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Wednesday, November 28, 2018

By Hsuan-Mei Hong; Yi-ping Chang, PhD; Pei-Hua Chen, PhD; Ying-Chuan Julie Ma, AuD

When a child is diagnosed with hearing loss, parents have considerable information to digest and numerous choices to make. Parents must understand their child's audiometric results, the impact of hearing loss on the child's development, obtainable technologies, and available habilitation programs, particularly manual and total (manual combined with oral), and oral communication. If parents choose an oral communication mode, audiological management is a vital foundation for listening and spoken language outcomes. Audiological management includes understanding children's audiometric status, fitting and handling the hearing technology, and monitoring children's hearing status.


In our study, we investigated the degree of implementation of audiological management by parents of children with hearing loss who were newly enrolled in aural habilitation program provided by the Children's Hearing Foundation (CHF) in Taiwan (Hong, et al., 2018). A clinical assessment tool—the Audiological Management Checklist (AMC)—was developed by CHF's experienced pediatric audiologists. The AMC consists of 20 items that can be divided into three dimensions: audiometric status understanding, hearing technology handling, and audiological monitoring. Detailed descriptions and sample items for each dimension in AMC are presented in Table 1. A rating of 0, 1, or 2 was assigned to each item, where a higher rating indicates a higher degree of understanding or implementation by parents. The total score of AMC was 40. The parents and the auditory-verbal specialists of 95 children with hearing loss were recruited in the study. These children had been receiving auditory-verbal programs from the CHF for less than one year prior to initial assessment; these children were selected because the parents may not be as familiar with audiological management as those who had enrolled in the programs for a longer period. In addition, these children may have been wearing hearing devices with relative inconsistency compared with those who had been enrolled in the programs for a longer period. The parents' implementation of audiological management was evaluated using AMC by auditory-verbal specialists and the parents themselves. Based on the initial assessment, pediatric audiologists counseled the parents on how to improve for the items they received low ratings for. Follow-up assessments were conducted at six months.

 Table 1. Audiological Management Checklist

DimensionDescriptionSample Item
Audiometric status understanding (5 items)To evaluate the degree of parents' understanding of their child's audiometric status. "Do you know your child's degree of hearing loss?"
Hearing technology handling (10 items)To evaluate the degree of understanding of hearing technology settings and degree of familiarity with hearing device handling. "Do you understand the program settings in the hearing device?"
Audiological monitoring (5 items)To evaluate parents' sensitivity to possible variations in their child's hearing performance and whether they regularly monitor their child's hearing status. "Do you regularly apply speech sound tests to monitor your child's detection performance?"

The study results revealed that after being counseled by pediatric audiologists, most (87% based on parents' self-ratings; 89% based on the auditory-verbal specialists' ratings) parents' implementations of audiological management improved compared with the initial assessment. The parents' mean rating of the two assessments significantly increased from 33.78 to 37.19 (t = -9.82; p < 0.001), whereas the auditory-verbal specialists' mean rating significantly increased from 26.29 to 32.62 (t = -7.24; p < 0.001). AMC is a useful tool for audiologists and early intervention professionals to evaluate the audiological management status of parents who lacked knowledge of audiological management. Based on the results of AMC evaluation, the audiologists and hearing health care professionals provided advice to meet the parents' needs. In this study, the results revealed that the parents' ratings were significantly higher than the auditory-verbal specialists' ratings for both assessments (t = -11.08, p < 0.001 for the initial assessment; t = -7.65, p < 0.001 for the follow-up assessment); the differences between the ratings from the parents and the auditory-verbal specialists reduced at follow-up compared with the initial assessment. These results indicated that the observation of parents became more consistent with that of the auditory-verbal specialists after counseling from pediatric audiologists.

Table 2 summarizes the results for the most successful and most poorly implemented dimensions for both evaluators and for both assessments. Dimensions of "audiometric status understanding" and "hearing technology handling" were the most successfully implemented for the auditory-verbal specialists and parents at initial and follow-up assessments, respectively. However, "audiological monitoring" was found to be the most poorly implemented dimension based on the ratings from parents and auditory-verbal specialists at both initial and follow-up assessments.

Parents of children with hearing loss must develop habits for monitoring their child's hearing status or maintaining their child's hearing technology in daily life. Our study found that these habits take time to develop. Notably, although "audiological monitoring" was the most poorly implemented dimension, it was the most improved dimension after counseling from pediatric audiologists.

Table 2. Dimension implementation comparison of the ratings from parents and auditory-verbal specialists at the initial and follow-up assessments.

  Parents' rating resultsAuditory-verbal specialists' rating results
Initial assessment The most successfully implemented dimension Audiometric status understanding Hearing technology handling
The most poorly implemented dimension Audiological monitoring
Follow-up assessment The most successfully implemented dimension Hearing technology handlingHearing technology handling
The most poorly implemented dimension

Audiological monitoring

(also the most improved dimension)



The results revealed that although the parents' audiological management improved after receiving some counseling from audiologists, they still poorly monitored the audiological condition of their children. Therefore, we suggest that in aural (re)habilitation, hearing care providers should provide parents with additional support to better monitor their children's hearing status.

Parents spend considerably more time with their children. Thus, they can provide valuable information about their children that providers may not be able to observe in therapy sessions or audiometric exams. Their reports are often utilized to evaluate the effectiveness of hearing amplification or the auditory skills development of children. However, our study showed a significant difference between ratings from parents and that of hearing care providers. Nonetheless, professionals should consider parents' self-evaluation to improve audiological management at home.

About the Authors: Hsuan-Mei Hong is a research assistant of Speech and Hearing Science Research Institute at Children's Hearing Foundation (CHF) in Taiwan, where Dr. Yi-ping Chang is the director. She's also an adjunct assistant professor in the Department of Audiology and Speech-Language Pathology at Mackay Medical College in Taiwan. Dr. Pei-Hua Chen is a research fellow of Speech and Hearing Science Research Institute at CHF, focusing on the application of psychometric in children with hearing loss. Dr. Ying-Chuan Julie Ma is a pediatric audiologist and the director of audiology at CHF. She's also an adjunct assistant professor at Mackay Medical College and an adjunct lecturer at Chung Yuan Christian University.

Monday, October 29, 2018

Raising and educating children always invite dynamic conversations and raise complex questions including how to become "good" caregivers. Across different cultures, fathers have been associated with being the family's economic provider and mothers as the caregiver. So a scenario of a father taking care of a child may incite doubts and suspicions about the father's suitability as a caregiver.

Perhaps the recent movie Incredibles 2 can be a good example of a father taking care of a "special" child (Bird, 2018). In the beginning of the movie, Bob Parr, who is a father and a superhero, thought that parenting was not that difficult at all. However, after spending some time with his "special" children, he realized that parenting is the toughest job he'd ever encountered. Then, after a significant time of learning and adjustment, he began to adapt to his parenting life and learned how to interact with his "special" children. Going back to reality: Can fathers overcome these difficulties and break the stereotyped role of a father in the family?


According to a previous Auditory-Verbal Therapy (AVT) study, they answered yes to the question that father might be a potential caregiver to the children with hearing loss (Huang & Chen; paper presented at 2018 Hearing Across the Lifespan 2018). They assessed 10 caregivers (five fathers and five mothers) by using two multidimensional 5-point Likert scales to investigate the differences in parental teaching and behavioral skills between the different genders of caregivers in three different times. These follow-up assessments, due to the child participate in auditory intervention duration at 12months (time 1), 17months (time 2), and 20months (time 3), will be given and rated by AVT therapists.

The results showed that there was a significant interaction between caregivers' gender and time points by using generalized estimating equation (GEE) method since the limitation of the sample size will not be the primary consideration factor. The results indicated that fathers received higher scores than mothers in the dimensions of instructional goal-settings skill (Wald χ2=4.116, p=.042 ) from the parental teaching skill scale, and emotional and behavioral skills( Wald χ2=6.532, p=.011 ), parenting behavior (Wald χ2=3.894, p=.048 ) from the parental behavioral skill scale after six months training of AVT. Furthermore, the fathers' language usage skill was not significantly higher than that of the mothers (Wald χ2=3.658, p=.056 ), but the fathers' improvement rates in language usage is higher than that of the mothers' from time 2 to 3(Father: M = 4.2; Mother: M = -1). As the figure shows, the fathers showed improvements in all domains since time 1 to time 3.

Figure 1. 




Due to the growth trajectories obtained from GEE analysis, fathers were detected on the trajectory for increased levels across four specific domains after enrolling in AVT for six months. Study results showed that fathers would also be suitable to be their child's language facilitator. As the length of training session increased over time, their performance was like what mothers can contribute. These results show the great potential of fathers as caregivers of children with hearing loss.

About the authors: Tang-Zhi Lim is a research assistant at the Speech and Hearing Science Research Institute of the Children's Hearing Foundation in Taiwan, where Pei-Hua Chen is a research fellow.

Thursday, October 18, 2018

Critics have called A Star Is Born a "modern classic" in its retelling of the 1937 film of the same title—but this time alluding to the adverse impact of tinnitus and hearing loss. Interestingly, the film's director and main character, Bradley Cooper, cast his own ear doctor, William H. Slattery III, MD, from the LA-based House Clinic, to play his character's ear doctor. But beyond the silver screen, Dr. Slattery has been fighting the good fight to help patients—Hollywood stars or not—whose struggles with tinnitus are very real. For Audiology Awareness Month, The Hearing Journal (HJ) spoke with Dr. Slattery on the challenges and opportunities in managing tinnitus. (Be warned: The Q&A contains spoilers.) 

HJ: A Star is Born takes the audience to a complex, multi-layered journey. Though staged in fiction, how much of the character's experience with tinnitus and its impact on one's mental health and quality of life would you say reflects the true challenges of people with tinnitus?

Dr. Slattery: There are many millions of Americans suffering from tinnitus, but the severity varies from individual to individual. Jackson Maine in A Star Is Born has very significant tinnitus and, as the character is also dealing with alcohol problems and some other issues, he's not handling it very well. So, it's a portrayal of someone with very significant tinnitus that's really affecting his career, which has sadly been the case in real life in the past as well.

                                           A Star is Born, Bradley Cooper, Lady Gaga

                                      Dr. William H. Slattery III at the set of A Star is Born starring Bradley Cooper and Lady Gaga 

HJ: In the movie, you play the physician of someone who's resistant to wear hearing technology that may help his condition. I imagine such resistance is not only among rock stars. How have you handled these patients?

Dr. Slattery: First, I think we have to differentiate between hearing loss treatment and tinnitus. Many who are bothered by tinnitus are frustrated that they're not being offered adequate treatment options and are being told to just "live with it," or frustrated that the treatment options are not good enough. On the other hand, patients suffering from hearing loss are often resistant to treatment or tend to delay the treatment for years.

HJ: So, what do you think is the most challenging aspect(s) of treating and managing tinnitus today?

Dr. Slattery: The big issue is the lack of success in treating tinnitus, as there is no definitive cure. There is, however, an opportunity for new types of tinnitus treatment. Though it's frustrating that the present treatments are not always as successful as we'd like them to be, it's one of the core things we're focused on improving at House Clinic.

HJ: The film shows how serious and destructive tinnitus can be—and, at the very least, informs the public of a condition they may have never heard of. How can hearing health professionals like yourself effectively contribute to this conversation and promote awareness?

Dr. Slattery: I have to give Bradley Cooper credit for being brave enough to put hearing loss and tinnitus in a movie as a subplot. That's how we raise awareness for issues like this: We continue to talk about it, find avenues where we can make it relevant to a wider audience, and give people the information they need to treat themselves better and recognize a problem if it arises.

For more information on tinnitus, visit our online collection.

Monday, October 15, 2018

By Sophie Cheng Xiaolin

Hearing loss is the third most prevalent impairment among children in Singapore (Chihiro, 2011; Low, 2005). Recent advancements in technology has enabled 80 to 90 percent of children with hearing loss to receive education in mainstream schools (Low, 2005). However, there are issues related to the acceptance of these children in society, such as stigma and loss of self-worth (Poon, 20010; Vergrugge et al., 2005). In fact, Singaporeans still hold negative feelings toward assistive devices in general (Verbrugge et al, 2005). Studies have also shown that there is a 65 percent chance that a child with special needs experience bullying on any given day (Taylor, 2010). However, there is limited research findings on the experience of both children with hearing loss and their caregivers. Leiter et al (2004) have advocated for the experience of mothers to be further explored as they are profoundly affected by their experience of caring for their child with special needs. Notably, the term "mother-blame" was coined to describe the prevelant culture of blaming mothers for the poor outcomes of their children (Ryan, 2012).

Noting the above-mentioned context, we investigated the following the question: What is the experience of caregiving mothers (referred to as “caregiving mothers” in this study) with hearing-impaired children who are enrolled in regular schools. Improving our understanding of the experience of these caregiving mothers will help health and hearing care professionals better support this patient population as well their caregiving mothers with regard to the child’s experience in mainstream education.
To understand their experience, qualitative interviews were conducted for this IRB-approved study. Participants were recruited based on inclusion and exclusion criteria (i.e., cargiving mothers of children aged 7-12 who require hearing devices and enrolled in mainstream schools). Informed consent was taken and individual interviews, conducted in English or Mandarin. Interviews were recorded, transcribed verbatim or translated, coded, and analyzed. The following questions were explored from the point of view of caregiving mothers:

1. Should my child receive hearing device intervention?
2. Should I enforce compliance?
3. What can I hope for in my child?
“Should my child receive the hearing device intervention?”
Participants verbalized their hesitation for using hearing devices. Some felt worried about disturbing their pre-operation homeostatic situation as they have found a way to cope. They verbalized fears on the success of the cochlear implant operation, future costs of hearing device(s) and the unknown future. One participant said “Now we get funding. The equipment spoils easily. How is she going to afford it next time?”
“Should I enforce compliance?”
Participants felt a sense of ambivalence about the use of the device. While they knew the device helps in hearing (ensures communication, learning, social interaction and safety), they were aware of the stigma, cost of use, and difficulty of use. A participant shared candidly “Sometimes I know they are talking about my children nonetheless. I will always feel sad about that.”
“What can I hope for in my child?”
In this study, most participants have accepted their child’s hearing problems, though one shared her hope for her child’s hearing loss to be cured. She shared: “Sometimes when she is sleeping(without any hearing device), she will (say) ‘mummy mummy I can hear from this ear.’ I (felt) so happy…”.

The other participants shared their hope for normalcy for their children, particulalry in becoming independent, finding employment, and getting married in the future. One participant shared, “I asked [my child], ‘What about the future? Wouldn’t you work?’ He asked if he could always just accompany me. I said that he will to find work someday. He remained silent. I said your parents will grow old, so if you want to survive you have to work.”
The study uncovers three key thoughts for health and hearing care providers. First, we need to be patient with parents’ ambiguity in making clinical decisons (e.g., to operate or not) regarding the care of their children. This speaks to mother-blaming where mothers are blamed and deemed responsible for the outcomes of their children (Green, 2007; Ryan, 2012). Caregiving mothers may feel the burden of making vital decisions as they may feel responsible for any possible outcomes. As practitioners, we should think about the support they may need in making decisions, such as financial assistance (e.g., insurance to obtain a hearing device), knowledge (e.g., trajectory of hearing loss),  and advocacy (e.g., anti-stigma). This will help reduce the ambiguity of outcomes so that mothers can be in less distress when making these decisions. In the event where these mothers still feel the weight of ambiguity, empathy extended to these mother may prove to be the support they need.

Second, we need to appreciate the ambivalence on compliance. The concept of cyclical grieving can be applied here (Blasca, 1998). As caregiving mothers become unsure about what to hope for (i.e., healing? normalcy?) and deal with the cyclical grief, it might be difficult for them to ensure compliant use of the devices. This study showed that while caregiving mothers were aware of the benefits of compliance, they had their reservations due to stigma and their continued hope for healing. The idea of normalcy is also challenging for them to grapple with. While the hearing device helps their child hear, the device itself is a physical symbol and reminder that their child is different.

Lastly, we need to consider the anxiety surrounding the ability to hope. Young & Tattersall (2007) found that the joy of motherhood was often over overshadowed by the parents’ need to deal with a child’s diagnosis of hearing loss, in this case. While the participants in this study verbalized fears about their child’s future, they also held hopes for their child’s future. Being associated with someone with a stigmatized condition (i.e., hearing loss), these mothers may experence courtesy stigma (Green, 2003). While hearing care providers would want to promote positivity and hope to these caregiving mothers, it is important to recognize their anxiety and experience of being stigmatized. We can provide more appropriate interventions through empathy and supportive services (e.g., adult services for those with hearing impairment, advocacy, etc.).

This study had a small sample size so it’s difficult to generalize the findings. In addition, because of the need to translate some interviews from Mandarin to English, some data could have been inadequately translated. Nonetheless, the experiences of these caregiving mothers shed light on their complex dilemmas despite the success of their children with hearing devices and attendance in mainstream schools. With these findings, hearing care providers can better design interventions that fully address the needs of the patients and their families.

About the Author: Sophie Cheng is a senior medical social worker at Sengkeng General Hospital in Singapore, working primarily with with patients with hearing loss and their families. 

ACKNOWLEDGEMENTS: This study was supported by the Medical Social Workers, Ms. Elcoe Wan and Ms. Koh Poh Lin.   
Blasca, J.K. (1998).  Cyclical Grieving, Recurring emotions experienced by parents who have children with disabilities.
Chihiro, Y (2011) Maternal Stress in Mothers with Children with Special Needs. Green, S. E. (2007). “We’re tired, not sad”: Benefits and burdens of mothering a child with a disability. Social Science and Medicine Vol 64: 150-163.
Leiter, V; Kraus, M. W.; Anderson, B; Wells, N (2004) The Consequences of Caring Effects of Mothering a Child with Special Needs. In Journal of Family Issues April 2004 29(3): 379-403.
Low, W.K. (2005). Managing Hearing Loss in Children and Adults: Singapore Context. Annual Academic Medicine Singapore 2005;34:295-300.
Poon, C.H. (30 September 2010) Hearing Loss - The Stigma. The Straits Times - Mind Your Body.
Ryan, H.A.M. (2012). Mother Child Attachment Development in Children with Hearing Loss: Effects of Early versus Late diagnosis of hearing loss.
Taylor, J. (2010) Supporting Children with Special Needs: Bullies, Victims, Bystanders. In Ng, E & Rigby (Eds) Breaking The Silence: Bullying In Singapore. Singapore: Armour Publishing. Pp. 183-206.
Verbrugge, L.; Mehta, K.K.; & Wagenfeld-Heintz, E. (2005) Working Paper Series: Views of Disability in the U.S. and Singapore. Singapore: Asia Research Institute, National University of Singapore.
Young, A., & Tattersall, H. (2007). Universal newborn hearing screening and early identification of deafness: Parents’ responses to knowing early and their expectations of child communication development. Journal of Deaf Studies and Deaf Education 12 (2), 209-220.

Friday, September 21, 2018

Dr. Mango.JPGOver 69 million people in the United States suffer from vestibular disorders that adversely affect their quality of life. As such, for this year's Balance Awareness Week, we highlight the invisible yet debilitating challenges of imbalance and dizziness to promote proper intervention and awareness of the complexities of vestibular conditions.

Addressing these issues are at the forefront of the practices led by Howard T. Mango, AuD, PhD, in Newport Beach and Ladera Ranch, CA. Since embracing the growing field of vestibular testing in the late 70s, Dr. Mango has become an expert in the field and pioneered the latest technology and techniques in vestibular rehabilitation. But his vocation comes with challenges—and opportunities that he gladly explored with The Hearing Journal.

Hearing Journal: Dizziness and balance disorders are invisible but serious disabling concerns. What has been the top challenge in managing patients with these conditions?

Dr. Mango:One of the top challenges is seeing patients who have been previously tested and deemed not having vestibular dysfunction. Following our comprehensive evaluation, we often discover these patients have pronounced vestibular deficits. 

Test batteries where only a VNG is performed, which is widely accepted as standard diagnostic procedure, misses up to 68 percent of patients who actually have vestibular deficits. This is confirmed in the 2010 study by Chung and Chu. ​ Our practice utilizes a comprehensive approach to diagnostic testing, which assesses all ten end organs of the inner ear in both a static and dynamic state.

Hearing Journal: How would you characterize a patient-focused care in managing balance/vestibular issues?

Dr. Mango: At the Newport-Mesa Audiology Balance & Ear Institute, patient-focused care starts with a differential diagnosis of each individual patient and establishing a treatment program customized for each patient's individual vestibular deficits. 

Through comprehensive testing, we can focus our care to each patient's specific vestibular dysfunction. Then, individualizing our proprietary Advanced Vestibular Treatment (AVT) to each patient, we can provide truly patient-focused care versus a 'one-size-fits-all' approach. 

Hearing Journal: We've been seeing impressive innovations in hearing technology. What technological updates in vestibular treatment are you most excited about?

Dr. Mango: We're most excited about our "Vestibular Virtual Reality" (VVR) technology that we're developing in conjunction with Mark Cuban. Our use of propriety optokinetic stimulation and eye-tracking software delivered through customized AVT enables us to treat patients remotely from around the world. It's very rewarding to have such substantial results in patients' quality of life, with the convenience of tele-medicine.