A New Generational Approach: Integrating Psychology and Audiology Care

Editor’s note: This text-based course is a transcript of the webinar, A New Generational Approach: Integrating Psychology and Audiology Care, presented by Michael Hoffman, PhD.

Learning Outcomes

After this course, learners will be able to:

• Describe a model for integrating psychology and audiology services.
• Discuss research on psychopathology within patients with hearing loss.
• Discuss strategies for counseling complex families.

Introduction

My name is Dr. Hoffman. I have a Ph.D. in clinical psychology with a focus on pediatric psychology. I am currently employed at Nemours/Al DuPont Hospital for Children, which is where I performed my residency and fellowship. One of the things that have made my background unique is that I have hearing loss. I have a cochlear implant on my right side and a hearing aid on my left. I was born with severe to profound hearing loss. I was diagnosed at four months and was aided immediately. I used hearing aids for about 28 years until I got implanted in my right ear about 2 1/2 years ago. My personal experience with hearing loss is what motivated me to go into this field. 

Today, I'll begin by reviewing some of the existing psychosocial research on hearing loss, covering early childhood development through older adolescence, and extending into adulthood and dementia. After that, we will discuss a model for integrating psychology and audiology. As we conclude, we will talk about counseling challenging families.

Psychosocial Research

Next, we're going to review some of the research that exists concerning the psychosocial impact of hearing loss. During the early diagnosis period, I commonly hear questions from families, such as "Does my child understand that they're going to have hearing aids or an implant?" or "Do they recognize that they might be different from other children?" "What will it be like for them?" Some of the early research at this time has shown that children begin to develop their self-awareness around age three. At that point, their brain has reached a phase where they can start to make comparisons between themselves and others. In the early preschool years, children start to recognize, "Hey, I have these things on my ears, but no one else does." By age four, children develop theory of mind, where they can take the perspective of others. They might believe that others perceive them differently because of their hearing aids or implants. Often, families are quite worried about how their two- or three-year-old child is going to respond to having hearing aids. Developmentally, at that young age, most children aren't quite aware of those differences yet. But we do know that children with hearing loss begin experiencing some of these psychosocial effects at a pretty early age. At age four, five, or six, most children aren't making decisions about their self-care. It's still very much in the court of their parents, which can have an impact on the child if they feel that it is out of their control.

Within hearing loss in general, there is a lot of research that has examined varying rates of psychopathology or psychosocial difficulties. Gallaudet has an annual running program where they will look at various rates of diagnoses across the hearing loss spectrum. One of the main findings that have come out of those studies is that about 40 to 50% of children with hearing loss have a comorbid diagnosis. ADHD is a common one. We see increased rates of ADHD in children with hearing loss (about 20% in children with hearing loss versus about 7% in the general population). We also know that, more broadly, children with hearing loss experience difficulties with academic performance, as learning to read and doing the phonological processing can be a challenge. They may exhibit behavioral difficulties related to communication delays. Also, other children may tease them because they are different, leading to increased rates of psychopathology. These children may also experience general social withdrawal due to the teasing, as well as because they have trouble hearing in settings. These broader challenges stretch across their lifespan and can occur in a lot of different areas.

The National Institutes of Health conducts broad population studies where they've looked at all of the children whose parents identified them as having hearing loss. They determined that about 16.6% of children with hearing loss have seen a doctor for social-emotional problems compared to less than 5% in the general population. Additionally, 11.5% of children with hearing loss have seen a psychiatrist or have received some sort of medication for emotional difficulties. That could include not only ADHD but also other conditions like anxiety and depression. Within the hearing care field, especially for these younger children with hearing loss, moving toward an integrated and collaborative care model can benefit this population.

Hearing Loss and Autism Spectrum Disorder (ASD)

Another common association is between hearing loss and autism spectrum disorder (ASD). Children with hearing loss have higher rates of autism. The risk ratio for ASD is 14.1 times greater in those with hearing loss compared to the general population. To put that into context, one out of 59 children with hearing loss have autism versus one out of 68 in the general population. One of the biggest challenges in diagnosing autism is that the symptoms of hearing loss (e.g., language delays, social difficulties) can very much mimic the symptoms of autism. Often, children receive the hearing loss diagnosis first (either through newborn hearing screening or failed ABRs in school). At about age two, three, four, when those other social skills are beginning to develop, parents might receive a dual diagnosis of both autism and hearing loss. I've had a couple of providers at our hospital ask me, "Mike, can you help me out? Something off. What's going on there?" I encourage them to look out for the traditional hallmarks of autism, such as hand flapping, toe walking, and other self-stimulatory behaviors. Those are the traits that we would not see in a child with hearing loss, regardless of how severe. Not surprisingly, another common overlap is increased rates of auditory processing disorder in children with autism and hearing loss. Children who have autism often have sensory challenges, and many of them end up with auditory processing diagnoses.

Maternal Sensitivity

I wanted to shift gears a bit and discuss some of the broader research in psychology that has looked at family interactions. One of the studies that I've participated in has examined what we refer to as maternal sensitivity (Quittner et al., 2012). That involves looking at the interaction between mother and child and studying piece-by-piece how moms engage with their children with hearing loss. Some research has shown that mothers of children with hearing loss tend to be a little bit more controlling, a little bit more directive, and more intrusive during their interactions with their children. In other words, those moms are probably used to advocating on behalf of their child, guiding their child, helping them out, helping their child with language. As a result, moms of children with hearing loss don't always grant those children the opportunity to, for example, go out and explore in the playground or try and solve a task by themselves. They might be more quick to jump in and be directive, to tell their child what to do, and be more guiding.

In the Quittner study, we looked at 188 children with cochlear implants as compared to typically developing children, specifically focusing on this maternal sensitivity. We looked at four areas of focus in the relationship between mother and child: maternal responsivity, respect for child's autonomy, positive regard, and hostility. In children with cochlear implants, it's no secret that the earlier that the child receives the implant, the better they do in life. Not surprisingly, children who are implanted before two years of age perform much better as compared to children who receive implants after two years of age. Dr. Quittner and her colleagues discovered that when we code in maternal sensitivity (when we looked at moms who were less intrusive, less directive, serving more of a "cheerleader" role and using positive language reinforcement), the difference in language development over time was almost equal to what we would see for age of implantation. This demonstrates that family context and maternal sensitivity can have just as much of an impact on language development as the age of implantation.

In this study, they took a closer look at breaking down the relationship between maternal sensitivity and linguistic stimulation (i.e., how much language the mom is providing). Not surprisingly, the children that performed the best had mothers who were giving a lot of language and who were sensitive. That is something our speech pathologists work on with families. The findings from this study suggest that we need to work with moms to provide them with more sensitivity strategies and more language development skills in the home, resulting in better outcomes for their child.

Effects of Hearing Loss in Adults

At this time, I'm going to shift the conversation to talk about adults with hearing loss. The way we conduct hearing loss research in adults is quite different than how we study children. With children, everyone is concerned with development and the factors that help our children hear well. In adults, the emphasis has been more on the deterioration that occurs later in life. According to Abrams, if you have an individual with hearing loss, even if it's later-onset hearing loss, they start to experience compromised speech perception, which leads to greater challenges in communicating. Ultimately, that hearing loss leads to reduced social engagement. If I can't communicate effectively, and if I'm struggling to stay engaged in a conversation in a restaurant, I'm not going to keep trying. Hearing loss can result in impaired cognition, poorer physical functioning, and overall poorer quality of life (Abrams, 2017).

Not surprisingly, adults with hearing loss often display social withdrawal (Sung et al., 2016). About 30% of adults with severe hearing loss who do not wear any devices report depressive symptoms. They're also more likely to report things like anxiety, paranoia, and emotional insecurity (National Council on the Aging, 2011). One study found that the odds of depression in the elderly were 1.5 times greater per 25 dB of hearing loss in the better ear (Mener et al., 2013). In other words, the worse your hearing is, the more at risk you are for some sort of depression, and most likely, some sort of comorbid anxiety and social withdrawal.

In elderly adults, hearing loss contributes to cognitive decline and dementia. In a 2015 study by Ameiva and colleagues, they evaluated the potential link between hearing loss and dementia. They discovered a link between cortical amyloid plaques in Alzheimer's disease and loneliness, which can be exacerbated by hearing loss (Ameiva et al., 2015). Hearing loss itself can also contribute to brain tissue loss, which affects a person's ability to process sound and speech (National Council on the Aging, 2011). There is also some interesting research that has examined the link between hearing loss and cardiovascular disease, as well as the link between hearing loss and diabetes. A lot of other challenges and comorbidities can be occurring for an individual with hearing loss, far beyond the hearing loss itself. It can have a cascading effect on that person's functioning. 

Integrating Psychology and Audiology

Thus far in the presentation, we have seen that hearing loss can have a significant psychosocial effect across the lifespan. The research has shown that individuals with hearing loss are impacted in a lot of different ways, above and beyond the hearing loss itself. That fact opens up the door to have a greater conversation about what more we can be doing for these families. We should be providing more broadband, holistic support and focus on integrating psychology and audiology. 

Audiologists are incredibly well-trained to assess issues of speech and language. As the health care model shifts more toward collaborative care models and value-based care models, we need to be thinking about providing services that address the whole child. What can we do to improve their care in a more holistic way? Rather than only thinking about the individual's language, speech, and hearing, we need to think about how hearing loss can have an impact on other areas of their life. That is an area of expertise where psychologists are well-positioned to provide assistance. To that end, I have been growing and building a broad integration model to assist with bridging the gap between audiology and psychology. I have broken up this model into different areas of focus:

• Cochlear Implant Team: If 40 to 50% of these children have a comorbid diagnosis, we should be conducting some sort of developmental evaluation and assessment of them. We can be checking in to see how the families are preparing and getting ready for surgery. 
• Central Auditory Processing Disorder (CAPD) Patients: Many of our CAPD patients have a history psychoedu or psychodiagnostic evaluations. We can support these families by consulting with them regarding these evaluations, as well as discussing other diagnoses.
• Providing Handouts/Information
• Sound Sensitivities: For patients who have conditions like hyperacusis, tinnitus, and misophonia, we can provide outpatient therapy involving biofeedback and CBT.
• Ear Anomalies: For children with conditions such as microtia and atresia who might be undergoing some type of ear reconstruction surgery, we can provide standardized screening and work with families on preparing for surgery.
• Research: It is important that we track our outcomes and publish data to show that our efforts are effective and worthwhile.
• General Audiology: This involves standardized audiology screening and booth testing, as well as providing outpatient therapy. We also need to meet with newly identified hearing loss families to discuss issues of device compliance. 

Cochlear Implant Team

Within the cochlear implant team, one of the main things that we can be doing is to assess a family's readiness for surgery. Each member of the interdisciplinary team has their own area that they need to assess when preparing for surgery. During this process, it is important to pause ask the family and the patient if they truly understand what is going to happen. In my experience, there are so many details that we tell families, some of the information often gets lost in the shuffle. They misunderstand things. We need to take time to sit down with them and make sure they understand the implant process. Do they understand that they're not going to get activated for a month after surgery? What's their perspective on hearing loss, and how are they feeling about pursuing spoken language versus sign language or a combination of both? What are their goals as a family for their child? What is the goal of that individual for him or herself? Are there any concerns about appearance, or concerns about surgery? A lot of parents worry about that. What other barriers and challenges exist that may potentially interfere with this child's care? Do the parents have steady housing? Do they have jobs? What kind of insurance do they have? Can they get back and forth to weekly or biweekly speech appointments, mapping sessions, programmings and meetings with the surgeon? There are a lot of logistics during the course of that implant process. What's going to interfere with that? Is there a history of parental mental health that might be interfering with or complicating care? Are there other stressors going on in terms of, say, another child with medical needs? What is the child's placement during the school day? Understanding all of these things can set us up to be more successful with our families who choose to undergo implantation.

One of the most critical areas to assess are whether there are any barriers to follow-up care. It's not just about putting the device on someone's head. The process involves a variety of rehabilitation steps that they need to take. Another key area to assess is whether these families fully understand the CI process. We want families to know ahead of time the appointments that they need to keep and the realistic timeline of events that need to occur. It's vital to ensure that families understand these things and they are included in the process. 

Most CI centers conduct some type of speech/language screening with their children before they pursue an implant. Given that 40%-50% of these children have a comorbid diagnosis, we should also be assessing their motor functioning and their cognitive functioning, in addition to their language. I use a developmental assessment called the Bayley. It occurs over a period of about 16 days. I will do the assessment with a child before surgery and track them after surgery. That way, we can ascertain whether they're hitting all of their developmental milestones, not just within speech but in cognitive and motor functioning. That assessment can serve two purposes. First, it can get families looped into services if they don't have them. Second, it can also help to detect other diagnoses or issues that might be going on (e.g., autism, ADHD, other developmental delays, motor delays). We should be screening and tracking these things and not waiting for the moment when someone says, "My child is not making progress in speech therapy." We can be doing a better job tracking them earlier and following them.

CAPD and Sound Sensitivities

Many of the families who have a child with CAPD come in with extensive reports due to a history of diagnoses of psychological comorbidities. As psychologists, our instinct is to rule out ADHD, autism, or other learning issues, and so we conduct screenings for ADHD and autism. We can help families interpret those reports. In addition, we can help families work with the schools as it relates to their IEPs or their 504 programs. There is a lot of integration that can occur with CAPD families and making sure that we're looking at the whole child.

Another area that I've been working to grow within our clinic is the misophonia children, or the "sound sensitivity" children. A lot of these children who are presenting with misophonia, as it's becoming a more well-known condition, have these stressors in school, these triggering sounds. We can provide outpatient psychotherapy to give these children some coping strategies and ways to deal with misophonia. I always tell my patients, "I am not going to cure your misophonia, but I can help you come up with some strategies and give you some tools in your toolbox to make you feel like you have a little bit more control over what's going on and not just wanting to burst into tears and run out the door or punch the offending person in the face."

One calming technique that has shown promise is to conduct biofeedback to teach diaphragmatic breathing to people with misophonia, tinnitus and hyperacusis. That involves measuring a person's heart rate, skin conductance, and other biological markers. We're teaching children breathing strategies to see if they can decrease the level of activation within their system. I've had early success with some patients that I've used it with and there has been some promising research in this area.

Ear Anomaly Clinic

We run a clinic for children who have conductive hearing loss, microtia and atresia. When they come into our clinic, they get to see plastic surgeons, ENTs, audiologists, and then we do a psychosocial consult with them. For these children who have some sort of physical difference occurring, that definitely puts them at added risk for anxiety, worry, and social challenges, not to mention the contribution of the hearing loss on top of it. I will meet with a lot of our patients who come in through the ear anomaly clinic and I do an initial assessment with them to see how they're functioning. Are they considering surgery? Are they thinking about getting an ear reconstruction? Which path toward ear reconstruction are they thinking about and why? Similar to our cochlear implant families, we can be checking in with these children and their parents to find out the stressors they are experiencing. What might be affecting or complicating care? How is your child functioning, or how are you functioning? Do you feel like you've had a lot of worry or anxiety related to this? Do have any appearance-related concerns that you want us to address, or are you happy with how things are right now?

Children with microtia or atresia sometimes have other conditions, such as Goldenhar syndrome. We can be checking in to see how they're performing from a developmental standpoint and if they have received the appropriate early intervention services. If not, we can loop them in. How are they doing with their academic functioning? Are there other things that might be impacting their physical health? Again, we are thinking about the child not just from a reconstruction or hearing improvement standpoint, but also providing support from a more holistic standpoint. How are they doing in school and with their friendships? How are they doing at home? How are they feeling about having a BAHA or having ear surgery?

In addition, it is important to determine whether there are any other psychosocial challenges in terms of previous anxiety, depression, ADHD, or other diagnoses. Are there questions about academic functioning, IEPs? Are there any other psychosocial concerns impacting physical health? For some of these children I've seen, especially adolescents who are in the process of considering an ear reconstruction, they are trying to decide if they want a full prosthesis. Do they want to do the implantable BAHAs? Do they want to do some sort of reconstruction of their ear using their own cartilage? The process involves a lot of big, weighty decisions that include significant surgeries. It's incredibly stressful for anyone, let alone a for a teenager or a child to make. We can help make sure they understand and are ready for that process.

Screening Patients

Personally, my most favorite area would be screening patients for things like anxiety, depression, or other issues. Within the field of pediatric psychology, there are some medical conditions that have clear demarcations for providing psychosocial involvement. For example, in patients with diabetes, they might have a certain A1C or a certain blood glucose level that we're jumping in on. If you have a cancer diagnosis, you're pretty much always going to get some sort of psych help. If you go to our weight management clinic, and you were thinking about bariatric surgery, you might get a psychological evaluation. Within the field of audiology, there are no clear demarcations of who should be referred for psych services and who shouldn't, with the exception of maybe our cochlear implant children. If we set up standardized screening, it can help to figure out who should be referred for a psychological screening, and it can be done in a very easy way to allow for clearer identification of those who would benefit from treatment.

Screening can also save you time. Think about all of those complicated patients who have kept you in the room for maybe an extra 20 or 30 minutes, and now you are running behind on your next five patients for clinic, and they're going on about things like challenges in school or social difficulties, or their child doesn't want to wear their device. If you are able to screen, you can provide that family with referrals and get them looped in with psychology. It can get you out of the room faster, because parents will say, "Okay, that sounds good, we'll talk to them."

The way that I set up our model in our hospital is that we screen all of our permanent hearing loss children. They get screened at device selection or fitting, at that one-month or three-month followup, and then every six months after that. Because things change. Patients' experiences change. That adjustment changes. We might need help at different times. Repeated screening allows us to have serial data. We can track our patients over time and see if they're getting better, if things have gotten worse, or if they're staying about the same. A child may do great with their devices and may not have any major concerns when they're five, six, or seven. However, when they come back at age 12, 13, or 14, when they're going into middle school or high school, it might be a totally different picture. They may be saying, "I don't want to wear my hearing aid anymore", or, "I'm not using the FM system in class". This helps us capture those children as they age and they progress.

We have three age ranges that we screen. From birth to five years of age, the parent reports how their child is doing. From age six to 12, we obtain a report from the parent and a self-report from the child. For adolescents (age 13 and above), we ask the child to self-report. The screening consists of six to eight questions and takes about three to four minutes to complete. Although psychologists are notorious for using long, complex, drawn-out measures, I try to design our screening to be concise, geared toward dissemination and implementation, and making it feasible for audiologists to use.

The following questions were taken directly from one of my screeners. I ask parents and children to complete the questionnaire and respond with "never", "sometimes", "often", or "always". The first three questions are specific to hearing loss in general. 

• How often is your child bothered by his/her hearing loss?
• How often does your child feel different from other children because of his/her hearing loss?
• How often does your child wear his/her hearing devices?  

The next few questions relate to psychological issues:

• How often does your child feel down, depressed, or bad about him/herself?
• How often does your child feel nervous, anxious, or on edge?
• How often does your child have difficulty falling or staying asleep?

Finally, there are a couple questions that are specific to parents:

• How often do you feel stressed or worried about your child's development or behavior?
• How often do you feel stressed or worried about managing your child's hearing loss?

Not surprisingly, parents of children with hearing loss are more stressed-out than parents of typically-hearing children. This allows us to screen them and determine with a certain cut point at a certain score whether the families should be referred for psych services.

What Can Psychologists Do?

What can psychology do? We can treat a lot of issues that are specific to hearing loss, but there are also are many other things we can help with, including:

• Sleep, feeding, behavior problems, anxiety, depression
• Device usage, parental stress, parental decision-making
• Identity formation around hearing loss
• Brief assessments for ADHD
• Adjustment for parents and children following initial diagnosis
• Transition periods – adolescence/college/young adulthood
• Improving family communication around hearing-related issues
• Brief developmental assessments for children
• Warm handoffs or complex booth testing assistance

What Can Audiologists Do?

As audiologists, you may thinking, "What can I do it if I don't have access to psychology, or if I work in a private practice?" The answer is that you can do quite a bit. There are three areas you can help with: 

• Provide patients with information about psychosocial functioning in individuals with hearing loss. Knowing that social withdrawal or depression symptoms are common can help to normalize their experience.
• Generate a list of community mental health providers that you can give to patients with hearing loss if they want to seek out those resources.
• Screen for anxiety and depression.

The first screening tool we will review is called the PHQ, or the Personal Health Questionnaire. There are two versions: PHQ-8 and PHQ-9. The PHQ-8 removes the suicidality question. This is a free, nationally provided measure for screening depression in adults. It's easy to download. There are clear guidelines about how to score it and what a cut point is, and a threshold is. This would allow you to screen for depression and takes about two minutes to complete. To locate a copy of the PHQ (version 8 or 9), simply type PHQ-8 or PHQ-9 into an internet search engine, and you can readily find this questionnaire online.

The next screening measure is called the Generalized Anxiety Disorder 7-item scale (GAD-7). This allows you to screen for anxiety. Similar to the PHQ-8 or the PHQ-9, there are clear thresholds and cut points for what a referral is. The GAD-7 takes approximately five minutes to complete. They can do it in the waiting room. Using this tool, you can get a sense of whether or not you should be referring a patient for psych services. This also opens up the door to have a conversation with them and say, "Hey, it seems like you're struggling a little bit with some things right now. Maybe we can help out." Again, it is free to use and download. To easily locate and download a copy online, type "GAD-7" into a search engine like Google or Yahoo.

In summary, screenings are free, quick and easy to use. You do not need a Ph.D. in psychology to administer these screenings. Offer psych referrals to patients, and be able to share resources and places they can go for more information. Providing support to your patients and acknowledging that some of these issues are challenging can go a long way. Also, use your clinical judgment. Screening is not meant to be an end-all-be-all. You have spent a lot of years working with patients and families. You have clinical intuition. You have judgment, use it. If someone is under-reporting everything, but your radar detects that something is going on, you can give out a referral for psychological services. The worst-case scenario is that someone says they are not interested.

Counseling Difficult Families

Now I want to shift gears and talk about counseling difficult families. Especially with our younger families, when referring to myself, I will use the term "behavioral health specialist", as families may be more comfortable with that term than "psychologist". The first thing I do when I meet with a family is to try and normalize the experience for them. When I say "normalize", I tell them that these are common experiences for a lot of people. I reassure them that for many children, it's not uncommon for them to have difficulties or "poor compliance" in wearing their hearing aids. It's also common to experience anxiety and stress, for both the child and the parents. For our parents of very young children, I assure them that as behavioral health specialists, we know that hearing loss can impact other areas of development. Psychologists are developmental experts who can help out with a lot of common issues, such as behavioral challenges, anxiety, sleep issues, or ADHD concerns.

New Diagnosis Families

For families who receive a new diagnosis of hearing loss, many of them are experiencing feelings of guilt, as well as mourning the change in the expected trajectory of their child's life. Another common concern for new diagnosis families is whether their child make friends, or what others will think about them. Are they going to date? Are they going to get married? Initially, parents aren't as focused on the language piece as much as how the hearing loss is going to affect their child's daily functioning.

As audiologists, when you are helping these families, your mindset shouldn't be, "I'm going to make them feel better, I'm going get them hearing aids, they're going to be fine." If you do that, you're not giving them the space to process the diagnosis. You want to make them feel heard. Ask questions like, "What's going through your mind right now? What are you thinking about?" Whatever they say, you can normalize and validate their feelings with phrases such as, "I can see why you might feel that way. I can see where you're coming from." When a parent is talking, you can use active listening techniques and reflective language to make them feel heard. Use phrases like, "If I'm understanding you correctly" or "It seems like you're really worried about what it's going to be like for your child when they go into preschool." Using those types of phrases opens the door for the family or the patient to correct you or clarify what they meant, or to concur that is exactly what they are feeling.

When communicating with new diagnosis families, avoid specific, targeted questions. Also, if you are asking closed-ended "yes or no" questions, that doesn't allow them the chance to share more information about what they're feeling and experiencing. Also, telling the family about your previous professional experience closes the door on the conversation for the parents to say, "This is what I'm experiencing right now." If you can have an open conversation with the family, you can help to build trust, create buy-in, and get them listening to your recommendation to move forward.

Other Family Challenges

Another type of family that can pose a challenge is when they read a lot of information online. For example, one recent patient was just diagnosed with hearing loss at three years old. His mom wanted slim tubes and the dome instead of an ear mold because she read about those online. If I were to try and exert my expertise and explain to mom all the reasons why she shouldn't get the slim tube and the dome, that serves to put mom in a defensive position like she's backed up into a corner. The proper way to handle that situation is to elicit a ton of information from parents, asking open-ended questions to gather information. For example, "Why do you think you want the dome? What do you think would be the difference between the dome and a full earmold? What do you think that difference might be between the full tubes versus the slim tubes? What is influencing you to make this decision?"

One technique you can use is reflect the information back to them. For instance, "On one hand, I'm hearing that you want to get Bobby the hearing aids, and you want to help them moving forward. But on the other hand, you really don't want it to be so visible." Another reflective phrase to use is, "I'm a bit confused because I hear you saying that you want to let them pick different colors, but you yourself are feeling like that's not an area to go." I often use the phrase, "Help me understand. Teach me a little bit about what's going on." Finally, an effective technique to use is to ask the family permission to provide them information. For the family that is insisting on slim tubes, ask, "Is it okay if I provide you with a little bit of information about some of our other fitting strategies?" A family will almost never say no. And if they do say no, they probably weren't in a position where they wanted to hear anything you had to say. When a parent or patient grants you permission to provide information, they are acknowledging that they have to listen to what you have to say, which creates more buy-in from the parents. All of these communication methods elicit more information from your parents about what they're thinking and what they're doing. As you gather that information, you get them talking, it becomes easier to offer your thoughts.

When encountered with the patient who refuses to wear their hearing aids (or implant or BAHA), again, your first step should be to gather as much information as possible. You want the patient to be doing most of the talking. We don't want to be talking at them. We want to draw attention to their ambivalence or their mixed feelings about the situation. For example, you could say, "I understand that you get frustrated in social situations where you can't hear what's going on, but you also say that you don't want to wear your hearing aid because it makes you feel different." Getting them to talk about and acknowledge their contradictory feelings and thoughts can help them better understand the situation.

Motivational Interviewing Strategies

There's a whole field within psychology called motivational interviewing. The cornerstone of motivational interviewing is a set of core skills called OARS. OARS stands for:

• Open Questions
• Affirmations
• Reflections
• Summaries

The crux of motivational interviewing is all about eliciting ambivalence and then getting patients talking about why they might want to change, what those barriers to change are, and how to address them. We want to avoid being the "finger wagger." It is so easy to tell a family or a patient what they "should" or "should not" be doing.  However, research on behavior change within psychology indicates that being the finger wagger, or taking on an authoritative perspective is not helpful. It makes people defensive. Get them talking, let them feel involved in the care, and let them help out. 

If you are interested in learning more about motivational interviewing strategies, I highly recommend the book "Motivational Interviewing" by William Miller and Stephen Rollnick. It is designed around helping patients and families in the medical process with change and motivation to engage in different health behaviors. A lot of the research has been done on things like smoking cessation, weight loss, healthy sexual behaviors. These strategies are effective with families and children down to the age of 12.

Thank you for your participation today. I hope that over the course of this presentation, I've convinced all of you to go advocate for psych and that you have been inspired to integrate audiology and psychology in your practice. If you have any questions or thoughts, please send me an email at Michael.Hoffman@Nemours.org. 

Questions and Answers

How do you recommend audiologists recruit psychologists' help?

If you are in some sort of hospital setting or integrated care setting, you can go to your supervisors let them know you feel that you should be screening so we can move through patients faster and see them quicker. Tell them that if we provide more screening, we can shift more toward a value-based care model. Most hospital settings have a division of psychiatry or psychology. You can reach out to them. There are also plenty of private practices. If you look up some of those private practices in your community, you can reach out to them and tell them you would love to be able to refer patients to them. Most of them would be happy to receive referrals.

How do you address parents who are frustrated that their children cannot wear hearing aids?

For parents who are frustrated that their children can't or won't wear hearing aids, I would normalize that with education, and help them to understand that children with hearing loss cover a huge spectrum. You can probe a little bit deeper and say something like, "When you say you're frustrated that your child can't wear hearing aids, what is it that is most upsetting to you?" Then when you get that data, if they say, "I'm really worried about my child's ability to communicate with other people," that opens up the door for you to offer other types of resources. Maybe you can hook them up with augmentative communication if that's needed. I think if you can try and make meaning around why it is that they're frustrated, then you get more information that's underlying that, and you can address those concerns.

References

Abrams, H. (2017, September). 20Q: Hearing loss and its comorbidities. AudiologyOnline, Article 21217.  Retrieved from www.audiologyonline.com

Cruz, I., Vicaria, I., Wang, N. Y., Niparko, J., Quittner, A. L., & CDaCI Investigative Team. (2012). Language and behavioral outcomes in children with developmental disabilities using cochlear implants. Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology, 33(5), 751.

Mener, D. J., Betz, J., Genther, D. J., Chen, D., & Lin, F. R. (2013). Hearing loss and depression in older adults. Journal of the American Geriatrics Society, 61(9), 1627-1629.

Sung, Y. K., Li, L., Blake, C., Betz, J., & Lin, F. R. (2016). Association of hearing loss and loneliness in older adults. Journal of Aging and Health, 28(6), 979-994.