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''Hearing Aids: Reasonable Expectations for Parents''

Rose L. Allen, Ph.D.
Assistant Professor of Audiology
East Carolina University
Dept. of Communication Sciences & Disorders
Greenville, NC

Christine Gilmore Eubanks, Ph.D.
Director of Audiology
John Tracy Clinic
Los Angeles, CA

INTRODUCTION:

Since you are considering the purchase of hearing aids for your child, it is important for you to establish reasonable expectations for the performance of your child and these highly sophisticated devices. The acquisition of hearing aids is not a simple act. Rather, it is a complex process - one that evolves over time.

The reality is that hearing impairment has detrimental effects on learning potential and oral speech and language development. Realize that you are the key to helping your child reach his/her potential. Your decisions are critical and will influence your child for the rest of his/her life. Some children are too young to understand the importance of wearing amplification or they are not motivated to wear the hearing aids. Your attitude and willingness to help your child are crucial and will be the most important factors in determining how well your child accepts hearing aids.

It is important for you to realize that your child may not experience the exact same benefits from amplification as other children do. The type and severity of hearing loss, as well as the age at which the hearing loss was identified, habilitation/rehabilitation services provided (such as speech-language therapy), and parental support are all factors which will affect your childs progress and success with his/her hearing aids.

The title of this article implies there are "reasonable expectations" for parents when purchasing hearing aids. Therefore, there must also be "unreasonable expectations". For the most part, there is only one totally unreasonable expectation - do not expect your child to have normal or perfect hearing. Your childs hearing aids will provide sufficient amplification to help him/her develop communication skills. Too much amplification may cause loudness discomfort and your child will reject the hearing aids. Hopefully, this tutorial will help guide you in establishing realistic and reasonable expectations for your child and his/her hearing loss. Other items addressed include the professionals you interact with throughout the process of acquiring of acquiring hearing aids, learning how the aids operate, teaching your child maintenance and care of the aids, and watching your child reach his/her greatest communication potential.

1. Expect your child to be diagnosed at a very young age and recommendations for treatment made promptly. Many states have mandatory newborn hearing screening. In these states, infants are now being screened for hearing impairment shortly after birth, and before discharge from the hospital. Generally, these are hearing screening tests to determine if a significant impairment exists that would prevent a child from developing normal speech and language skills. Infants who fail the initial screening will be followed until their hearing loss is either ruled out or confirmed.

The primary goals of a new national program, the early hearing detection and intervention (EHDI) program, are to identify all infants with hearing loss by 3 months of age and obtain amplification and other treatment by 6 months of age (JCIH, 2002).

Nearly one-half of all hearing impaired children, however, acquire hearing loss after birth (JCIH, 2002). Causes include illness and accidents. So, you may have noticed that your childs hearing gradually or suddenly changed and his/her behavior prompted you to seek the advice of an audiologist or physician. You may have already made several visits to these professionals to obtain an accurate diagnosis and discuss the recommendations for treatment. However, if you have not already chosen an audiologist in your area, you should do so immediately, and you can search the yellow pages under "audiologists" or "speech and hearing". Another option is to go to the Healthy Hearing web site (www.healthyhearing.com), and if you enter your city and state, or just your zip code, a list of professionals will be created for you.

2. Expect your audiologist to be knowledgeable, thorough, courteous, and accommodating. Be prepared to provide detailed information about your childs behaviors that caused your concerns about his/her hearing. The audiologist will take a thorough case history and want to know details of the birth history as well. S/he is searching for information about your childs hearing loss, its probable cause, whether other offspring may be affected, and what professional assistance you have obtained. The audiologist will conduct comprehensive hearing and hearing aid evaluations. These evaluations will provide information about the degree and nature of your childs hearing loss.

If your child is old enough to repeat or point to pictures, his/her ability to process and discriminate the fine sounds of speech will also be tested. For infants and toddlers, the audiologist will want to conduct subjective and objective procedures to establish hearing levels. Subjective tests allow the audiologist to watch the behaviors and responses your child makes to sounds produced either from speakers or a headset. Objective tests record mechanical and electrical activity within your childs auditory system and results do not depend on voluntary responses from your child. These tests are painless and often include auditory brainstem response (ABR) or otoacoustic emissions (OAE). Sometimes, young or difficult to test children must be sedated to perform the ABR test and obtain accurate results.

The audiologist may also test your childs tolerance for loud sounds. These measures are made to determine how loud sound can get before it becomes offensive or triggers a negative response from your child. This information is critical in establishing the upper limits of loudness for your childs hearing aids.

If your child needs hearing aids, ear impressions will also be made of your childs ears so that his/her earmolds or hearing aids will be custom fit. The ear impression can be used to make earmolds for behind-the-ear hearing aids, or they will be used to make a custom fitted hearing aid shell.

You will have time to talk with the audiologist about the differing styles of hearing aids (in-the-ear, in-the-canal, completely-in-the-canal, behind-the-ear), the advantages and disadvantages of each style for children, and maintenance issues and costs involved. Although approximately 80% of all hearing aids sold fit in the ear (Strom, 2001), infants, toddlers, and young children are fit with behind-the-ear aids primarily due to the rapid growth of the ear.

3. Expect differing opinions. If you choose to seek the advice of two or more audiologists, you may get different opinions about the "best aid" for your child. Everyone in the hearing aid industry acknowledges the fact that there is not a single "best" hearing aid. Rather, there are many excellent hearing aid brands available and there are many different types of circuitry that will benefit your child. Due to the complexity of todays hearing aid circuitry, many audiologists will limit the number of brands of hearing aids they dispense. Your audiologist is very knowledgeable about the particular programming capabilities of the aids they dispense and they have very good rapport with the service representatives of those companies.

4. Expect a recommendation to purchase two hearing aids if both ears are hearing impaired and "aidable." There are many benefits to binaural (two ear) hearing, including improved speech understanding in noisy situations and improved sound localization. Your audiologist will explain more of the advantages of binaural fittings and the importance of children having binaural hearing (Staab, 2000). Nonetheless, it is very important to understand that if your child has two ears with hearing loss and your child only wears a hearing aid on one ear, s/he will still have significant hearing problems, even under the best of circumstances.

5. Expect your audiologist to assess your childs listening difficulties and the effects on educational performance. In recent years, there has been a growing interest in developing scales that measure your childs abilities through the use of parent and teacher interviews. According to Lewis (2000), some of the more widely used scales are the Life Inventory for Education (LIFE), the Screening Instrument for Targeting Educational Risk (SIFTER), and the Meaningful Auditory Integration Scale (MAIS). Some scales, like the Childrens Abbreviated Profile of Hearing Aid Performance (CA-PHAP) allow you and your child to rate his/her performance before and after the fitting of the hearing aid/s so a comparison of benefit can be made.

6. Expect to be offered a 30-day trial period. Although not always required by law (it varies state-by-state), many audiologists offer a trial or rental period of 30 days before you purchase hearing aids for your child. You may be asked to pay a non-returnable fee during this time. This trial period allows time for your child to initially adapt to amplification and for you to determine the immediate benefits. You may be asked to keep a log or journal at home to write down your childs reactions to sounds in his/her environment. Not only is it important to recognize responses to soft and medium loud sounds and speech, but also to loud, sudden sounds. The log will assist the audiologist in fine tuning your childs aids, particularly if your child is too young to describe what s/he is hearing. If you are not sure about the benefits your child is receiving from amplification, discuss extending the trial period with your childs audiologist.

7. Expect a referral to a physician to rule out any medical condition that may contribute to your childs hearing loss. All hearing aids are medical devices and, as such, are governed by regulations of the Food and Drug Administration (FDA). The FDA requires that a physician, preferably one who specializes in diseases of the ear, called an otolaryngololgist, or an ear-nose-and-throat (ENT) doctor, examine all individuals before they acquire hearing aids. If you have not taken your child to a physician that specializes in diseases of the ear, your audiologist will refer you to one. It is important to establish the presence of any medical condition associated with hearing loss and determine if there is medical treatment that could improve your childs hearing. You can not waive this medical evaluation for your child unless it is against your religious beliefs to see a physician. We believe it is in the best interest of your child to see an ENT physician prior to the hearing aid fitting, but particularly if s/he has a history of ear problems or hearing loss of unknown origin. Once your child reaches the age of 18, s/he may be given the opportunity to sign a medical evaluation waiver that will allow the audiologist to proceed with a hearing aid fitting without benefit of an ENT consultation.

8. Expect the hearing aids to be expensive! Presently, there are three categories of hearing aid technology - analog, digitally programmable, and digital. Remember, the average life-span of hearing aids is five to seven years.

Analog technology has been around for many decades. Aids utilizing this technology are also called "conventional" hearing aids and they are the least expensive, and the least sophisticated. According to the most recent dispenser survey published in the Hearing Review in June of 2002, indicated the average price of an analog hearing aid was $900 to $1500 per aid, depending on the size of the aid - the smaller the aid, the larger the price (Strom, 2001

Digital hearing aids use digital signal processing - the newest technology on the market. Digital hearing aids are complete computers, similar to the PC on your desktop. The computer chip inside each aid is as small as a pencil eraser! These aids cost approximately $2500 per aid, similar to your PC.

Digitally programmable hearing aids will probably cost somewhere between the conventional price and the digital price. Your child may benefit from any of the three types of technology. Research studies on adults suggest that programmable or digital technologies provide greater benefits. It is generally accepted that children will benefit the most from programmable or digital technology with some form of compression circuitry. Among other advantages, this technology gives the audiologist more flexibility in fine-tuning your childs hearing aid/s.

Speak extensively with your audiologist about the types of circuitry, the advantages and disadvantages, and which would be best for your child. Importantly, in 2003, some basic digital hearing aids are now available at a lower price than in previous years. Many of the manufacturers have switched the focus of their product lines to completely digital offerings, as digital products are more efficient and have broader application. Consequently, as the demand and sales have increased, the price has gone down a little. The bottom line is that there are many more digital hearing aids on the market now than in 1999 and the prices vary tremendously, as do the products.

Also ask your audiologist about special funding sources. Some clubs, like the Lions or Kiwanis, will provide financial assistance for needy children. A few health insurance plans cover a portion of the cost of hearing aids so call your insurance agent to see if you have hearing aid provisions. Presently, there is a nationwide effort to make insurance coverage of hearing aids for children and adults mandatory. At this time, five states (Kentucky, Oklahoma, Connecticut, Maryland, and Missouri) have been successful in getting laws passed that pertain to insurance coverage of hearing aids for children (ASHA, 2002).

In addition to the cost of the hearing aids, you will need to replace the earmolds (for behind-the-ear-aids) about every 3 6 months and youll need to purchase batteries. Ask your audiologist about additional insurance coverage beyond the standard 1-year warranty period to cover repairs and loss/theft of the aids.

9. Expect an initial orientation session with your childs audiologist where you will learn how to handle and care for your childs hearing aids. You, your family members, and your childs immediate caregivers should accompany your child to this first critical session in getting oriented to the hearing aids. During this session, the audiologist will teach you and your child (depending on his/her age) how to operate the hearing aids, how to clean them, and how to change the batteries.

You will receive written information about the aids - a booklet called a "User Instructional Brochure" - which is a requirement of the FDA. Please note that the batteries are particularly important. Be absolutely sure to store them and use them exactly as your audiologist advises. Battery ingestion can cause serious medical problems in children and in pets, so be very vigilant about the care and handling of the batteries. The hearing aids provided to young children need to have tamper resistant battery doors as well. It may be difficult for you to remember all the things the audiologist tells you during this first session, so dont leave the office without the instructional brochure. It will be very valuable to you, particularly during the first weeks after fitting the aids to your child.

10. Expect a period of adjustment to adapt to the hearing aids. Initially, your child may need to wear the aids for a limited period of time each day. This helps in adjusting to the new sounds s/he is hearing as well as to the feel of the earmolds or hearing aids. It is important to inspect your childs ears for any redness or soreness that may develop as a result of wearing something new in the ear. If you see signs of irritation, call your audiologist for an appointment or instructions. You will also need time to learn how to assist your child in checking the aids, inserting and removing the aids/earmolds, adjusting the volume control (some hearing aids have volume controls, other are automatic), cleaning the aids, changing the batteries, and getting accustomed to placing the hearing aids in a dry-aid kit at bedtime. It will take time to learn how to manage this care and make it a part of your normal daily routine. The older your child is, the more s/he can be involved with this daily care. By the time your child is 6 years old, s/he should be able to do everything except the daily listening check.

Remember too, that while you are adjusting to the new routine of caring for the hearing aids, your child is adjusting to new sounds. S/he will be hearing sounds that s/he never heard before. Although some of these sounds are pleasurable, a few will be frightening. Comforting the child and keeping the journal for your audiologist will help in the event that the aids need adjusting. Research in this area has shown that adaptation or adjustment may take a few months for adults. Be patient with your child as it takes time for the brain to learn or re-learn all these sounds.

11. Expect to replace the earmolds frequently. The audiologist will make your childs ear impressions so the earmolds (which are used with behind-the-ear aids) or hearing aid shells will be custom fit. However, your childs ears will grow rapidly. When the earmold or aid becomes loose fitting, the hearing aids will squeal (feedback) even at low volume control settings. Earmolds should be remade every 3 6 months during the childs early years and once a year after age 5 (Northern, J. & Downs, M., 2002). Some public school systems assist in financing earmolds, so if your child is school age, check with the school audiologist.

12. Expect multiple follow-up appointments. With children, it is necessary to monitor hearing levels and hearing aid performance frequently. Sometimes, monitoring can be done at school. If the child is younger or the school does not provide audiology services, multiple trips must be made to the private audiologist. One of the greatest advantages of programmable and digital hearing aid technology is the flexibility in programming the sound quality, as well as many other electroacoustic characteristics of the hearing aids. If your childs hearing levels change, digital and programmable aids may be re-programmed to meet the new needs of your child. It is also wise to periodically have the hearing aids checked by the audiologist to ensure that the aids are in good working condition and are performing as intended. It is strongly recommended that young children be seen by an audiologist every 3 months during the first 2 years of using amplification and every 6 months thereafter, unless concerns arise (Pediatric Working Group of the Conference on Amplification for Children With Auditory Deficits, 1996).

13. Expect your audiologist to evaluate the benefits provided by the hearing aids. This is normally done in at least two ways. First, electronic measurements of "real ear" performance give the audiologist an idea of how the aids are functioning when the hearing aids are actually sitting in your childs ears. Your audiologist may make measurements in which a small microphone is placed in your childs ear to measure what is happening in the ear canal with and without the hearing aid. This is an objective measure, a great starting point for subsequent changes in the performance of your childs aids, and a baseline measure for later comparisons. Secondly, the audiologist may have your child seated in a sound booth and measure his/her responses to sounds and speech from the loudspeakers. For adults and older children, there are many subjective assessment scales that are used to evaluate pre- and post-fitting performance. A few scales have been developed for children, parents, and teachers (Dillon, 2001). These scales help establish goals for changes in the childs performance as a result of the aids.

14. Expect your child to be able to hear well, but not perfectly, in quiet one-to-one situations and in small group settings. In order for your child to hear well, the audiologist will fit the hearing aids to make sound audible (loud enough to barely hear it), and then later, comfortably loud. Your childs hearing aids should amplify sound so speech is comfortably loud. Through speech therapy or aural habilitation sessions, your child will learn to look at people when conversing with them. In this way, your child also learns to utilize visual cues from a persons face, lips, or even hand gestures. Your child will perform best in quiet, one-to-one or face-to-face settings. Listening to conversations in a small group setting of three to four people will be more challenging, but still manageable. The larger the crowd, the more background noise present and the more difficult it will be to hear. The classroom can be a very challenging environment. The use of frequency modulated (FM) units and the support of the classroom teacher can assist your child in functioning well in that setting. Please speak with your audiologist about these issues.

15. Expect an optimal "distance for hearing". The best distance for hearing with amplification will be dependent on the type of hearing aids and other factors. However, a general effective listening range or effective "distance for hearing" is approximately 10 feet in diameter. People within this distance will be the most audible. Once the distance is increased between you and your child, it will get increasingly difficult for him/her to hear you - just like without the hearing aids. Research has been done on the efficacy of children wearing auditory trainers or FM units at home. These devices help "eliminate" the distance issued through electronic equipment and these approaches are very good. Again, please discuss FM systems with your audiologist.

16. Expect your child to have difficulty hearing in noisy situations. Background noise is a nuisance for everyone, even normal hearing individuals. As sophisticated as todays technology is, a hearing aid still cannot eliminate background noise. However, some of the more sophisticated digital circuitry can effectively reduce (although not eliminate) background noise. It is important for you to know that your child may not be able to hear or understand you if there is a high level of background noise present, such as in a noisy restaurant.

17. Expect the hearing aids to squeal (also called "whistle" or "feedback") under some circumstances. If a hearing aid is somewhat functioning and has a good battery in it, a squeal (acoustic feedback) will occur when the hearing aid is cupped in the hand. However, your child should be able to wear the hearing aids at a comfortable loudness level and not experience this squeal when the aids are in the ears. If there is no "off" switch or volume control on your childs hearing aids, they will squeal when you place them in his/her ears - until you get them placed appropriately. If the hearing aids do not have telephone switches (also called a telephone coil, or a T-coil), the aids will squeal when the telephone is pressed too tightly to the ear. This squeal or feedback may also result from a poor fitting earmold or aid, a blockage of earwax or debris in the ear canal, or an internal malfunction in the hearing aid. Report these events to your childs audiologist for troubleshooting and management.

18. Expect repairs and maybe a lost hearing aid now and then! Hearing aids are incredibly sophisticated devices being inserted in the ear canal where moisture and cerumen (earwax) are waiting to attack any foreign object! Especially with children, hearing aids are also prone to being thrown, dropped, chewed on, stepped on, squashed, and flushed down the toilet. Microscopic solder points that connect the tiny wires of the microphone and receiver to the computer chip in the hearing aid can be jarred loose. All repairs cannot be avoided, but many repairs can be prevented with careful handling and regular maintenance. Establishing a good preventive maintenance schedule at home, at the caregivers home, at school, and at your audiologists office can significantly reduce the number of repairs on hearing aids. Hearing aids usually come with a standard one-year warranty that covers repairs and a one-time replacement of the aid, but some manufacturers offer additional warranty periods. Another option is to purchase hearing aid insurance that is available from a number of companies, after the standard warranty expires. Talk to your audiologist about additional warranty options when you purchase the aids.

19. Expect to buy batteries. Most hearing aid batteries last a week or two in the hearing aid. Hearing aid battery service life varies based on the hearing aid circuit, the quality and type of battery, and environmental conditions (temperature, humidity etc.). Some people ask why hearing aid batteries dont last as long as watch batteries. The answer is the hearing aid battery accomplishes a great deal more work and requires much more electrical energy than does a watch battery. The information you receive during the hearing aid orientation session will define a reasonable length of time for the batteries to last. When the hearing aids are new, you might want to keep a calendar indicating the days you change batteries. Report any significant changes in battery usage to your childs audiologist. Many professional offices offer battery promotions or special programs for their patients. Ask your childs audiologist about any special program s/he might offer.

Again, all hearing aid batteries are toxic if swallowed. There are two ''NEVERs with batteries: (1) NEVER allow young children to handle batteries, as they might ingest one, and (2) NEVER keep batteries with any medicines, as one might accidentally get ingested. Keep batteries in a safe place and be sure to recycle the batteries properly.

20. Expect to purchase new hearing aids every 5 years. This may come as a surprise, particularly if you just decided to purchase a set of digital hearing aids for your child! However, hearing aid technology changes rapidly, just like computers, and new technology may benefit your child greatly. Durability, usage, and care will affect the life of a hearing aid. Some adults may keep the same pair of hearing aids for 10 to 12 years, particularly if their hearing loss remains stable over time and if they do a great job with maintenance, but the average life expectancy is about five years.

21. Most importantly, expect your child to develop communication skills! Depending on the degree of your childs hearing impairment, s/he may be able to develop normal speech and language skills and enjoy auditory leisure activities such as listening to music. The hearing aids will also help your child to hear safety sounds to help keep him/her safe and well.

References

American Speech-Language-Hearing Association (2002). 2002 Audiology in ASHA: Our Year In Review. [Brochure]. Baltimore, MD: ASHA.

Dillon, H. (2001). Hearing Aids (pp 422-424). New York: Thieme.

Joint Committee on Infant Hearing: Year 2000 Position Statement: Principles and guidelines for early hearing detection and intervention programs. AJA 2000:9:9-29.

Lewis, D. L. (2000). Hearing Instrument Selection and Fitting in Children. In Valente, M., Hosford-Dunn, H., and Roeser, R. J. (Eds.), Audiology Treatment (pp. 149-211). New York: Thieme.

Northern, J. L. and Downs, M. P. (2002). Hearing in Children (p. 325). Baltimore, MD: Lippincott Williams and Wilkins.

Staab, W. J. (2000). Hearing aid selection: An overview. In Sandlin, R. E. (Ed.), Textbook of Hearing Aid Amplification: Technical and Clinical Considerations (pp 63-64). San Diego, CA: Singular Thomson Learning Publishing Group.

Strom, K. E. (2002). The HR 2002 dispenser survey. The Hearing Review, 9 (6), 14-32.

The Pediatric Working Group of the Conference on Amplification for Children With Auditory Deficits. (1996). Amplification for infants and children with hearing loss. American Journal of Audiology, 5(1), 53-68.

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