Assistive Listening Devices: Options for Children with Hearing Loss

1. Assistive Listening Devices: Options for Children with Hearing Loss An Overview For Parents of School-Aged Children By: Michelle Lazaro

2. Learning Objective: The parents of school-aged children will become familiar with the three types of hearing loss and their main causes. They will familiarize themselves with the options children have with assistive listening devices (ALDs), as well as their costs, advantages, and disadvantages.

3. Hearing and the Ear:

4. The Ear Consists of Three Distinct Areas: * The Outer Ear (the pinna, auditory canal, and eardrum) * The Middle Ear (the space behind the ear drum that contains the small bones called the ossicles, up to the cochlea) *The Inner Ear - (the cochlea and vestibular system)

5. How We Hear: Sound travels down the auditory canal and strikes the eardrum, making it vibrate. Those vibrations in the eardrum cause the ossicles to vibrate thereby creating movement of the fluid in the inner ear. This movement in the cochlea causes changes in the tiny structures called hair cells, which send electrical signals from the inner ear up the auditory nerve to the brain. The brain interprets these electrical signals as sound.

6. Hearing Loss:Types and Causes Three Types Most Common Causes • Conductive hearing loss: sound is not conducted efficiently through the outer ear canal to the middle ear - - some type of barrier exists in the outer or middle ear. This type can often be corrected medically or surgically. *** • Sensorineural hearing loss (also called nerve deafness): damage to the inner ear or the nerve pathways from the inner ear to the brain. This is the most common type of permanent hearing loss. It cannot be corrected medically or surgically. • Middle ear fluid from colds • Ear infections and allergies • Malformations of the pinna • Impacted ear wax (cerumen) • Perforated eardrum • Presence of a foreign body *** • Head trauma • Exposure to loud noise • Age-related hearing loss, called presbycusis, or genetic or hereditary hearing loss • Meningitis and illness-related hearing loss • Malformation to the inner ear

7. Hearing Loss:Types and Causes Third Type Most Common Causes • Mixed hearing loss: having both a conductive hearing loss and a sensorineural hearing loss. There may be damage in the outer or middle ear and in the inner ear (cochlea) or auditory nerve. • Combination of wax impaction with presbycusis - aging • Ear infection with a meningitis-related hearing loss • Malformed pinna (outer ear) with abnormal cochlea

8. Degrees of Hearing Loss Normal range of hearing: 0 – 25 dB Mild hearing loss (HOH): 25 – 40 dB • Soft noises are not heard. Understanding speech is difficult in a loud environment. Moderate hearing loss (HOH): 41 – 70 dB • Soft and moderately loud noises are not heard. Understanding speech becomes very difficult if background noise is present. Severe hearing loss (HOH/Deaf): 71 – 90 dB • Conversations have to be conducted loudly. Group conversations are possible only with a lot of effort. Profound hearing loss (deaf): 91 + dB • Some very loud noises are heard. Without a hearing aid, communication is no longer possible even with intense effort.

9. Listening Devices There are listening devices available depending on the type and degree of the hearing loss. Technology Options: Hearing Aids Cochlear Implants FM Systems Infared Systems Assistive Listening Devices

10. Hearing Aids • A hearing aid is an electro acoustic - body worn apparatus - which typically fits in or behind the wearer's ear, and is designed to amplify and modulate sounds for the wearer. • All hearing aids work by collecting sounds from the environment through a microphone, amplifying the sound and then directing this amplified signal into your ear by way of a loudspeaker. The amplified signal stimulates your inner ear, which activates nerve fibers that carry the sound impulses to your brain. • Wearing two (binaural) hearing aids allows more information to reach your brain and makes it easier to hear speech against background noise.

11. Hearing Aids Recommended for Children • Behind-the-Ear (BTE) Aids All parts of the aid are contained in a small plastic case that rests behind the ear. The case is connected to an earmold by a piece of clear tubing. This style is often chosen for infants and young children for safety and growth reasons. • In-the-Ear (ITE) Aids All parts of the aid are contained in a shell that fills in the outer part of the ear. These aids are larger than in-the-canal aids and, for some people, may be easier to handle than smaller aids. This style is often chosen for older children and adults.

12. Hearing Aid Styles • Behind-the-Ear (BTE) & Mini B-T-E Aid: Open Fitting A small plastic case rests behind the ear, and a very fine clear tube runs into the ear canal. Inside the ear canal, a small, soft silicone dome or a molded, highly vented acrylic tip holds the tube in place. These aids offer cosmetic and listening advantages and are used typically for adults. • Receiver-in-Canal Aids (RIC) These aids look very similar to the behind-the-ear hearing aid with a unique difference: the speaker of the hearing aid is placed inside the ear canal, and thin electrical wires replace the acoustic tube of the BTE aid. These aids also offer cosmetic and listening advantages and are typically used for adults. Completely-in-the-Canal Aids (CIC) They are worn inside the ear canal and not in the concha. They are inserted and removed by a short clear cord. • Extended Wear Hearing Aids These aids are devices that are nonsurgically placed in the ear canal by an audiologist. They are worn up to several months at a time without removal. The devices are made of soft material designed to fit the curves of the ear. They are worn continuously and then replaced with a new device. They are very useful for active individuals because their design protects against moisture and earwax, and they can be worn while exercising, showering, etc.

13. Styles: Pros, Cons, & Costs Behind the ear (BTE): • Pros: Larger size makes it easier to manipulate. Direct audio input capability so it can be hardwired to an ALD. Accommodates directional microphone, volume control, easy to clean because the earmold can be detached and washed. • Cons: Conspicuous. Awkward for phone use. • Cost: $1,200-$2,700. In the ear (ITE): • Pros: Easy to insert; can house a directional microphone and volume control; easy to use with the telephone. • Cons: Conspicuous and bulky. • Cost: $1,300-$2,800. Middle Ear Implant: • Pros: , Reduction of occlusion effect and feedback, reduction of cerumen build-up problems, successful with patients who suffer from otitis media. • Cons: Necessity to under go anesthesia and surgery, and high cost. • Cost: $15,000 - $30,000. Mini behind the ear (Mini BTE): • Pros: Leaves the ear canal open, for more natural sound, especially your own voice. No custom mold required. No "plugged up" feeling. • Cons: Harder to use with the telephone. • Cost: $1,300-$3,000. Receiver in canal (RIC): • Pros: One of the least noticeable devices. Can give superior sound quality. • Cons: Harder to use with the phone. • Cost:  $1,400-$2,900. Completely–in-the-Canal (CIC): • Pros: Easy to handle, reduction of occlusion effect and feedback, elimination of wind noise, virtually invisible, improved sound localization. • Cons: High-maintenance devices, cerumen build up, does not accommodate directional microphones. • Cost: $300 - $2,000.

14. Cochlear Implants • A cochlear implant is a device that provides direct electrical stimulation to the auditory (hearing) nerve in the inner ear. Children and adults with a severe to profound hearing loss who cannot be helped with hearing aids may be helped with cochlear implants.

15. Cochlear Implants Continued • Cochlear implants are used for sensorineural hearing losses, which means there is damage to the tiny hair cells in the part of the inner ear called the cochlea. Because of this damage, sound cannot reach the auditory nerve. With a cochlear implant, the damaged hair cells are bypassed, and the auditory nerve is stimulated directly. • The cochlear implant does not result in “restored” or “cured” hearing. It does, however, allow for the perception of the sensation of sound. • The benefits from a cochlear implant depend on many factors, such as: • The age of the patient when he or she receives the implant • Whether the hearing loss was present before or after the patient developed language skills • The motivation of the patient and their family

16. How does a cochlear implant work? • Cochlear implants have external (outside) parts and internal (surgically implanted) parts that work together to allow the user to perceive sound. • External parts: The external parts include a microphone, a speech processor, and a transmitter. The microphone looks like a behind-the-ear hearing aid. It picks up sounds—just like a hearing aid microphone does—and sends them to the speech processor.

17. Cochlear Implants – Parts: • The speech processor may be housed with the microphone behind the ear, or it may be a small box-like unit typically worn in a chest pocket. The speech processor is a computer that analyzes and digitizes the sound signals and sends them to a transmitter worn on the head just behind the ear. • The transmitter sends the coded signals to an implanted receiver just under the skin. • Internal parts: The internal (implanted) parts include a receiver and electrodes. The receiver is just under the skin behind the ear. The receiver takes the coded electrical signals from the transmitter and delivers them to the array of electrodes that have been surgically inserted in the cochlea. The electrodes stimulate the fibers of the auditory nerve, and sound sensations are perceived.

18. Children and Cochlear Implants • Children can be considered for cochlear implants. Children as young as 14 months of age have received cochlear implants, and the potential exists for successful implantation at younger ages. • It is generally agreed that the best child candidates are those who: • Have profound hearing loss in both ears • Have had limited benefit from hearing aids • Are healthy and have no medical conditions that would make the surgery risky • Are involved (when able), along with their parents, in all the steps in the process • Understand (when able), along with their parents, their role in the successful use of cochlear implants • Have (when able), along with their parents, realistic expectations for cochlear implant use • Are willing to be actively involved in their habilitation/rehabilitation • Have support from their educational program to emphasize the development of auditory skills

19. Cochlear Implants Advantages Disadvantages • An increased level of hearing • Children who get the implant are often able to function in mainstream schools rather than through specialized schooling for the deaf. • Another major benefit of having the cochlear implant is safety. Being able to hear some environmental sounds, ambulance sirens, a door opening or someone yelling are a few examples. • Cost is very high. The implant along with the surgery and post-operative care can easily cost over $50,000. While some insurance plans may cover this cost, there are many individuals who cannot afford to get a cochlear implant even if they want one. • The difference between natural sounds and the way sounds are transmitted through a cochlear implant is also considered to be a disadvantage of this technology. Children typically have an easier time relearning how certain sounds associate to different people and situations, but adults sometimes have difficulty interpreting the unfamiliar sounds they hear through a cochlear implant. • As with any surgery, there is also a risk associated with the procedure itself. There is still a chance that damage to the auditory nerve or facial nerve could occur.

20. FM Systems: Personal Frequency Modulation (FM) Systems Help You Hear More Clearly • Hearing aids perform best in quiet environments or when you are sitting close to the person you want to hear. Using an FM system (with or without hearing aids) makes it easier to hear in noisy environments or when you are sitting a distance away from the person you want to hear. They are like miniature radio stations. They operate on special frequencies assigned by the FCC. They usually consist of a transmitter microphone used by the speaker and a receiver and headset used by the listener. • FM systems are used in a variety of situations such as listening to a tour guide, a classroom lecturer, a sales trainer, a church leader, or to sounds at sporting event or theatre. In most situations, the microphone and transmitter is built into the overall sound system and can be used with hearing aids, cochlear implants, or without hearing aids. They have accessories including neckloops that are made for people with severe to profound hearing loss.

21. FM Systems Advantages Disadvantages • FM systems are portable, less restrictive, easy to install and generally work well with direct auditory inputs (DAI) of hearing aids. Additionally, they can be run in adjacent rooms if they are transmitting on different frequencies. They have transmission ranges of up to 1,000 feet. • FM receivers are required to hear the transmission, even if the hearing aid has a "T" coil. Both acoustic output and teleloop options must be available at public facilities. Also, systems must operate on different channels (frequencies) when used simultaneously in nearby rooms. It is possible that outside listeners tuning into the same frequency can overhear the transmissions.

22. Infrared systems • Infrared systems transmit sound using infrared light waves. Although they are often used in the home with TV sets, they can also be used in large settings like theaters and sporting events.

23. Infrared Systems Advantages Disadvantages • Adjacent rooms can operate the IR systems simultaneously without interference which ensures confidentiality (cannot be tapped outside the room). • Personal systems are easy to install and there is no size limitation as emitter panels may be connected for longer distances (room size restrictions are minimal). • As with FM systems infrared systems receivers are required to hear the transmission, even if the hearing aid has a "T" coil. • They are not practical for outdoor applications because of sunlight interference. There are some installation challenges required for large area systems. Electronic ballast for fluorescent lights can interfere with 95 kHz systems. • There can be some "shadowing" or loss of signal occur in areas of room that do not have direct line of sight with the IR transmitter.

24. Assistive Listening Devices “ALDs” There are a variety of additional ALDs, some of which are listed below: TTYs and TDDs Amplified Telephones Notification Devices Paging Systems Alarm Clocks & Watches Timers Public Payphone TTYs Fire Alarms & Emergency Calls 911 Response Center Equipment

25. Who pays for ALDs? • The ADA specifies that ALD receivers be provided at no cost, unless the facility has proven an undue hardship for providing access to an ALD. Some employers will cover these systems as part of a workplace accommodation. Schools can be required to provide these systems if it is a part of a student's IEP. Personal systems may also be covered under private insurance benefits. Vocational rehabilitation (VR), the Veterans Administration (VA), and State Medicaid may also be options for funding.

26. Health Insurance Coverage for Hearing Aids • There are various options available to assist in funding for hearing aids and associated services: • Some private health care plans cover the costs of audiologic tests, a hearing aid evaluation, and even partial or full coverage of a hearing aid. • At this time, Medicare does not cover hearing aids. Medicaid often does cover hearing aids and related services for adults, and must cover them for children. • Early intervention through the Individuals with Disabilities Education Act (IDEA) also provides coverage for certain costs associated with audiology services. Early intervention services are provided through either your local school system or your local health department, depending on the state in which you live. Check with your early intervention service coordinator to determine whether your child qualifies for early intervention and what is covered. • Hearing aid loaner banks may provide hearing aids on a temporary basis to children in need. Please call your early intervention program to see if this service is available in your area. • The proposed Hearing Aid Tax Credit law would provide a tax credit of up to $500 per hearing aid, once every 5 years, for parents purchasing a hearing aid for a dependent child. This credit could also be used by persons over 55 years of age for the purchase of a hearing aid. 

27. Bibliography/Webliography The American Speech-Language-Hearing Association , “ASHA” Hearing Loss. Retrieved September 15, 2013, from http://www.asha.org/public/hearing/Hearing-Loss/ Cynthia Compton-Conley, Ph.D. - Gallaudet University, Washington, DC, Assistive Listening Devices Detail. Retrieved September 19, 2013, from http://www.betterhearing.org/pdfs/assistive_device_detail.pdf Health Central , Sensorineural Hearing Loss. Retrieved September 15, 2013, from http://www.healthcentral.com/encyclopedia/408/532.html Disabled World Toward Tomorrow, Retrieved September 18, 2013, from http://www.disabled-world.com/assistivedevices/hearing/ TheHearingImpaired.com, Products for the Deaf and Hearing Impaired. Retrieved September 18, 2013, from http://www.ttyweb.com/new/catalog.aspx?category=Assistive Listening&categoryname=Amplification and Assistive Listening Devices ASU Speech and Hearing Center Assistive Listening Devices. Retrieved September 18, 2013, from http://www.astate.edu/dotAsset/08b7234b-302a-402f-af8b-cf7932dc3efc.pdf What is Normal Hearing? Retrieved September 16, 2013, from http://www.blameysaunders.com.au/sound-advice/what-is-normal-hearing Hearing Loss Association of American, Types, Causes and Treatment of Hearing Loss. Retrieved September 15, 2013 from http://www.hearingloss.org/content/types-causes-and-treatment AARP: Hearing Aid Styles: Pros and Cons. Retrieved September 19, 2013, from http://www.aarp.org/health/conditions-treatments/info-05-2011/hearing-aid-styles.htmls-causes-and- Treatment Phonak, What are the Degrees of Hearing Loss. Retrieved September 19, 2013, from http://www.phonak.com/com/b2c/en/hearing/understanding_hearingloss/types_of_hearing_loss.html