As a result of Early Hearing Detection and Intervention (EHDI) programs, infants with hearing loss are being identified within the first few months of life. Once hearing loss has been identified, it is imperative that these infants be provided with access to their auditory environment as soon as possible. The most common means of providing access is via hearing instruments. However, even when hearing instruments meet targets and provide audibility across a range of input levels, situations will occur where additional assistive tech¬nology will be necessary. Hearing assistance technology (HAT) has been defined as "a broad array of devices that may facilitate reception of auditory information, whether by means of amplification, vibrotactile stimulation, or a visual display" (Thibodeau, 2004).
The purpose of this paper is to encourage audiologists to look beyond hearing instruments when working with infants/children with hearing loss and their families. Our goal should be to allow each child to participate fully in his/her environment. As children mature, their needs for HAT will change. It is important that audiologists working with children are monitoring their changing needs so that appropriate technology can be accessed as needed.
As with hearing instruments, selection of other HAT for children begins with goals. These goals may change over time as a child develops, as needs change, and if hear¬ing loss changes. The goals of HAT include:
- Awareness of environmental sounds
- Communication access in a variety of environments
- Access to electronic media
- Fostering independence
- Ensuring safety
One of the first goals of HAT may be increase awareness of auditory events in the environment. At a young age, children with normal hearing can be expected to notice when family members answer the door or telephone after hearing the doorbell or ringing phone (Palmer & Mormer, 1997). Children with hearing loss may not hear those sounds, even while wearing hearing aids, especially if they are not in close proximity to the sound source. Amplifiers can be used to increase signal volume to an audible level. If amplification is not enough, visual signals such as flashing lights can be used. Visual signals have the added benefit of being noticeable even if the child is not wearing his/her hearing aids.
The need for communication access begins in infancy. Although we tend to think of infants as spending most of their time in close proximity to others, there will be times when that is not the case. In the car, for example, it is recommended that infants and children below 13 years of age ride in the back seat. In addition, infant car seats should be rear-facing for infants under 20 pounds or 1 year of age (American Red Cross, 2006). Even with normal hearing, it may be difficult to hear a talker who is in the front seat, facing away from the listener. For individuals with hearing loss, hearing aids may not be able to overcome the interference from car/engine noise when the talker is in the front seat and not facing the child. In these instances, an FM system can be used to allow infants to hear their parent and know that they are close by. As children get older, the FM system can mean the difference between meaningful conversation and limited interaction during the many hours parents spend chauffeuring the child to their many activities.
In addition to the car, HAT may be needed to help children communicate in a variety of listening environments where hearing instruments alone are inadequate because of distance, noise, and reverberation. For example, during family outings to the park or the zoo, an FM system can provide contact between parent and child as distance and noise increase. Children who learn to use FM systems when they are young may be more likely to continue to use those devices as adolescents. Consistent use may be more likely if these systems have been employed in a variety of everyday environments throughout the child's life and not used only in educational settings.
Once children reach school age, HAT is important in all academic environments. Individual and large-area FM, infrared, and induction loop amplification systems have been used in academic settings for many years. Advances in these systems in recent years have resulted in devices that are appropriate for all ages and degrees of hearing loss and across a variety of environments. In addition to being able to hear the teacher and other students, the child should have access to other audiovisual equipment such as computers, televisions, and music. Beyond the classroom, consideration should be given to children's ability to hear during extra-curricular activities such as assemblies, sports and clubs, as well as awareness of school alarms and ability to use a telephone when needed.
Infants and young children may not engage in telephone conversations. However, it is not uncommon for parents to allow them to "talk" (or perhaps I should say to "listen") at fairly young ages. Telephone amplifiers can be used even at young ages to assist in hearing phone conversations, allowing children with hearing loss to participate in normal day-to-day family events. As children get a little older, telephone devices that provide awareness of the telephone's ring as well devices that allow the child to communicate over the phone will become even more important. An amplified ringer for the phone may work well if children are wearing hearing instruments and/or are in close proximity to the phone. However, a visual device may be needed if they are not able to hear the ring due to degree of hearing loss or distance from the phone. Telephone amplifiers, telephones that can be used with hearing-instrument telecoils, and TTYs are all options that can be explored. Relay services allow TTY users to make phone calls to others who do not have TTYs. In addition, with voice-carryover, a hearing-impaired individual can talk directly to a normal-hearing person while receiving responses as text. It is helpful to begin using appropriate telephone devices when children are young to help them develop comfort and independence.
Although digital cell phone compatibility has been a problem for hearing-instrument users in the past, advances in hearing-instrument and cell-phone technology are making these phones more accessible to hearing-impaired consumers (Victorian & Preves, 2004). In addition, telephone accessories using either the hearing-instrument telecoil or Bluetooth technology can improve accessibility (Tchorz, 2005; Yanz, 2005). There also are compact TTYs that can be connected to cell phones. Given that there were over 200 million wireless subscribers in the U.S. at the end of 2005 (CTIA, 2006), accessibility to these devices is an important issue.
When I was young, the family telephone was the lifeline of all teenagers. Today, the family phone has been replaced by the computer. With the advent of Instant Messaging™, chat rooms, and weblogs (or blogs), children have become adept at a new language that many parents are at a loss to understand. The good news is that hearing loss does not limit these communication avenues via computer. Internet text and video relay services can even allow computer users to make telephone calls to voice numbers (Berke, 2006). In addition, video conferencing technology allows individuals to communicate with each other via computer using sign language (Technology Access Program, 2006). Portable devices such as web-enhanced cell phones and wireless handheld devices (e.g., Blackberry) also can provide access to telephone, email, web browsing, and instant messaging throughout a large portion of the U.S. and many other countries.
While cell phone use may not become routine until children are older, providing access to electronic media should begin at an early age. As toddlers begin to attend to television and music it is appropriate to consider whether additional assistive technology will be needed to provide adequate access. Some adults may be willing to use a hardwired connection from their hearing instruments to the television or stereo. However, that option will not be appropriate for active children who jump up to dance to a song or to act out the exploits of their favorite cartoon character. While output from MP3/CD/DVD players, computers, televisions, and other electronic devices can be connected directly to hearing instruments, wireless connections can be achieved for many of these devices using FM systems and/or Bluetooth devices.
Once children are old enough to read, closed captioning gives them access to the same programs and DVDs that their peers are watching. However, waiting for the DVD version of an anticipated movie can be difficult when all of your friends are talking about the latest action hero or teen heartthrob. Movie theaters across the country are beginning to offer open captioning, with the words printed on the screen, or Rear Window Captioning® where captions from the rear of the theater are reflected on transparent acrylic panels that can be attached to theater seats so that they appear superimposed on the movie screen.
Safety is another important goal of HAT. As children get older, they are more likely to stay home alone or to care for other, younger siblings while parents are away. It is important that children with hearing loss be aware when someone is at the door or the phone is ringing, be able to use the phone when needed, and be aware of alarms such as smoke detectors in the home.
Selecting and evaluating assistive technology before the child is in a situation requiring its use is prudent. When I ask families whether their children with hearing loss can hear the smoke detectors at home, the immediate response is often "yes". Further probing however, usually indicates that the children are awake, wearing hearing instruments, and close to the alarm when they hear it. Most parents do not know whether their children would hear the alarm if they were not wearing hearing aids, if they were asleep, or if the alarm was on the other side of a closed door. Reese (2003) reported results from a study revealing that the level of a smoke alarm heard through a closed bedroom door could be as low as 64 dB. First, it is important that families determine whether everyone can hear and respond to smoke alarms. Conducting tests under all conditions (asleep/awake, hearing instruments on/off) is necessary to ensure that the children will be able to respond in an emergency. If the children do not respond to the regular smoke detector, other options should be investigated. These include alarms with louder or lower frequency auditory signals or with vibrating or flashing alarms. Simply placing a smoke detector in a bedroom is not the best option as it would require the smoke/fire to be in the bedroom to activate the alarm. Rather, a remote transmitter can be placed by the detector in the hallway of the sleeping area. If that detector is activated, the sensor will pick up the auditory signal and transmit to a receiver in the bedroom where an auditory, visual or vibrating alarm can alert the hearing-impaired child. There also are interconnecting hard-wired smoke detectors that activate all alarms throughout the house when smoke/fire is detected by any of them. The issues related to smoke detectors also are important for carbon monoxide detectors.
Here in the Midwestern United States, the arrival of spring raises another important safety issue: severe weather. In our area, sirens are placed around the city to alert citizens during tornado warnings. However, those sirens will not be audible to most persons with hearing loss, especially inside buildings. In addition, our local news does not close-caption weather reports. A National Oceanic and Atmospheric Administration (NOAA) Weather Radio receiver provides local weather services as well as any non-weather emergency information. Many of these receivers can activate auditory, visual or vibrating alarms. A text display shows the type and length of the current emergency (NOAA, 2006). The website www.emergencyemail.org provides another means of receiving information pertaining to severe weather and homeland security issues. At this site, users can sign up (via their state and county) to have emergency information sent directly to a computer, wireless device, cell phone, digital pager, and/or fax.
As parents, our ultimate goal for our children is to allow them to become independent adults. Fostering independence helps prepare children for the time when they will be living away from their families. One aspect of independence is the ability to wake each day without someone's help. In talking with parents, I often find that they wake their children each day. When asked how the children will wake up once they leave home, many families are unsure. Wake-up alarms for individuals with hearing loss can be visual (e.g., flashing lights), auditory (loud or of a different frequency), or vibrating. Families should be encouraged to begin investigating the various options while their children are still at home (with parents as a back-up) so that the most effective device can be selected. I recall one young woman who told me she tried a vibrating alarm but it always "jolted" her awake and left her feeling out of sorts as she started the day. A visual alarm woke her more gently and let her start her day more relaxed. Another individual told me that the only device able to wake her was a vibrating motor bolted to the frame of her bed! Audible alarms must consider others who may be "in range" and have normal hearing. A loud alarm will not make a college student popular with roommates who do not have to get up at the same time. As children are old enough to travel away from home, portable wake-up alarms should be considered.
As children enter adolescence, another important aspect of independence is privacy. Most of us can remember reaching the age when we wanted others to knock before entering our bedrooms. Imagine that you have a hearing loss and people are always "barging" into you room because you cannot hear them knock, especially if you are not wearing your hearing instruments. One simple solution is the use of a portable door knock device. These devices typically are attached to the door via Velcro and have a light that flashes when anyone knocks at the door. The device can easily be moved from room to room (e.g., bedroom door, bathroom door). In addition, it can be used if the child travels to visit friends or relatives, when staying in a hotel, or later when working or at college.
Older children and teens will be spending more of their time away from home. As such, portable devices may be needed to provide access in a variety of situations. For the most part, devices that provide hearing assistance in the home have portable counterparts. While parents serve as wonderful advocates for their children, they also can help their children become self-advocates by teaching them how to determine the availability of and to request hearing assistance in public venues (e.g., theaters, museums). When traveling, parents can show children how to request assistive technology from hotels, amusement parks, etc. so that they will be familiar with the procedures when they are older and travel on their own.
Determining Need and Selecting Devices
When choosing assistive technology for a child, individual characteristics should be considered. These include the child's age, degree of hearing loss, hearing instruments and their compatibility with assistive technology, physical limitations, the child's and family's lifestyle, and the family budget. As children mature, their needs will change.
How does the audiologist know when to recommend various types of HAT for infants and young children? The Developmental Index of Audition and Listening (DIAL), developed at the University of Pittsburgh (Palmer and Mormer, 1997) can provide some guidance in this area. The DIAL provides a table of auditory and listening skills that can be expected at specific ages for children with normal-hearing from birth to 22 years of age. For example, at 8-12 months of age normal-hearing children begin to attend to TV. By 2 years of age these children are listening on the telephone and dancing to music. For those children whose hearing loss was identified and amplification fitted within in the first year of life, it may be appropriate to use the same general age ranges when considering appropriate HAT.
Discussion of and recommendations for HAT should be incorporated into regular audiological visits. The Pediatric Hearing Demand, Ability and Need Profile (HDAN) allows the audiologist to assess communication difficulties with and without amplification, current compensations for those difficulties, and recommendations for other solutions (Palmer and Mormer, 1997). The categories include alerting, personal communication, and other activities. Difficulties are addressed with and without hearing instruments across home, work, and travel environments. This type of profile, or one adapted to include additional categories, can be completed at various ages to ensure that appropriate HAT is being recommended for current needs. For example, needs could be expected to change from infancy to preschool age, again when entering elementary, middle, and high school, then again when the young adult is entering college and/or the work force. During interim audiological visits, current strategies and difficulties can be discussed and adapted as needed. Having examples of the technology available for families also can be an important part of the discussion and decision process.
In summary, HAT should be considered as part of the audiological management of children with hearing loss. By discussing communication needs across the lifespan and recommending appropriate assistive technology, audiologists can ensure that communication access is never limited.
Works Cited
American Red Cross (2006). Health and safety tips: Car safety. Retrieved April 25, 2006 from www.redcross.org/services/hss/tips/carsafety.html.
Berke, J. (2006). Internet Relay Services. Retrieved May 1, 2006 from deafness.about.com/cs/relayservices/a/internetrelay.htm.
CTIA (2006). Wireless Quick Facts. Retrieved April 17, 2006 from files.ctia.org/pdf/WirelessQuickFactsApril06.pdf.
NOAA (2006). Emergency warnings save lives. Retrieved April 26, 2006 from www.nws.noaa.gov/nwr/emwarnsavelives.htm.
Palmer, C. & Mormer E. (1997). A systematic program for hearing aid orientation and adjustment. Hearing Review, High Performance Hearing Solutions Supplement, 1, 45-52.
Reese, S. (2003). Sound asleep: Research is needed to determine why children are sleeping through smoke alarms. National Fire Protection Association Journal, July/August. Retrieved April 26, 2006 from www.nfpa.org/categoryList.asp?categoryID=724&URL=Publications/NFPA Journal®/July / August 2003/Features&cookie_test=1
Tchorz, J. (2005). Utilizing Bluetooth for better speech understanding over the cell phone. The Hearing Review, 12(2), 50-51, 80.
Technology Access Program (2006). Video telecommunications. Retrieved May 2, 2006 from tap.gallaudet.edu/video.htm.
Thibodeau, L. (2004). Hearing assistance technology (HAT) can optimize communication. The Hearing Journal, 57(11), 11.
Victorian, T. & Preves, D. (2004). Progress achieved in setting standards for hearing aid/digital cell phone compatibility. The Hearing Journal, 57(9), 25-29.
Yanz, J. (2005). A wearable Bluetooth device for hard-of-hearing people. The Hearing Review, 12(5), 38-41.
Partial List of Resources for Hearing Assistance Technology
Accessibility for Deaf and Hard of Hearing deafness.about.com/od/accessibility/
Better Hearing Institute www.betterhearing.org/hearing_solutions/listeningDevicesDetail.cfm
Captioned Media Program www.cfv.org/
Technology Access Program at Gallaudet University tap.gallaudet.edu/
Audiology Online www.audiologyonline.com/ access the archive and select the topic category "assistive devices" or search for "assistive devices" via the search box to find pertinent articles
Hearing Journal archives www.audiologyonline.com/articles/hj_archives.asp select "assistive devices" from the pull-down menu of topics
Hearing Review archives www.hearingreview.com/ search for "assistive devices" to find pertinent articles
Partial List of Distributors of Hearing Assistance Technology
Harris Communications www.harriscomm.com/
Hitec www.hitec.com/
Ultratec www.ultratec.com/
Weitbrecht Communications www.weitbrecht.com/index.phtml
HARC Mercantile www.harcmercantile.com/
Global Assistive Devices www.globalassistive.peachhost.com/
Potomac Technology www.potomactech.com/index.phtml
