20Q: Hearing Aid and Cochlear Implant Wear Time in Children - Eyes Open, Ears On!

From the Desk of Gus Mueller

I think we all can agree, that when providing amplification - hearing aids or cochlear implants - audibility is a good thing. And, that this is even more important when working with infants, toddlers and young children. Fortunately, we have well-designed prescriptive fitting approaches to guide us - as a reminder, the “S” of DSL is for “sensation.” Also, to assist in delivering appropriate audibility, probe-mic systems now calculate the aided speech intelligibility index (SII) for us for different speech input levels. Additionally, the folks at Western University have developed handy charts that can be used to determine if the aided audibility is appropriate relative to the child’s degree of hearing loss (you can find these charts here).

Unfortunately, however, as we are patting ourselves on the back while watching our young patients leave our clinic with good audibility, there is another factor lurking in the background that is even more important - how frequently will the child use the amplification we have provided? This, of course, can and will have a significant impact on speech and language development. What can we do to help? 

There are many factors that influence the wear-time of an amplification device, and some are difficult to control. In a perfect world, we want the child to be using the amplification instrument(s) most all of their waking hours. This notion has prompted one hearing center to develop the mantra “Eyes Open Ears On,”  and we just happen to have the head of this center with us this month to tell us all about it.

Jace Wolfe, PhD, is the Chief of Audiology and Research at the Hearts for Hearing Foundation in Oklahoma City, and has faculty appointments at the University of Oklahoma Health Sciences Center and Salus University. He provides clinical services for children and adults with hearing loss and is actively engaged in research in several areas pertaining to hearing aids, cochlear implants, hybrid cochlear implants, and personal remote microphone systems.

You probably know Dr. Wolfe from his presentations and many publications, including his impressive list of textbooks: “Cochlear Implants: Audiologic Management and Considerations for Implantable Hearing Devices,”  “Pediatric Audiology: Diagnosis, Technology, and Management,” “Pediatric Audiology Casebook” and “Programming Cochlear Implants.”

Jace, of course, also is known for his popular column in The Hearing Journal, “The Tot Ten” (which gets high ratings for the title alone!). Once you finish reading his excellent 20Q posted here, you might want to check out his latest Tot Ten column  where he discusses the lessons learned since Hearts for Hearing was founded 20 years ago.

 

Gus Mueller, PhD
Contributing Editor

Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q

20Q: Hearing Aid and Cochlear Implant Wear Time in Children - Eyes Open, Ears On!

Learning Outcomes 

After reading this article, professionals will be able to:

• Describe the challenges children face with hearing technology wear time and its effect on outcomes.
• Discuss factors that influence wear time.
• List clinical tips for optimizing hearing-technology wear time in children with hearing loss.

Jace Wolfe

1. Eyes Open, Ears On?

Eyes Open, Ears On! is the rallying cry we have developed at our Hearts for Hearing clinics about a decade ago to stress the importance of hearing technology (e.g., cochlear implants [CI], hearing aids, etc.) use during all waking hours for infants and children with hearing loss. The mantra has been reinforced by a couple of clinical experiences that really highlighted the relationship between hearing technology wear time and the outcomes of children with hearing loss. The first eye-opener occurred during one of our periodical clinical team meetings (in 2013, I think), in which our audiologists, listening and spoken language specialists (LSLS), and physicians discuss patients who have unique needs or who are failing to make the progress we would expect. Upon review of the clinical records of four children with significant spoken language delays, we noticed that each had hearing aid data logging records that indicated less than three hours of hearing aid use a day. Although there may have been other factors responsible for those children’s delays, we acknowledged the fact that the delays were unlikely to be mitigated without a considerable increase in daily hearing aid wear time. Since that time, we have kept a close eye on the data logging records of the children we serve.

2. That’s a pretty clever slogan to stress the importance of hearing aid wear time! What was the other experience that emphasized the importance of Eyes Open, Ears On?

The second reminder came almost two years ago. Several of the children we serve had recently received a new CI that contained an MRI-compatible magnet. The data log of a CI sound processor lists the average hours a day the processor is powered on and also “coil-on” time, which represents the average hours a day the sound processor is delivering stimulation to the CI (i.e., the amount of time the child is hearing sound with the CI each day). Conversely, the data logging record also indicates “coil-off” time, which refers to the average amount of time a day the processor is powered on but not delivering stimulation to the CI. Of the 20 children we were serving with the new cochlear implant, 19 had coil-off time exceeding one hour a day, and 15 had coil-off time exceeding 20% of the total time their CI processor was powered on. Moreover, the average coil-on time for children under three years of age was 5.5 hours. If the typical 18-month-old is awake about 12 hours per day, half the waking hours of these children were spent without sound.

We initially suspected the new magnet was causing an intermittent connection between the sound processor and the CI. However, a closer inspection of our data indicated the limited coil-on time was largely exclusive to children birth to three years of age. Once the children became older, their coil-on time improved. A failure to achieve Eyes Open, Ears On use of the CI was not due to a hardware fault. It was simply due to the challenge of keeping a CI on the head of an infant or toddler throughout their waking hours. 

3. That’s interesting, but is hearing technology wear time a common problem for children with hearing aids?

Yes, it definitely is, and in fact, there is actually quite a bit of published research on this challenge. Christine Jones and her Phonak Colleagues were among the first to report on this topic (Jones & Launer, 2010; Jones & Feilner, 2013). Jones and Feilner (2013) reviewed the records of 6,696 Phonak hearing aid users and found an average daily wear time of about 4.5 hours for infants and toddlers. Elizabeth Walker and colleagues (2015) from the multi-center Outcomes of Children with Hearing Loss (OCHL) study also reported data logging results indicating five hours or less of daily hearing aid use for children from birth to two years of age. Similarly, Karen Munoz and colleagues (2014) found that 56% of children under five years of age used their hearing aids 6 hours per day or less.

Interestingly, Walker et al. (2015) and Munoz et al. (2014) each reported that the caregivers of infants and toddlers generally reported about two to three more hours of hearing aid use per day than what was indicated by hearing aid data logging records. Walker and colleagues (2015) noted that there are many situations in the lives of infants and toddlers in which hearing aids might be removed. Examples include naps, bath time, riding in a vehicle, temper tantrums, etc. The frequent need to remove hearing aids in these types of situations may make it difficult to estimate the actual time that hearing aids are worn each day. 

4. Is wear time also a common challenge for infants and young children with cochlear implants?

Unfortunately, it is. Lisa Park and colleagues (2019) took a novel approach at quantifying CI wear time in young children. They reviewed the literature dealing with sleep patterns of infants and young children. As you might expect, the literature showed children sleep much more as infants and toddlers than they do in elementary school and beyond. For instance, infants under 12 months are only awake about 11 hours per day; toddlers are awake about 12 hours per day; elementary-age children are awake about 14 to 15 hours per day. Given the differences in waking hours between younger and older children, Park et al. acknowledged that the number of hours constituting “all-day use” varies as a function of age. As such, they established “full-time use” (FTU) of the CI as that which comprises 80% of the child’s waking hours. For an infant under 12 months, FTU would be achieved with about 9 hours of CI use, whereas an elementary-age child would need about 11 to 12 hours of wear time to achieve FTU.

Park et al. looked at data logging in 40 children who received their CIs around 12 to 24 months of age. They reported that 57.5% took more than one year to reach FTU of their CI, and 30% took more than two years. Only 53% of the children had reached FTU by their third birthday. Additionally, Kathryn Wiseman and Andrea Warner-Czyz (2018) studied CI wear time in 71 children and found the majority of infants birth to three years of age used their CIs less than six hours per day.

5. Wear time sure does seem to be an issue! So, I’m guessing there’s a relationship between wear time and outcomes?

You are most certainly correct. Bruce Tomblin, Elizabeth Walker, and their OCHL colleagues have shown the impact of hearing aid wear time on the language outcomes of children with mild to severe hearing loss (Tomblin et al., 2015). Specifically, they examined the effect of daily hearing aid use (measured in hours) from two to six years of age on the language outcomes across that same time period for 290 children. They found that children who wore their hearing aids for less than 10 hours a day showed no improvement in their language scores from two to six years old, whereas children who wore their hearing aids for more than 10 hours a day showed significant improvement in their language scores from two to six years of age. At six years of age, the average language scores of children using their hearing aids more than 12 hours a day were almost ½ standard deviation higher than the average language scores of their peers who used their hearing aids for less than 10 hours a day. Additionally, the average language scores of the children who used their hearing aids approximately 12 hours a day approached the typical language score achieved by normal-hearing children on the standardized tests used in the study. In other words, age-appropriate listening and spoken language outcomes are quite possible when hearing aids are worn during all (or nearly all) waking hours. The findings of the OCHL study are clear. Eyes Open, Ears On use of hearing aids leads to better outcomes.

6. I would guess that the research regarding wear time and outcomes for children with cochlear implants would tell the same story?

The cochlear implant literature does not contain a study as large as the OCHL project, but yes, you’re right, there are certainly studies that demonstrate the importance of wear time on the outcomes of children with CIs. Lisa Park and colleagues (2019) looked at the relationship between CI wear time and the language abilities of 40 children who received their CIs in infancy. They reported that all children who achieved FTU of their CIs by 24 months of age had language scores that were within normal limits when measured at three years of age. Unfortunately, only 21 of the 40 children achieved FTU of 24 months of age. On average, it took 17 months for the children to achieve FTU of their CIs. Of note, the age at which FTU was achieved was a better predictor of the children’s language scores at three years of age than age at implantation. In short, it’s not just enough to receive a CI at an early age; we also have to ensure children are using their CIs during all waking hours from the start!

It’s also worth mentioning that Vijayalakshmi Easwar and colleagues (2018) examined the relationship between CI wear time and the speech recognition of 65 children with CIs. They found aided speech recognition to be positively associated with CI wear time. It should be noted, however, that Easwar’s findings do not necessarily demonstrate a causal effect between CI wear time and speech recognition. It may be the case that children with better speech recognition are more likely to use their CIs. Either way, their study did suggest that greater CI wear time is related to better speech recognition. 

7. Do we know why it’s so hard to make Eyes Open, Ears On a reality?

There are some excellent research studies that have explored the factors that influence hearing technology wear time. As you would probably expect, the age of the child is a big factor that influences hearing aid wear time. The OCHL team found hearing aid wear time to generally be pretty limited (i.e., less than four hours a day in many cases) for children up to about two years of age (Walker et al., 2015). Wear time typically increased to around eight hours a day for children between two to four years of age, and usually exceeded 10 hours a day by the time the children reached school age (i.e., 5 years old and up). Munoz and colleagues (2014) have examined the effect of age on wear time and found almost exactly the same trends as the OCHL group. 

As I mentioned before, infants take frequent naps and have other disruptions in daily routines that may interfere with hearing aid use. However, as I also mentioned, the typical infant is awake around 10 to 12 hours a day during the first two years of life. With that in mind, it sure does seem like we should strive for more than fours hours of hearing aid use a day.

The infancy and toddler period also brings many challenges to our quest of achieving Eyes Open, Ears On use of hearing technology. The small ears of infants simply do not provide a lot of real estate on which hearing aids and CI processors can reside. Moreover, infants begin exploring their own bodies around three to six months of age, a time at which they may begin to pull out their own hearing aids. Audiologists must equip parents with strategies, resources, and products to help facilitate retention of hearing technology on the little ears of little ones.

8. All good points! Are there other reasons that influence hearing technology wear time?

There are several additional factors. Research has shown that wear time is greater for children with greater degrees of hearing loss (Munoz et al., 2014, Walker et al., 2015). Presumably, FTU of hearing aids is considered more essential for children with moderate to severe hearing loss than it is for children with milder degrees of hearing loss.

Also, greater hearing aid wear time has been associated with higher maternal education levels (Walker et al., 2015). Similarly, Kathryn Wiseman and Andrea Warner-Czyz (2018) reported that all children of mothers with professional graduate degrees achieved 10 hours or more of CI use a day, whereas the majority of children whose mothers had a high school education or less had less than 10 hours of CI use a day. Wiseman and Warner-Czyz also found significantly higher CI wear times for children whose healthcare was covered by a private commercial insurance carrier relative to children whose healthcare was covered by Medicaid, a finding that suggests a positive association between wear time and socioeconomic status. Furthermore, they found lower CI wear times for children who had additional disabilities other than hearing loss.

In another study with 81 children, Tjeerd de Jong and colleagues (2021) found children with higher non-verbal IQ scores tended to have greater CI wear time. They also found greater CI wear time to be associated with the exclusive use of listening and spoken language relative to the use of sign language in isolation or in conjunction with spoken language. In related research, Walker and colleagues (2013) found hearing aid use was less likely in situations in which infants and toddlers could not be monitored closely (e.g., the car, public places like parks and grocery stores, daycares, etc.). Finally, these same researchers also found “child state” to be a big factor impacting hearing aid use. Specifically, temper tantrums and meltdowns often make it difficult to keep hearing technology on during all waking hours, and those outbursts seem to peak around two to three years of age and decline at four to five years of age.

9. I’ve always thought parents are the real experts when it comes to their own children. Has anyone asked them why Eyes Open, Ears On is so challenging?

Karen Munoz and colleagues have done a fantastic job of helping us understand why parents feel it’s so difficult to make Eyes Open, Ears On a reality. Many of the reasons given were quite practical and somewhat unsurprising (Munoz et al., 2014). Parents reported difficulties with hearing aid retention on small ears and concerned that the hearing aids would fall from their children’s ears and be lost or damaged or be a choking hazard. They also reported that they received insufficient support in identifying retention solutions, such as pilot caps, double-sided tape, hearing huggies, snug-fits, proper earmold insertion, behavior modification, etc.

Parents also reported acoustic feedback to be a problem that interfered with full-time use of hearing aids, particularly in the infant period when ears grow quickly. They also reported that frequent middle ear infection sometimes was a barrier to FTU of hearing aids. Additionally, they reported they were often uninformed about a recommended hearing aid wear time and were unaware they should strive for use of hearing aids during all waking hours. Moreover, parents often stated they were unaware of the association between FTU of hearing technology and listening and spoken language outcomes. Many parents also noted they were uncertain of whether hearing aids were really necessary for their children, a feeling that may be more likely when a child has a milder degree of hearing loss. Similarly, some parents reported that they were unaware of the potential impact hearing aids could have on their children’s development. For instance, parents of children with profound hearing loss may have believed hearing aids would be of limited benefit, whereas the parents of children with mild hearing loss may have believed their children could hear well enough without hearing aids. 

10. Did parents say anything else pediatric audiologists should know about?

Yes! In another one of Karen Munoz’s studies (2015), 80 families of young children with hearing loss were surveyed about factors that impact hearing technology wear time. The highlights of the survey were:

• 64% reported certain skills were not taught by their audiologist such as troubleshooting, listening checks, battery testing, etc. The lack of these skills may have led to insufficient confidence in their ability to take care of their children’s hearing technology. 
• 41% of respondents were not taught how to complete a Ling 6 sound test.
• 56% not informed of how to instruct others (e.g., family members, daycare workers, etc.) how to insert HAs.
• 67% reported they were not taught how to emphasize the importance of FTU of hearing aids to others (e.g., daycare, extended family, etc.).
• 30% did not remember receiving information regarding a recommended hearing aid wear schedule (e.g., hearing aids should be worn during all waking hours)
• Although 96% reported hearing aid information was given via verbal explanation, only 57% and 9% were provided information via written and video form, respectively. Adults have numerous learning styles, so information should ideally be provided via multiple mediums. Also, today’s younger adults have learned through YouTube their entire lives, so it makes sense that many might prefer to learn about hearing aids through the video medium. 
• Although 40% reported being overwhelmed by HA information given at initial appointment, 84% wanted comprehensive HA information at initial appointment. This finding suggests we should provide comprehensive information at the fitting appointment but revisit that information multiple times across future appointments.
• Parents reported they wanted more information regarding what their child can hear with and without hearing aids.
• Parents also wanted information regarding peer support and opportunities to connect with other parents of children with hearing loss.
• Only 36% reported that their audiologist helps them manage their emotions related to their child’s hearing.
• 73% were concerned about how they would manage child’s feelings about wearing hearing aids.
• 53% reported confusion regarding optimal strategies to keep hearing aids on their child.

11. That’s a lot to process! Are there any other factors that influence hearing technology wear times for children?

Yes, and some of these factors are pretty heavy. Munoz and colleagues (2015) reported that 22% of the respondents in their study were dealing with depression. Of those, 40% of respondents reported depression made it difficult to manage their emotions, and 46% of mothers who were depressed reported their depression made it difficult to manage their responsibilities at work and home. Previous research has shown higher levels of depression in parents of children with disabilities. Research has also found that depression can negatively impact a caregiver’s ability to take care of a child’s special needs. Post-partum depression is another factor that can adversely affect the support mothers provide for their infants with hearing loss. Indeed, family-centered habilitation should target parental mental/emotional health.

Other real-life complications can serve as barriers to FTU of hearing technology. Serious hardships such as food insecurity or lack of access to safe shelter/housing, access to basic utilities, etc. are likely to push FTU of hearing technology to the back burner. Also, threats to safety (e.g., domestic violence) and substance abuse are likely to jeopardize FTU of hearing technology.

12. What can audiologists do to help families work toward FTU of hearing technology?

At our Hearts for Hearing clinics, we have developed an Eyes Open, Ears On program that is comprised of five different components including:

1. Setting Goals
2. Education
3. Retention Strategies
4. Coaching
5. Assessment and Adjustment

13. Sounds interesting! Tell me more.

Let’s start with goal setting. We begin by discussing an ideal hearing technology wear schedule with the family. We have elected to adopt an approach similar to that described by Park and colleagues (2019). Based on a meta-analysis study on the literature involving children’s sleep (Galland et al., 2012), we have defined FTU as hearing technology use during 80% of expected waking hours, which results in the following goals (in average hours of hearing technology use a day) as a function of age:

Next, we have become very intentional in our quest to frequently review data logging records and do everything we can to support families to help them achieve our Eyes Open, Ears On hearing technology use goal. We unofficially subscribe to the mantra, “What gets measured, gets done!” In other words, we are much likely to achieve our goals when we measure our progress throughout our pursuit. At Hearts for Hearing, audiologists and LSLSs partner to serve children with hearing loss at the same facility. The LSLSs typically see patients much more frequently than the audiologists (often on a weekly or biweekly basis as compared to monthly or less frequently for audiologists). Consequently, the LSLSs connect their patients’ hearing aids and CI sound processors to the programming computer at each appointment, review the data logging record, save it in the patient’s clinical chart, and discuss the results with the family. We do our best to make this a positive endeavor. The LSLSs and audiologists discuss FTU of hearing technology as a global challenge that takes “all-hands-on-deck” to conquer. We ensure the family that we are on their team in the journey to help their children reach their full potential and optimize their development, and we promise we are committed to supporting them to reaching that goal. Of note, Karen Munoz and colleagues (2014) have shared some excellent advice regarding a positive approach at which data logging can be explained to and shared with families, including a sample script to guide the conversation. It’s worth a read!

14. What about the education component?

Research has suggested families may struggle to achieve FTU because they feel ill-prepared to meet the hearing-related needs of their children. Education is key to empowering families so they feel confident in their abilities to fully meet their children’s needs. To meet the concern that many families are uncertain of their child’s hearing needs and abilities with and without hearing technology, we begin by providing a basic review of the auditory system with a discussion of the areas that are affected and the cause of the child’s hearing loss.

Then, we discuss the child’s audiogram and attempt to provide a description of what the child can hear with and without hearing technology. The Familiar Sounds Audiogram is a good tool to help explain what the child can hear with and without hearing technology. For hearing aid wearers, we also discuss the unaided and aided speech intelligibility index (SII), which provides the family with a tangible, quantifiable representation of the audibility of speech with and without hearing aids. We have found it is also helpful to show the results of real-ear probe-microphone testing, which offers a clear and simple illustration of the audibility of speech without and without amplification. It is important to point out the impact of amplification on the audibility, not only of average conversational level speech but soft speech as well. The audiologist should also note that soft speech is more representative of speech that originates from a distance, which occurs commonly in the real world and is an important contributor of language development for infants and young children.

Of course, we provide a clear description of the care, use, and maintenance of hearing technology including troubleshooting, safety, warranty terms, etc. Additionally, we provide an elementary overview of the relationship between listening and spoken language outcomes and hearing technology use during the first few years of life (e.g., OCHL findings, Lisa Park study, etc.). Hearing healthcare professionals are intimately familiar with the critical period of language development and the need to provide enriching and abundant stimulation during the first two to three years of life. Laypersons are less likely to be aware of these neurodevelopmental realities. It is our job to ensure that families understand the urgent and lifelong importance of optimal early intervention for children with hearing loss. Moreover, we discuss the relationship between consistent access to intelligible speech during the formative years of language development and the development of the child’s brain. As audiologist Carol Flexer has said, childhood hearing loss is all about the brain! We have found that Eyes Open, Ears On use of hearing technology is more likely when families understand this concept. 

15. That sure seems like a lot for families to process. Any tips on how we can best deliver all this information?

It is a lot, and we must be savvy in how we share information with parents. First, we must remember that parents want comprehensive information at the fitting of new hearing technology (and when new information is provided after diagnostic appointments), but we also know families feel overwhelmed with all the information they receive, especially at initial appointments. We must also remember that patients often forget a fairly significant amount of the information they receive from healthcare providers (Laws et al., 2018). For these reasons, information should be revisited across multiple appointments. Also, audiologists, LSLSs, and other members of the family’s hearing healthcare team should coordinate their efforts to share information with families. Attempts should be made to ensure the same information is shared by all parties involved to avoid conflicting knowledge, advice, and recommendations. Ideally, the team of professionals should establish a formal plan that guides the type of information that is shared and the schedule for how it’s shared.

We must also provide information across multiple mediums. Written information should be provided to families, especially at initial appointments. Examples include a copy of the familiar sounds audiogram with thresholds (or minimal response levels) included, documents describing proper operation and care of hearing technology, illustrations of probe-microphone results including the unaided speech spectrum, brief summaries of auditory anatomy and physiology, and research describing the relationship between wear time and outcomes. Of note, the OCHL group has created excellent written materials that are available at no charge on their website (see www.ochlstudy.org).

Videos and live demonstrations are also very powerful. Hearing technology manufacturers have created hearing technology care and troubleshooting videos that are available on YouTube. Researchers and clinicians have also created excellent videos that discuss auditory anatomy and physiology and the importance of FTU of hearing technology. For example, the Western University National Centre for Audiology (in collaboration with the Ontario Infant Hearing Program) has developed excellent videos promoting the importance of FTU of hearing technology (see www.YouTube.com/HearOnVideos). Further, some families may benefit from seeing videos of other older children with similar hearing loss as their child, so they can realize that excellent outcomes are possible with FTU of properly selected and fitted technology.

Finally, hearing is believing. Providing an audible demonstration of a simulation of a child’s hearing loss (ideally both unaided and aided) might quite possibly be the most compelling and convincing strategy to demonstrate the importance of Eyes Open, Ears On hearing technology use.

16. How about retention? What are some tricks to keep hearing aids on little ears?

We take a two-pronged approach with hearing technology retention strategies. The first aspect is simply helping families to identify physical tools that assist with retention. Of course, hearing aids should be equipped with a pediatric earhook, and infants’ earmolds should contain a helix lock. Families should be provided with examples of retention aids including double-sided tape, hearing huggies and snug-fit accessories, off-the-ear wearing options for cochlear implants, pilot caps for children who are inclined to pull their hearing technology off their ears, retention cords, etc. At our Center, we keep all these things in stock so they’re always readily available for families. We also attempt to provide each of these items at a one-time no cost, so families are not burdened with the costs associated with experimenting with different retention items that might work for their child.

The second aspect is assisting the family with behavioral modification. We remind them that this is a common problem experienced by almost every family of a child with hearing loss, so the family realizes they are not failing at a task with which others typically experience no problems. We also remind them that this period will pass (there is light at the end of the tunnel), and in the future, they will be grateful for all their current efforts to strive for FTU of hearing technology. It’s like an investment. All the work invested in hearing technology use will pay big dividends down the road.

We also attempt to equip the families with skills to modify and manage their children’s behavior. Managing meltdowns and temper tantrums can be very challenging for even the most experienced of families. All parents can benefit from the tried-and-true practices that have been shown to be helpful in managing a toddler’s behavior. Hearts for Hearing is a proponent of the Love and Logic parenting approach (Cline & Fay, 2000) and the Conscious Discipline approach (Bailey, 1996), too. We also employ a patient care therapist who is endorsed as an infant mental health specialist and rostered in child-parent psychotherapy. Many families have benefitted from the professional support they have received regarding the management of their relationship with their children and their children’s behavior.  

17. So, what can you tell me about coaching?

John Wooden, who is quite possibly the best college basketball coach of all time, said, “A good coach can change a game. A great coach can change a life.” At Hearts for Hearing, we believe the lives of children with hearing loss are positively changed when families are supported by a great coach. The Eyes Open, Ears On program at Hearts for Hearing is largely spearheaded by the Listening and Spoken Language team under the direction of Darcy Stowe. The LSLSs work in tandem with audiologists to set and pursue goals, educate, and support the families we serve. The LSLSs have spent considerable time studying adult learning styles so they can engage, motivate, and inform the families we serve in a way that is tailored to the needs and learning styles of each family.

Pediatric hearing healthcare professionals should consider embracing the fundamentals of an emerging discipline called Health Coaching, which utilizes evidence-based clinical interventions and strategies to engage patients in behavioral change designed to improve health. Health Coaching includes numerous components such as behavior change theory, motivational interviewing, active listening, cognizance of health literacy, ethics of inaction, energetic intentions, etc. Many universities provide degree programs or certificates in Health Coaching (see the Vanderbilt Hearing Coaching Program for an example). Another method coaches and clinicians may use to facilitate behavioral change is the capability, opportunity, motivation, behavior model (COM-B) of behavioral change process, which has been shown to improve hearing technology use in adults with hearing loss (Barker et al., 2016).

18. Are there tests we can use to evaluate a caregiver’s comfort level with hearing technology?

Sophie Ambrose and colleagues (2019) have done some great work in this area. Ambrose and Margo Appenzeller (2019) designed the Early Device Use Questionnaire, which is an assessment tool that queries barriers to FTU of hearing aids. It’s an excellent tool to identify areas in which clinicians may be able to provide support to families to increase use of hearing technology. Ambrose, Appenzeller, and Jean DesJardin (2019) also developed the Scale of Parental Involvement and Self-Efficacy- Revised (SPISE-R), which evaluates parents’ beliefs, knowledge, confidence, and actions relevant to supporting their child’s hearing device use and language development. If parents are not confident in their ability to care for their children’s hearing technology and listening and spoken language development, then they are less likely to achieve Eyes Open, Ears On use of hearing technology. The SPISE-R can identify uneasiness and apprehension in parents’ own self-perceived ability to support their children, and professionals can then provide education and support to bolster parents’ confidence and ability to provide the care their children need.

Munoz and colleagues (2015) developed the Parent Hearing Aid Management Inventory (PHAMI), to explore parents’ self-perceived feelings regarding the information they have received and their experiences in four areas including 1) parent confidence in performing skills related to hearing care and operation, 2) expectations, 3) communication with the audiologist, and 4) hearing aid use challenges. The PHAMI is another excellent tool to identify areas in which families may need support to achieve FTU of hearing technology. Similarly, the Practical Hearing Aid Skills Test, developed by Karen Doherty and Jamie Desjardins (2012), is another great tool to evaluate families’ comfort level in the care, use, maintenance, and troubleshooting of their children’s hearing technology.

19. Those sound like great tools. Any other types of measures that may be helpful?

As we talked about earlier, Eyes Open, Ears On use of hearing technology is unlikely to happen if families are struggling with serious life issues such as depression, food insecurity, transportation, significant financial woes, domestic violence, etc. Questionnaires, such as the Depression, Anxiety, Stress Scale (DASS; Akin & Cetin, 2007), the Centers for Epidemiologic Studies Depression (CES-D) scale (Radlof, 1977), and the Parenting Stress Index Short Form (PSI-SF) scale (Abidin, 2012) may be used to identify parental depression or stress that may negatively impact the support that can be provided for children with hearing loss. Many clinicians may wish to partner with a psychologist, counselor, or social worker who can help administer these types of assessments. When serious depression or other psycho-emotional conditions are suspected, hearing healthcare clinicians should refer the family to professionals who specialize in the assessment and treatment of these conditions.

There are also questionnaires that exist to assess and identify basic life needs, but many of these are not adapted for clinical use. For example, the Urban Institute’s Well-being and Basic Needs Survey identifies a family’s basic life needs (e.g., food insecurity, safety, etc.). When basic life needs are not met, they may serve as barriers to the care children with hearing loss need pertaining to their listening and spoken language development. Once again, hearing healthcare clinicians may choose to partner with a social worker or counselor who is well-versed in assessing families’ basic needs and familiar with resources and interventions that may be offered to help families overcome challenging issues they may face. At a minimum, we should be aware of the basic life needs of the families we serve and be prepared to partner with other professionals to assist families in obtaining the resources needed to support their children.

At this time, it is worthwhile to mention some sage advice delivered by Ryan McCreery, who was one of the researchers in the OCHL study. In noting the fact that some families have extenuating circumstances that make FTU a significant challenge, McCreery (2021) has noted that he sometimes suggests families focus on quality time rather than quantity. In other words, he recommends that families start out by trying to identify times throughout the day in which the child could use the hearing technology and be engaged in a stimulating and enriching activity replete with intelligible speech. Then, those experiences are celebrated and used as building blocks to work toward FTU of hearing technology.  

One more quick thought… For children whose families are struggling with serious life issues (e.g., depression, substance abuse, neglect, etc.) that prevent hearing technology use during all or most of the day, the child may achieve greater wear time if she/he is enrolled in a daycare setting or an early childhood education center (e.g., Early Head Start). In cases in which hearing technology wear time is dismal, the pediatric hearing healthcare provider may want to assist the family in identifying a local childcare program that is willing to support hearing technology use throughout the day along with the provision of a language-rich listening environment.

20. Any other take-home messages?

Yes! The five components of the Eyes Open, Ears On program are interrelated. For example, the assessment of one family may show hearing aid retention to be the most pressing issue, whereas the assessment of another may reveal serious depression or homelessness. Obviously, the support provided by the hearing healthcare team is very different for those two examples.

Additionally, the help a particular family needs is likely to vary across time. At first, the family may be overwhelmed by the complexity of their child’s hearing technology and frustrated with their lack of understanding of their child’s hearing needs. Several months later, the same family may be experts on those topics but may be dealing with depression, anxiety, or concern about the social-emotional impact the hearing loss will have on their child. Once again, the supports offered to the family will be different depending upon the immediate needs. Jan Moss, a mother of two adults with multiple disabilities and a former professor of mine, was known to say, “Help is not help unless it’s what the family wants, when the family wants it.”

One more thing… Making Eyes, Open Ears On a reality for infants and toddlers with hearing loss is not simple. There is no "Easy Button.” The Eyes Open, Ears On program is evolving at Hearts for Hearing. There is not a one-size-fits-all protocol that will magically lead to FTU of hearing technology for every child we serve. As the research shows, hearing technology wear time in children is a multi-faceted issue. It’s also a very important issue. We have decided that we will simply do the best we can in supporting the needs of our families so they can best support the needs of their children. We will learn from the things that work well and also the things that don’t work so well, and we will adapt our Eyes Open, Ears On services appropriately. We will always approach families in a positive spirit of servitude with the goal of pursuing the best outcomes for each child. We will reassure families we are all in this together as we try to tackle this complicated and common challenge, and we will move forward with a sense of urgency knowing that full-time access to robust, high-quality auditory input is imperative during the first two to three years of a child’s life. Without that, the child will not reach her/his full potential. Eyes Open Ears On! It’s not always easy, but it’s always worth it.

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