HLAA Position / Policy Papers - Using Them the Best Way

by Marcia Finisdore

Through the HLAA network, discuss the various aspects of a particular issue. This can also be an excellent way to educate new members about different aspects of hearing loss. Policy papers can be published in your chapter newsletter. If one of the position papers reflects a particular issue for your chapter or for some members, a chapter might want to gather a group of members to approach a legislator or government agency for help in addressing the issue and use the position paper for written explanation of the problem.

For example, one of the greatest frustrations people with hearing loss often face is the lack of assistive listening devices. If some of the members of your chapter want to make sure a movie theater or town meeting has listening systems, you might want to visit the theater or town officials using the position paper on hearing assistive technologies. Your personal experiences, your desire to attend the movies or town meetings, and the position paper can often help inform people and persuade them to install assistive listening systems.

Chapters and groups are frequently asked questions about how HLAA feels about cochlear implants, education of children with hearing loss, or other issues. Position papers can be distributed to help answer these questions. You may also want to be very proactive (a characteristic of many members!) and send the position papers to relevant leaders in your community. Members can be available to answer questions or discuss the issue in greater depth.

One of the most important places for HLAA position papers to be widely disseminated is at the grass-roots level. The more all HLAA members know about our positions and talk about them in their communities, the sooner the world will become a more accessible place for persons with hearing loss. As you know, HLAA position papers reflect the needs and desires of our members. They talk about the myriad aspects of hearing loss, and what we need in order to achieve our goals: to successfully live and function in the hearing world and to be able to communicate with our loved ones, succeed in our work, and contribute to our communities. Our positions, from the provision of assistive listening devices, to universal screening of infants, to training for vocational rehabilitation counselors, are all directed toward these two major goals:

  1. Ensuring that hard of hearing people, children and parents can benefit from the technology, policies and practices that allow them to succeed; and,
  2. Ensuring that the professionals who deliver services truly understand our needs and the barriers we face.

The more you know and talk about HLAA positions, the more effectively you can advocate. As we all know, some advocacy takes place in Washington, D.C., and some in our state capitals. A great deal of it also takes place in our local communities and in HLAA chapters across the country. When thousands of HLAA members are writing to their congressmen and state legislators, to regulators and to professionals, our voices are heard and heeded.

How Do Members Actually Use the Position Papers?

There are many ways to do that. One is to set aside a chapter meeting to talk about the papers. You might want to invite a group of audiologists or hearing aid dispensers to share the position on hearing aids. This could include the position on telecoils, binaural amplification, return policy, and group hearing aid orientation. This could be the start of a great relationship between local audiologists and your chapter. Even more, contact your state speech and hearing association and ask if you can submit a paper for presentation on HLAA positions on the above issues at their next state convention.

Another Example of Advocating Using an HLAA Position

Hard of hearing people are very often underserved by the vocational rehabilitation programs in operation throughout the country. This is so because hard of hearing people are not considered severely disabled. Few counselors have the training to understand the broad range of issues that affect hard of hearing people. Invite counselors to a chapter meeting or ask them if you can do a presentation for counselors at your local vocational rehabilitation office. Learning from people who are living with the problem, and who experience difficulty on the job, is the best education that can be provided by those who are helping persons with hearing loss find employment.

HLAA’s initiative for children who are hard of hearing opens up many opportunities for chapters to become involved with local school districts and the state department of education. Teachers often do not understand that the educational needs of hard of hearing children are very different than for deaf children. Because HLAA members understand the importance of acoustics, lighting, noise levels, and visual environment, they can speak with authority to educators about what hard of hearing children need in the classroom. Call your local school district to see how hard of hearing children are accommodated. Find out if assistive listening devices are provided in the classroom. Are the floors carpeted? Many teachers will welcome the knowledge you have, and parents will be grateful that someone in the community understands hearing aids, residual hearing, telecoils, and hearing assistive listening devices all defined in HLAA position papers and all things their children are or should be experiencing.

I’d love to hear how you are using the position papers in your chapters. The best ideas are generated by our membership on the local level.

Marcia Finisdore is a Past-President of the HLAA Board of Trustees.

HLAA Position Statement on Hearing Aids for People with Hearing Loss

Even though a hearing loss is one of the most common of physical and sensory impairments, it is also perhaps the most misunderstood and underestimated. It has been called the "invisible" condition since it is not possible to "see" a hearing loss directly, only its effects upon behavior and communication. The fact that these effects can be so variable, depending upon the individual and the situation, is what makes hearing loss such a confusing condition.

Sometimes a person with a hearing loss can fully comprehend utterances, sometimes not at all, and sometimes only partially. This confusion and uncertainty, often not even fully apprehended by the person with the hearing loss, is what is responsible for the tension, conflicts and anxieties that are often the daily fare of someone with a hearing loss. Indeed, by diminishing a person's ability to effectively engage in interpersonal communication, the condition has the potential to impact every aspect of one's life, ranging from the psychosocial to the cultural and vocational domains.

In short, it is not a condition that should be treated casually, with haphazard, ill-advised and superficial measures taken to ameliorate its effects. Such an approach trivializes the impact that impaired communication can have upon the life and well being of the affected person. Given the significance of the sense of hearing, HLAA believes that people with hearing loss require the care of qualified professionals who follow best professional practices.

Once the medical implications of a hearing loss have been considered and managed, the most effective therapeutic measure is usually appropriately selected hearing aids. At the present time, hearing aids can be purchased by consumers from many sources, ranging from Hearing & Speech Centers, Otologists, Audiologists, and Hearing Instrument Specialists to mail order catalogues and Internet sites. These latter alternative sites for obtaining hearing aids are likely to increase in the future, particularly since many catalogues and Internet sites offer apparently substantial discounts compared to the more traditional sources. It is not the province or intent of HLAA to dictate to consumers from where they should purchase hearing aids.

Rather, HLAA takes a position that no matter how or from whom a hearing aid is obtained certain requisite conditions need to be considered to ensure that the interests of people with hearing loss are fully protected.
These follow:

  1. It is recommended that people obtaining a hearing aid, particularly new hearing aid users, first receive a medical evaluation (by a primary care physician, otolaryngologist or otologist). This provision, in accordance with current FDA regulations, can be waived by informed adults (over the age of 18) if they so desire.
  2. Every potential hearing aid candidate should receive a comprehensive audiological evaluation, conducted by an audiologist with the appropriate state license to practice audiology or, in states that do not have licensing provisions, by someone who holds the requisite professional audiological credentials.
  3. A component of this audiological evaluation must be the determination of "red-flag" observations, those that would mandate a medical referral. These include:

a) a recent history of progressive or sudden hearing loss, tinnitus, vertigo, otorrhea (ear drainage), otalgia (ear pain), fluctuating hearing, aural pressure or fullness;
b) an abnormal external ear canal or tympanic membrane on otoscopy;
c) conductive hearing loss as manifested by an air-bone gap;
d) abnormal immitance measures;
e) 10 db or more asymmetry in thresholds between the two ears at two or more frequencies; and,
f) speech perception scores much poorer or asymmetric than expected on the basis of the pure-tone thresholds.

  1. HLAA believes that the selection of a hearing aid for a specific person is a highly individualized process, one that requires a personal relationship between the dispenser and the consumer. It is necessary to consider the life style and communication demands upon a consumer, in addition to the nature of the hearing impairment, before it is possible to make an informed decision regarding an instrument that incorporates the necessary features and electroacoustic characteristics.
  2. HLAA believes that the hearing aid selection process should incorporate those tests and measurements that reflect current "best professional practices." These may include various types of objective aided and unaided speech tests, individualized electroacoustic programming via a computer interface real-ear measures as well as subjective self-assessment performance and handicap scales.
  3. HLAA reaffirms our previous position papers that directly impact upon the hearing aid selection process. These are:

a) Hearing Aids (including a 60-day trial period, and the desirability of binaural aids and telecoils);
b) Hearing Assistive Technologies (their evaluation and selection); and,
c) The inclusion of a Group Hearing Aid Orientation Program into the routine hearing aid dispensing process.

In summary, the fact that a hearing loss can have profound effects upon people necessitates that remediation measures be conducted personally by qualified professionals. The hearing instrument itself is only a tool, but a sophisticated and complex one that requires individualized fitting by trained personnel. Furthermore, because a hearing loss can affect the psychosocial, vocational, and social-cultural domains, rehabilitative measures are often required that transcend the simple provision of hearing aids and/or other assistive technologies. The selection of a hearing aid, in other words, needs to be conceptualized as a package, one that incorporates the evaluation and provision of other remedial measures related to the impact of a hearing loss upon a person's life.


HLAA Position on Group Hearing Aid Orientation Programs

The decision to purchase one or more hearing aids is not one that hearing aid users take lightly. Beyond the specifics of where to go and what unit to buy, they have had to first accept the reality of their own hearing impairments. For many people, this is a difficult period in their lives and they need all the help, information, guidance and support that they can get. While hard of hearing people are quite aware that they have trouble hearing, they may still not be fully cognizant of the total impact of the hearing loss on their lives. Many hearing aid users expect more from the hearing aid than is realistically possible, while others may not be deriving as much benefit as it can confer (e.g. the telephone coil as an assistive listening device).

During the course of the hearing aid selection process and several follow-up appointments, the vast majority of hearing aid dispensers will make a sincere effort to respond to their client's informational needs. The reality is, however, that much of this information will be incompletely understood or retained by the hearing aid user. Additionally, there are inherent limitations in the effectiveness of the one-on-one dispenser-client relationship. There are some areas of need that can best be met in a group setting, where people with hearing losses have an opportunity to learn and share with others who have similar problems; in other words, the interchanges occurring in a group offer advantages and possibilities that cannot be met in individual follow-up appointments. The effectiveness of group hearing aid orientation programs have been repeatedly demonstrated in studies which compared hearing aid satisfaction and use by people who have been enrolled in such programs as opposed to those who were not. These programs should be designed to supplement, and not supplant, individual hearing aid follow-up appointments (although they may help reduce the frequency of unscheduled "drop-ins" as well as the incidence of hearing aid returns).

It is the position of HLAA that people who purchase a hearing aid should have an opportunity to participate in a group hearing aid orientation program. Typically, these programs schedule weekly 1 to 2 hours meetings for about 4 to 6 weeks. While the specific content and outline may vary, the intent must be to provide sufficient time for both an instructional component and for the emergence of group exchanges. Examples of the content in the instructional component would be:

  1. types of hearing losses
  2. understanding the audiogram
  3. troubleshooting and effectively using hearing aids
  4. hearing assistive technologies other than hearing aids,
  5. introduction to speechreading and auditory re-learning
  6. coping and conversational repair strategies,
  7. and the implications of the ADA for hearing-impaired people.

The goals in the group meetings would be to help hearing aid users to:

  1. understand that their experiences are not unique,
  2. share their concerns, problems, and solutions with the other members in the group,
  3. provide mutual support in adopting a more"assertive" communication style,
  4. relate their perception of the views of "others" (family, friends, employers, co-workers, etc.) to their hearing losses
  5. and, finally,to lay the groundwork for a more optimistic view of the future.

Since hearing loss is a family affair, the participation of hearing relatives and friends should be encouraged. We also recommend that local members of HLAA be brought into the group as resource people. Not only can they serve as role models, but they can demonstrate that HLAA can be a significant ongoing personal resource after the completion of the group program.
We are not suggesting that every hard of hearing person be obliged to enroll in a group hearing aid orientation program subsequent to the hearing aid dispensing process. Furthermore, while the intent of this position paper is to assert the value of group hearing aid orientation programs for hearing-impaired people, we are also not suggesting that hearing aid dispensers conform to any specific content or model. The professional literature is replete with this kind of material. We are recommending that hearing aid dispensers make such programs available to their clients and that they encourage participation in them. Those conducting the programs should be sensitive to any indication that a participant may require additional services, such psychological counseling, intensive communication therapy, vocational rehabilitation, or a specific assistive device and make the necessary referral. It is our judgment that the audiologists and hearing aid dispensers who offer this service are displaying higher standards of professional conduct than those who do not.

HLAA Position on Residual Hearing

Hearing loss is not an all or nothing phenomenon: people with hearing losses are not usually completely deaf, but ordinarily, show varying degrees of hearing loss at different frequencies in one or both ears. Although this fact is obvious, its implications are often overlooked. The unique needs of hard of hearing people, and those children who are potentially hard of hearing, can hardly be realized when the fact that hearing loss exists on a continuum is ignored or its impact minimized. Perhaps this occurs because of the human tendency to polarize issues and judgments (i.e. "deaf or hearing"), because hearing loss is an "invisible" and so often denied disability, because the potential of modern amplification technology is not fully understood, or because the optimum use of residual hearing is seen by some members of the Deaf community as a threat to their cohesion and future. But whatever the reason or reasons, the practical result is that when residual hearing is ignored or its potential minimized, it cannot serve any of its inherent purposes.

As one of the five senses that human beings are normally born with, nature has endowed the sense of hearing with significant social and biological functions. These range from the reflex alerting to the sounds around us, to the relatively effortless development of speech and language skills. Though these skills will be affected by the presence of a hearing loss, they do not disappear as long as some residual hearing remains and is fully utilized.

At its most basic, sound is produced by a force(for example, wind) acting on some object (for example, trees,the ocean). The awareness of sound (consciously or unconsciously) is a way that human beings adapt to, and feel part of, their immediate environment (for example, the sounds of nature, traffic, and home appliances). The sense of hearing, the perception of sound and its biological purposes, is not,therefore, a trivial consideration that can be lightly dismissed. On the contrary, it is a human birthright that must be respected and utilized to the fullest extent possible. It is on this premise that HLAA was founded and continues to operate.

Perhaps even more than those with normal hearing,hard of hearing people value what hearing can offer, precisely because they are better able to recognize what they are missing or what they have lost. One of the primary desires of hard of hearing people is to increase our auditory perceptual capabilities, by encouraging the development of new technology and the better utilization of existing technology.
We do not respond to our hearing difficulties by denying the value of the sense of hearing itself, for ourselves or for other people with hearing loss. We regard the sense of hearing as a gift, from our evolutionary forebears and/or from the Creator depending how we view the world. And it is not for us who possess some measure of this gift to disregard its presence, to whatever degree it is present.
Adults who do not hear, or choose not to hear, have the power and authority to make their own decisions regarding the use, or non-use, of their own (and their children's) residual hearing. Having never experienced auditory sensations, or having them but finding the occasions unpleasant or irrelevant, these adults are free to ignore any residual hearing they possess. They do not have the right to make this decision for others, particularly for children who cannot make their own informed judgments regarding the potential value of hearing in their lives. Note that this is not an argument for or against any communication mode for children; it is an assertion that no professional or educator or care giver has the right to deny young children a reasonable opportunity to use their residual hearing. To do that is to impose one's personal values on a very fundamental sensory inheritance of other human beings.

It would be less than honest to deny that the early and proper use of residual hearing may very well affect the life course and self-identity of an individual. But, what is the alternative? Are we to assume that we must restrict a person's sensory experiences of the world in order to pre-ordain educational placement and communication mode choices? The point here is that we cannot dismiss as an irrelevancy a part of our biological heritage because it may be viewed by some members in the Deaf community as a threat to their future viability. Our stance, however, is not negative but positive: We are for the full utilization of residual hearing and not against any group or individual.
HLAA recognizes a number of common concerns with those who define themselves as culturally Deaf, but we insist that the power and potential of residual hearing not be overlooked, minimized, or disparaged as a consequence of any collaborative efforts.

To recap, it is the position of HLAA that every effort be made to fully utilize the power and potential of the residual hearing of all people with hearing losses. While our hearing loss is undoubtedly a burden that we would gladly forgo if we could, we view the hearing that remains as an opportunity that can help us lessen the impact of that burden. To this end, we welcome all scientific advances in medicine and technology that can help eliminate and reduce the effects of a hearing loss. The intent is to foster the capability of people with hearing losses to more effectively participate in and contribute to the social, cultural, and vocational opportunities of our society.

HLAA Policy Statement Universal Newborn Infant Hearing Screening

Hearing Loss, March-April, 1999
There are psychosocial, linguistic, and educational advantages for children who receive appropriate management for their hearing condition at an early age (Ross, l998). Studies completed over ten years ago have shown that the English language and auditory skill development is superior for these children compared to those whose hearing loss is detected and managed at a later date (Watkins, 1987; White & White, l987; Levitt, McGarr, & Geffner, l987).

In the most recent study of this type (Yoshinaga-Itano, Sedey, Coulter, & Mehl, l998), the earlier results have been corroborated. It was found that children whose hearing losses were identified before six months of age demonstrated significantly better language scores than children whose losses were detected later. Early management can also spare parents the years of agonizing uncertainty and feelings of helplessness that often occur when there is a delay in the detection of their child's hearing loss. In short, there are compelling reasons for the necessity to detect hearing loss in children at an early age, with no apparent dissenting voices.

Until recent years, however, there has not been an efficient and cost-effective way of identifying hearing loss in newborn infants on a universal scale. Previous efforts often resulted in too many normally hearing children "failing," or too many children with hearing loss "passing." In the last several years, technical developments have made it possible to efficiently set up a nationwide newborn infant hearing screening program that is both accurate and relatively inexpensive. Existing models in several states clearly demonstrate that infant hearing screening programs using the otoacoustic emission (OAE) phenomenon can reliably and accurately identify the presence of a hearing loss.

These programs are administered by audiologists, and conducted by medical technicians and nurses under the supervision of an audiologist. Children who fail the hearing screening at least twice are referred to an audiologist for an auditory brainstem response (ABR) test. The results of this test can accurately estimate the degree and general configuration of a child's hearing loss in each ear. Once these measurements are made, and after an otolaryngological examination is conducted to consider the medical implications of the hearing loss, it is then necessary to provide for a comprehensive management program for the infant and his/her family by qualified early intervention specialists, state health agencies, the state educational system, and consumer and parent organizations. Such a program would include the selection and fitting of an appropriate amplification device or determining whether or not a child is a cochlear implant candidate. Indeed, and this should be stressed, without such a management program the process would be incomplete.
Thus, a model universal newborn hearing screening program would include the following components: hearing screening, diagnostic audiological testing, a medical examination, and a habilitation process that is a component of, and flows from, the identification and diagnostic procedures.

HLAA supports the passage of legislation to mandate a Universal Newborn Hearing Screening program. Furthermore, we recommend that such legislation directly or indirectly address the necessity for a linked non-medical habilitation component.

Levitt, H., McGarr, N.S. & Geffner, D. (l987). Development of language and communication skills in Hearing-Impaired Children, ASHA Monograph #26, Washington, D.C. American Speech- Language-Hearing Association.
Ross, M. (l998). Implications of delay in the detection and management of deafness. Educational Audiology Review, 15(4) 10-15.
Watkins, S. (l987). Long term effect of home intervention with hearing-impaired children. American Annals of the Deaf, 132, 267-275.
White, S. J. & White, R.E.C. (l987). The effects of hearing status of the family and age of intervention on receptive and expressive oral language skills in hearing-impaired infants. In Levitt, McGarr & Geffner (Eds.), Hearing-Impaired Children, ASHA Monograph #26, American Speech-Language-Hearing Association.
Yoshinaga-Itana, C., Sedey, A. L., Coulter, D. K., & Mehl, A. L. (l998). Language of early and later identified children with hearing loss. Pediatrics, 102(5), 1161-1171.

HLAA Policy Statement on Assistive Device Warranty Laws (Lemon Laws)

The Assistive Device Warranty (ADW) laws, also known as "lemon laws", is a blanket term for consumer protection laws that are being passed in state legislatures throughout the country. Its primary intent was to protect elderly and disabled consumers against faulty motorized wheelchairs, but this original purpose was soon extended to apply to all types of assistive technology devices, including hearing aids. Generally, these laws require manufacturers to either replace the product or to refund the full purchase price if the device is returned for repairs two to four times in the course of a year, or if it is out of service for a total of 30 days during this period.

Some trade and professional associations have taken a public stand opposing the ADW. Their argument is that many hearing aids may be returned for shell modifications and or electroacoustic adjustments as an outgrowth of the normal fitting process, rather than reflecting mechanical or electrical malfunctions. HLAA agrees that hearing aids are often returned for this purpose and that these instances should not trigger the provisions of an ADW law. Indeed, at least some of the ADW laws explicitly exempt modifications not related to mechanical function. For example, the Rhode Island law states "nonconformity does not include a condition of the device that is the result of normal use which could be resolved through fitting adjustments, cleaning, or proper care."

With the inclusion of this provision, HLAA supports "lemon laws" as a consumer protection law. While it may be an infrequent occurrence, some consumers have purchased hearing aids which, despite repeated repair efforts, continue to malfunction. These people, many elderly and disabled, require the protection of an ADW law. It is very unlikely that such a law will increase the number of hearing aids being returned for full credit or for replacement. Nevertheless, it is in the interest of both consumers and the industry that those hearing aids that do fall under the provisions of an ADW law should be returned. It does the industry no credit to support malfunctioning instruments, and it certainly does the consumer no good. We do recognize that the overwhelming majority of hearing aid dispensers do not require a "lemon law" provision to replace a faulty hearing aid during the initial warranty period. To reiterate then: with the exemption of returns for purposes implicit in the hearing aid fitting process, HLAA supports the passage of ADW laws as they pertain to hearing aids.


HLAA Position on Hearing Aids

Binaural Hearing Aids
HLAA recommends that binaural hearing aids be the normal fitting practice, to be modified by clinical considerations and the expressed wishes of the hearing aid user. There are two reasons for this recommendation.

First, it is a fact that two ears, normally provide superior listening capabilities than one ear, for all normal hearing people, and for the majority of those with hearing losses. This fact have been known for many years. To determine if this generalization applies to a specific person, HLAA recommends that hearing aid evaluations include objective and subjective comparison between monaural and binaural listening (including a trial period when necessary or desirable).

Secondly, in recent years, evidence has been accumulating on the phenomenon termed "adult-onset auditory sensory deprivation." This body of research has demonstrated that the ability to understand speech in an unaided ear deteriorates over time compared to the ability in an aided ear. For many people, this deterioration in speech recognition abilities in the unaided ear is reversible if a hearing aid is later fitted to this ear (provided the ear is suitable for amplification). However, if the deprivation is long enough (presently undefined), and if the person is not too old (also undefined), then not only is recovery unlikely but binaural advantages may never be attainable. That is, if we don't "use" it, we may indeed "lose" it.

HLAA recognizes the added financial burden that a second hearing aid may present to many people with hearing loss. We also recognize that the ultimate decision regarding binaural hearing aid use rests with the prospective user. Hearing aid specialists are simply obliged to provide the necessary information to prospective users so that they can make their own, informed decision regarding binaural hearing aid use.

National and Uniform Standards for Hearing Aid Dispensers

Hearing aids are the most direct and effective therapeutic tool for the majority of people with hearing loss. They also represent the beginning of a habilitative and rehabilitative process. Developments in hearing aid technology and hearing aid evaluation procedures provide almost daily additions to the body of knowledge undergirding hearing aid fittings and follow-up. No one should engage in the practice of hearing aid dispensing unless he or she can demonstrate a high degree of mastery of this body of knowledge.
HLAA believes that the nationwide variations in standards and licensing requirements for hearing aid dispensers are inappropriate, inefficient, and not in the best interests of hard of hearing consumers. We recommend that a national and uniform standard be adopted for state licensing of hearing aid dispensers. Furthermore, we recommend that this standard be sufficiently rigorous to ensure that only those with the necessary knowledge and skills be permitted to dispense hearing aids. To do less is to devalue the auditory channel as a major sensory channel for human communication.

Hearing Aid Return Policies Hearing aid return policies vary depending upon the state, manufacturer, and individual dispensers. When a return policy is in force, it usually extends for 30 days. During this time, a client can return a hearing aid and receive a full refund, minus the cost of an ear mold and a "reasonable" user's fee.

For all hearing aid users, but new ones in particular, 30 days may not be sufficient time to determine if the cost of the hearing aid justifies the expense. We know that it often takes a longer period before a hearing aid wearer realizes the full benefits hearing aids can confer. During this period, the initial apparent benefits may not persist, or not be sufficient to justify the cost of the aids. On the other hand, with time and practice, the positive contributions of the hearing aids may increase and more than justify their expense.

HLAA recommends that hearing aids be purchased with a minimum 60 day money-back trial period, minus the direct cost of ear molds and a "reasonable" user's fee. We realize that the term reasonable is imprecise and subject to wide variations in interpretation. Whatever the lower limits, we believe that the upper limits of this "user's" fee should not exceed one-tenth the cost of the hearing aid.
Given appropriate pre-selection procedures, and a conscientious and scheduled hearing aid orientation program, it is our judgment that the incidence of returns would not impose an excessive financial burden on hearing aid dispensers. Insofar as consumers are concerned, this 60-day trial period should result in greater satisfaction and more frequent use of hearing aids.

HLAA Position on Cochlear Implants


In the last 25 years, cochlear implants have developed from a speculative laboratory procedure to an accepted clinical practice. The limited benefits possible with the initial generation of implants -- improvements in overall speechreading skills and auditorily "coupling" to a sound-producing environment -- were of sufficient value to these first subjects to warrant continued research on the device. Early studies proved that in the combined mode (implant plus vision), speechreading skills were superior to those obtained with vision alone. Except for several "stars" among the early cochlear implant recipients, however, the initial generation of implants could provide little or no open-set auditory recognition of speech.

Cochlear implants have benefitted from the remarkable advances occurring in recent years in microprocessors and miniature electronic circuitry. The primitive single channel cochlear implants have been superseded by multi-channel devices which provide access to a range of salient speech cues.

There is no doubt that they are here to stay. The major issues now concern the potential auditory and social implications of long-term implant use; the most suitable candidates; and, most importantly, who has the major responsibility for making the implant decision.
Insofar as adventitiously deafened adults are concerned, these questions are easy to answer. The rapidly accumulating body of research evidence shows that most such people receive some degree of benefit from an implant. This benefit varies from, at the lower limits, improved bi-sensory speechreading skills, to some auditory-alone speech recognition capability (achieved by over half the implant recipients). Once the possibilities, as well as the limitations of an implant are explained to them, these people have the capacity and authority to make their own decision regarding its desirability.

These questions are also relatively easy to answer for adults with congenital hearing losses. For the most part, these people have rarely had successful, or useful, experiences with traditional sound amplification. Generally, when someone in this population has tried an implant, the results have been much less favorable than for the adventitious group. However, as adults they, too, have the right and power to make their own decisions, based on a full and objective exposition of the possible consequences.
Children are a different matter; someone else must make the implant decision for them. Current surgical practice does not consider children as potential candidates until they reach two years of age. Based on the current research, the results with children can be broken down into two groups.

The first group of children are those who were born with normal hearing, but who developed a total or exceptionally profound hearing loss sometime after birth. The best candidates in this group are generally those who have had the longest period of normal hearing, as well as the shortest period from the onset of the hearing loss to the implantation. The results with these children indicate that the implant gives them immediate access to important speech features, which they can demonstrate by imitating most phonemes and combinations of phonemes through audition alone. Those whose hearing losses date from well into the lingual period have the capacity to respond to an implant in much the same fashion as do adventitiously deafened adults.

At this point, the children in this first group may diverge into two subgroups. Those who are given a sustained auditory language learning focus in their training continue to make auditory progress, eventually functioning like children with severe hearing losses who have received appropriate clinical/educational training. Their speech may exhibit some articulatory problems, but their voice quality is essentially normal. With training and experience, an increasing number are capable of comprehending speech through the auditory channel alone. In the second sub-group, those whose training program does not emphasize auditory learning continue to make auditory progress, but not at the same rate, nor do they reach the same level, as the children in the first sub-group. For all of these children (as for most children with hearing losses), the adequacy of the training program is a key factor in their overall educational progress.
The second group of children are those with pre-lingual and profound hearing losses. When implanted, these children do not display the same auditory responsiveness as the children in the first group. Lacking an auditory memory, the goal with these children is to help them develop auditory awareness, unlike the first group who simply need their previous auditory memory status re-stimulated. This second group of children must be taught to be aware of sounds in the environment, to "scan" for auditory events, and to listen and to imitate incoming speech sounds (the auditory-vocal monitoring system). Although progress is slower than in the first group, what research and clinical observations are making it increasingly evident is that, given an appropriate auditory language training program, auditory progress does continue. The most recent observations suggest that after several years of experience and training, this group of children may reach the same auditory developmental level as that of the first group. For children in both groups, receptive benefits continue to increase after 12-24 months of use, unlike the pattern seen in adults with adventitious hearing loss whose performance plateaus after this period.

Policy Recommendations

  • A. General

HLAA recognizes cochlear implants as a prosthetic device that can improve auditory skills. Future developments in health care technology may include other types of implants to more central auditory brain structures, or other, not yet even conceived, possibilities. Conceptually and functionally, the purpose is to improve access to auditory events. As with any prosthetic device, the employment of a cochlear implant depends upon the needs and status of the individual involved.

  • B. Adults
    • HLAA recommends that all adults with profound or total hearing loss, congenital or adventitious, be considered potential candidates for a cochlear implant. The hearing loss must be of sufficient magnitude to preclude the comprehension of speech through the auditory channel alone using conventional amplification devices. The decision whether an implant should be obtained depends, and must depend, upon the informed consent of the individual involved.
    • The key provision is informed. Now that cochlear implants are an approved clinical procedure, it is possible that some surgical centers would now necessarily conduct the desirable preliminary studies (including neuro-otological, audiological, social, and psychological components) and follow-up studies routinely accomplished by major medical centers.
    • HLAA recommends that persons contemplating a cochlear implant be evaluated and implanted in a center with demonstrable expertise. Factors to consider are the experience of the center, the nature of the preliminary evaluations, the frequency of the routine follow-up evaluations, and whether an aural rehabilitation program is recommended and conducted. When in doubt, persons contemplating a cochlear implant should avail themselves of a second opinion.
  • C. Children
    • No child should be considered a candidate unless he or she first receives an intense auditory language learning program utilizing more conventional technology (hearing aids, personal FM systems, vibro-tactile devices, or frequency transposers). There is currently no consensus regarding the length or composition of such a preliminary program, nor is there an agreement when the decision to implant should be made. As a general rule, the decision should be made as soon after an adventitious hearing loss has been sustained and as early in the child's life as possible for those with pre-lingual hearing losses.
    • At the present time, children who can recognize speech through audition alone are not considered implant candidates. The actual degree of hearing loss (within the severe to total category) is less an indicator of candidacy than the functional use of residual hearing. Those children who effectively employ a bi-modal speech perception system may be suitable candidates.
    • The final decision regarding a cochlear implant must be made by a child's parents. The responsibilities of the professional team involved in the implant process are to provide the parents with all the information they need to make such a decision. The full range of possible results must be explained, including explicit comments that the procedure does not replace the ear (as many parents think) or produce normal hearing. It is reasonable to use the average accomplishments of children who have been implanted to date as a legitimate prognostic marker.
    • The capacity of a child to benefit from a cochlear implant is directly related to the adequacy of the subsequent educational program. Unless audition is intensively and continually stressed in the training program, it is unlikely that the full potential benefits of the implant can be realized. Therefore, post-implant auditory-based speech and language training should be seen as a critical component of the entire implant process.
    • As yet, there is no information on the ultimate social and psychological consequences of implanting a young deaf child. We do not know how implantees will feel about the procedure when they are young adults, as they begin making their own decisions regarding their future. Judging from experiences to date with children with severe and profound hearing loss who use conventional amplification techniques, there will be no unanimity of responses. Some will resent the "imposition" of a prosthetic device upon them; others will bless their parents for making the decision. Most children will probably fall between these two extremes. When implanted children reach young adulthood, they have the capacity and authority to make their own decision regarding continued use of the implant, as well as the cultural and social milieu in which they feel most comfortable.
    • With the acknowledgment that the ultimate authority for the implant decision rests with the parents, and subject to the qualifications expressed above, HLAA recommends that cochlear implants be considered as a viable option for deaf children.

HLAA Policy Statement on Vocational Rehabilitation of Persons Who Are Hard of Hearing

The United States government operates an extensive vocational rehabilitation (VR) program that provides a wide range of services and job training to people with disabilities who want to work. To be eligible for VR services, a person must have a physical or mental impairment that is a substantial impediment to employment; be able to benefit from VR services in terms of employment; and require VR services to prepare for, enter, engage in, or retain employment . Priority is given to people with the most severe disabilities.

A 1992 report on underserved populations found that hard of hearing people, who represent one of the highest incidence of disability groups, are significantly unserved and underserved by the current VR system. This finding is buttressed by extensive anecdotal experience among people with hearing loss.

HLAA believes this inadequate record of service to hard of hearing people is due primarily to two factors. First, few VR counselors have been appropriately trained in the unique needs of hard of hearing people. Often, they fail to make the crucial distinction between being hard of hearing and being deaf, and thus inadequately consider the unique needs of each group. In fact, the typical VR office has no one on staff who is adequately trained regarding the most important issues affecting people with hearing loss. Most notably, too many VR counselors lack:

  • Awareness of, and sensitivity to, the communicative, psychosocial and adjustment consequences of partial hearing loss.
  • A general knowledge of hearing health and relevant professional services.
  • Knowledge of the ever-increasing selection of assistive technology and related services that can reduce communication barriers in employment situations.

HLAA Recommendations:
To improve the quality and quantity of vocational rehabilitation services to hard of hearing people, HLAA recommends that the Rehabilitation Services Administration (RSA) dramatically increase the amount of training provided to VR counselors about the differences and unique needs of people exhibiting a range of hearing loss.

HLAA also recommends that the criteria used to determine severity of disability include standardized self-assessment scales as well as degree of hearing loss. Both of these types of measures are necessary in order to determine the extent to which the hearing loss constitutes a barrier to full employment for a particular individual.

Further, HLAA suggests that the government sponsor or conduct research projects to evaluate the nature of current barriers to full employment faced by hard of hearing people, and the kind of "reasonable accomodations" that can be made to eliminate or minimize these barriers.

HLAA Policy Statement on Educating Hard of Hearing Children in Regular Schools

Hearing Loss, Nov.- Dec., 1997

HLAA views the sense of hearing as a human birthright, one that should be valued and exploited as fully as possible regardless of what system a person employs as a primary communication mode. By definition, hard of hearing children possess usable residual hearing and, with appropriate auditory management, are capable of employing audition as their primary channel for perceiving and developing an auditory-based language system. Because of this capability, their educational needs will differ from children who are educationally or functionally deaf, those whose primary communication mode is visually based. Because both groups of children have impaired hearing, it has been, and still is, common practice to routinely combine deaf and hard of hearing children within the same classes, offering all of them the same basic educational program and requiring all of them to communicate primarily through a visual mode. There is a major problem with this practice, conceptually and practically.

From a conceptual point of view, hard of hearing children generally have much more in common with normally hearing children than they do with deaf children. Like normally hearing children, hard of hearing children developed their auditory-verbal skills (however aberrant) primarily through audition. Deaf children, on the other hand, acquired their communication skills primarily through the visual channel. By combining both groups in a single educational setting, and exposing both to similar educational practices, the effect is a de-emphasis of the auditory potential of hard of hearing children. In this group, we include children who are the recipients of cochlear implants who have the capability to function as hard of hearing, given an appropriate auditory-based therapeutic and educational program.

The major practical implication in making this distinction is that for hard of hearing children education can proceed most efficiently through the "ear" (which then carries over to reading, given the heavy dependence of English orthography on the sounds of the language), while for deaf children, education must be primarily visually-based. Certainly, both groups of children deserve the best kind of education we can provide them. However, educating hard of hearing children with and like deaf children results in a heavy emphasis on the visual channel, in conflict with their need to have audition and oral communication emphasized throughout the entire educational process. The use and emphasis of audition can best be accomplished in a regular educational setting, where hard of hearing children cannot only benefit from the conversational models provided by their normally hearing classmates, but where they are also exposed to the same high academic expectations as their classmates.

It is the position of HLAA that most hard of hearing children can, and should be, educated in regular, as opposed to special, educational settings. We emphasize "most", since educational decisions should be made, for any child in any group, on the basis of the individual child's needs and not by some categorical, often arbitrary, grouping imposed upon a child. We do know that all hard of hearing children require appropriate auditory management. This would encompass any step taken to ensure maximum use of their residual hearing, such as the careful selection and supervision of various kinds of amplification devices (hearing aids, personal and FM sound-field systems, etc.) and the optimization of the acoustical environment in the classroom. This latter requirement is particularly important for hard of hearing children since it would assist them in hearing the questions and comments made by their hearing classmates. Other supplemental services such as speech/language therapy and academic tutoring must be provided when required. Given appropriate support services - and these should be written into a child's individual educational plan (IEP) - the vast majority of hard of hearing children are fully capable of performing at grade level while fitting in psychosocially with their normally hearing peers. In other words, placement in a regular classroom should be considered as the first option for a hard of hearing child, to be modified only as necessitated by specific circumstances (i.e. parental preferences, the child's performance, etc.).

HLAA Policy Statement on Insurance Coverage of Hearing Aids

If you wish to urge your employer to include hearing aids as an eligible expense in your insurance policy, HLAA has some advice for you. Begin by identifying the office responsible for managing and making decisions about health care benefits. Meet with the appropriate individuals and explain why you or someone in your family needs hearing aids. Be sure to discuss how hearing aids enhance your ability to function at work. For a child, note that hearing aids allow fuller participation in the classroom and enhanced language development. If you already have hearing aids, discuss how much they cost. Also note that the hearing aid fitting and follow-up must include services from a qualified hearing care provider. Review the information on the right before going and leave a copy with the benefits personnel. Be sure to let us know if you are participating in this effort and what the result has been.
The full text of the above discussion was published in Hearing Loss and will be provided upon request from the HLAA National office (Please include a stamped, self-addressed envelope.) We encourage you to use the Fact Sheet in your efforts. Permission is given in advance to anyone who wishes to print this web page or copy the Fact Sheet: Hearing Aids, Health Benefits and Insurance Coverage from Hearing Loss.

  1. Hearing aids are a critical first step in treating hearing loss. Being properly fitted with hearing aids can make a major difference in an individual's ability to understand speech. Consequently, hearing aids can make a major impact on quality of life.
  2. More than 80 percent of all hearing loss is sensorineural. This type of hearing loss is generally not amenable to medical or surgical treatment. Fortunately, it can be helped most of the time by being fitted with hearing aids.
  3. Hearing aids are effective. The new circuitry designs of today can effectively compensate for hearing loss experienced by people of all ages with a wide variety of hearing loss, from mild to profound.
  4. Hearing loss is a health issue, and not necessarily a natural process of aging as perceived by some people. If not treated, it can impact on the general and psychological health of the individual through higher stress and anxiety levels resulting in more medical visits and hospital stays. Studies show that people with hearing loss are at risk of experiencing depression, anxiety, stress and chemical dependency which can impact their performance at work and their lifestyles at home.
  5. Hearing loss affects a large percentage of the population. Approximately nine percent of people in the United States have hearing loss that results in communication problems. More than half of the 26 million hard of hearing adults in the United States are age 65 or less; and 72 percent report that their hearing loss resulted from factors other than aging. (Data from the National Center for Health Statistics, National Health Interview Surveys, 1988 and 1994).
  6. There is a stigma attached to hearing loss which, for some people who are hard of hearing, may result in an attempt to hide or deny their hearing loss. This is particularly true of employees who fear being seen as less competent if they admit to hearing loss in the workplace. Many people do not want to "make an issue" of their hearing loss, and, therefore, do not request insurance coverage of hearing aids.
  7. Hearing aids are a major uncovered health care expense. The average cost of a hearing aid in 1997 was $971. Since most people have hearing loss in both ears, the expense is considerable for the individual.
  8. Children need hearing aids to maximize their residual hearing to enable them to learn language and to participate fully in the education process. Children need new hearing aids regularly during their growth years. Therefore, this is a logical area in which to "spread the risk" by providing insurance coverage so that more employees and family members can afford needed hearing aids.
  9. Some insurance policies cover hearing aids. This has had a negligible effect on premiums to date.
    1. The California Public Employees Retirement System (CalPERS) -- Benefits include hearing test and hearing aid evaluation at no cost. Coverage of up to $1,000 (per insured individual) every 36 months for hearing aids. This benefit also covers earmolds, hearing aid instrument, initial batteries and other needed equipment.
    2. The State of Minnesota Employees Insurance -- Employee insurance provides coverage for hearing exams and hearing aids (with coverage of 80 percent of one hearing aid per year as durable medical equipment) for all its employees. The estimated cost of providing this benefit is between 15-23 cents/month for a single employee; and between 37-57 cents/month for an employee and family members.
    3. Hartford Insurance -- Offers hearing testing and the full cost of two aids every five years.


HLAA Position on Telecoils

All hearing aids contain three basic components:the microphone, amplifier, and loudspeaker (called a "receiver" in hearing aid terminology). The microphone picks up sound waves and converts these into a tiny electrical current. This current is then amplified and changed back into sound by the hearing aid receiver. The best way to conceptualize a telecoil is as a microphone, but one that responds to a varying electromagnetic field rather than to sound waves.

About 50 years ago, a very astute hearing aid engineer by the name of Sam Lyberger, realized that the sound heard through a telephone was produced by an electromagnetic field vibrating a diaphragm in the telephone earpiece, and that this field could be directly accessed by hard of hearing people. He substituted a coil of wire wound around a metal core (termed an "induction" coil) in the same circuit position as the microphone within the hearing aid. By placing this coil in the varying magnetic field, an electrical current was "induced" in it; this current could then be amplified and converted back into sound by the hearing aid receiver.

These were the days when only body worn hearing aids were available and trying to listen to a telephone by placing the hearing aid against the telephone receiver was not always possible. Not only was the already limited fidelity further decreased, but environmental noise and acoustic feedback made effective telephone communication a difficult chore at best, and an impossible dream at worst. By using the induction coil (now called the "telephone coil" or "telecoil" ) instead of the microphone, a direct "inductive" coupling was possible, thus bypassing the potential problems of acoustical coupling. Thus was born the whole idea of Hearing Aid Compatible (HAC)telephones.
HLAA believes that telecoils in hearing aids area valuable hearing aid feature that are currently insufficiently utilized or appreciated. Industry figures indicate that only about 30% of modern hearing aids incorporate a telecoil (the "T"switch). Because, unlike the old body worn hearing aids, effective telephone communication may be possible with many in-the-ear (ITE), in-the-canal (ITC) and completely-in-the-canal (CIC) hearing aids, and because there may be insufficient physical space to include telephone coils in the smaller aids, some dispensers evidently think That they are unnecessary.

This is unfortunate and short-sighted. While initially designed to detect the electromagnetic field around telephones, in actuality a "T coil can detect any electromagnetic field, including that emanating from room, area or neck loop. It is this additional property of "T" coils that is being overlooked when hearing aid dispensers only consider "T" coils in terms of telephone usage.

Large and small area assistive listening devices transmit signals to a listener using either Infra-Red (IR)light, FM radio waves, or an electromagnetic field (via a loop of wire on the floor). To detect the IR or FM signals, the listener has an option to couple their IR and FM receivers to the hearing aids with either a neck loop or silhouette inductors. Both of these transmission modes require that the hearing aid be equipped with a "T" coil. Without the "T" coil, the listener must use earphones to hear the signals, necessitating either the removal of the hearing aid or the placement of the earphones directly over the hearing aids. Besides being less convenient, when earphone listening is substituted for personal hearing aids, listeners are deprived of the specific electroacoustic characteristics of the aids and the advantages they presumably offer. And, of course, when an induction loop is the transmission mode, all a listener has to do is switch the hearing aid to the "T" position to be "on the air". Clearly, the addition of a "T" coil in a hearing aid facilitates the provisions of auditory access as mandated by the Americans with Disabilities Act.

Many hearing aid users were not informed about telecoils and their potential as an assistive listening device when they purchased their hearing aids. Other users, while being aware of telecoils and their primary purpose for improved telephone access, may not be fully cognizant of their other assistive listening possibilities. HLAA recommends that all hearing aid dispensers inform their patients of the function and potential advantages of "T" coils during the course of the hearing aid selection process and strongly suggest their inclusion in the hearing aids. It is evident that including "T" coils in hearing aids may require somewhat larger hearing aids and a slight additional cost. While hearing aid users may elect to forgo them, as it their right, they also have a right to be fully informed of their potential usefulness and given an objective demonstration of their efficacy. The ultimate decision to incorporate them or not rests with the hearing aid user and not with the hearing aid dispenser. HLAA strongly recommends that consumers accept this option.

HLAA further recommends:

  • That hearing aid manufacturers ensure that the electroacoustic characteristics of the hearing aid in the "T"coil position be identical to that of the microphone response. Whatever advantages are presumed to occur when a certain response is "prescribed" in the conventional, microphone listening mode, should also be present when listening through the "T" coil.
  • That manufacturers incorporate "M/T" capability whenever possible. In some situations it may be advisable to be able to hear through both the "T" coil (an FM output for example), and the hearing aid microphone (monitoring one's own voice or conversing with a companion in some large-area listening situation).
  • That "T" coils be developed which are insensitive to changes in the relative positioning of the electromagnetic field and the hearing aid. Currently, inducing the best possible signal In a "T" coil is different when using a telephone or listening through a neck or floor loop.

In brief, it is the position of HLAA that telecoils be given the prominence they deserve as a valuable hearing aid feature that will allow the expanded use of assistive listening devices.


HLAA Policy Statement on Hearing Assistance Technologies

Hearing aids are the most effective and potent therapeutic tool available for the vast majority of hard of hearing people. It is agreed that they are a crucial and necessary component in any effort designed to mitigate the consequences of a hearing loss. But some problems caused by a hearing loss either cannot be helped by a hearing aid, or the aid by itself may be inadequate, as the two following examples will illustrate:

1. Many hard of hearing people have difficulty understanding a lecture or a sermon, or following the dialogue in a theater performance or movie house. In these types of locations, any large-area assistive listening device can further improve comprehension beyond that possible with hearing aids.
2. Hearing aids are not designed to serve as an alarm clock, and unless the hard of hearing sleeper wears the hearing aid all night (not a good idea), an audible alarm may not wake this person up. Hearing aids, in other words, while necessary for hard of hearing people, cannot serve purposes for which they were not designed.

In recent years, a entirely new class of Hearing Assistance Technologies (HAT) have been developed. These include the three major types of large-area assistive listening systems (Induction Loop, Infra-Red (IR), and FM Radio), personal FM systems, telephone amplifiers and TTY's, TV listening devices and captions, various types of conference and hand-held microphones, and a large number of signaling and warning devices (e.g. visual or vibratory alarm clocks and smoke alarms, telephone and doorbell lights, motion detectors, etc.). Some HAT are separate units from hearing aids (e.g. signaling and warning devices, FM and IR receivers) and can stand alone, while others are designed to work with or through a hearing aid (e.g. telecoil or direct audio input capability). Direct audio input (DAI), for example, is a way of avoiding electromagnetic interference while accessing assistive listening devices (e.g. the audio output from a computer). There are many types of HAT; one only has to consult one of the catalogs available (check Hearing Loss Magazine) to appreciate their full range.
Chances are that many hard of hearing people have need for such a device, at least at some times and for some purposes. However, hard of hearing people are not generally aware of the existence of these devices nor understand how their effective use can improve awareness and accessibility to acoustic signals, either through substitution (i.e. converting the sound into light, vibration, or text) or sound enhancement (e.g. a personal FM or TV listening system ). HLAA suggests that all hard of hearing people receive a careful "needs assessment" during the hearing aid selection process. This should include a check-list of various kinds of communication situations to ensure that no important ones are overlooked. It is necessary to determine a person's communication needs at home, on the job, during recreational, social, and religious activities, while traveling for fun or business, or any other kinds of situations unique to the individual. Such check lists have already been developed and are being used by leading audiologists. Whether a detailed interview technique or a check list is used, the goal is to ensure that the possible usefulness of HAT be thoroughly explored with each potential hearing aid candidate.

Furthermore, HLAA suggests that dispensers make specific HAT recommendations, in much the same way they do with hearing aids, and assist their patients to learn how to use them, again in the same way they do with hearing aids. The introduction to, and assistance with HAT can, HLAA suggests, be included into the hearing aid selection process, most logically during the hearing aid trial period (see 1 below) and within the subsequent hearing aid orientation period (see 2 below). Because of the potential benefits of HAT for hard of hearing people, HLAA recommends that all hearing aid dispensers incorporate the evaluation and dispensing of HAT as an integral component of their practice.

1) In a previous position paper, HLAA has recommended that dispensers provide their clients with a minimum of a 60 day trial period.
2) In a previous position paper, HLAA has recommended that all hearing aid dispensers offer their clients the opportunity to participate in a group.

HLAA Position Statement on the Au.D. - The Doctor of Audiology Degree

It is generally accepted that the profession of audiology had its genesis during and immediately after World War II. Servicemen deafened by war injury required aural rehabilitation services, and various types of health care professionals joined forces to provide such programs. After the war, these programs became the basis for the creation of formal academic programs in colleges and universities designed to train "speech and hearing therapists". These professionals were trained to evaluate the auditory system and to define and manage the communicative implications of a hearing loss. At that time, aural rehabilitation conducted by these therapists consisted mainly of speechreading and auditory training, and the recommendation, but not the dispensing, of hearing aids.

As the profession matured, the speech (and language) areas became differentiated from the "hearing" areas, a development that has continued to this day. Certification requirements for both areas were defined and promulgated by the American Speech-Language-Hearing Association (ASHA). These requirements reflected the increasing proliferation of knowledge necessary both to evaluate the status of the auditory system and to conduct the non-medical therapeutic measures designed to reduce the impact of the hearing loss (again, excluding the actual dispensing of hearing aids). The standards under which the audiology profession is currently operating were implemented in l965, at which time certification requirements were defined at a single level (the current Certificate of Clinical Competency, or CCC). At the time these standards were adopted, it was considered unethical for an audiologist to actually dispense hearing aids. This position was modified in the late l960s, primarily because many audiologists believed that this position prevented them from providing follow-up hearing aid services and that it interfered with their rehabilitative interactions with clients. To qualify for the CCC in audiology, a candidate had to complete a master's degree (M.A.) with a minimum of 30 graduate academic credits, work under supervision for a clinical fellowship year (the CFY) after graduation, and pass a national examination administered by the Educational Testing Service. While the M.A. was considered the "entry" level degree for clinical practice in audiology, many audiologists continued their education and completed a doctoral degree, most often the Ph.D. Many doctoral level audiologists functioned, and continue to function, as advanced clinicians rather than the traditional scholarly and research role that this degree was designed to fulfill.

In the last ten years, not only has the extent of available information regarding the evaluation and management of auditory disorders increased dramatically, but the scope of practice of audiology and audiologists has also been extended to encompass additional clinical areas. Audiologists are now found in medical centers and physician offices, non-profit Audiology centers, nursing homes, school settings, industry, and, increasingly, in various kinds of private practice. Their clinical obligations span the age range from the neonatal to the geriatric population, with responsibilities that include the administration and interpretation of advanced diagnostic auditory and vestibular tests. They are expected to define and manage the communication implications of a hearing loss, which includes the evaluation and selection of all types of hearing assistive technologies. It is in response to this increasing body of knowledge and clinical responsibilities that the profession is now engaged in another effort to upgrade the proficiencies of the clinical practitioner.

After much debate and discussion, a consensus was achieved among audiology organizations that the entry level into the clinical practice of audiology should be a doctoral degree. This degree is seen not only as a clinical necessity, with the opportunity it offers for intensifying training programs and experiences, but a practical necessity as well since, in this era of managed care, a practitioner's credentials may influence professional autonomy and reimbursement patterns. The current, operative document regarding the new credentials is that developed by the ASHA Council on Professional Standards, adopted after all member audiologists had an opportunity to review the draft version. (Modifications proposed by the American Academy of Audiology do not appear to address these initial standards, but focus instead on re-credentialing issues.) This degree is designed to supplant the current M.A. degree, but not the Ph.D., which would revert to a stringently defined scholarly and research degree.

There is also a consensus that the Au.D. (doctor of audiology) should be the designator for this new, doctoral-level clinical degree in audiology. Instead of 30 graduate credit hours, the Au.D. will consist of 75 post-baccalaureate hours. The program is designed to last for four years, one of which will be a full-time, 12-month, clinical experience supervised by the training facility. At the conclusion of the program, candidates will be required to take and pass a national examination in order to be certified. This training requirement will become effective for people who apply for initial certification after December 31, 2006. The doctoral degree will be an additional requirement for those who apply after December 31, 2011. During the period between 2006 and 2011, in other words, while the Au.D. itself will not be obligatory for new audiologists, the increased certification standards will be in force. Existing M.A. audiologists may continue to function with their present degree and credential. For those who wish to upgrade to the Au.D. while maintaining their clinical practice, a number of universities are organizing distance learning programs that can accommodate them. How long it will take an experienced M.A. audiologist to complete the Au.D. requirements is not explicitly defined; most likely a committed candidate could complete the requirements in about two years. While these university programs may award credit for experience or by equivalent examinations, they will also require a demonstrated fulfillment of a doctoral- level curriculum before awarding the degree.

Currently, there is a great deal of controversy on this issue in the audiology profession. A significant minority of audiologists (no more than 30 percent) recommend and support an "earned entitlement" (EE) concept. In this concept, practicing audiologists have an opportunity to apply for an Au.D. "designator" (not the academic degree) through application to an independent foundation. The EE application entails that they submit their self-rated experience and credentials to an independent foundation and after being given an opportunity to correct deficiencies and the payment of a fee, the Au.D. designator is granted by the foundation.
HLAA believes that the EE concept would be confusing to consumers and not in their best interest. Our judgment is that people awarded Au.D.degrees through accredited universities will be better trained to serve the interests of consumers than those audiologists granted Au.D. "designators" by a private foundation. Consumers will generally be unaware whether an audiologist with an "Au.D." was granted it by a private organization or had earned it through an accredited university. This is an important point: HLAA believes that the doctoral designator Au.D. be restricted to degrees awarded by an accredited institute of higher learning. University-sponsored programs are being organized at a rapid rate. By the fall of l998, there should be at least seven of them in place at accredited universities, with three or four currently (spring l998) operating.

Insofar as the degree itself is concerned, ordinarily this would be considered an internal matter falling under the purview of the profession involved. However, since its ultimate purpose, and the rationale on which it is based, is to enhance the effectiveness of audiologists in working with people with hearing loss, HLAA, representing this population, is a direct stakeholder in this process.
As consumers view the Au.D., they need to be assured that their interests and needs, as they perceive them, are furthered by this new entry level degree for clinical audiologists. If a future generation of practitioners holding this degree are not academically and experientially prepared to provide superior service for people with hearing loss, then insofar as HLAA is concerned, the degree is simply irrelevant.

HLAA recognizes that in the last decade there has been an information explosion in all areas pertaining to health care, and that this information includes material pertaining to Audiology. It seems quite apparent that there is insufficient time in the current M.A. training program to include all the information that a new generation of audiologists must master. In principle, therefore, HLAA endorses the concept of the Au.D. In practice, HLAA has some reservations. hese reservations are based on our reading of the "Standards and Implementation for the Certificate of Clinical Competency in Audiology," approved by the ASHA Council on Professional Standards in September l997.

There does not appear to be sufficient emphasis in the "standards" on topics that relate directly to the psychosocial impact of a hearing loss on the person involved, on the family constellation, in various types of situations, and in different stages in a person's life. No course work in interpersonal counseling or group facilitation is explicitly required. Hearing aids and assistive technology are listed in only three of the nineteen items in the "treatment" section, a fact that could lead to inadequate training and experience in these areas if each item is given equal emphasis in the training program.

From HLAA's point of view, these three are crucial areas that require more explicit attention. Only one "treatment" item refers to aural rehabilitation, which is not further defined. It is not clear whether this item will include such old and modern concepts as coping and repair strategies, assertiveness training, speechreading and auditory training, group hearing aid orientation programs, etc. HLAA has adopted a number of position papers that outline the types of services consumers desire from their audiologists. These services include a comprehensive evaluation of hearing assistive technologies as well as group hearing aid orientation programs that provide information and support crucial for hearing aid users and their families. As written, the standards do not make clear how these consumer concerns will be addressed.

It is true that all of these concerns can be accommodated depending on how the program director and certifying bodies interpret the competency-based statements within the standards. Nevertheless, it may be possible for one program to provide only one or two courses related to hearing aids and assistive devices while another provides three or four, yet for both to be given official approval. One program may emphasize the diagnostic process while another focuses on the rehabilitative.
Before HLAA unambiguously endorses the concept of the Au.D., we do require more assurance that the additional training will be reflected in more knowledgeable and more sensitive attention concerning the psychosocial consequences of a hearing loss and its non-medical management. Consumers need to be convinced that Au.D. audiologists can provide services to them that hearing instrument specialists, many of whom hold no formal academic degree at all, cannot provide. There is no way yet, in other words, to determine how a doctoral level audiology profession will play out in terms of the care, particularly the non-medical care, of people with hearing loss and their families. This is particularly applicable for older adults with progressive hearing loss, who represent the majority of patients seen in audiology clinics. In theory, there should be a positive impact; in practice, many other factors intervene. HLAA, therefore, while endorsing the concept of an Au.D., is reserving its final judgment until it can be empirically determined that a doctoral-level audiology profession ensures superior rehabilitative services to consumers than is now offered by M.A. audiologists.

HLAA Policy Statement on Hearing Screening in Schools

Hearing Loss, May-June, 1999
A hearing loss is not only a frequent occurrence in school children, but can have more severe consequences than are generally realized. As reported in the Journal of the American Medical Association, the incidence of unilateral or bilateral hearing loss among children from 6 to 19 years of age was found to be almost 15 percent using a criterion of 16 dB or more in either the high or the low frequencies (Niskar et al., l998). Depending upon the nature and extent of the hearing loss, it may be responsible for deficient or delayed speech and language skills, poorer academic accomplishments, and more problematical psychosocial adjustment.

These effects not only occur with children who have moderate, severe, or profound hearing loss, but may also be present in children with unilateral, minimal, and fluctuating conductive problems as well. Because individual children with lesser degrees of hearing losses may not overtly display any apparent communication or academic problems (that is, they apparently hear and respond appropriately in face-to-face situations), the academic and linguistic "risk" status of such children tends to be overlooked. It is only when group performance is considered, or when a detailed evaluation is conducted on a specific child, that deficiencies in a number of areas become apparent.
This is clearly shown in a study conducted by Bess, Dodd-Murphy, & Parker (l998). The primary focus of the study was the academic achievement and functional status of children with minimal sensorineural hearing loss (MSHL); secondarily, the overall incidence of hearing loss in a public school setting was also determined. The investigators took great pains to ensure a representative sample of children in their study and it is likely that their results would be applicable to school systems throughout the country.

The overall prevalence rate of a hearing loss in their study population was 11.3 percent, of which 5.4 percent of the children exhibited MSHL. The other children had conductive and mixed hearing losses. Three categories of children with MSHL were identified: (1) unilateral hearing loss (one ear normal); (2) bilateral losses averaging between 20 and 40 dB; and (3) a hearing loss of 25 dB or more in either ear at frequencies above 2000 Hz (high frequency hearing loss). When they compared the academic and functional status of the MSHL children to their hearing peers, they found that 37 percent of them failed at least one grade, compared to a two percent failure rate by their normally hearing peers.

Other academic achievement problems were noted as well, particularly for the children in the lower grades. For the MSHL children in the higher grades, functional comparisons revealed poorer ratings for stress, self-esteem and social support than those observed with the normally hearing children. It is important to stress that these results are not unique. There are many other studies that show the negative impact of unilateral and mild hearing losses upon school-age children (the Bess study contains extensive references to them).
These findings should send an unequivocal signal that a hearing loss, of whatever degree, is not an inconsequential event. They demonstrate the crucial role that audition plays in learning. Hearing is the key avenue with which children become acculturated into our society and learn its language. Moreover, it is through this auditory-based language that children can most effectively approach the reading process. It is important to emphasize this latter point: children normally learn how to read by associating the language learned through audition with the written word. Reading skills, in other words, are initially and most efficiently grounded in the sense of hearing. It is because congenitally and profoundly deaf children do not possess an auditory-based linguistic system that they have such difficulty reading at grade level.

Children in regular schools, and this applies to normally hearing children as well as to those with minimal hearing losses, must hear in order to learn, and the more they hear, the more they are likely to learn. They must be able to hear the teacher as he/she moves around the room, faces the blackboard, and during the noise of normal classroom activities. They must be able to hear the comments and questions of the other children in the class. Since even a 10 dB reduction from normal thresholds will reduce the subjective loudness sensation of a speech signal by half, no degree of hearing loss can be considered "acceptable." Hearing the teacher at half or quarter (a 20 dB hearing loss) of the loudness sensation enjoyed by other children may permit comprehension of most of the teacher's message most of the time, but at a cost of increased fatigue, "tuning out" or "acting out," and an uncertain grasp of many of the grammatical features of speech (particularly those conveyed by weak final consonants). Children have enough hurdles to overcome during the learning process without the added problem of an undetected and untreated hearing loss.

The need to identify children with hearing loss in schools was recognized more than 70 years ago (Roush, l992). Many states now mandate some sort of hearing screening program, but others make no such provision. In some states, the authority for the hearing screening program rests with the state department of health, while in others the department of education takes on this responsibility. When a state does not require a hearing screening program, the local school authorities may or may not fill the gap. Some states mandate that kindergarten children entering school have their hearing examined, and then follow through with a hearing screening program at later times.

For other children, however, this kindergarten "certification" may be the last time in their school career that the status of their hearing is examined. In some locales, newly enrolled children, those with special needs, or children with known hearing losses are examined every year, while other jurisdictions have different or no such provisions at all. Some states and districts provide guidelines that incorporate specific testing procedures, including tympanometry and otoscopic examination, as well as required follow-up procedures, while others leave the details to the local authorities. When a state or district does offer a hearing screening program for the children, rarely are children in private or parochial schools included. In short, the national status of hearing screening programs for school-age children is a disorganized mess, varying from non-existent or incomplete, to excellent in a few places.

HLAA believes that the hearing of school children is too important to be left to chance. We believe that it is essential that all school-age children in all our schools have their hearing screened at regular intervals. Moreover, it is our recommendation that the hearing screening activity itself be integrated with, and a component of, an overall hearing conservation program in which the implications of each child's hearing loss are explicitly addressed. Our experiences over the past number of years have shown thatit is not reasonable to expect each state independently to conduct an effective hearing screening program in schools. HLAA, therefore, recommends that the U.S. Department of Education develop and enforce specific guidelines for a nationwide hearing screening program. We recommend that these guidelines be established by a task force composed of representatives from state and national health and education agencies, as well as those from the medical and audiological professions.

Furthermore, HLAA believes that, at a minimum, the following elements must be included in the guidelines:

  • All children in the lower grades and some of the upper grades in all schools in our country (public and private) should have their hearing screened.
  • Tympanometry should be a routine part of the program for the children at the lower elementary levels.
  • Only specially trained personnel should conduct the program, under the general supervision of a certified audiologist.
  • If a child does not pass the entire screening process, parents must be notified and encouraged to have their children's ears examined by a physician.
  • All children who do not pass the screening must be carefully followed up, both with the parents (to ensure compliance) and in the school (to ensure appropriate educational management).
  • Children with permanent hearing loss and conductive hearing losses not responsive to medical/surgical treatment should receive comprehensive audiological, speech and language, educational and psychosocial evaluations.

Private and parochial schools, as well as public schools, should be included in a nationally mandated hearing screening program. Given the inclusion of these elements in a hearing screening (conservation) program, it should be possible to minimize the potential impact of a hearing loss upon the academic achievement and psychosocial adjustment of school children. Moreover, the very fact that such a national program is implemented can, in itself, send a message to all segments of our society regarding the crucial importance of hearing to learning. It will help remove hearing loss from society's "back-burner" and truly make it an "issue of national concern."

Bess, F. H., Dodd-Murphy, J. and Parker, R. A. (l998). Children with Minimal Sensorineural Hearing Loss: Prevalence, Educational Performance, and Functional Status. Ear and Hearing, 19(5), 339-354.
Niskar, A. S., Kieszak, S. M., Holmes, A., Esteban, E., Rubin, C., & Brody, D. B. (l998). Prevalence of Hearing Loss Among Children 6 to 19 Years of Age. Journal of the American Medical Association, 279(14), 1071-1075.
Roush, J. (l992). Screening the School-age Child. In Screening Children for Auditory Function (F. Bess and J. Hall, Eds), Nashville, TN: Bill Wilkerson Center Press.