Aural Education and Rehabilitation

Once hearing loss has been identified, it is essential that the next step includes education and counseling on the options available to help improve communication. There is a common misconception that hearing aids represent a cure for hearing loss. In reality, hearing aids are simply a tool to aid in the rehabilitative process. With realistic goals and knowing what to expect from hearing aids, an individual suffering from hearing loss can be successful in improving communication and understanding through amplification. This process takes dedication, commitment, and help from a hearing health care professional.

Education

Knowledge is power, and the first step to improving hearing loss is to be properly informed. All aspects of hearing loss should be covered by a hearing health care professional. From type and degree of hearing loss, tools for communication, and preventative and rehabilitative recommendations, the more an individual understands about the issue, the better decisions they can make to correct it.
If, after a through hearing exam is performed and amplification is recommended, a hearing health care professional should provide a step-by-step guide to the fitting and aural rehabilitation process. Before continuing with a fitting, the individual should conduct some of their own research in the types of hearing instruments available, how the adjustment process works, and the use of communication strategies to help aid in the rehabilitation process. The hearing health care professional should offer support and information in all of these areas, including several amplification options for your specific loss, as well as outlining a level of support after being fit with hearing aids.
Creating that support group of family and friends is key to the success of the individual who suffers from hearing loss. Educating these close individuals during the decision process allows them to better understand the hearing difficulties facing the individual and options available with today’s technology.

Expectations and Goals

Successful hearing aid use begins with setting realistic goals. Everyone’s needs and expectations are different, and so it is vitally important the hearing impaired sit down, one-on-one, with the hearing health care professional to outline the specific goals and expectations. Understanding what realistic expectations are is the first step. For example, if an individual expects their hearing to return to normal, this is unrealistic for even the most sophisticated hearing instruments available. If, however, the individual expects the hearing aid to ease the effectiveness of communication, this is a more realistic goal. Like many things in life, unrealistic expectations are the main cause of frustration with hearing aids. Including family and friends in the process of setting goals and understanding expectations will also contribute greatly to the success of the individual.
Identifying specific and timely goals is of the utter most importance. For example, most first time hearing instrument users experience fatigue during the first couple of months wearing their hearing aids. It is a good idea to set small goals that include specific levels or increments of hearing aid use. For example, during the first week, the individual might set a goal to wear the hearing instruments for only 2-3 hours per day, and increase the wear time by an hour every week. Other goals might include specific listening environments or situations that are particularly difficult for the individual to communicate in.

Post Fittings Sessions

The rehabilitation process begins immediately after the individual is fit with hearing aids. This process is much more than simply purchasing and wearing the hearing aids. It is imperative that the hearing health care professional provide post-fitting sessions as needed. These sessions are opportunities for the individual and hearing health care provider to work one-on-one verifying the hearing aid fitting, making proper adjustments, counseling on hearing aid use, and providing communication training.

Verification, Counseling, and Communication Strategies

Verification is most often performed using a Real Ear Measurement system. The hearing health care provider inserts a small microphone into the ear canal, along with the hearing instrument, and measures the actual amplified sound reaching the ear drum. This process helps provide objective information that can be compared side-by-side with the audiogram of the individual. It also provides an opportunity for the professional to make adjustments, based on the data, to the hearing aid to ensure a successful and proper fit. Other verification includes subjective situations including speech comprehension tests, and speech in noise tests, that measure the individual’s ability to understand speech in certain listening environments.
Starting with hearing aids can be very challenging. Because most hearing loss occurs gradually over time, the individual can become comfortable living in their quiet world. Small sounds that were once natural, such as footsteps, wind, or clanking dishes, can become a nuisance when brought back at all at once with the aid of hearing instruments. Adjusting is an individual issue and may take weeks or months. The hearing health care professional should be willing to help counsel and guide the individual through this period of adjustment.
Hearing instruments are effective tools for aiding in communication. Like all tools, however, they are only effective if used properly. Often time individuals who have suffered from chronic hearing loss have developed poor listening skills that require adjusting. Once hearing aids have been fit, it is extremely important that the individual’s communication skills be properly addressed. Working one-on-one with your hearing health care professional, the individual should be counseled and guided on improving communication skills including visual cues, environmental manipulation, where to position a listener in different situations, communicating in noise, and many other helpful communication skills.

Group Hearing Aid Orientation

Many hearing health providers are offering group hearing loss rehabilitation services, rather than on an individual basis. These sessions are attended by individuals who suffer from hearing loss, as well as their family and friends or support base. The Hearing Loss Association of America's Utah Chapter meets at 5709 South 1500 West Taylorsville, UT 84123-5217 every Wednesday from 7-9pm. For more information you can visit their website at http://www.hlaslc.org/.

Summary

When choosing a hearing health care provider, be sure to determine if they will be able to offer the variety of services required. Hearing aids are not a quick fix. Simply purchasing a hearing instrument and wearing it will not ensure a successful fitting or improved quality of life. Hearing instruments are simply tools that must be understood, adjusted, and used properly. If the individual’s motivation is improved communication by proper amplification, learning effective communication strategies, and effective counseling the chances are excellent for a proper fitting.
To learn more, or to schedule a complimentary hearing exam, call us at Salt Lake City 801-485-5595 | Provo 801-373-5887 or visit our website at http://www.edisonstanfordhearing.com

Hearing Loss and Utah Jobs

Did you know that over 28 million Americans suffer from hearing loss and only 5% have taken steps to treat the problem? When an individual delays a decision to get hearing help, they are unaware of the fact that receiving early treatment for hearing loss has the potential to literally transform their lives. Research by the National Council on the Aging on more than 2,000 people with hearing loss demonstrated that hearing aids clearly are associated with impressive improvements in the social, emotional, psychological, and physical well-being of people with hearing loss in all categories from mild to severe.

Hearing loss treatment was shown to improve: Earning power, communication in relationships, intimacy and warmth in family relationships, ease in communication, emotional stability, sense of control over life events, perception of mental functioning, physical health, and group social participation.

We understand that there is a great possibility some of the employees in Utah suffer from hearing loss and we are offering to help in any way possible. Our office of professional staff is ready to provide a complimentary hearing exam to any of the public over the age of 18. Due to the nature of the testing process, we recommend that the hearing exam is performed in our sound treated office, or for a preliminary evaluation, individuals can take our free 5-min hearing test online at http://www.edisonstanfordhearing.com/5-min-online-hearing-test.

It is also our pleasure to inform the public that through a new Utah State funded program, individuals whose job performance may be affected by hearing loss could qualify to have hearing aids provided at no charge. Working with the local government office we have already assisted in improving the quality of life for many individuals. We are confident that this has resulted in increased productivity and improved job performance for these individuals. These funds, however, are limited and we strongly recommend starting the process as soon as possible.

Please contact our office at your earliest convenience to set up a free hearing screening for your company. You may reach us, Monday-Friday, at our Salt Lake Office 801-485-5595 or Provo Office 801-373-5887.

Regaining Control of Your Life through Self-help Groups

Brenda Battat, MS, Executive Director
Hearing Loss Association of America, Bethesda, MD

“I wish someone had told me about the value of self-help groups such as the Hearing Loss Association of America (HLAA) years ago. It would have saved me so much stress in coping with my hearing loss." This is a refrain we hear from people with hearing loss over and over again.

Most people who purchase hearing aids are not aware when purchasing hearing aids they may need counseling, aural education, supplemental technology, help in everyday issues such as choosing a correct cell phone and peer support to optimize success with their hearing aids.  In this article we will explore the value of self-help groups.

Complementary Counseling

People with hearing loss need to be evaluated from the broadest perspective—beyond diagnosis, hearing testing and hearing aid evaluation—to see what their functional needs are. Given that audiologists and hearing instrument specialists are likely to be the first professional assessing the individual with hearing loss, they are in a perfect position to do full-scale needs assessment and make referrals to a local self-help group when necessary.  Not all hearing health professionals conduct extensive aural rehabilitation or education classes with their clients.  So it is very appropriate for hearing health professionals to inform their clients about organizations such as HLAA because many people need the complementary counseling effect that a support group provides.

Most hearing loss is for life and likely to get progressively worse. It can't be cured; it has to be diagnosed and managed by professionals and coped with by the individual who has the hearing loss. In that sense hearing loss is like other medical conditions without a cure¬ - the coping falls to the individual. When we walk out of the audiologist's office with our hearing aid, the door closes and we are faced with the reality of a big, insensitive world. We've been tested, evaluated and fitted with a state-of-the-art electronic device that certainly makes it easier to communicate; but we still have a hearing loss. We've learned how to care for the hearing aid and given it a good test run during the trial period, but the bottom line is there are still going to be situations where we cannot hear well. That means dealing on a daily basis with the stigma, embarrassment and frustration that goes with a hidden disability.

Hearing loss, even with the best-fitting hearing aid, impacts every interaction of our lives—relationships, work, education, intimacy. It also impacts our interaction with ourselves, undermining self-confidence, self-esteem, and mental and physical well-being.

So how does participating in a self-help group help someone cope? People who are hard of hearing are mainstream. They do not have a separate culture and language like people who are deaf and use sign language to communicate. They may not know another single person with hearing loss. They can feel alone and may retreat from social interactions due to their embarrassment about having difficulty communicating.

HLAA local chapters were formed thirty years ago on the basis of self-help. By giving people information about hearing loss, they are better able to cope with it and regain control of their lives.

Research has shown the benefits of people getting together to share common experiences. For example, according to the Agency for Healthcare Research and Quality (AHRQ), a study of breast cancer survivors revealed that the women who participated in a support group lived longer and had a better quality of life than those who didn't. Women in the support group learned coping skills and shared their feelings with others in the same situation.

Learning and Sharing

At a chapter of HLAA, individuals with diagnosed hearing loss will meet other people with hearing loss at different stages of personal adjustment. These become role models, confidantes, motivators and, sometimes, literally saviors. Individuals coming to a chapter meeting experience--most likely for the first time--an environment that is hearing friendly. Chapters set up assistive listening devices (ALDs), usually hearing loops because they are easy to install, portable and not too costly. New members will learn, often for the first time, the value of a telecoil that turns their hearing aid into a wireless receiver. They are amazed how much easier it is to listen through the hearing loop system. Some chapters have captioning to ensure everyone can participate fully, including those who cannot use ALDs.

Monthly educational programs arranged by the chapter provide information on the latest assistive technology, coping strategies, communication skills, research and other topics. These are inter-spersed with social events where people can put into practice in real life situations the communication strategies that they learn.

Gradually, new members see they have legal rights to access. They learn about legislation that can impact their lives and resources in their state and community, such as the state relay service, vocational rehabilitation, speech reading classes, state agencies serving people with disabilities, and equipment distribution programs. In addition, they learn many of these agencies must have consumers on their advisory boards, so they begin to get involved in formulating public policy.

Getting Involved

Ask you hearing health professional about local support groups. They may be held in senior community centers, churches or synagogues near you. The largest network in the U.S. is the 200+ chapters of the Hearing loss Association of America

Through involvement in various chapter committees, individuals develop leadership skills that help them regain self-confidence. As they get back a sense of control, they start to feel worthy and whole again. They then can put this new-found confidence to work in advocating for implementation of laws in their community and nationally.

They also learn the most important strategy of all—telling people they have a hearing loss and asking for help communicating. It's very common to deny hearing loss. Often a family member or friend encourages an individual to seek help. Many valuable years of using a hearing aid and learning vital coping skills are wasted as people continue to reject the notion that they are losing their hearing. In a group of people where everyone has hearing loss, it is OK to say it and to do something about it publicly.

Are self-help groups right for all people with hearing loss? Probably not. Some people don't like groups of any kind but will benefit from joining HLAA and receiving the bimonthly magazine Hearing Loss, the online eNews, the website, online chats and the annual convention. There are many options and ways to get involved apart from going to a chapter meeting.  Other benefits of belonging to HLAA are that people become informed consumers and smart hearing aid users. They will come back to the audiologist or hearing instrument specialist more often to try the latest technology because they will hear about it through involvement in HLAA.

In a recent survey seventy-five percent of our members indicated they had made a hearing aid purchase within the past three years. Nearly half said they used ALDs such as FM, loop, infrared or hard-wired systems; and 61 percent indicated they used assistive listening systems and telephones with a telecoil in their hearing aid.

HLAA members may enlist you as a professional advisor to the chapter to suggest speakers, keep members abreast of developments in the field of audiology, contribute articles to their newsletter, and get involved in communication access projects in the community. All this is good for your business and reputation.

Currently, there are 200 HLAA chapters nationwide. They meet once a month in the evening. Some also have daytime meetings to accommodate those who do not like to drive at night. Chapter locations are posted on the HLAA website at www.hearingloss.org.

Twelve Reasons Why Self-help Groups are Good for You

In ending let me inspire you with 12 reasons why you should attend a self-help or peer-support group for people with hearing loss. Self-help groups:

• Provide a community of people with hearing loss who understand and are empathic to your unique problems
• Help you deal with the issues of hearing loss stigma
• Will help you understand your legal rights as a person with a hearing disability
• Will teach you coping and communication strategies
• Will help you to adjust and communicate your needs in a "hearing" workplace
• Will share technologies beyond your hearing aids that will enhance your ability to function in the world
• Will educate you on technologies and strategies for ensuring your safety
• Will show you how to stay tuned into family conversations
• Will suggest strategies for communicating in noisy situations
• Will show you how to accommodate your hearing loss while traveling
• Will empower you through exchange of knowledge, encouragement and the sharing of experiences
• Will alleviate the despair and isolation of hearing loss through their support

Hearing Loss Forum

To kick off the new year we've created a small online community to help support those who directly and indirectly suffer from hearing loss. Covering such topics as:

• Hearing Loss 101
• Think you may have a hearing loss? Were you recently diagnosed with a loss? Wondering what to do next?

• Financial Assistance
• Share information about insurance coverage, tax credits, and national benefit organizations that help people access hearing loss treatment devices.

• Hearing Loss Treatment-Hearing Aids
• Discuss alternative options available to treat hearing loss including cochlear implants, medical treatment, assistive devices, and aural rehabilitation/counseling.

• Family and Relationships
• Does someone in your family have a hearing loss, but they won’t admit it? Discuss strategies for communicating with loved ones who have a hearing loss, including learning how to deal with resistance and denial.

• Technology
• Advancements in hearing loss technology and accessibility occur every day-discuss them here.

Please take advantage of this wonderful opportunity to share and help others who suffer from hearing loss and spread knowledge and experiences with others. Together we can make a difference.

You can visit the forum at: http://forum.edisonstanford.com .

Note: All posts on the forum are mediated.

The Importance of Hearing Loss Pre-assessment

Hearing health professionals and hearing aid manufacturers have been using the common-sense "signs of hearing loss" in their public relations and advertising probably since the beginning of the hearing health industry as a method of educating people to seek treatment for their hearing loss with hearing aids.

This continues to be one of the most critical on-going education activities we can do to help people with untreated hearing loss for the following key reasons:

• 6 of 10 new hearing aid users purchased their very first hearing aid because they realized their hearing loss was getting worse. (Source: MarkeTrak VIII)
• 50% of people who admit they have a hearing loss but do not use hearing aids report they chose not to adopt hearing aids because they have never had their hearing checked. (Source: MarkeTrak VII)
• Offering people FREE hearing tests may be effective in bringing in some people into hearing health professional offices, but for the vast majority of people with untreated hearing loss sitting on the fence, they lack insufficient information to make any step toward entering a hearing health professional's office.
• It is our belief that hearing loss problem recognition is a critical precursor to hearing loss problem resolution.

To this end utilizing both objective and subjective information across four databases involving nearly 11,000 subjects, Sergei Kochkin, Ph.D. and Ruth Bentler, Ph.D. have shown in the November 2010 Hearing Review that the BHI Quick Hearing Check has high validity, reliability and utility; it is significantly related to nearly all key quality of life issues; and it demonstrates that standard audiological definitions of hearing loss based on dB loss better ear, may in fact need to be re-thought, since consumers tend to rate their subjective hearing loss much higher than what we state in our text books. The research demonstrates this tool can be used for effectively providing consumers with more information about their hearing loss and moving those with hearing loss closer to seeking a hearing solution.

The availability of this instrument represents a major opportunity for the hearing health industry to strategically attack one of the key barriers to hearing aid adoption; consumer's insufficient information about their hearing loss. There are currently two easy-to-use versions of this test—and both can be used for free and without permission from BHI (www.betterhearing.org). One is a paper and-pencil form in which the test-taker simply circles his/her responses and then uses the instructions on the back of the sheet to obtain a hearing score and recommendation for taking action.  HHP may print this form themselves or purchase them from the BHI in tablet form.

A simpler “no brainer” version that automatically scores the test and presents the results with the click of a button can be found online at www.hearingcheck.org (also a BHI Web site). It’s our hope that hearing care professionals and the hearing industry will instantly see the huge opportunity this test affords us and use it in all hearing-related promotions

Hearing Better May Mean Earning More

(NAPS)—People with untreated hearing loss may see their income decrease by as much as $30,000 a year, according to a national survey by the Better Hearing Institute. But hearing aids were shown to reduce the risk of income loss by 90 to 100 percent for those with milder hearing loss, and from 65 to 77 percent for those with severe to moderate hearing loss.

Most of the more than 34 million Americans with hearing loss are either in the workforce or in school. The loss in income for people with untreated hearing problems, due to underemployment, is estimated at $176 billion.

Hearing is critical to effective communication in the workforce. The ability to hear and listen well enables employees to be more productive and understand the work that has been assigned. Poor communication can result in unhappy customers, missed deadlines, poor morale among co-workers and mistakes on the job.

Effective hearing may also be critical to ensure safety on the job.

In the study, those with unaided severe hearing loss had unemployment rates double that of the normal-hearing population, and nearly double that of their aided peers.

“People are losing their hearing earlier and staying in the workforce longer,” says Sergei Kochkin, executive director of the Better Hearing Institute. “In today’s tough job market, hearing your best is essential for career success.”

Hearing aids remain the optimum treatment for the vast majority of people with hearing loss. Yet only 40 percent of Americans with moderate to severe hearing loss, and only 9 percent of those with mild hearing loss, wear them.

Half of all people with untreated hearing loss have never had their hearing professionally checked. To help, the Better Hearing Institute has a five-minute hearing test at www.hearingcheck.org. You can learn more about hearing loss and how to help it at www.betterhearing.org.

People With Diabetes More Likely to Suffer Hearing Loss

(NU) - A new study published by the Annals of Internal Medicine suggests that diabetics are susceptible not only to vision problems, but to hearing problems as well. “For years, physicians who treat people with diabetes have regularly ensured that their patients receive regular vision check-ups,” said Dr. William Luxford, BHI Board member and an Otolaryngologist at the House Ear Clinic in Los Angeles. “This important study underscores the need for physicians now to encourage each of their patients to get their hearing checked as well.”

In the study, National Institutes of Health (NIH) researchers analyzed data from hearing tests administered to 5,140 participants between 1999 and 2004 in the National Health and Nutrition Examination Survey (NHANES). Their findings? Patients with diabetes are more than twice as likely to suffer hearing loss than non-diabetics. More than 40 percent of the patients who participated in the study had some hearing damage.

“People with diabetes should ask their doctors to check their hearing,” said Sergei Kochkin, Ph.D., executive director of the Better Hearing Institute (BHI). “A hearing check can be invaluable in identifying diabetic patients with potential hearing loss, and giving them an opportunity to receive the treatment they need.”

Studies conducted by BHI, a not-for-profit educational organization whose mission is to educate the public about hearing loss treatment and prevention, show that people with untreated hearing loss experience a lower quality of life than people with normal hearing or people who use hearing aids.

The Better Hearing Institute has designed a “Quick Hearing Check” to help people quickly assess whether they have a hearing loss requiring a comprehensive hearing test by a hearing professional. The quick check is available online at www.hearingcheck.org.

Helping Loved Ones Hear Better This Holiday Season

Helping Loved Ones Hear Better This Holiday Season

Salt Lake City, November 16, 2010—Edison Stanford Hearing Center is urging families within the Utah County area to be alert for relatives and friends who seem to have trouble hearing this holiday season.

Hearing loss affects the ability of people to celebrate the holidays with family and friends, often leading to isolation and depression. Hearing loss is one of the most commonly unaddressed health conditions in America today. More than 34 million people in the United States have hearing loss—roughly 11 percent of the population.

“The holidays are a time to gather together with family and friends,” says Paul Lloyd, Edison Stanford Hearing Center. “But for friends and relatives with untreated hearing loss, the holiday season can be bittersweet. By staying alert to the signs of unaddressed hearing loss, and by encouraging those we love to address the problem, we can help them regain their quality of life and strengthen our relationships with them.”

There is a very easy, free and convenient way for people to check their hearing, or encourage loved ones to do so. The Better Hearing Institute (BHI) has made available a simple, interactive, online screening tool where families can check their hearing in the comfort and privacy of their own homes, at www.hearingcheck.org. BHI also has an online discussion forum and information exchange available at www.betterhearing.org, where people can join the dialogue on hearing loss and gain valuable support and information.
Hearing loss occurs at all ages. For example, among people aged 46 to 64, about 15 percent already have hearing problems. Sixty percent of people with hearing loss are below retirement age. Hearing loss can occur due to exposure to loud music or noises.

There is increasing evidence that people with certain medical conditions—such as diabetes, Alzheimer’s disease, kidney disease, heart disease, and even vision loss—may be at an increased risk of hearing loss. And numerous studies have linked untreated hearing loss to a wide range of physical and emotional conditions.

According to a BHI study, family members play a critical role in whether loved ones address a hearing loss. More than half (51%) of new first-time owners of hearing aids said that family members were a key factor influencing their purchase. Fifty-five percent of new hearing aids users sought treatment once they realized through testing how serious their hearing loss was.

In the vast majority of situations, hearing aids can help a person hear better. Studies have shown that hearing aid wearers experience significant improvements in quality of life and decreased depressive symptoms; have significantly higher self-concepts compared to individuals who do not wear hearing aids; and their functional health status improves significantly after three months of hearing aid use.

"Many people decide to get their hearing checked because someone they love suggested it and provided support,” says Sergei Kochkin, PhD, executive director of BHI. “If someone you love appears to have a hearing loss, please urge them to get a hearing screening. With the BHI quick hearing check available at www.hearingcheck.org, it’s easier for people to take that first, critical step in reclaiming their hearing, quality of life, and relationships. What better gift can you give someone you love this holiday season?”

Signs of Hearing Loss

There are several social, emotional, and medical signs of hearing loss that people can watch for this holiday season:

Social:

• require frequent repetition
• have difficulty following conversations involving more than two people
• think that other people sound muffled or like they're mumbling
• have difficulty hearing in noisy situations, like conferences, restaurants, malls, or crowded meeting rooms
• have trouble hearing children and women
• have your TV or radio turned up to a high volume
• answer or respond inappropriately in conversations
• have ringing in your ears
• read lips or more intently watch people's faces when they speak with you

Emotional:

• feel stressed out from straining to hear what others are saying
• feel annoyed at other people because you can't hear or understand them
• feel embarrassed to meet new people or from misunderstanding what others are saying
• feel nervous about trying to hear and understand
• withdraw from social situations that you once enjoyed because of difficulty hearing

Medical:

• have a family history of hearing loss
• take medications that can harm the hearing system (ototoxic drugs)
• have diabetes, heart, circulation or thyroid problems
• have been exposed to very loud sounds over a long period or single exposure to explosive noise

# # #

To take the BHI Quick Hearing Check, visit at www.hearingcheck.org. To participate in the discussion forum, visit www.betterhearing.org, click on “Discussion Forum,” and go to “Welcome!” to register.

# # #

Paul Lloyd is an Audioprosthologist at Edison Stanford Hearing Center in Salt Lake City Utah, and can be contacted at T: 1 (801) 485-5595, F: 1 (801) 467-1125, www.edisonstanfordhearing.com, e-mail: edisonhearing@hotmail.com.

The Efficacy of Hearing Aids in the Workplace

The majority of people with hearing loss are under retirement age.  Therefore, it’s crucial that we educate people with untreated hearing loss in the workforce to understand in this tough job market that hearing better could have profound implications for their marketability, success on the job and their earning potential.
In our latest MarkeTrak VIII publication “The efficacy of hearing aids in achieving compensation equity in the workplace” (Hearing Journal, October 2010) we have demonstrated conclusively in a study of 40,000 households that:

• People with untreated hearing loss lose as much as $30,000 annually, depending on their degree of hearing loss.
• For those that use them, hearing aids were shown to mitigate the impact of income loss by 90%-100% for those with milder hearing losses and from 65%-77% for those with severe to moderate hearing loss.
• The loss in income for people with untreated hearing loss due to underemployment is estimated at $176 billion, and the cost to society is estimated to be as high as $26 billion in unrealized federal taxes.
• There was a strong relationship between degree of hearing loss and unemployment for unaided subjects. Those with severe hearing loss had unemployment rates (15.6%) double that of the normal-hearing population (7.8%) and nearly double that of their aided peers (8.3%). Thus, one would expect that the cost to society of unemployment benefit payments is double that for normal-hearing households, depending on degree of hearing loss.

In the coming months we will be promoting this study nationally and developing OpEd and press releases for hearing health professionals to educate the public at a local level. We believe educating consumers about hearing loss and its relationship to job success is an effective strategy for influencing people with untreated hearing loss (and perhaps in denial) to seek hearing solutions earlier in their life.
Earlier this year we issued a Q & A article targeted to Human Resource executives. Hearing Health Professionals are invited to distribute this article to HR executives in their community as a means of introducing their services.

What You Should Expect From Hearing Aids

If your hearing loss has progressed to the degree that you need hearing aids, a critical factor in their success is your understanding and acceptance of realistic expectations of their capabilities. Hearing instruments, regardless of brand or type of technology, can never replace normal hearing in all listening situations.
Expecting results that cannot be achieved will only lead to frustration and dissatisfaction. If you know what to expect, you'll be free to enjoy the improvements that hearing aids can make in your life. Here are some guidelines which should help you and your provider agree on a set of realistic expectations for you.

• The extent to which the lost hearing function can be restored through amplification is based on the severity and duration of your hearing loss. The degree and extent of hearing loss is determined by using calibrated equipment called an audiometer.
• The more sever your hearing loss, the larger the hearing aid must be to provide room for a larger amplification and components.
• Crowded social gatherings and restaurants are examples of noisy conditions where even a person with normal hearing has trouble hearing conversation. As a person's hearing deteriorates, so also does the ability of a hearing aid to correct for hearing loss in these situations. Your provider's goal is to select an appropriate circuit for your hearing aid that will deliver a natural loudness throughout your entire listening range without getting too loud or too quiet.
• In difficult listening situations normal hearing listeners rely on using speech reading cues and focusing their attention on the speaker. These listening skills are even more important for the hearing aid user when faced with these circumstances.
• In quiet, many hearing aid users can achieve a performance level equal to normal hearing. But as the difficulty of the listening task increases, the gap between a person with normal hearing and a person with hearing loss widens. The more severe the hearing loss, the wider the gap.
• With properly fitted hearing aids you should be able to hear many normal sounds that you may not otherwise be able to hear clearly, such as the voice of your client or the words of a loved one. You may also begin to hear sounds you have forgotten were a part of your world, such as the hum of the motor on your refrigerator or the buzz of your fluorescent lights.
• Hearing aids in the advance, programmable and digital categories should prevent normally loud sounds from becoming uncomfortable.
• Depending on the degree and severity of your loss, hearing aids may allow you to hear speech more clearly in some noisy situations.
• You'll need time to get used to your new hearing aids to learn how to achieve maximum performance from them.
• Hearing aids will not restore your hearing to normal. Science has not been able to match the human hearing mechanism.
• Hearing aids will not "filter out" background noise, despite some advertising claims. Some hearing aids have circuitry that will avoid boosting the volume of some types of background noise, but this can also remove some of the speech you want to hear. This is usually a benefit, however, providing a more comfortable listening experience and better sound quality in some types of noisy situations.
• Hearing aids should allow you to understand speech more clearly, with less effort, in a variety of listening situations.
• Hearing aids should keep others from noticing your hearing loss.
• Your hearing health care provider should have the same goal as you: to find a way to help you reach the best possible hearing improvement. Using the best testing and assessment equipment science has to offer, and the availability of hearing aids from more than 30 national manufactures.

Tips for Communicating With Persons With Hearing Impairment

1. If necessary, speak louder, but don't shout.
2. Speak clearly and slowly.
3. Speak at a distance of between 3 and 6 feet.
4. Stand in clear light facing the person with whom you are speaking for greater visibility of lip movements, facial expressions, and gestures.
5. Do not speak to a person with hearing impairment unless you are visible to him or her (e.g. not from another room or while he or she is reading or watching TV).
6. Move away from background noise.
7. If a person with hearing impairment does not appear to understand what is said, rephrase the statement rather than repeat only the misunderstood words.
8. Do not over-articulate. Exaggerating your pronunciation not only distorts the sound of speech, but also the speaker's face making the use of visual cues more difficult.
9. Do not cover your mouth with a cigarette or hands and do not chew food while speaking.
10. Arrange the room (living room or meeting room) where communication will take place so that no speaker or listener is more than six feet apart and all are completely visible; communication for all parties involved will be enhanced.
11. Include the hearing-impaired person in all discussion about him or her. Individuals with hearing impairment sometimes feel quite vulnerable and left out; this approach will aid in alleviating some of those feelings.
12. Ask what might make conversation easier.
13. In meetings or any group activity where a speaker is presenting information (church meetings, civic organizations, etc.) make mandatory that the speaker use the public address system.

Republished from: Better Communication and Hearing Aids, D.S. Wayner, PhD and J.E. Abrahamson, MA

Spotlight On Hearing Loss

Assisting Employees with Hearing Loss

By Sergei Kochkin, Ph.D.

Question: What can organizations do to plan for and address the impact of employee hearing loss?

Answer: Employers can take a number of simple steps to educate employees about hearing loss and to facilitate the use of hearing aids, where needed.

In a 2009 survey of 46,000 U.S. households, the Better Hearing Institute (BHI) determined that over the past generation hearing loss grew at 160 percent of the U.S. population growth— primarily attributable to the aging of the American population. Yet the study found that 60 percent of people with hearing loss are below retirement age, meaning that 16.3 million people with hearing loss were in the U.S. workforce in 2010.

Previous research at BHI has shown that 50 percent of people with untreated hearing loss have never had their hearing checked by a professional and lack sufficient information to know whether they need to take action to correct it. Human resource professionals can help employees understand if they need treatment by:

Educating employees on the impact of untreated hearing loss on quality of life.

Encouraging employees to take valid online hearing tests such as the five-minute hearing evaluation offered by BHI.

Encouraging local hearing health professionals to conduct on-site hearing screenings.

In many cases hearing aids can help protect employees from being at a competitive disadvantage with peers. Organizations can encourage the use of hearing aids, when needed, by ensuring that health insurance covers such devices and by recommending that employees purchase hearing aids using pretax medical flexible spending account funds.

In addition, employers can:

• Create a corporate climate where hearing loss is recognized so those with hidden hearing loss feel more comfortable.
• Avoid noisy restaurants as meeting locations. 
• Summarize meeting minutes in writing to be sure that those with hearing issues are clear on the outcome of the meeting.
• Provide easy accommodations, such as moving an employee's desk away from noisy hallways, machines, or air conditioning and heating vents, or installing a phone that amplifies high frequencies.
• Build work environments that facilitate better hearing by choosing cubicles with noise-absorbent materials and equipping meeting rooms with an inductive loop that creates a wireless zone for hearing aids with telecoils, headsets or microphones.

By encouraging employees to treat hidden hearing loss rather than hide it, an employer creates a win-win situation by ensuring that the loss of hearing does not interfere with job performance, productivity, safety, or the employee’s career or quality of life on or off the job.

Sergei Kochkin, Ph.D., is executive director of the Better Hearing Institute, a not-for-profit that educates the public about hearing loss, prevention and treatment.

Reprinted from: The Society for Human Resource Management (www.shrm.org)

Hearing loss hits 1 in 5 U.S. teens

By Liz Szabo, USA TODAY

One in five American teenagers now suffers from some type of hearing loss, an increase of 31% since the mid-'90s, new research shows.

Most cases of hearing loss are slight, affecting only one ear and involving mostly high-frequency sounds, according to a study in today's Journal of the American Medical Association. Many teens may not even notice the hearing change. About one in 20 have "mild or worsening" hearing loss, which can make them struggle to follow conversations or teachers at school.

ON THE WEB: NIH tips on protecting kids' hearing

"It's very concerning," says study author Josef Shargorodsky, an otolaryngology/head and neck surgery resident at the Massachusetts Eye and Ear Infirmary in Boston.

Other studies show that even a small hearing loss can harm a child's school performance, language development and social interactions, he says.

Parents may have trouble spotting the change as well, given that teens often tune their parents out, says Shargorodsky, whose research was conducted at the Channing Laboratory at Brigham and Women's Hospital, also in Boston.

Parents may notice other changes — such as an unexplained drop in grades — that could signal hearing loss, he says.

Because hearing loss is cumulative, these teens are at high risk for significant hearing problems as adults, says Brian Fligor, director of diagnostic audiology at Children's Hospital Boston, who wasn't involved in the study. Instead of developing noticeable hearing problems at age 50 or 60, these teens may have trouble hearing beginning at age 40.

Researchers based their findings on records of and interviews with nearly 4,700 kids ages 12-19, led by the Centers for Disease Control and Prevention.

They found no link between hearing loss and ear infections. Kids who reported being exposed to loud noise for at least five hours a week were no more likely to have hearing problems than others, says Shargorodsky, although he notes that teens usually aren't very good at accurately keeping track of their noise exposure.

Children living below the poverty level were much more likely to have hearing loss, possibly because poor kids have worse health in general, Fligor says.

Shargorodsky says his research doesn't explain why hearing loss is becoming more common. But doctors say the study points out the need to do more to protect children's hearing.

"Kids are growing up in a noisier world," Fligor notes.

An Australian study of kids with "mild to moderate" hearing loss found that using a portable music player, such as an iPod, was linked to 70% increased risk of hearing loss. And in a study of New York college students, Fligor found that more than half were listening to an MP3 player above the recommended exposure levels, which are 90 minutes a day at 80% of the maximum volume.

But iPods and rock concerts aren't the only source of noise in a child's world. Kids are also at risk if they fail to protect their ears when mowing the lawn, hunting with a rifle or attending noisy events, such as NASCAR races, Fligor says. Kids can protect their hearing by wearing headphones or inexpensive foam earplugs, Fligor says.

Other health trends also may be harming kids' hearing. Both high blood pressure and obesity can increase the risk of hearing problems, Fligor says. The number of children with diabetes has increased significantly in recent years, and a third of children are now overweight.

"What is scary is that these kids are setting themselves up for earlier hearing decline," says Mark Brown, an Austin otolaryngologist who treats a lot of children. "We will see the consequences of this down the road."

Originally published on USA today: http://www.usatoday.com/news/health/2010-08-18-hearing18_st_N.htm

Even Minor Hearing Loss Puts Kids at Risk for Learning Problems, Better Hearing Institute Warns

Washington, DC, August 9, 2010 - Children with even a mild hearing loss are at risk for learning and other social, emotional, and behavioral problems, the Better Hearing Institute (BHI) warned today.

BHI is urging classroom teachers to be alert to the needs of children with unaddressed hearing loss, which is often overlooked or attributed to other learning and behavior-related issues, such as Attention Deficit Disorder (ADD/ADHD). BHI also is urging schools to incorporate hearing health education into the curriculum and to adopt hearing protection policies.

The warnings came as schools across the country are opening their doors for the start of the school year.

“Too many children with hearing loss aren't getting adequate help and are being put at risk”,   says Sergei Kochkin, PhD, executive director of BHI and co-author of the national study, Are 1 Million Dependents with Hearing Loss in America Being Left Behind?  “Educators, pediatricians, and other healthcare providers underestimate the impact of mild hearing loss. And sadly, it’s the kids who are suffering.”

The scientific literature is clear that untreated hearing loss affects nearly all dimensions of the human experience. And the pediatric literature demonstrates that even children with "minimal" hearing loss are at risk academically compared to their normal hearing peers.

Hearing loss of any type or degree in a child can present a barrier to “incidental learning.” Up to  90 percent of a young child's knowledge is attributed to incidental reception of conversations around him or her. Hearing loss poses a barrier to the child's ability to overhear and to learn from the environment, as well as miss a significant portion of classroom instruction.

Hearing loss also frequently causes a child to miss social cues. Not surprisingly, many of the symptoms of unaddressed hearing loss in children overlap those of Attention Deficit Disorder (ADD/ADHD).

A large part of the problem is that many parents today either don't recognize their child's hearing problem, minimize it, or have been given misinformation regarding the ability to treat it.  At least 50 percent of parents don't seek additional professional testing when their infant fails an initial hearing screening.

According to Eileen Rall, AuD CCC-A, an audiologist from the The Center for Childhood Communication of The Children's Hospital of Philadelphia, teachers can help children with undiagnosed hearing loss.  She said:

"First and foremost, teachers can pay attention to the listening environment of the classroom and how the students are functioning in it. There are many low cost, creative ways to improve the acoustics of a classroom including something as simple as teaching children to create good listening environments—make eye contact, reduce distance, taking turns speaking and reducing the noise the students are making themselves. Some schools install sound field systems in their classrooms. Sound field systems amplify the teacher's voice and deliver his/her voice through speakers placed strategically in the classroom. Most importantly, teachers who suspect that a child is having difficulty hearing should bring it to the attention of the child's parents and school administrators so the child can undergo a thorough hearing assessment by an audiologist."

Some basic steps that teachers can take on their own to help a child with a confirmed or suspected hearing loss include the following:

• Arrange the child's seating away from the heating and cooling system, hallways, playground, and other sources of noise. If the child's hearing loss affects only one ear; if it's greater in one ear, seat the child in front of the room with his better ear toward the teacher.
• Allow the child to move around in the classroom to clearly see the speaker.
• Assign a helper, or notetaker, for the child.
• Try to speak clearly and not too fast.
• While you are speaking, don't turn away to write on the board or cover your mouth.
• Write key words or visual aids for the lesson on the board.
• Write assignments on the board so the child can copy them down into a specific notebook used for this purpose.
• If the child does not understand something, rephrase what you have said rather than repeat the same words again and again.

"Children need to be able to hear, not just in the classroom, but also because hearing affects language competence, cognitive development, social and emotional well-being, and academic achievement" says Kochkin. "Children who cannot hear well—that is, when their hearing loss is untreated or under-treated—could face a life of underperformance and broken dreams."

According to Kochkin:

• Only 12 percent of children under the age of 18 with hearing loss use hearing aids; yet an estimated 1.5 million youth (including adult dependents) under the age of 21 have hearing loss that may be improved with amplification.
• The study found no evidence of the use of any form of hearing assistance in the classroom (e.g. FM systems, hearing aids, speakers), other than front-row seating.
• Hearing loss leaves children vulnerable to other problems, according to three out of four parents of children with hearing loss. Common problem areas include:
• Social skills (52%)
• Speech and language development (51%)
• Grades in school (50%)
• Emotional health (42%)
• Relationships with peers (38%)
• Self-esteem (37%)
• Relationships with family (36%)

Compounding the problem is the increased use of portable media devices such as MP3 players, which children are listening to at high volume levels for long periods and putting their hearing at risk. According to the Centers for Disease Control, an estimated 12.5 percent of children and adolescents aged 6 to 19 years—or approximately 5.2 million youth—have permanent hearing damage from excessive exposure to noise.

"Parents, healthcare providers, and educators need to come together to thoroughly address a child's hearing loss if we are to allow that child a fair and equitable opportunity for success," says Kochkin. "As schools gear up for the start of the new academic year, I strongly encourage all educators to do their part to recognize the problem of unaddressed hearing loss in the classroom and to advocate for these children.”

Republished at www.EdisonStanfordHearing.com

Hearing Aids: Reasonable Expectations for the Consumer

Rose L. Allen, Ph.D., CCC-SLP/A, Assistant Professor of Audiology, East Carolina University, Dept. of Communication Sciences & Disorders


Editor’s Note: This article was the winning submission for the Audiology Online (www.audiologyonline.com) contest sponsored by Rayovac Ultra Pro Line, for the best new article written for consumers and patients, titled "Hearing Aids: Reasonable Expectations for the Consumer." We offer Dr. Allen our congratulations for her excellent work, and we invite the readers to download (in it’s entirety) and distribute this article to their patients for educational purposes. ---Editor
INTRODUCTION:

Since you are considering the purchase of hearing aids, it’s important for you to establish reasonable expectations from these highly sophisticated, miniature devices. Acquiring hearing aids is not merely a simple act of going to a store and purchasing a product.

Rather, it is a complex process - one that evolves over time and begins with the hearing-impaired individual accepting the realization that hearing impairment has detrimental effects on interpersonal relationships and safety. The hearing impaired person’s motivation to hear well is the single most important factor in determining the success of the hearing aid fitting. It is important to realize that you will not experience the exact same benefits from your hearing aids as your neighbor does. This individuality is a critical component, and I want to emphasize that your expectations should be based on you, your type and degree of hearing loss, your past experiences, and the improvements you personally receive from amplification.

The title of this article implies there are "reasonable expectations" for the consumer. Therefore, there must also be "unreasonable expectations". For the most part, there is only one totally unreasonable expectation - do not expect normal or perfect hearing.

It is my hope that this point-by-point tutorial will help guide you in establishing realistic and reasonable expectations from hearing aids, from the professionals you interact with, through the process of acquiring hearing aids, using them effectively, maintaining them, and living the fullest life possible.

1. Expect others to notice your hearing loss before you do! A common complaint of hearing-impaired individuals is that other people mumble - and if they would just speak up, it would be easier to hear them! This is placing the "blame" externally, rather than accepting the reality that your ears are not as good as they used to be. Realize that it is your hearing. Take that step to have your hearing tested before you blast your loving spouse out of the den with the blaring sound of the TV set. Seek the advice of your local audiologist or hearing instrument specialist (HIS), who you will find listed in the yellow pages under "audiologists" or "hearing aids". Of course, another option is to go to the Healthy Hearing website (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/hearing instrument specialist to be knowledgeable, courteous, and accommodating. Your audiologist/HIS will take a thorough case history. He/She is searching for information about your hearing loss, it’s probable cause, and whether your offspring may be affected. It is important to establish the presence of any medical condition associated with your hearing loss as this will trigger a medical referral. Comprehensive hearing and hearing aid evaluations will be conducted. These evaluations will provide information about the degree and nature of your hearing loss, as well as your ability to process and discriminate the fine sounds of speech. Comfortable listening levels will be defined, as well as a determination about how well you tolerate loud, intense speech and other sounds. These findings are very important as they allow the professional to pre-set some of the characteristics of the hearing aid’s circuitry. You will have time to talk with the audiologist/HIS 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, and maintenance issues and costs involved. Approximately 80% of all hearing aids sold fit in the ear¹. After you and your hearing professional determine the best style of hearing aid for your needs, an ear impression will be obtained. The ear impression is a plastic cast of your ear which reveals the exact shape of your ear, so the laboratory can place circuitry in a hearing aid shell that will fit your ear(s) only.

3. Expect differing opinions. If you choose to seek the advice of two or more audiologists/HISs, you may get differing opinions about the "best aid" for you. 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 may benefit you. Your audiologist/HIS uses the case history information and the evaluation results to make the best recommendation for you and your lifestyle. Expect a recommendation to purchase two hearing aids if both of your ears are hearing impaired and are "aidable." There are many benefits to binaural (two ear) hearing, including being better able to understand speech in noise, and being better able to localize sound. Your audiologist/HIS will explain the advantages of a binaural fitting versus a monaural fitting in more detail². Nonetheless, it is very important to understand that if you have two ears with hearing loss, and you only wear a hearing aid on one ear, you will still have significant hearing problems, even under the best of circumstances. A reasonably good analogy is to consider wearing a single eye glass (monocle) for a two-eye vision problem, such as being near-sighted or far-sighted – it simply will not work well for very long!

4. Expect your audiologist/HIS to assess your hearing difficulties in several environments and define individual goals for you. Although there are many self-assessment scales available, a popular one is the Abbreviated Profile of Hearing Aid Benefit (APHAB) developed by Cox and Alexander³. It may be administered to you prior to and following the hearing aid fitting to identify the benefits you receive from the hearing aids and to measure the reduction of any disabling effects of your hearing loss. The COSI (pronounced "cozy") is the Client Oriented Scale of Improvement which was developed by Dr. Dillon and colleagues at the National Acoustics Laboratory in Australia ⁴. As you will remember from my earlier comments, I emphasized that benefits from hearing aids are highly individualized. The COSI allows the audiologist/HIS to determine, based on your input, five major goals or changes you want to occur as a result of wearing hearing aids. These goals may include hearing your spouse better in the car, hearing your friends better on the phone, or any others that relate to you and your hearing difficulties. These assessments are not like the hearing evaluation given by the audiologist/HIS. These are tools that allow us to measure your self-perception of how your hearing loss affects your activities of daily living and how amplification can improve your quality of life.

5. Expect to be offered a 30 day trial period. Although not always required by law, many audiologists/HISs offer a trial or rental period of 30 days for you to adapt to amplification. You may be asked to pay a non-returnable fee during this time. Ask about this trial period, and if not offered, seek a second opinion. Use this 30 day period to test the hearing aids in the environments that are typical of your lifestyle - not only at home, but also at your friends’ and relatives’ homes, your favorite restaurant, shopping center, grocery store, or place of worship.

6. Expect a referral to a physician to rule out any medical condition that may contribute to your 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 all users of hearing aids be examined by a physician, preferably one who specializes in diseases of the ear. If you are over the age of 18 years, you may be given the opportunity to sign a medical evaluation waiver that will allow the audiologist/HIS to proceed with your hearing aid fitting. It is in your best interest to be evaluated by a physician prior to the hearing aid fitting, but particularly so if you have a history of ear problems or hearing loss of unknown origin.

7. Expect the hearing aids to cost more than you think they should. There are three categories of hearing aid technology - analog, digitally programmable, and digital. Analog technology has been around for many years. Aids utilizing this technology are also called "conventional" hearing aids and they are the least expensive. According to the most recent dispenser survey published in the Hearing Review in June of 2001, the average price of a hearing aid with analog technology will cost approximately $900 to $1500 per aid, depending on the size of the aid - the smaller the aid, the larger the price¹. Digital hearing aids use digital signal processing - the newest form of technology on the market. Digital hearing aids are indeed complete computers, similar to the PC on your desktop, but they are the size of 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. You may benefit from any of the three types of technology. Speak with your audiologist/HIS about the types of circuitry and which would be best for you. Importantly, in 2002, some basic digital hearing aids are 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 in 2002 than there was in 1999, and the prices vary tremendously, as do the products.

8. Expect an initial orientation session with your audiologist/HIS in which you will learn how to handle and care for your new aids. You should invite your spouse or significant other to attend this first critical session in getting oriented to your new aids. During this session, you will be taught how to operate the hearing aids, how to clean them, and how to change the batteries. You will receive written information about your aids - a booklet called a ‘User Instructional Brochure’ which is a requirement of the FDA. Please note, batteries are particularly important. Please be sure to store them and use them exactly as your hearing healthcare professional advises. Please be sure to keep all batteries way from pets and children. It may be difficult for you to remember all the things the audiologist/HIS tells you during this first session, so don’t leave the office without your instructional brochure! It will be very valuable to you, particularly during the first weeks of owning your new hearing aids.

9. Expect a period of adjustment. Remember the 30-day trial or rental period mentioned earlier (see point 5 above)? Once you get your new hearing aids, expect an adjustment period of several days to many weeks to get used to the daily care and maintenance of the hearing aids.

You’ll need time to learn how to; insert and remove the hearing aids from your ears, learn to adjust the volume control (some hearing aids have volume controls, other are automatic), learn how to clean them, learn how to open and close the battery door, learn to change the battery, get accustomed to placing the hearing aids in a dry-aid kit for the times when they are not in your ears. As you can see, there is a lot to learn, and people learn at different speeds. I recommend that you go slowly, learn one thing at a time, practice, and stay in contact with your hearing healthcare professional.

Many times, a spouse (or significant other) is very useful in helping you adjust to the new responsibilities of ownership of hearing aids. The largest adjustment you will go through is, of course, listening with your new hearing aids. You will hear sounds that you have not heard for a long, long time. Some of these will be "good sounds", like the songs of the birds or high-pitched voices of children. Other sounds, the "obnoxious ones", are sounds we need to hear for our safety and/or general knowledge of what is happening around us. These are sounds like the refrigerator or air conditioning units humming and buzzing, the sound of our footsteps, or a "knock" in the sound of the car engine. Research in this area has shown that this adaptation or adjustment period may last a few months. It takes time for the brain to re-learn all these sounds. Be patient!

10. Expect your voice to sound different. For many reasons, your voice will sound strange to you at first - like being in a barrel. This is a normal early perception and it is often called the ‘occlusion effect’. If you don’t adjust to this after a few days, discuss this with your audiologist/HIS. Many times, this feeling can be alleviated through changing the vent size in your hearing aids or changing the amount of amplification you are getting for low-pitched tones. Your audiologist/HIS deals with this issue regularly, and they will be able to solve this with you, over a short period of time.

11. Expect a good, comfortable fit. Initially, it will take a while to get used to having the hearing aids in your ears. You may experience a little soreness or irritation at first, but after a few days or a week or so, you should be able to wear the aids for several hours per day without any pain or discomfort. I always find it reassuring when patients tell me they often forget that they are wearing their aids. Remember - even though the audiologist/HIS will make your ear impressions so your hearing aids will be custom fit, many things can happen in the manufacturing process and any discomfort should be reported to your audiologist/HIS immediately. If your aids are not comfortable, you will not get the maximum benefit from them, and you should not wear them. Report all discomfort or irritations to your hearing healthcare professional, and do not wear the hearing aids until he/she advises you as to how to best address the problem.

12. Expect multiple follow-up appointments. The greatest advantage of digital hearing aid technology is the flexibility in programming the sound quality, as well as many other electro-acoustic characteristics of your hearing aids. These hearing aids are highly sophisticated instruments with many features. The computer software that is used to program your hearing aids allows the audiologist/HIS to make a multitude of adjustments while the aids are in your ears. You can actually hear many of the changes as the audiologist/HIS is adjusting different features or characteristics. Other features will only be noticeable in other environments. So, be sure to tell your audiologist/HIS as much as you can about your listening experiences in many environments. If you are a new user, you may get an initial setting of about two-thirds of the amplification that will be ideal for you. As you get used to your aids, the audiologist/HIS will increase the amount amplification over several visits. This will help in your adjustment period and lessen the chances of rejection due to over-amplification.

13. Expect your audiologist/HIS to evaluate the benefits provided by your hearing aids. This is normally done in at least two ways. First, electronic measurements of "real ear" performance give the audiologist/HIS an idea of how the aids are functioning when the hearing aids are in your ears. Your audiologist/HIS may make measurements in which a small microphone is placed in your ear to measure what is happening in your ear canal with and without the hearing aids in place. This is an objective measure and a starting point for successive changes in the performance of your aids. Secondly, the APHAB, COSI, or other assessment scales may be repeated so the audiologist/HIS can help you evaluate pre- and post-fitting hearing difficulties. These two evaluation methods are important in establishing the benefits you personally receive from amplification. If there are no significant changes in these measures, your audiologist/HIS will need to make additional changes in your hearing aid fitting.

14. Expect to be able to hear well, but not perfectly, in quiet one-to-one situations and most small group settings. In order for you to hear well, we must make sound audible, then comfortably loud. Your hearing aids will amplify sound so speech will become comfortably loud. You should be able to hear most of what is said without having to watch a person’s lips all the time. However, even people with normal hearing watch the person speaking in order to gain more information! Even when wearing the hearing aids, you should combine your vision and your hearing to maximize your benefits from the hearing aids. When sound is comfortably loud, it will be easier for you to listen and the stress of straining to hear rapidly diminishes. Therefore, listening in social situations becomes pleasurable again. If everyday sounds are uncomfortably loud, report this to your audiologist/HIS immediately.

15. Expect an optimal "distance for hearing". The best distance for hearing with your aids will be dependent on the type of microphones in your hearing aids, and other factors. The hearing aids may be directional or omni-directional. Find out from your audiologist/HIS which type of microphones you have, and the effective listening range or effective "distance for hearing". People within this distance will be the most audible to you. Once you increase the distance from the source you want to listen to, it will get increasingly difficult to hear - just like without the hearing aids.

16. Expect to have difficulty hearing in noisy situations. You may say that you can hear fine in quiet and that the noisy situations are the ones in which you need the most help. This is a common statement made by individuals who have presbycusis (hearing loss due to aging), noise-induced hearing loss, or any hearing loss where the
high-pitched tones are affected the most. Eventually though, as your hearing loss progresses, your ability to hear in quiet settings is also affected. Background noise is a nuisance for everyone, even normal hearing individuals. As sophisticated as today’s technology is, hearing aids still cannot eliminate background noise for you. Some of the more sophisticated digital circuitry can effectively reduce (although not eliminate) background noise. If you are in a lot of noisy environments, it is important to discuss this with your audiologist/HIS when discussing your case history and setting your goals for improvement.

17. Your hearing aids may squeal (also called "whistle," or "feedback") under some circumstances. If a hearing aid is somewhat functioning and has a good battery in it, this squeal (acoustic feedback) will occur when the hearing aid is cupped in the hand. Most users find that this helps determine the status of the battery and it is a good sign! However, you should be able to wear your hearing aids at a comfortable loudness level and not experience this squeal. If you do not have a volume control on your aids, they will squeal when you place them in your ears - until you get them placed comfortably. Sometimes, your aids will squeal if you press the phone too tightly to your ear. Report these events to your audiologist/HIS and determine what is normal, what is abnormal, and what can be done to reduce unnecessary acoustic feedback.

18. Expect repairs. You should realize that hearing aids are incredibly sophisticated devices being inserted in the ear canal where moisture and cerumen (ear wax) is waiting to attack any foreign object! Hearing aids are also prone to being dropped if our fine motor dexterity is a little compromised. Microscopic solder joints 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 the majority of repairs can be avoided with regular and careful maintenance! Being careful and establishing and maintaining a good preventive maintenance schedule, at home and at your audiologist’s/HIS’s office, can significantly reduce the number of repairs on hearing aids. Your aids will probably come with a standard one year warranty, and after that, you can purchase hearing aid insurance from a number of companies. Talk to your audiologist/HIS about additional warranty options when you purchase the aids.

19. Expect to buy batteries. Hearing aid batteries will probably last a week or two in the hearing aid. Hearing aid battery service life varies based on the hearing aid circuit and the quality and type of battery and is also dependent on environmental conditions (temperature, humidity etc.). Some people ask why hearing aid batteries don’t 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 your batteries. When your 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 audiologist/HIS. Many professional offices offer battery promotions or special programs for their patients. Ask your hearing healthcare professional about this.

20. There are two ‘NEVERs’ with batteries. NEVER keep batteries with your medicines, as you might accidentally ingest one. NEVER allow young children to handle batteries, as they might ingest them. All hearing aid batteries are toxic if swallowed. Keep them in a safe place and be sure to recycle your batteries properly.

21. Expect to purchase new hearing aids every 5 years. This may come as a surprise, particularly if you just purchased a set of digital hearing aids! However, hearing aid technology changes rapidly, just like computers, and new technology may benefit you greatly. Some people 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.

22. Most importantly, expect to enjoy the sounds of life again! Your hearing aids are a key ingredient to staying active and improving the quality of your life. You will once again enjoy social events, leisure activities, and conversations with your family, friends, and co-workers. Your hearing aids will also help you hear sounds to keep you safe and well.

References
1. Strom, K. E. (2001). The HR 2000 dispenser survey. The Hearing Review, 7 (6), 20-42.

2. 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.

3. Cox, R. M. and Alexander, G. C. (1995). The abbreviated profile of hearing aid benefit. Ear & Hearing, 16 (2), 176 - 186.

4. Dillon, H., James, A. and Ginis, J. (1997). Client Oriented Scale of Improvement (COSI) and its relationship to several other measures of benefit and satisfaction provided by hearing aids. Journal of the American Academy of Audiology, 8 (1), 27-43.

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Assistive Devices: Inexpensive and Alternative Ways to Address Hearing Loss

Nancy L. Aarts Ph.D., University of South Alabama


I. Introduction & Overview:
Assistive devices for individuals with hearing impairment fall into two main categories. Assistive Listening Devices (ALD) are products that address problems associated with listening in noise, at a distance, and in high reverberation. Alerting Devices (AD), are products that alert one to the presence of sound in the environment. Assistive devices may be used to improve communication in interpersonal and small and large group settings, on the telephone, while enjoying television programs, or to notify an individual of an important signal in their environment such as the telephone, doorbell, or a safety alarm.

When audiologists and other hearing professionals address the communication needs of people with hearing loss, assistive devices "fill in the gaps," they pick up where traditional ear-level amplification leaves off.

Traditional hearing aids have a relatively small "effective area" within which they work maximally, due to microphone size and microphone location. In other words, if two people are engaged in a conversation at a party, and if they move a few feet apart, the distance between the hearing aid microphone and the person speaking can increase dramatically, decreasing the signal-to-noise ratio while introducing significant ambient noise into the conversation. Typically, hearing aids provide acoustic signals only (FM and DAI systems used in tandem with hearing aids do indeed vary from the "traditional" limitations and are addressed below), which are subject to reverberation, signal-to-noise issues, background noise and other sources of degradation.

Assistive devices typically pick up signals closer to the sound source, that is, the microphone is placed in close proximity to the sound source. This is accomplished using a variety of methods including various and multiple microphones, induction pick-up systems, and direct connection. Assistive devices can transmit high quality auditory signals across significant distances, such as when an FM or infra-red system is used in a theater or lecture hall. Assistive devices can deliver the signal of interest to the end-user in several ways to assure a high quality sound. Options include various headphones and acoustic couplers, direct audio input or neckloop coupling to a personal hearing aid, vibrotactile signal, or the signal can be visually coded as in captioning.

There are times when assistive devices offer a more appropriate and more efficient solution to communication problems than do hearing aids. Depending on an individual’s communication demands and financial constraints, ear-level amplification may not be the best solution. For example, a telephone amplifier and/or knowledge about how to access closed captioning on a home television set may yield a greater return on investment in a particular situation than would ear level amplification.

Recent studies examined how often audiologists provide information to patients about assistive devices. Prendergast and Kelly (2002) surveyed audiologists to determine the type and amount of audiologic rehabilitation techniques they employed. Results showed that 100% of the 120 respondents reported recognizing the benefit of providing more information about ALDs to their patients, while 78% of the respondents reported they provided information about ALDs to their patients most of the time.

A different perception of how often audiologists provide information about assistive technologies was provided by a survey of consumers. Stika, Ross, and Cuevas (2002) analyzed surveys from 651 members of Self-Help for Hard of Hearing People, Inc (SHHH). The respondents indicated they were hearing aid users who received services from audiologists. Whereas 48% of respondents reported their audiologist made certain they understood their t-switch, only 34% of respondents stated their audiologist informed them about other assistive technologies.

The discrepancy between the survey of audiologists and consumers regarding how often assistive device information is provided could be a matter of perception, recall, or miscommunication. However, it may also serve to alert audiologists and other hearing health care professionals that consumers of our services are not recalling or retaining information about ALDs and ADs, and perhaps we need to transmit the message more consistently, and with greater emphasis.

Despite the benefit of assistive listening devices (ALD) and alerting devices (AD), some audiologists and hearing professionals are not able to provide adequate sample space for assistive technologies "in-house" due to cost, space, display, or inventory concerns. Others may not have the same expertise and comfort level with assistive devices as they have with hearing aids, and therefore they may elect to not offer these devices in the office.

II. Inexpensive Options:
A. The Benefits Of T-Coils
There are multiple benefits to flexible, adaptable (larger) hearing aids. T-coils can be built into behind-the-ear (BTE) and in-the-ear (ITE) hearing aids, but very few in-the-canal (ITC) and completely-in-the-canal (CIC) models contain t-coils, a pre-amplifier, and a mic/t-coil switch (Marshall, 2002). Despite the benefits of t-coils, less than 40% of hearing aids sold in the U.S.A. include t-coils (Ross, 2002). This is perhaps due in part to user preference for small, seemingly hard-to-see hearing aids.

My personal experience indicates that more often than not, when faced with the options and alternatives, most people choose t-coils. I generally provide patients with specific advantages and disadvantages of various styles of hearing aids, including a discussion regarding t-coils. Most patients conclude the functional benefits of a BTE or ITE style with a t-coil outweigh the cosmetic advantages of an ITC or CIC style hearing aid.

The key points relating to hearing aid selection, t-coils, and assistive devices, which I address with my patients and their families are noted below.

1. How t-coils and direct audio input (DAI) are used to couple ALDs to hearing aids via neck loops, small area and room loops.
2. How and why a t-coil can improve speech understanding with wired, mobile and cell telephones.
3. How t–coils (and DAI) are generally available in larger hearing aid styles.
4. The availability of ALDs in the community due to the Americans With Disabilities Act (ADA).
5. The benefits of ALDs in situations where hearing aids may not help. For example, in a movie theater or a worship service.
6. I also demonstrate (by wearing) a BTE aid with a clear ear mold in one ear and an ITC in the other ear to demonstrate their appearance when in use.

Providing the above information about t-coils and demonstrating the appearance of different types of hearing aids requires a few minutes of time during the initial discussion, but reduces frustrations and potential remake time later.

B. Order an appropriate t-coil.
An appropriate t-coil must be oriented in the hearing aid in a way that maximizes signal strength. It must be of sufficient strength to provide an audible signal, and lastly, it needs to be activated in a way suitable to the hearing aid user.

Proper orientation is dependent on how the t-coil will be used. The t-coil should be horizontal for telephone use and vertical when a neck or floor loop is used. A diagonal orientation compromises the usefulness of the t-coil in all uses situations. An alternative to diagonal orientation would be to orient the t-coil to the loop and have the user move the receiver to a position that generates the best signal while talking on the phone (Ross, 2002).

The audiologist can specify the orientation when ordering custom products by drawing a line on the earmold impression while it is in the ear to indicate horizontal to the manufacturer. For BTE products, the audiologist should contact the manufacturer to determine each models’ t-coil orientation.

The strength of the t-coil pick-up is dependent on the size of the metal rod around which wire is coiled and on the presence of an amplifier for the t-coil. The larger the rod the more turns of wire, and the more powerful the t-coil (Ross, 2002). The size of the rod may be reduced when a pre-amplifier is available. Some manufacturers offer t-coils that include an integrated amplifier while other manufacturers will require that the audiologist order a pre-amplifier along with the t-coil. Regardless of the way in which the amplifier is added, the audiologist should ensure that an amplifier is included with the t-coil to maximize induction strength.

T-coils can be activated by the common Microphone/Telephone/Off (MTO) switch or a Microphone/Mic+T-coil (M/MT) switch, or, in some BTE models, a switch that offers both M/T/O and M/MT/O options. This type of switch can be difficult to operate for individuals with reduced dexterity. A newer t-coil control option is the "touchless" t-coil. This system automatically switches from the microphone to the t-coil when it "senses" the magnetic energy of the telephone and switches back to the mic when the magnetic field is no longer apparent (Marshall, 2002). This type of system makes t-coil activation much easier for the hearing aid user, and in particular, for those with limited or reduced dexterity.

C. Confirm the t-coil is working properly.
Real-ear probe-microphone measures (REM) are often used to fit, verify, and adjust hearing aids. The purpose of REM is to ensure the hearing aid output is appropriate. It makes sense to fit, verify and adjust the hearing aid output when the t-coil is active. Additionally, REM can indicate the placement of the telephone near the ear that results in the greatest signal strength and whether or not the volume control wheel (VCW) setting needs to be increased in order to maintain appropriate signal strength in the t-coil mode. See Mueller (1992), and Grimes and Mueller (1991a, 1991b) for specific directions on how to obtain REM with an active t-coil.

D. Teach patients how to use the t-coil.
Adults have reported they received inadequate training on how to use their t-coils when fit with hearing aids (Stika et al., 2002). Education at the time of fitting should include determining the telephone receiver position and VCW setting that produces the greatest signal strength (see above), verification that the patient can manipulate the control switch or remote control, and can recognize when the aid is on "M" versus "T".

Additionally, if the patient has access to a neck loop or small area or room loop in their home or community (see below), he or she should be reminded that the signal of interest can be accessed just by activating the t-coil and adjusting the VCW if necessary.

The patient should be notified of the availability of a directional array microphone (http://www.etymotic.com/) that can be used with hearing aids that have a t-coil. I also recommend that the patient be given information about the "Let’s Loop America" initiative, a public awareness program designed to bring loop systems to more hearing aid users (Myers, 2002).

E. Provide Tips On How To Improve Telephone Communication
Hearing impaired people using wireless phones can often switch from the traditional audible ring option, to the vibrating option. When hearing impaired listeners are having difficulty due to ambient noise levels present while using their phone, they can cover the phone mouthpiece while listening. This simple act reduces the level of background noise picked up by the handset mouthpiece which is also directed to the listener’s ear. Simple and inexpensive ways to increase the intensity of the acoustic signal include a strap-on portable amplifier (for wired, wireless and cellular phones) or an in-line tabletop amplifier (for wired phones) both of which are available from Ameriphone and NFSS. The HATIS cellular phone amplifier (CPA) is available from Life With Ease. Similarly, the telephone’s electromagnetic signal can be amplified with an inductive coupler such as the Oticon TE-80 induction adapter available from Earlink or the Phonear PE 850 available from HARC. Table 1 (below) provides contact information for these and other companies.

F. Encourage Use Of Closed Captioning At Home
If your television has a screen larger than 13 inches and was manufactured after 1993, it will have closed captioning capability. Many people are unaware of closed captioning, its potential benefits, and how to access it. Consider instructing patients in how to access the captioning function via the menu button on their television’s remote control. Some models allow the user to select the size of the captioning text and whether or not the text appears in a box.

G. Educate Patients About The Americans With Disabilities Act (ADA):
The ADA (Public Law 101-336) is landmark civil rights legislation. The ADA went into effect in January 1992 and it provides a comprehensive national mandate for the elimination and prevention of discrimination against individuals with disabilities. Because of the ADA, businesses and employers must take steps to ensure that disabled people, including those with communication disabilities, have access to all goods, services and facilities available to non-disabled people. Additionally, the ADA prohibits discrimination on the basis of disability by private entities and ensures that individuals with disabilities have access to public accommodations, employment opportunities, transportation and telecommunications (U.S. Equal Employment Opportunity Commission, 1992).

All individuals with hearing-impairment, regardless of their age, are affected by the ADA. It is the responsibility of public access facilities, employers, and telecommunication providers to comply with the ADA, but it is the responsibility of the consumer to demand compliance.

However, some consumers -- such as those with hearing loss -- may be unaware of the benefits of the ADA. Therefore, audiologists are the most logical professionals to educate consumers with hearing-impairment about the ADA and the rights of the hearing-impaired. Following are some ways in which audiologists can help their patients learn about and take advantage of the ADA.

1. Display access symbols.
Display the symbol that represents international access for the hearing impaired on your office door, in advertisements, on letterhead, and on mailings. Or, make a flier to instruct patients about this and other relevant symbols about the availability of assistive devices. These symbols are available on the websites www.accessibility.com.au/melbourne/product/signs.htm and http://www.monmouthartscouncil.org/ADA_icons/ADA_icons.html.
2. Provide a list of public access facilities in your community that have assistive devices and encourage ALD use.
Generate a list of theaters and other public venues in your community that are ADA compliant and have assistive devices for the hearing impaired. If time is a concern, you could consider contacting other individuals or organizations and ask them to help you with this task. For instance, you may ask an area SHHH or AG Bell group, or local middle or high school students, who are required to obtain volunteer hours, and suggest they take on this task as a community improvement effort. This list could be put in the form of a flier or brochure that is kept in your lobby, given to patients an initial during appointment, mailed to patients with a monthly bill or used as a column in your quarterly newsletter.

3. Educate Patients About Specific Assistive Listening And Alerting Device Options
There are a number of things that can be done to educate patients about specific devices. First, obtain catalogs from assistive device providers and put the catalogs in your waiting room alongside the magazines (see Table 1). Second, create a notebook of fliers that display photos, descriptions, and purchase information about various devices, and keep this notebook in your waiting room. Third, mail one of these fliers with monthly invoices or post them in your patient care areas. Fourth, develop of list of local providers and distributors in your area who offer reasonable policies for individual purchases, including inventory and price information, and return and repair policies. Fifth, show a looped videotape of assistive devices in your waiting room such as Cindy Compton’s video, "Doorways to Independence." Sixth, for patients who have access to the Internet, compile a list of websites about the ADA and assistive technologies. See Table 2 for a short list of such websites. Make this flier available in the waiting room or put the information in your quarterly newsletter. Seventh, volunteer to give presentations to local SHHH or AG Bell support group meetings, worship groups, senior centers, local professional groups, or adult retirement communities. Presentation topics could include the ADA, local ADA compliance and self-advocacy regarding ADA compliance, t-coil use, the "Let’s Loop America" initiative, and demonstrations of specific assistive device technologies.


Table 1. Assistive listening and alerting device sources available on the Internet.

Ameriphone, Inc. (800 874 3005) http://www.ameriphoneinc.com/

Audio Enhancement (800 383 9362) http://www.audioenhancement.com/

Beyond Hearing Aids http://www.beyondhearingaids.com/

Global Assistive Devices (888 778 4237) http://www.globalassistive.com/

HARC Mercantile/HAC Group (800 445 9968) http://www.accessolutions.com/

Hearing Aid Telephone Interconnect Systems (HATIS) http://www.hatis.com/

Hearing Resources On-Line Store http://earlink.com/

Life With Ease (800 966 5119) http://lifewithease.com/

NFSS (888 589 6671) http://www.nfss.com/

Phonic Ear, Inc (800 227 0735) http://www.phonicear.com/

Plantronics (408 426 5858) http://www.plantronics.com/

Siemens (800-766-4500) http://www.siemens-hearing.com/

Silent Call Corporation (800.572.5227) http://www.silent-call.com/

Sonic Alert, Inc (248 656 3110) http://www.sonicalert.com/

Ultratec, Inc (800 482 2424) http://www.ultratec.com/

Williams Sound Corp (800 843 3544) http://www.williamssound.com/

Weitbrecht Communications Inc (WCI) (800 233 9130) http://www.weitbrecht.com/


Table 2. Assistive device information available on the Internet.

Funding Assistive Technology For Persons With Disabilities: The Availability Of Assistive Technology Through Medicaid, Public School Special Education Programs, And State Vocational Rehabilitation Agencies
http://www.nls.org/vrbooklt.htm

Gallaudet’s Assistive Devices Center web page http://aslp.gallaudet.edu/aslpweb/business/ald/ald_desc.html

International Hearing Dog, Inc
http://www.ihdi.org/

Let’s Loop America
http://www.hearingloop.org//loopAmerica.htm

National Institute on Deafness and Other Communication Disorders (NIDCD) captioning information
http://www.nidcd.nih.gov/health/pubs_hb/caption.htm

Ross, M. (2002, January/February). Telecoil and telephones: The most commonly misunderstood "assistive listening device". Hearing Loss.
http://www.hearingloss.org/html/rosstelecoilarticlejf02.HTM


References
Grimes, A. M., & Mueller, H.G. (1991a). Using probe-microphone measures to assess telecoils and ALDs Part I: Assessment of telecoil performance. The Hearing Journal, 44, 16-18.

Grimes, A. M., & Mueller, H.G. (1991b). Using probe-microphone measures to assess telecoils and ALDs Part II: Assessment of ALDs, telephones, and telephone amplifiers. The Hearing Journal, 44, 16-18.

Marshal, B. (2002). Advances in technology offer promise of an expanding role for telecoils. The Hearing Journal, 55, 40-41.

Mueller, H. G. (1992). Assessment of telecoils and assistive listening devices. In H.G. Mueller, D. B. Hawkins, & J.L. Northern (Eds.) Probe microphone measurements: Hearing aid selection and assessment (pp. 227-249). San Diego: Singular.

Myers, D.G. (2002, Sept). The coming audiocoil revolution. The Hearing Review, 28-31.
Prendergast, G.S., & Kelley, L.A. (2002). Aural rehab services: Survey reports who offers which ones and how often. The Hearing Journal, 55, 30-35.

Ross, M. (2002, Sept). Telecoils: The powerful assistive listening device. The Hearing Review, 22-26, 57.

Stika, C.J., Ross, M., & Cuevas, C. (2002, May/June). Hearing aid services and satisfaction: The consumer viewpoint. Hearing Loss, 25-31.

U.S. Department of Justice. (2002). Enforcing the ADA: Looking back on a decade of progress. Washington, DC: U.S. Government Printing Office.

U.S. Equal Employment Opportunity Commission. (1992). The Americans With Disabilities Act questions and answers. Washington, DC: U.S. Government Printing Office.