JCPSLP Vol 21 No 1 2019

and pre-existing hearing loss that increased over time. A recent data linkage study of just under 23,000 children in WA showed that the presence of one chronic illness in early childhood, the most common of which in the cohort was middle ear disease, is a risk factor for school readiness (Bell, Bayliss, Glauert et al, 2016). During our discussion, Christine talked about what had been her dream job as a child: a receptionist in a doctor’s surgery. She recalls the moment when she realised that, because of her poor hearing, this could not be a pathway for her. Patients in a clinic waiting room need to be able to talk discreetly at times to reception staff, but Christine always needed people to speak up. That she recalls this suggests it was a significant moment in her life. Following this first appointment in the prison, I visited again to fit Christine’s hearing aid and several weeks later I returned to follow up on her progress. I had no idea what to expect. This was the first time I had provided rehabilitative hearing services to a client in a prison environment. What I found was remarkable: Christine had been wearing the aid constantly. The most significant difference was the way she held herself. In contrast to the first time I saw her, Christine was relaxed, sitting back in her chair, conversing easily, with a relaxed expression. Her friends had been commenting positively about the change in her: the way she held herself, the way she communicated, and this seemed to be an additional positive reinforcer. Christine could now hear and contribute in rehabilitation group sessions. She loved that she could talk to her mum on the phone, something she had not previously raised, but unremediated hearing loss amplifying loneliness and separation in prison is a common theme in the literature (Dahl, 1994; McCulloch, 2012). I will never forget Christine saying “There is nothing better than being able to hear”. Today, no jurisdiction routinely screens for hearing loss in prisoners; however, anecdotally, there appear to be coincidental plans for a trial of hearing assessment and tele-otology services in two states, so momentum may be building. The inquiry into treatment of youths in NT detention centres has brought fresh attention to hearing loss as a causal factor in incarceration (Australian Medical Association, 2017). Access to rehabilitative hearing devices and services appears inconsistent across jurisdictions, but anecdotal reports suggests it is increasing. To speech-language colleagues working in the justice system, my request to you is to be vigilant for opportunities to raise awareness among prison staff of the high rates of hearing loss, the behaviours that signal it, and provide strategies on how to accommodate for it in daily communication. If you have the opportunity, please promote the need for routine hearing screening and onwards connection to appropriate services. Together we can work to improve hearing and communication outcomes. A few months later, when I was running a clinic at the Aboriginal medical service, the doctor who visited the prison caught my attention as I walked past her office to let me know that Christine had been moved to a lower security prison to serve out the remaining months of her term, and that she had just been elected Aboriginal women’s advocate. We both understood the significance of this, and we stood for a moment together feeling a bit emotional. This really spoke to how unrecognised and unremediated hearing loss disempowers and limits potential, and conversely, how hearing well empowers and throws open the possibilities again. Disclaimer: The views expressed in this paper are mine and not necessarily those of my organisation.

A longitudinal cohort study found a direct association between diagnosed language impairment at age 5 and late adolescent delinquency, after controlling for verbal IQ (Brownlie et al., 2004). For children with hearing loss that occurs early in the post-newborn period, including Aboriginal children experiencing early and chronic ear disease, risk of late diagnosis and remediation persists (Australian Hearing, 2018). Christine talked about having had ear trouble as a young child. She recalled not hearing well at school and leaving early. Although there may well have been other contributing factors leading to early disengagement from school, unremediated hearing loss was likely to have played an important role (Williams & Jacobs, 2009). Christine’s almost total ear drum perforations suggest that she had had chronic suppurative otitis media, with repeated episodes of pus discharging from the middle ears for extended periods, rupturing and re-rupturing the ear drums and eroding the middle ear bones. The age of onset was likely to have been early, during the critical language and communication-learning years, from birth to three and a half years (Leach et al., 1994). For most Australian children, otitis media, or middle ear infection is transitory, self-limiting, and chronic suppurative otitis media is rare (Kong and Coates, 2009). Early onset, recurrent or chronic otitis media and related hearing loss is less likely, for most children, to lead to poorer long-term language and communication outcomes if the child is from socioeconomically advantaged family, has no other delays or disabilities and the hearing loss is not significant and unremediated (Roberts, Rosenfeld, & Zeisel, 2004). It is likely that two of these factors were relevant to Christine: socioeconomic disadvantage and the late age of remediation of significant hearing loss. The relevant aspect of socioeconomic advantage is the quality of the home language environment. Globally, children growing up in socioeconomically disadvantaged households are more likely to experience poorer quality of communication and a smaller number and range of words daily compared, on average, to children in socioeconomically advantaged homes (Hirsh-Pasek et al., 2015). Today, socioeconomic circumstances are improving for a proportion of Aboriginal people. Although 1.8% of Aboriginal people are now in the most advantaged decile of the population, Aboriginal and Torres Strait Islander families are still overrepresented in the most disadvantaged decile. In the 1960s, there was an even stronger likelihood that Christine and her family grew up experiencing socioeconomic hardship. It cannot, however, be assumed that the quality of Christine’s home language environment was poor. Given her use of visual cues, context and language base to construct fluent conversation, she may have had a rich home language environment. We know already that Christine had significant and unremediated hearing loss. Today, the average age of first hearing aid fitting for Aboriginal and Torres Strait Islander children is 6 years (Australian Hearing, 2018). Given the early age of onset of chronic ear disease, this indicates delays in the identification – diagnosis – remediation pathway. In the past decade, the average age of first fitting for Aboriginal children has lowered by 2 years (Australian Hearing, 2018), but continues to be late when referenced to age of onset and the critical window for development of language and communication skills. When Christine was a child, in the early 1960s, the proportion of Aboriginal children with aidable hearing loss who successfully connected with government-funded hearing services was undoubtedly significantly lower. Christine is likely to have started school with language and communication delay

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JCPSLP Volume 21, Number 1 2019

Journal of Clinical Practice in Speech-Language Pathology