs had any effect on the prevalence of NIHL. But if we consider each student who might be exposed to excessive sound levels, we should all—as clinicians, educators and parents—try to spare children and adults from the debilitating consequences of NIHL. Then future generations of musicians and others in high-volume professions won't need to wonder, "Tommy Can You Hear Me?"

Robert L. Folmer, PhD, is a research investigator at the National Center for Rehabilitative Auditory Research of the Portland VA Medical Center and associate professor of otolaryngology at Oregon Health & Science University.

cite as: Folmer, R. L. (2013, May 01). Sonic Youth : Protecting ourselves from noise-induced hearing loss should begin in childhood. What can audiologists do to convince kids—and their teachers and parents—to protect their hearing? . The ASHA Leader.

More Resources

Other organizations that provide online information about NIHL prevention for children include:


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