Background:
Hearing is essential for children’s language development, communication, and social interaction. Untreated hearing loss, even when mild or unilateral, can lead to delays in speech and language acquisition, negatively impacting academic achievement and social inclusion. In low- and middle-income countries like Pakistan, barriers such as limited screening and resources contribute to delayed diagnosis and intervention, exacerbating adverse outcomes.

Objective:
To assess the impact of untreated hearing loss on educational performance and social inclusion in children aged 6–14, with emphasis on how delayed detection and lack of intervention affect language development, academic achievement, peer relationships, and overall well-being.

Methods:
A cross-sectional study was conducted involving 225 children recruited from mainstream and special schools and a hospital outpatient clinic in Lahore, Pakistan. Hearing assessments were performed using audiological tests and classified per WHO criteria. Academic performance was evaluated through school records and standardized tests, while social inclusion was assessed via validated questionnaires and interviews with caregivers, teachers, and children. Quantitative data were analyzed using ANOVA and multivariable regression, and qualitative data underwent thematic analysis.

Results:
Children without hearing loss scored highest academically (mean 82.4/100) and demonstrated better social participation and fewer behavioral difficulties. Academic scores declined progressively with hearing loss severity (mild: 75.1; moderate: 68.7; severe: 60.3). Similarly, behavioral difficulties increased and social participation decreased with greater hearing impairment (all p < 0.001). Regression analysis showed moderate and severe hearing loss independently predicted significant decreases in academic scores after adjusting for socioeconomic factors.

Conclusion:
Untreated hearing loss in children is associated with significant impairments in academic performance, increased psychosocial difficulties, and reduced social inclusion. Early detection, timely intervention, and inclusive educational strategies are crucial to mitigate these effects and improve developmental outcomes, especially in resource-limited settings. Addressing socioeconomic disparities is also vital to ensure equitable access to care and support.