By Dr. Max S. Chartrand Ph.D.
Almost always, those who require extended compensation beyond amplification are moderately severe, severe, severe-to-profound or profound patients. As a population of the typical hearing instrument practice they comprise approximately 15 percent of all patients. The most debilitated portion of the population is in the severe-to-profound and profound cases, comprising approximately two percent of the typical practice's patient base.
When hearing aid amplification alone becomes increasingly limited in meeting the communicative needs of these patients, other means of compensation increase in value (see Figure 1). Moderate losses, for instance, may require only a brief review of speechreading and coping strategies, while those with moderately severe losses may require numerous sessions of training in not only speechreading and coping strategies, but instruction in the use of assistive devices. Those on the cusp between hearing aids and cochlear implant candidacy may require the services of a speech pathologist, deaf educator or speechreading trainer.
As cochlear implant candidacy criteria continue to broaden, many of those struggling with hearing aids and assistive devices today will be enjoying a new lease on life with the near miracle of cochlear implantation tomorrow.
In those cases, hearing aids continue to play an important, albeit supportive, role. But the question is asked, "Where did all of these new severe and profound patients come from?" The truth is that they came from the same hearing aid patients who were mild and moderate cases only yesterday. Hence, the pool of those with the worst forms of hearing impairment continues to grow exponentially faster than our profession's ability ro keep up.
To date, most adults with cochlear implants still wear a hearing aid in the non-implanted ear, and utilize assistive devices and coping strategies intensively to complete their rehabilitation. There is, therefore, a growing number of cochlear implant and hearing aid users who need the continued services of a hearing health specialist.
Prevalence of Those Needing Intensive Assistance
Out of the 28 million hearing impaired Americans, there are 2.7 million severely and profoundly deafened children and adults (see Figure 2). Of this population, 64 percent wear hearing aids, cochlear implants or reside in the deaf community, as shown in Figure 3. These are the open and shut cases of which none should fall between the cracks of the current delivery system. Also, there are many "shades of gray" losses (moderately and moderately severe) which also need to be addressed from a compensatory counseling standpoint. They, too, can benefit from assistive technology and coping strategies in addition to hearing aid amplification.
Aural Rehabilitation Counseling
Traditionally, aural rehabilitation has been the domain of audiologists, but in recent years Hearing Instrument SpecialistsÆ have become more involved as they guide their patients through available avenues of compensatory strategies and devices. However, it is not a blanket assumption that Hearing Instrument SpecialistsÆ are also aural rehabilitation counselors. Aural rehabilitation is an integral facet of practice when the specialist plans and prepares for the task. Continuous education and training become critical requisites, whether obtained on the job, through continuing education courses, by formal study or through a combination of these.
Most long experienced specialists have evolved into aural rehabilitation in the quest to meet the needs of their patients whose hearing losses have grown progressively worse over many years. This necessitates working in accordance with other professionals who have specialized skills in areas such as formal speechreading training, communicative rehabilitation of stroke victims, CAPD cases or cochlear implant use. In this way, community hearing health care reams have evolved nearly everywhere, driven by the rapidly growing number of patients who need additional and intensive clinical services that cannot be provided by any one professional.
Needed: Caring Specialists
The most important qualification for the hearing health specialist becoming involved in the rehabilitative aspects of hearing correction is to care enough to do the necessary research for each case where immediate solutions are not available. This would mean that all hearing instrument patients should be able to gain access to those resources through their specialist. In turn, patients- must be willing partners in the quest to utilize all possible options to help them pick up where hearing aids leave off. By adding compensatory services to their dispensing practice, the specialist is providing a total communication concept.
Total Communication Concept
The habilitative/rehabilkative philosophy of total communication declares that a person has a right to have information access through any means possible, including:
- Hearing aids
- Cochlear implants
- Assistive listening devices (ALDs)
- Speechreading
- Written language
- Auditory closure
- Gestures and facial expressions
- Sign language
- Fingerspelling
Every practitioner of hearing rehabilitation should consider the total communication concept. Our reference to total communication does not mean the restrictive (non-oral/aural) philosophy of total communication held by some, but instead an all-inclusive or holistic approach in utilizing all forms of communication, especially oral/aural.
Step One: Recognizing and Accepting Limitations
As in any rehabilitative situation, the first step in conquering limitations is to recognize and accept them. This entails a keen understanding of how hearing loss affects one's life. The cause is essentially transparent, but the effects are indeed real. Assessing how these effects are impacting one's psychosocial well-being is no time for masking over the truth. The truth, in this case, needs to be dragged out into broad daylight and carefully examined so the patient and their loved ones can begin to move forward.
After all that can be done with amplification alone, the specialist should direct attention toward self-assessment of the limitations that remain afterward. Following is an example of a case where the user has a moderately sloping loss through the low frequencies, a steeper drop in the mid-range frequencies and no aidable hearing after 2KHz:
Mr. Jones, after all that can be done with the fitting and adjusting of these instruments, you'll still have a substantial hearing loss. The frequencies you'll be missing are critical for two reasons. The first is in speech understanding. Some of the softer consonant sounds, which define words in the English language, will be difficult to hear no matter how loudly you adjust your volume control. The second is in understanding speech while in noise. The masking effect of the
lower frequencies which you already hear will cause an "upward spread of masking" covering some essential parts of words.
Following are some ways you can help this situation:
- First, you must realize the permanent auditory limitations arising from your hearing loss. Hearing aids are only part of your hearing solution. Since you have no residual hearing after 2KHz. it is impossible to give you hearing in that range with any hearing device. You'll need to learn not to become frustrated in critical listening situations. Trying too hard only makes it more difficult.
- You must develop better Speechreading skills. I will help you locate Speechreading learning resources in your community. They are often inexpensive or free. It will take practice on your part, but will be of tremendous help.
- Whenever possible, try to limit communication in very noisy places. Ask your visitor(s) to walk with you to a quiet area. Furthermore, tell them that speaking loudly does not help that amplifying or increasing the sounds that you cannot hear will not improve your speech understanding. Knowing that it is difficult for you to function where you cannot easily see the person speaking, consider lighting and distance.
- When faced with a difficult listening situation, such as in a telephone conversation from a public phone, make the other party aware of your hearing loss and ask them to have patience. Don't try to bluff your way through.
- You may create a more functional environment for yourself by obtaining several other items:
a. Closed-caption or infrared listener on your TV
b. Lower-pitched alarm clock and telephone ringer.
c. FM auditory system for large area listening
d. Distortion-free amplified telephone or low-frequency emphasis speaker phone
e. In all future purchases such as automobiles, recreational equipment, etc., think in terms of how you can communicate in the noise created by these items. Look for the lowest possible ambient noise levels.
Note: A copy of the above dialog may be given the client to read if that will assure better communication. Too often a person with this type of loss has resorted to nodding in agreement even though they miss many essential points.
By way of counseling in the above manner, patients will realize greater success while framing expectations in a more realistic light. They will also have a viable format from which to accept and accommodate the necessary limitations of their aurally corrected loss.
In Part II of this series, we will enumerate several methods of compensation, the actual application of which will depend upon the specific needs of each individual hearing aid user.
References
Aural Rehabilitation Concepts, Study of the severely hearing impaired population in the U.S., Gainesville, TX (1997).
Busse, L., "When Hearing Aids Are Not Enough," continuing education course, Cochlear Corporation: Englewood, CO (1996).
Chartrand, M. S., "The Unreported Story: Schools Still Failing in Hearing Healthcare," Hearing Health, May/June, pp. 12-13, 49 (1997).
Chartrand, M. S., Market Analysis: SHI, Englewood, CO: Cochlear Corporation (1998).
Chartrand, M. S., Patient Care Course, Series I, a continuing education course, Livonia, MI: National Institute for Hearing Instruments Studies (1999).
Costello, E., Signing: How to Speak With Your Hands, New York: Bantam Books, Inc. (1983).
Tye-Murray, N., Foundations of Aural Rehabilitation, San Diego, CA:
Singular Publishing Group, Inc., pp. 2-14 (1998).
