Academy of Doctors of Audiology

By Jane R. Madell, Ph.D.

We all know that hearing aids and cochlear implants are not like eye glasses. For most people, eyeglasses cure vision problems. Not so with hearing loss. No matter how good the technology, we are listening through a damaged auditory system. So why would we expect that just fitting technology will be all that a person needs? Boothroyd (2017) describes comprehensive hearing health care as having four parts. Part 1 is sensory management: what we do when we fit technology (hearing aids, cochlear implants, bone-anchored hearing aids, and remote microphone systems). Part 2 is instruction: instructional counseling about maintenance and function of technology. It may include how to control the environment including both visual and acoustic controls. Part 3 is perceptual training. This is usually described as auditory training, lip-reading and communication strategies. Part 4 is counseling. This may include communication counseling, helping people cope with the imperfect assisted technology and psychosocial counseling designed to help the person deal with the impact of imperfect aided technology and improving emotional state and quality of life.

Audiologists are usually very good at the first and second part. A very few may offer some of the counseling Boothroyd discusses in Part 4, but almost no audiologists offer or participate in Boothroyd’s 3rd criteria although I think that everyone would agree that it would be beneficial.

Let’s review all the parts of a comprehensive hearing health care program. The primary goals of technology are to provide auditory access to the listener’s brain that is audible, comfortable, and provides access to intelligible speech. How do we know this is happening? Hearing aids are fit using real ear and we “assume” that the person will do well with those settings. Cochlear implants are fit using programming devised by implant manufacturers. Great start! We can verify that the technology is doing what the manufacturer intended will work for the person sitting in front of us. But how do we know? Validation is good, but until we verify what a person is hearing, we really don’t know. When a person with hearing loss complains that they are not hearing well we need to listen to them. We cannot know how well a person is doing with technology without testing them. Can you hear me? How does this sound? Good basic questions, but without testing we really do not know. I cannot count the number of people with hearing loss who have said to me, “I don’t know what I am missing because I didn’t hear it.”

I am a really big fan of aided thresholds. They provide a lot of information about what to expect from speech perception. The goal is aided thresholds at 20-25 dB across the frequency range. If a person is not hearing high frequencies with technology, we can expect that she will have trouble hearing /s/, /sh/, /f/, /ch/, and voiced and voiceless /th/. This effects understanding of grammatical markers like possession, pluralization etc. So just seeing aided thresholds with poor high frequencies will tell the audiologist that technology settings should be adjusted to provide more high frequencies.

Testing speech perception with technology is critical if we really want to know how a person is hearing. We need to know how a person is hearing normal conversation, soft conversation, and how he or she is hearing in the presence of competing noise. In an ideal world, when there are no time limits to how long we can spend in testing, it would be great to fill in all the boxes in Table 1.

Right Technology	Left Technology	Binaural Technology
50 dBHL
35 dBHL
50 dBHL
+5 SNR

It is essential that testing be performed right, left, and binaurally for normal conversation. If time is a problem, testing for soft speech and speech in noise can be performed in the binaural condition only. The reason it is critical to test each ear separately is to determine if the person hears equally well in both ears. If a person hears worse in one ear than the other, it gives us information about what we might change in technology settings, as well as information about how to proceed with rehabilitation. It is the first clue that we need to provide assistance. For example, if a person has a speech perception score of 46% in one ear and 76% in the other ear, and if the aided thresholds tell us that he is hearing equally well in both ears, we know that we need rehabilitation to build skills in the poorer hearing ear and to improve overall performance. Without testing, we don’t know.

When I do speech perception testing, in addition to recording whether the response was correct or incorrect, I record the errors. A total score is useful, but does not help you determine what needs to be fixed. I record perception errors and then look at a frequency allocation table to determine what frequency bands the person seems to be missing. That tells me how to adjust the technology settings. For example, if a person is misperceiving /s/, /f/, and /ch/, knowing that /s/ has energy 5000-6000 Hz, and that /f/ and /ch/ have energy at 4000-5000 Hz, helps me determine what to change in hearing aid or cochlear implant settings. A critical component of dispensing hearing technology is teaching our patients to use it. Teaching has to be two way – not just lecturing, but having a dialogue. Patients need to really understand how their technology works and know what they can do to improve listening. They need to be able to learn to recognize what situations are difficult and understand what actions they must take to improve outcomes. Who needs rehabilitation?
Rehabilitation cannot be successful if the child or adult is not hearing well. First, the audiologist needs to be sure that technology is performing as well as possible. The goal of aided thresholds is 20-25 dB. If a person is not hearing one or more of the frequency bands, no amount of rehabilitation will make him hear it. If you can’t hear /s/, therapy will not make you hear it. It may teach you how to compensate, but it will not help you hear sounds you cannot hear. So, audiology first.

Children
Children with hearing loss need auditory-based therapy. They need it to help them develop language and to help them build their auditory skills. A listening and spoken language therapist can help a child build an auditory base, which can be used to learn spoken language and can build literacy skills. Children who develop good listening skills will be able to self-monitor their speech and correct it as they hear the speech of those around them. Even children with mild hearing losses are hearing things in a different way and will benefit from listening and spoken language therapy. They may not have as much difficulty as those with more severe hearing loss, but they are still missing things and need assistance. This is supported by looking at speech perception scores for soft speech and in competing noise.

We know that literacy is phonologically based. Children read by sounding out words. They need to know what a /b/ or /t/ sound like so they can pick it out when reading. If they cannot use phonics to learn to read they will have to learn words by sight, which will limit the number of words they know, and make it difficult to learn new words.

Every child, with any degree of hearing loss, should be referred to a listening and spoken language clinician or a speech-language pathologist who is skilled in an auditory-based approach to developing skills in children with hearing loss. Not only will he/she be able to develop skills in the child, but he/she will be able to help the audiologist know what the child is and is not hearing. Language skills should be monitored yearly to assure that the child is developing appropriately and to know if additional assistance is needed, and if so, when and how much.

Adults
Adults with acquired hearing loss may be able to “fill in the blanks” when they are not hearing high frequencies or other sounds because of their knowledge of language. However, it is a lot of work and is exhausting. Whatever we can do to improve a person’s auditory skills will permit her to function more easily.

What is rehabilitation?
Who needs rehab? People who are getting excellent results with their technology may not need any additional rehabilitation. The technology may be enough. But what is “excellent”? By excellent, we mean speech perception in multiple conditions in each ear at 90% or better. For anyone, whose speech perception is not excellent, additional assistance should be considered.

All children need therapy. There are no children for whom therapy should not be considered. Every child with hearing loss should be referred to a listening and spoken language therapist to evaluate language, speech, and auditory skills. Therapy is usually individual because training includes both improving language and developing language skills. Group therapy may be added to individual therapy to assist in teaching language skills, communication in small groups, turn taking, and other communication skills. For young children, therapy is primarily directed at teaching parents to be the primary providers of language and listening skills.

Therapy for adults is different. Hearing aid users report that hearing aids make things louder, but they don’t always make things clear, especially in competing noise. Those who are not happy with hearing aids need additional rehabilitation. The goals of perceptual training include reducing listening difficulty, listening effort, and listening fatigue. Building auditory skills is primary, but some therapy includes building lip-reading skills and other communication strategies. Therapy can be individual, in small groups, or via telemedicine. In the past, some clinics offered small groups for new hearing aid users. The groups were designed to teach attendees various ways to improve listening in difficult listening situations, to allow them to practice in difficult listening situations, and to discuss ways to discuss their hearing needs with communication partners. Preminger and Lind (2012) have demonstrated that including communication partners in therapy groups improved performance. Most audiologists, who are not involved in cochlear implant programs, do not know who should be referred for cochlear implant evaluation. When I was director of a cochlear implant center, most of the adults who came for cochlear implant evaluation reported that their hearing aid audiologists told them they were not candidates for cochlear implants. However, almost all of them were. Why? I think it is because the audiologists didn’t know the current criteria. For adults with severe and profound hearing loss, using hearing aids is not easy. These patients are usually not satisfied with the performance of their hearing aids, so they are not the patients we all look forward to seeing. It stands to reason that if audiologists knew these patients would be better off with implants they would have referred them.

Criteria for cochlear implants can change quickly. Years ago, only patients who received no benefit from hearing aids were considered candidates. Implant criteria then included patients with profound hearing losses who received minimal gain from hearing aids, and then moved to include patients with severe hearing losses. As cochlear implants have improved, criteria have changed. Current research indicates that people who have severe or profound hearing loss will perform better with cochlear implants than they will with hearing aids. In fact, they will perform like patients with moderate hearing losses. (Leigh et al, 2011). Hybrid implants have been used for patients with good low frequency hearing for several years. Some clinics are now providing implants for patients with unilateral hearing loss. Patients who are not doing well with hearing aids need additional help. Patients who do not have aided thresholds at 20-25 dB HL, and are not receiving speech perception scores of 70% or better, are not hearing well enough. They will not hear soft speech and they will have trouble hearing in noise. These patients need technology that will provide them with greater access. If we can adjust the hearing aids, or if we can provide them with different hearing aids that provide sufficient benefit, then they can proceed with hearing aids. But if not, cochlear implants should be considered. For patients who are receiving sufficient gain from hearing aids, but who have speech perception scores worse than 60%, referral for rehabilitation and for cochlear implant evaluation should be considered. Unfortunately, rehabilitation is no longer universally included in audiology training. Those of us educated in the 1960’s and 1970’s did have rehabilitation included in our training. Many of us ran rehabilitation groups teaching lip-reading skills, auditory training, and counseling for individuals to better communicate with their families. Thankfully, a few programs continue to teach these important skills, such as the program at the University of Louisville, organized by Dr. Jill Preminger. When I was learning to run aural rehabilitation groups, hearing aids were not great. They were analog and had limited frequency range. As hearing aids improved, the need for therapy may have appeared to be less necessary.

Cost is certainly another consideration. It can be difficult to charge for rehabilitation. It may, or may not, be reimbursable by insurance, but even if it is covered, reimbursement may be limited for a variety of reasons, including the patient’s age or coverage plan. Diagnostic audiology and hearing aid dispensing pay more. But, if we look at the number of people who do not consider getting hearing aids, even though they know they are not hearing well, and those who reject hearing aids after trying them, we know we are not doing a good job. Maybe we need to consider rethinking our role.     Jane R. Madell, Ph.D., is an audiologist, speech-language pathologist, and listening and spoken language specialist Certified Auditory-Verbal Therapist. She has worked as a pediatric audiologist directing Speech and Hearing Programs and Cochlear Implant programs for 50 years. She can be reached at www.janemadell.com. and [email protected]. Boothroyd, Arthur (2017) Aural Rehabilitation as Comprehensive Hearing Health Care; SIG 7, Vol 2 (Part 2), Perspectives of the ASHA Special Interest Groups; American Speech-Language-Hearing Association. Rockville, MD

Leigh, J, Dettman, S, Dowell, R,k and Sarant, J (2011) Evidence-Based Approach for Making Cochlear Implant Recommendations for Infants and Residual Hearing; Ear and Hearing, Vol 32, No. 1.

Preminger and Lind, (2012) Assisting Communication Partners in the Setting of Treatment Goals: The Development of the Goal Sharing for Partners Strategy. Seminars in Hearing. 33, 1, 53-64.