REVIEW Open Access
An overview of motor skill performance and
balance in hearing impaired children
and Finita Glory Roy
Childhood hearing impairment is a common chronic condition that may have a major impact on acquisition of
speech, social and physical development. Numerous literature states that injury to the vestibular organs may resul t
in accompanying balance and motor development disorders. But still postural control and motor assessments are
not a routine procedure in hearing impaired children. Hence, we aim to provide an overview on motor skill
performance and balance in hearing impaired children.
Childhood hearing impairment is a significant public
health problem, which is associated with long-term aca-
demic and communicative difficulties [1,2]. The preva-
lence of moderate to profound hearing loss in children,
including sensorineural hearing loss and conductive
hearing loss is 1 to 6 of 1000, of which, 10% hav e hea r-
ing levels that fall in the profound range [3-6]. More-
over, it is estimated that about 440 million children
worldwide have hearing loss above 85 decibels, and this
increases to about 800 million when the threshold is
reduced to 50 dB [7,8]. Although many children have
hearing impairments, each child is unique.
Newborn hearing screening has led to earlier identifi-
cation and treatment of infantswithhearingloss[7,8].
However, t he earlier identification of childhood hearing
impairment is considered critical for normal speech, lan-
guage, cognitive and social development .
As routine screening does not include assessment of
balance and motor deficits, physical therapy ser vices are
not included in the educational programme, unless
obvious neurological or orthopedic disorders are diag-
nosed. However teachers and parents of these children
often report inco-ordination, clumsiness and balance
deficits which may hinder the child’ s optimal perfor-
mance . Moreover, many pediatric health care provi-
ders are often too busy or i nadequately trained in
conducti ng elaborate developmental screening tests dur-
ing the regular clinics. These tests are performed only
when the child present with an obvious deficit .
Hence, we aim to provide a concise description on bal-
ance and motor performance in hearing impaired
Degree of hearing impairment
The degree o f hearing loss explains the severity of hear-
ing impairment. Table 1 shows the degrees of hearing
loss according to American Speech-Language Hearing
Classification of hearing impairment
American speech-lang uage hearing association has cate-
gorized hearing loss based on the part of the auditory
system damaged. Accordingly there are three basic types
of hearing loss: conduc tive hearing loss, sensorineural
hearing loss, and mixed hearing loss .
Conductive hearing loss
Results from disruption in any of the mechanism, which
conduct sound waves from external canal to the oval
window. eg. Outer ear, ear drum or middle ear. It
usually involves inability to hear faint sounds.
Sensorineural hearing loss (SNHL)
It is the most common type of permanent hearing
impairment and results from damage to the inner ear or
the nerve pathway from the inner ear to the brain.
Mixed hearing loss
It is a combination of both conductive and sensorineural
Further more, hearing impairment may exist as unilat-
eral or bilateral, and pre-lingual or post-lingual.
* Correspondence: firstname.lastname@example.org
Department of Rehabilitation Science, Holy Cross College affiliated to
Bharathidasan University, Tiruchirappalli-620 002, India
Rajendran and Roy Italian Journal of Pediatrics 2011, 37:33
© 2011 Rajendran and Roy; licensee BioMed Central Ltd. This is an Open Access article distributed under th e terms of the Creative
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People have impairment in only one ear.
People have impairment in both the ears.
It refers to hearing impairment that is sustained prior to
the acquisition of language. eg. Congenital, early infancy.
It refers t o hearing impairment that is sustained after
the acquisition of lang uag e, which can occu r as a result
of disease, trauma or a side-effect of a medicine .
Davidson et al has proposed an e tiologic classification
which c larifies the i nterac tion between time of insult,
causation and time of expression of hearing loss. Most
of the SNHL are idiopathic, and appears to occur almost
twice as often as in developed countries. Where the
cause is known it may be genetic; pre-natally acquired;
peri-natally acquired; pos t-natally acquired; cranio-facial
anomalies; and other [13,14].
Almost 50% of permanent childhood hearing impair-
ments have a genetic cause and influenced by consangui-
nity. It may be autosoma l domi nant, autosomal rece ssive
and sporadic inheritance [ 13,15]. Parker et al studied the
family history of hearing loss, the results pointing
towards different genetic disorders with autosomal domi-
nant, autosomal recessive and sporadic inheritance .
Prenatal Infections such as rubella and toxoplasmosis
are considered to be the main cause of prenatally
acquired hearing impairment. Maternal exposure to
alcohol, streptomycin, quinine and chloroquine phos-
phate may destroy neural elements of the inner ear and
contribute to congenital hearing loss . Sever et al
has r eported in his study that 38.7% mothers had anti-
bodies to toxoplasmosis during pregnancy, and their
children had double the risk of developing permanent
childhood hearing loss by age 7 .
Perinatal factors such as prematurity, low birth weight,
hypoxia, Apgar scores 0-4 at 1 min; and 0-6 at 5 min,
ventilation required for five days or more, hyperbilirubi-
nemia r equiring transfusion, and admission to the neo-
natal intensive care unit for 48 hours or longer may
predispose to permanent childhood hearing impairment
. Davis and wood found that one in 174 NICU grad-
uates had a hearing impairmen t compared with one in
1278 non-NICU babies .
Post natal factors
There are many and varied postnatal causes for child-
hood deafness, which may result in sensorineural or
conductive loss or both. The postnat al cause for child-
hood deafness includes bacterial meningitis, infectio n
(eg. middle-ear infection, CMV infection), viral labyr-
inthitis (eg. measles and mumps), recurrent or persistent
OME for at least 3 months, complications of otitis
media, immunization, genetic causes, and head trauma
with loss of consciousness or skull fracture .
Hearing- a reflex process
Hearing is a reflex during the first couple of the month
of li fe. Responses to sound at a threshold are yet to
obtain during this period. The onl y response the child
posses during this period is the startle reflex- a response
to a l oud sound, which is analogo us to the protective
reflex of hearing in animals. Fol lowing this, there is a
development of comprehension hearing. The child
begins to understand the sound with the help of experi-
ence and learning as the cerebral cortex takes over the
control of auditory responses, with the simultaneous
inhibition of the reflex h earing. Thus the child at the
age of six to seven months does not give any response
to a loud sound, but turn and look towards a faint
sound that the child feels to be pleasant .
Age appropriate hearing milestones
It is hard to know whether a child has a hearing problem
or not. Hearing problems may be suspected if a child
does not respond to so und or does not develop language
skills appropriately. The National Institute on Deafness
and Other Communication Disorders (NIDCD) has listed
age-appropriate hearing milestones .
Several hierarchies of auditory development have been
proposed by numerous researchers and interventionists.
Pollack et al has ranked auditory development in four
Hearing a sound, pay attention to auditory signals,
attend to sounds at a distance, search for and turn to
the source of sound.
Discriminate the auditory stimuli, monitor the informa-
tion and modify the speech production.
Table 1 Degree of hearing impairment
Degree of hearing loss Hearing loss range (dB)
Normal -10 to 15
Slight 16 to 25
Mild 26 to 40
Moderate 41 to 55
Moderately severe 56 to 70
Severe 71 to 90
Rajendran and Roy Italian Journal of Pediatrics 2011, 37:33
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Select a word from group of wo rds spoken, rem ember
and recall information and language make cognitive
Synthesize meaning a nd respond to spoken language
Neurophysiology of postural control and motor
It is necessa ry to understa nd the neurophysiology of
postural control and motor development to get a clear
construct of dys function. T he ability to maintain a sta-
tic posture (eg. sitting, standing) and dynamic posture
(eg. walking) is operationally defined as static and
dynamic balance respectively. Both the static and
dynamic postural control are very important and
necessary to exe cute mov ement [23 ,24]. The de velop-
ment an d mainte nance of postural control are known
to be a p re-requisite for the performance of skilled
movement. Simple or complex gross and fine motor
tasks necessitate a person to maintain his or her center
of gravity over the base of support. The development
and maintenance of postural stability are a complex
process that necessitates the involvement of multiple
systems such as sensory system, central nervous system
processing and co-ordination of motor output and the
vestibular system. Three sensory systems (sensory triad
of postural control) contribute to provide information
from somatosensory, visual, and vestibular sources to
maintain postural control, which is achieved by coordi-
nated motor outputs. The visual and somatosensory
system gathers information from the environment (eg.
position in relative to other o bjects) and the vestibular
system provides an internal reference (eg. head’sorien-
tation in space). Maturation of the vestibular system is
responsible for the stabilization of eyes, head and body
in space that helps to maintain an upright posture.
The vestibular system is composed of two parts; (i) the
vestibular ocular system, which maintains t he visual
stabilization, (ii) the vestibular-spinal system, which is
responsible for the orientation of the body in space
and maintenan ce of the postural tone, which is neces-
sary for the development of motor milestone. It is nor-
mal for a human to have a certain amount of postural
sway for various age groups and both the sexes have
been documented. However, the child imitates the
adult pattern of postural control by the age of seve n to
ten years. According to the sensory systems’ perspec-
tive, young children depend on the visual system t o
maintain balance. As they grow older, there is a pro-
gressive domination of the somato-sensory system and
the v estibular system [25-27].
Patho-physiology of postural control and motor
development in hearing impairment
Delayed postural development and motor development
is a common sensorimotor impairment in profoundly
deaf children. The vestibular en d-organ and coch lea are
closely related both anatomically and functionally.
Therefore, injury or trauma prenatally, perinatally, or
postnatally may cause damage to one or both systems
[28-30]. Moreover, damage to portions of the vestibule-
cochlear nerve is a presumed cause of sensorineural
hearing loss, may include damage to both co chlear
vestibular system is also critical for gaze stabilizati on.
Thus damage to vestibular system ca uses gaze and bal-
ance impairments . Potter and Silvermann has stated
that many deaf children compensate for vestibular defi-
cits through v isual and kinesthetic systems to maintain
static balance with eyes open or closed . In a cross-
sectional study Sharon et al studied 40 c hildren with
SNHL and found that 50% had abnormality in horizon-
tal semicircular canal function, 38% had dysfunc tion in
higher frequency canal function and 40% had abnormal-
ities of saccular fu nction . Since damage to vestibu-
lar structures is known to cause the balance deficit,
which may interfere with no rmal motor development, it
has been postu lated as the primary cause of motor defi-
cit [35,36]. Crowe and Horak in a cross-sectional study
found that hearing impaired children with sens ory orga-
nization deficits have poor balance and motor profi-
ciency in many areas . Esther Hartman et al
examined the motor performance in deaf elementary
school children and found that deaf children had signifi-
cantly more borderline and definite motor problems
than the normative sample .
Early identification and intervention
Early identification of childhood hearing impairment
and prompt intervention are crucial for improved out-
comes. Vestibular deficit related impairments and the
efficiency of therapy i ntervention for such impairments
in children are only recently documented [39-41]. In
spite of the existing documentation, postural control
and motor assessments are not a routine procedure in
hearing impaired children. Moreover, in developing
countries, early detection poses a significant practical
challenge. Many pediatri c health care providers a re
often too busy or inadequately trained to conduct an
elaborate developmental screening test in re gular clinics
. Consequently, balance and motor deficits in child-
hood are an overlooked entity and intervention to ame-
liorate th ese impairments is not provided. While testing
the vestibular function, test s of canal and oto lith func-
tion should also be included as semici rcular canals and
Rajendran and Roy Italian Journal of Pediatrics 2011, 37:33
Page 3 of 5
otoliths, mediate the vestibular ocular reflex and vesti-
bule-spinal respo nses  . There is amp le evidence that
children with SNHL have concurrent mo tor and balance
deficit. However, there is paucity in investigations of inter-
vention for balance and motor performance deficits in
hearing impaired children. Gheysen et al investigated the
consequences of cochlear implantation on the motor abil-
ities of deaf chi ldren and foundthatdeafchildrenwith
cochlear implantation did not perform better on balance
and motor skills than children without cochlear implanta-
tion . Hence exercise intervention should be incorpo-
rated to improve balance and motor performance. Lewis et
al found improvement in balance skill in 6-8 year old chil-
dren following participation in balance and body awareness
program . Braswell and Rine found improvement in
dynamic visual acuity, critical print size, and reading acuity
following visual-vestibular exercises . Rine et al
reported improvement in sensory organization for postural
control and halt of progressive motor delay following exer-
cise intervention that focused on enhancement of sensory
integrative postural control abilities .
Childhood hearing impairments are a world-wide pro-
blem that causes the most serious limitation that can
befall a child, as it prevents his optimal develop ment. It
has to be viewed as a multifaceted condition as a variety
of factors determines the effect of hearing impairment
on child’ s dev elopment. The focus of evaluation and
treatment for these children is primarily on the language
development. Therefore in order to minimize the
adverse effects on normal development of hearing disor-
ders, it is crucial to carryout screening examinations
and appropriate interventions of balance and motor def-
icits, which enable early detection of these dysfunc tions,
which are often either not noticed or under estimated.
It is also important to re-evaluate motor function in
these children during t he course of their childhood in
order to assure early intervention.
The authors thank Deepa J (Physiotherapist) who provided writing
Both the authors contributed to the conception of the study and were
involved in writing, revising and approving the final draft of the manuscript.
The authors declare that they have no competing interests.
Received: 29 December 2010 Accepted: 14 July 2011
Published: 14 July 2011
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Cite this article as: Rajendran and Roy: An overview of motor skill
performance and balance in hearing impaired children. Italian Journal of
Pediatrics 2011 37 :33.
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