Secondary Logo

Online Only

Access online-exclusive articles and updates published ahead of print.

Tuesday, March 5, 2019

By Pei-Hua Chen, PhD; Tang-zhi Lim, MSc; and Shu-Fen Yeh, MSc

Chen was only 8 months old when he was diagnosed with hearing loss after his universal newborn hearing screening test (UNHS), just a year after the test's first implementation in Taiwan in 2012. In contrast, Zhu was diagnosed with hearing loss 29 months before the UNHS. Before the implementation of the UNHS, the average age of pediatric hearing diagnosis was around 42 to 48 months old, and only very few children were diagnosed before 24 months old (Halpin, Smith, Widen, & Chertoff, 2010; Sininger et al., 2009; Yoshinaga-Itano, 1999). Notably, some studies have demonstrated that diagnosis before a child turns 3 months old and early intervention before 6 months may greatly improve the child's language outcomes (Yoshinaga-Itano, Sedey, Coulter, & Mehl, 1998; Moeller, 2000). Thus, the UNHS has a pivotal role in shortening early identification waiting time and ensuring early intervention and prompt treatment for these children.


Social marketing addresses the needs of target audiences, promoting behaviors that maximize their welfare, whereas the 4Cs marketing structure (consumer needs, cost, convenience, and communication) focuses on promoting target concepts or behaviors among target audiences (Lauterborn, 1990). Social marketing concerns the desire of target audiences for improved quality of life and health, and balances their willingness to pay for it. Communicating with target audiences is crucial to understand their needs and to provide assistance by shaping behaviors and attitudes. The goal of the UNHS is to address and fulfill health-related needs; therefore, the 4Cs theoretical framework, which is based on consumer views, may be used to investigate consumer-oriented behavioral responses after UNHS implementation (Draskovic & Valjak, 2012). We take the Children's Hearing Foundation (CHF) as an analytic example, because the CHF started auditory–verbal (AV) sessions for children with hearing loss over 20 years ago in Taiwan. We analyze the effects of the UNHS on public awareness and share ways in which the CHF had utilized the 4Cs of social marketing after the implementation of the UNHS (see Fig. 1).



Consumers' willingness for improving their health and quality of life is often unclear; thus, defining the meaning of these needs and the actions that must be changed to achieve health benefits is essential to social marketers. Between the conception of the UNHS in 2012 and the end of 2015, 1039 families (a total of 45,406 people) contacted the CHF regarding AV sessions. The first contact period of parents to the CHF has been decreasing significantly each year, from an average of 311 days required in 2012 to 133 days in 2015 (F[3,363] = 9.45 , p < .001), meaning that the first contact period in 2015 was significantly shorter than those in 2012, 2013, and 2014. Furthermore, the age of intervention decreased significantly from 610 days in 2012 to 377 days in 2015 (F[3,363] = 11.65 , p < .001), and the post hoc analysis results were similar to the first contact period. The results have demonstrated the need for early intervention.


People with hearing loss might face more language-related, social, behavioral, and emotional-development difficulties than their peers without hearing loss do (Stevenson et al., 2017; Theunissen et al., 2014; Wong, 2017). Because Taiwan's UNHS program is still young, few studies or reports exist on the effects of the UNHS, meaning that the real costs of the UNHS are difficult to investigate. The World Health Organization (WHO, 2017) estimated that the annual average cost of education support for children with hearing loss worldwide is approximately US$3.9 billion. In addition, the social cost of social isolation or communication difficulties related to hearing loss is estimated to be approximately US$573 billion per year.

Moreover, Lee (2007) calculated the estimated costs of the UNHS using the formula proposed by Gorga and Neely (2003): According to this estimate, if a child receives the UNHS when he or she is born, then immediate intervention, special education classes during preschool, and further education in a mainstream school might save US$117,075 in education costs. Furthermore, people with severe or profound hearing loss can receive approximately 30% less income than their peers without hearing loss. In other words, people with the aforementioned levels of hearing loss might lose US$220,000 to US$440,000 income before their retirement (Shield, 2006). People with superior language outcomes may save approximately US$428,000 of social cost expenses in their entire lifetime compared with those with poor language outcomes. For this reason, using early intervention to improve language outcomes among people who have hearing loss might change productivity loss by an estimated 75% over their entire lives.


UNHS implementation means that many infants with hearing loss can be screened very early. The demand for early intervention is consequently higher. To provide relevant information on early intervention and to frequent AV sessions, the CHF not only established four service centers in various parts of Taiwan for face-to-face intervention but also offered online AV (telepractice) sessions for families unable to attend face-to-face intervention sessions. Moreover, the CHF also provided home-visit service sessions for families in rural or remote areas and completed approximately 25 home-visit service sessions by the end of 2015. Calculations using Google Maps confirm that the CHF has saved families in remote areas approximately 65.34 miles' worth of travel to AV sessions. Moreover, home-visit service sessions have also reduced time spent attending AV sessions by nearly 134.66 minutes for families traveling by car and by 183.16 minutes for families taking public transportation. Most notably, both telepractice and home-visit services also supported families unable to visit the CHF regularly—for reasons related to pregnancy, physical weakness, or large families—such that children with hearing loss in these families could receive AV sessions without interruption.


To emphasize the importance of early intervention and to counter stereotypes about hearing loss, the CHF actively engaged and communicated with public and target audiences through various platforms and planned various courses. From 2012 to 2015, approximately 232 people per year attended the CHF's experience courses and institution visits. Approximately 13,862 people per year used the CHF's Newborn Hearing Screening Consultation Hotline to get hearing-related information. Moreover, the CHF has provided e-newsletters to approximately 6,863 subscribers per year, and about 190,567 people access their website per year. In addition, the CHF established a Facebook fan page, which is regularly updated with hearing-related information and events.

First contact periods shortened every year after the implementation of the UNHS, and the proportion of families that contacted the CHF increased by 75% at the end of 2015. However, the mother or grandmother of a child with hearing loss was the person most likely to call the CHF, according to our statistics. This result indicates public recognition that early intervention is valuable. Obtaining information is no longer a passive process; the public has begun to actively obtain relevant information through various platforms.

In all, the impact of the UNHS shows that public awareness has incrementally increased along with the demand for early intervention.

 Acknowledgment: We want to thank our research assistants, Ms. Huang Wan-Qi and Mr. Liu Ting-Wei from Children's Hearing Foundation for collecting and coding the data.

ABOUT THE AUTHORS: Pei-Hua Chen is a research fellow at the Speech and Hearing Science Research Institute, Children's Hearing Foundation in Taiwan, where Tang-Zhi Lim is a research assistant focusing on popular science writing from the perspective of psychological view. Shu-Fen Yeh is an executive officer of the Children's Hearing Foundation in Taiwan.

Carney, A. E., & Moeller, M. P. (1998). Treatment efficacy: Hearing loss in children. Journal of Speech, Language, and Hearing Research, 41(1), S61-S84.

Draskovic, N. & Valjak, A. 2012. The 4Cs of the Croatian public healthcare system: social marketing challenges at the dawn of EU accession. World Review of Entrepreneurship, Management and Sustainable Development, 8(2): 221-235.

Gorga, M. P. & Neely, S. Y. 2003. Cost-effectiveness and test-performance factors in relation to universal newborn hearing screening. Mental Retardation and Developmental Disabilities Research Reviews, 9: 103-108.

Halpin, K. S., Smith, K. Y., Widen, J. E., & Chertoff, M. E. 2010. Effects of universal newborn hearing screening on an early intervention program for children with hearing loss, birth to 3 yr of age. Journal of the American Academy of Audiology, 21(3): 169-175.

Shield, B. 2006. Evaluation of the social and economic costs of hearing impairment. Hear-it AISBL, 1-202.

Sininger, Y. S., Martinez, A., Eisenberg, L., Christensen, E., Grimes, A., & Hu, J. 2009. Newborn hearing screening speeds diagnosis and access to intervention by 20-25months. Journal of the American Academy of Audiology, 20: 49-57.

Stevenson, J., Pimperton, H., Kreppner, J., Worsfold, S., Terlektsi, E., Mahon, M., & Kennedy, C. 2018. Language and reading comprehension in middle childhood predicts emotional and behaviour difficulties in adolescence for those with permanent childhood hearing loss. Journal of Child Psychology and Psychiatry. 59(2), 180-190.

Theunissen, S. C., Rieffe, C., Kouwenberg, M., De Raeve, L. J., Soede, W., Briaire, J. J., & Frijns, J. H. 2014. Behavioral problems in school-aged hearing-impaired children: the influence of sociodemographic, linguistic, and medical factors. European Child & Adolescent Psychiatry, 23(4): 187-196.

Wong, C. L., Ching, T. Y., Cupples, L., Button, L., Leigh, G., Marnane, V., ... & Martin, L. 2017. Psychosocial development in 5-year-old children with hearing loss using hearing aids or cochlear implants. Trends in Hearing, 21: 1-19.

Yoshinaga-Itano, C. 1999. Benefits of early intervention for children with hearing loss. Otolaryngologic Clinics of North America, 32(6): 1089-1102.

Thursday, January 3, 2019

By Sandro Burdo,  MD

The first year of life is the most important time for linguistic and cognitive development as human beings exploit their higher neuro-plasticity capacity for learning. In this period, the inter-neural connections will form on the basis of sensory experience mainly of the hearing apparatus, which is a real cognitive hub for the configuration of the individual connectome (Lancet Neurol. 2016; May;15(6):610). This is why congenital hearing loss not only involves hearing difficulties but also affects the linguistic and cognitive spheres.


Today, it is well-established that hearing is crucial for the brain maturation, which makes newborn hearing screening vital. In the same way, it is clear that a cochlear implant (CI) surgery is the preferred treatment for disabling deafness. However, due to evident and practical reasons, CI surgery cannot be carried out at birth and has to be postponed by some months, during which other rehabilitative activities must be organized. The aim of these activities is not to complete hearing recovery but to kick-start adequate linguistic and cognitive development.

For this purpose, clinicians should not forget that the residual hearing ability of a profoundly deaf child can be used as a support to activate the communicative pre-requisites of verbal communication. This way the deaf child is able to develop the skills to detect and meaningfully process speech that can be phonetically discriminated through lip reading*[1] but not through the hearing. As such, before CI surgery, it is essential to use visual inputs to guarantee linguistic-cognitive development, as residual hearing is insufficient.

But residual hearing must not be abandoned; it must be stimulated for functions it can fulfill without pushing for other unreachable functions like phonetic discrimination.

Before the age of CIs, it was well-established that severely deaf people were capable of perceiving low-frequency sounds, activating spatial awareness, attention, auditory detection, and processing prosodic speech features (acoustic contour of speech) that transmit communicative meaning during the first months of life (semantic prosody; RERC, 2000).

The rationale was about the role of residual hearing in activating communication pre-requisites so that lip reading could advance to phonetic discrimination, and consequently, the central nervous system could elaborate words (identify then recognize) to reach verbal comprehension (see Fig. 1). To get effective results, hearing aids had to be fit not only to deliver high amplification but also to extend this feature to low-frequency sounds, amplifying acoustic energy especially in the bandwidth where the child has more efficient residual hearing (Ross 2000).

Burdo Figure 1.jpg

Unfortunately, high amplification of the low-frequency sounds is taken for granted in modern digital hearing aids that can sufficiently compensate all degrees of hearing loss (except the more profound ones). Furthermore, the bandwidth limit is associated with a high cost due to the sophisticated electronics that are hardly ever used in this kind of hearing loss. We can call these powerful, low-frequency hearing aids "prosodic" as they leave out sophisticated acoustic features that are useless for people with profound hearing loss. Thanks to these characteristics, prosodic hearing aids can be sold at significantly lower prices.

Going back to clinical practice, it seems obvious that the clinicians must fully understand two things to ensure an optimal pre-operative rehabilitation: They must activate the pre-requisites for verbal communication and facilitate the development of lip reading skills enable rehabilitation. Once again, the importance of communication pre-requisites must be underlined because, before the surgery of people with severe-to-profound deafness, it is not possible to enable any further processing after prosodic discrimination. However, it should be noted that any communicative process cannot start without activating the communication prerequisites of awareness and attention.


Another form of hearing transmitted in the low frequencies is unconscious primitive hearing, which was described by Ramsdell at the end of World War II as one of the skills lost after a sudden hearing loss (Ramsdell 1978). Ramsdell described four hearing levels as follows:

1. The primitive level gives us the subconscious perception of background sounds completing the 180 degrees of the visual space for the environment's control. Ramsdell asserts that the perception of these sounds maintains our feeling of being a part of a living world. He comes to the conclusion that the loss of sound's perception on the primitive level is the major cause of depressive feelings reported by deaf adult patients. Furthermore, the lack of this hearing level could explain the motor hyperactivity that, as we have seen in our clinical experience, is highly common in deaf children. It may be related to the patient's needs of checking the environment around them and it is indicative that this kind of hyperactivity disappears with a correct sensory stimulation. The lack of these primitive functions could also be the cause of neck muscles hypotonia in babies. This inhibits proper contraction in response to a stimulus. It is useful to understand that the primitive level is sustained by the noise floor where low-frequency sounds are prevalent. It is also important to outline the concept that the noise floor keeps continuously active the unconscious primitive hearing level, but the same acoustic stimulus can stir the individual "awareness" when the brain decides to be conscious of the same sounds.

2. The warning level alerts and prepares us for action during a variation of the noise floor. At this level, we activate our attention, for example, to listen. 

3. The aesthetic level involves sounds that have an impact on our feelings.

4.  Finally, the symbolic level is when we understand speech to be informed, educated, entertained, and so on.


During the first months of life, it is important to provide the child with the necessary stimuli to activate the pre-requisites for communication and enable primitive hearing to give the child a feeling of safety. These stimuli can be provided using two devices: hearing aids for low-frequency amplification (prosodic hearing aids for primitive hearing, awareness, sounds detection, and semantic prosody) and a single-channel pre-sternal vibrator that has the unique function of activating communicative attention through signals (both environmental and verbal), giving "eyes in the back of one's head." While the skin doesn't allow for speech discrimination, it can be used to transmit the basic sounds. Recent research on the skin and speech discrimination have been confined to laboratories without any large practical diffusion. Moreover, our choice to place the vibrator on the skin over sternum was confirmed experimentally to be correct by Suarez, et. al (1997).

The vibrator and hearing aids must be used simultaneously all day and not only during the rehabilitation sessions. Only the combined use of these two devices can stimulate primitive hearing and activate the pre-requisites of communication in addition to prosodic discrimination. Clinical reports by Parravicini, et al., showed that using each device by itself is not as efficient as their combined use (2016). Primitive hearing and communication pre-requisites enable the easy construction of an individual connectome, which does not remain unaltered in the absence of stimulation but is destroyed without. As such, technology has to be used continuously.

Previous incorrect comparisons were made between the results obtained using CIs and a sternal vibrator. The results underlined the superiority of CIs (Carney 1993), and so sternal vibrators were eventually abandoned. However, this traditional method could still be useful in the first months of life of a severely deaf child until he or she undergoes surgery.

Some researchers also suggested the prolonged use of hearing aids and a sternal vibrator. Nittrouer and Chapman (2009) have demonstrated that children could benefit from a period of bimodal stimulation by delaying the bilateral surgery since prosody could aid in learning how to perceptually organize the signal received through a CI. Huang et al., (2017) combined electrical stimulation with tactile stimulation of the index finger, obtaining better results in noise when compared with electric stimulation alone.

If these last experiences confirm that tactile stimulation and prosodic amplification are beneficial in language acquisition and speech recognition, then it follows that they are absolutely indispensable in the period before the CI surgery because they represent the only tools to free the deaf child from silence.

Any treatment undertaken before cochlear implantation cannot be limited to checking whether a non-invasive technology is insufficient for a deaf child's complete rehabilitation, thereby justifying the CI surgery. Instead, clinicians must help a deaf child gain control his or her environment and form linguistic-cognitive connectome during this developmental period, keeping in mind the rule "Use it or lose it" in neurocognitive maturation (Burdo 2018).

[1] We use the terms "lip reading" in place of "speech reading" only for a historical reason because  the second expression is more correct (Ross 2000)

Burdo headshot.pngABOUT THE AUTHOR: 

Dr. Burdo is the Scientific Responsible of the Italian Association Free to Hear ( and a consultant otologist at the Bassini Hospital in Milan, Italy. 

He was the director of the audiovestibology unit at Varese Circolo Hospital where he led one of the main European centers for deaf rehabilitation.

Sunday, December 16, 2018

By Vinaya Manchaiah, PhD; Spoorthi Thammaiah; and Rajalakshmi Krishna, PhD

Sustainability has become the talk of today's stakeholders in the modern era in all areas from climate change to health care. In general context, sustainability refers to finding a way to use resources in a manner that prevents their deprivation. However, for charitable non-profit groups, the term "sustainability" refers to the organization's long-term ability to sustain itself and continue to fulfill its mission. Hence, the sustainability in the non-profit context extends beyond financial capacity and includes succession planning, adaptability, and strategic planning. Notably, the main aspect that most non-profits organizations struggle with is financial sustainability.

For a non-profit to be sustainable, the organization's key players need to know how much it costs to deliver the programs and services, so that they can raise enough resources to cover these costs. Otherwise, the organization will end up in a "starvation cycle" in which the main focus will become finding resources instead of accomplishing its mission. Hence, non-profits need to embrace a sustainable mindset from the beginning and review every stage and level of the organizational process—as is the strategy learned by Audiology India.


Audiology India is a non-government and not-for-profit organization that aims to promote hearing health care in India by breaking down known barriers to hearing service delivery. Founded by Vinaya Manchaiah, PhD, and Srikanth Chundu, AuD, in 2009, Audiology India was first established as a website that offered information about ear and hearing health care specifically for audiologists and audiology students. Expanding from the goals of a successful website, it has grown into a multidisciplinary team serving individuals with hearing difficulties, especially in suburban and rural communities. The group's main objectives are to:

(1) provide hearing health care services for underserved population using a community-based rehabilitation model;

(2) raise public and professional awareness of the importance of hearing health; and

(3) conduct high-quality research to understand the social and environmental factors that influence hearing health care outcomes and implement best practices in care delivery.

Audiology India mainly conducts free hearing screening camps and community-based hearing rehabilitation (CBHR). Hearing rehabilitation with hearing aids is conducted systematically in three phases that focus on the underserved and financially communities in the Southern India. So far, Audiology India has conducted 43 hearing screening camps and tested more than 2,100 individuals. At the screening camps, about 950 behind-the-ear (BTE) hearing aids have given for free to individuals who need them.

Audiology India also conducts public awareness programs on hearing and related disorders. Audiology India has organized more than 20 such programs so far including rallies, orientation programs, and newspaper articles.

In addition, Audiology India team has been conducting need-based research in the hearing-health sector in India. A survey-based project examined the practice across the country, places of work, and professional issues related to audiologists practicing in India (Indian J Otolaryngol Head Neck Surg. 2013 Dec; 65(Suppl 3): 636–644; Audiology Today. 2009;21(6): 38-44;; ENT & Audiology News. 2016; 25(1):73-74). Such surveys repeatedly provide evidence for the need to develop nation-wide guidelines for service delivery, diversification, and definition of clear roles for audiology professionals from varied degrees/background in training. More recently, the team members are involved in studying the efficacy and effectiveness of CBHR in comparison with the institution-based hearing rehabilitation (IBHR). First stage of this project was focused on translation and adaptation of structured outcome measures to Kannada language (Audiol Res. 2016 Apr 20; 6(1): 153; Int J Audiol. 2017 Mar;56(3):194-201; Disabil Rehabil. 2018 Nov;40(22):2650; Int J Audiol. 2018 Mar;57(3):161-175). In the current stage, we are gathering outcome data using these outcome measures to compare the hearing rehabilitation outcomes as a result of CBHR and IBHR service delivery models.


Funding requirements have grown since our humble beginning, where much of Audiology India activities were managed through collaborations. For instance, (CBHR) camps are usually sponsored by other government or non-government organizations (e.g., Rotary Clubs). However, our expanded objectives demand more directed funding to support an office, a full-time employee and travel expenses for volunteers.

Currently, we rely heavily on donations and fundraising activities conducted locally in Mysore, Karnataka. In the last seven years, the Audiology India team has conducted only two fundraising events. The team has agreed that the any fundraising initiative should have various other outcomes in addition to merely raising money, i.e., (1) promoting Audiology India's mission and activities; and (2) building good public relations.

The first fundraising activity was conducted in Mysore, India during July 2015. This included a musical event in which the local upcoming singers were recruited through auditions for a singing competition. The funds were raised through ticket sales paid by public for attending the music event and the event expense was generated through sponsorships. The second event was conducted in 2017 and it was a standup comedy show. These events generated ongoing news in the local media and by the end of the event most people in Mysore were aware about the organization and its mission.


After seven years of running a non-profit organization, we have identified various factors related to sustainability. Consider the ideas below that help ensure an organization's sustainability.

  • Have clarity of thought: People who are interested in humanitarian activities are enthusiastic. Often, they like to solve the problems in the world and they have plenty of ideas and projects in mind. The first step in making anything workable and sustainable is to develop clear objectives and working plan. Non-profit initiatives and organizations should give the highest importance to clarity of thought in their mission.
  • Keep costs low: There is no better way to be sustainable than keeping costs low. This could be related to products (e.g., finding affordable hearing aids of good quality, making earmolds in local place at cheaper price), services (e.g., finding volunteers, finding consultants who will work for limited allowances) and finding space (e.g., using schools during weekend as a place to offer services). Consider the best possible ways to reduce cost without compromising quality.
  • Recruit and retain committed volunteers: Volunteers play a key role in the success of charity and non-profit organizations. Attracting those who are interested in serving the organization, providing them with appropriate training, and keeping them engaged is important for sustainability. In our view, developing a good working relationship—in which volunteers become friends and not just co-workers—has proven to be an effective strategy. This way volunteers always find a way to meet, exchange ideas and to work on a common goal.
  • Collaborate with other organizations: Often the hearing health care organizations are small with limited resources. However, there are many other non-profit organizations with broader mission and sufficient resources. Hence, collaborating with such organizations by providing them required services in exchange to resources required to the organization could be one of the important considerations for ensuring ongoing endeavor.
  • Pilot test your service program to test feasibility and then scale it up: Many organizations often develop new ideas in launching a service program. To avoid the risk of failure, pilot test the program to see its feasibility and eventually scale it up to improve the chances of success and reduce risk.
  • Provide consultancy services to generate income: Often the volunteers of non-profit organizations may have various specialist skills. Such organizations can conduct various consultancy services (e.g., industrial hearing screening) in which volunteers will work for free and generate income that can be used to pay for key programs and services to meet the mission.
  • Conduct ongoing reviews and adaptation of goals and activities to ensure continuous work: Finally, one of the important elements of sustainability is to develop projects in such a way that there is continuity in work. Also, the goals and activities should be reviewed regularly  and necessary adaptations should be made to ensure the growth in the project meet service requirements.

ABOUT THE AUTHORS: Dr. Manchaiah is affiliated with Lamar University in Texas, as well as with Audiology India and the Manipal University in Karnataka, India. Ms. Thammaiah is affiliated with Lamar University in Texas, as well as with Audiology India. Dr. Krishna is affiliated with Audiology India and All India Institute of Speech and Hearing at the University of Mysore in India.

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.