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ToT 10

Eyes Open, Ears On: Supporting Hearing Technology Use in Children with Hearing Loss

Smith, Joanna MS, LSLS Cert. AVT; Wolfe, Jace PhD, CCC-A; Stowe, Darcy MS, LSLS Cert. AVT

Author Information
doi: 10.1097/01.HJ.0000755524.04499.e2
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“Eyes open, ears on!” This has been a mantra we have proclaimed to families of children with hearing loss for over a decade at Hearts for Hearing. The meaning of the statement is simple enough. A child who has hearing loss should wear her/his hearing aids, cochlear implants (CIs), or bone conduction devices during all waking hours. And although the point of the message may be fairly simple and memorable, its execution is quite challenging, especially for infants and young children. In reality, the rigors of life present numerous barriers to our goal of keeping hearing technology on throughout all waking hours of a child's life. Given the importance of consistent access to a language-rich listening environment replete with intelligible speech throughout the critical period of language development, pediatric hearing health care providers must do everything we can to support families in making “eyes open, ears on” a reality for their children.

Photo Credit/Hearts for Hearing, hearing aids, pediatric audiology, hearing loss.
Photo Credit/Hearts for Hearing, hearing aids, pediatric audiology, hearing loss.
Photo Credit/Hearts for Hearing, hearing aids, pediatric audiology, hearing loss.
Figure 1:
Age-Specific Goals for Wear Time, hearing aids, pediatric audiology, hearing loss.
Figure 2:
Examples of Hearing Aid and Cochlear Implant Retention Products, hearing aids, pediatric audiology, hearing loss.

Over the past decade, numerous researchers have explored the issue of hearing aid and CI wear time in infants and young children. These studies have evaluated the hours of wear time children achieve during the first few years of life, factors that influence wear time, and barriers that prohibit full-time use of hearing technology. Several researchers and clinicians have offered excellent advice for supporting families in facilitating full-time use of hearing technology. This installment of Tot 10 will highlight key studies that focus on strategies pediatric hearing health care providers can deploy to make “eyes open, ears on” a reality for the children they serve. This series is dedicated to all the hearing health care providers and researchers who are committed to the quest of supporting full-time use of hearing technology, including but not limited to Karen Muñoz, Sophie Ambrose, Elizabeth Walker, Mary Pat Moeller, and the rest of the Outcomes of Children with Hearing Loss (OCHL) study team, Lisa Park and colleagues at the University of North Carolina, and Dana Suskind.

10. Typical Wear Time: What Does the Research Say?

Christine Jones and Manuela Feilner1 provided one of the first published reports on hearing aid data logging to examine wear time trends in children. Jones and Feilner reviewed data logging records for 6,696 children and adults who were fitted with Phonak hearing aids at clinics across the United States. They reported that infants and young children (birth to four years old) used their hearing aids for an average of only 4.5 hours per day. Elizabeth Walker and her OCHL colleagues2 reported on a group of 272 children, ages 6 months to 7.3 years old, and noted an average of 8.3 hours of hearing aid use per day for the entire age range. Muñoz, et al.,3 examined data logging for 29 hearing aid users (7 months to 6 years old), and reported a median use of 7.5 hours per day with 56% of children under five years of age wearing their hearing aids for six hours per day or less.

Lisa Park and colleagues4 defined full-time CI use as wear time of at least 80% of a child's waking hours. They estimated waking hours based on a meta-analysis of studies that indicated the typical number of hours a child sleeps at different ages.5 For instance, during the first year of life, a child sleeps approximately 14 hours a day, which leaves 10 hours awake. Consequently, full-time use would be defined as eight hours per day. In contrast, a 3-year-old child is typically awake 12 hours per day, so the full-time use would be defined as 9.6 hours per day. Park, et al.,4 reported that only 53% of children with CIs achieved full-time use during the first two years of CI use. Collectively, research exploring the wear time has indicated that many children are not using their hearing technology during all waking hours.

9. Tracking Time: A Moving Target

Walker, et al.,2 found that caregivers overestimated hearing aid wear time by an average of 2.6 hours per day compared to the information obtained from data logging records. Similarly, Muñoz, et al.,3 found that caregivers overestimated hearing aid wear time by an average of 3.36 hours per day. Walker and colleagues6 reported that caregivers were likely to overestimate hearing aid wear time for children under four years old, but found good agreement between caregiver report of wear time and data logging for school-age children.

Walker, et al.,2 noted that it is reasonable to expect it to be harder for caregivers to estimate wear time for younger children. Infants and toddlers are likely to have many situations in which hearing aids are removed, such as frequent naps, bath time, and times when the child cannot be monitored. Certain situations (e.g., riding in a car, temper tantrums, etc.) may also lead the caregiver to remove the hearing aids due to concerns of choking and device loss or damage. Frequent removal and insertion of hearing aids in these situations make it difficult to achieve full-time use and may make it difficult to estimate daily wear time.

Alternatively, the method by which the hearing technology data logging system tracks wear time may underestimate daily hours of use. For example, some hearing aids store wear time in the instrument's permanent memory after every 60 minutes of use. As a result, if a child wears the hearing aids for 59 minutes before powering off, data logging will not store the information during that wearing session, and wear time will be lost. Likewise, if the hearing aids are worn for one hour and 59 minutes, data logging will record only one hour of use. As previously mentioned, younger children may wear their hearing aids for multiple short intervals throughout the day, and consequently, there may be several instances in which part or all of a wearing interval may be lost. In these cases, data logging may underestimate a child's wear time.

Some hearing devices log wear time on a minute-by-minute basis, whereas other devices only log on an hourly basis. Thus, clinicians need to understand the underlying protocol a child's hearing technology uses to store log wear time. For younger children, it may be helpful to ask families to keep a diary that details wear time, including the times and reasons for which hearing technology is removed throughout the day.

8. Factors That Influence Wear Time

Research has identified several factors that influence hearing technology wear time. Numerous studies3,4,6 have shown that wear time is significantly lower in younger children (i.e., birth to four years old). For instance, Walker, et al.,6 reported median wear times of approximately 3.5 hours, 8 hours, and 11 hours for children from 0 to 24 months, 2 to 4 years old, and 5 years and older, respectively.

Research has also suggested that the degree of hearing loss affects hearing aid use, with more wear time observed in children with greater degrees of hearing loss,3,6 especially outside school hours. Additionally, less wear time is associated with lower maternal education levels,6,7 lower income levels7 (e.g., children whose health care costs are covered by Medicaid instead of commercial insurance), lower non-verbal IQ,8 presence of additional disabilities and/or comorbidities other than hearing loss,6,7 and the use of sign language instead of listening and spoken language alone.7

7. Barriers to Full-Time Use

Research has also highlighted several barriers to the full-time use of hearing technology. Many barriers were quite practical, including earmolds becoming too small, acoustic feedback, middle ear infections, temper tantrums, removal of the hearing technology to explore the device (e.g., chew on it, toss it, etc.), and challenges in monitoring hearing technology use at all times because of the needs of other siblings, work, etc. Infants and young children were also less likely to use their hearing technology during all waking hours when caregivers were uncertain of the proper way to use, care for, and maintain the devices. Muñoz, et al.,9 found that many caregivers reported not being sufficiently educated on the topic of hearing aid insertion and care, and as a result, they were less comfortable supporting full-time use. Also, 56% of caregivers reported that they were confused about retention strategies to keep hearing technology on the ears during all waking hours and prevent the child from removing (and potentially losing or damaging) the devices. Caregivers often reported not feeling equipped to handle situations in which their child removed their hearing technology during a tantrum or meltdown.

Muñoz and colleagues3 also found that many caregivers did not demonstrate an understanding of the importance of full-time use of hearing technology. Caregivers frequently reported that they were confused about what their children could hear with and without hearing technology, and they did not fully understand the benefit of hearing technology use or the detriment of non-use to their child's development. Caregivers often reported that they did not realize the connection between wear time and listening and spoken language outcomes. Some caregivers even reported that they were never informed that their child should use the hearing technology during all waking hours or a recommended number of hours of use per day.

Interestingly, Muñoz, et al.,9 found that 40% of families reported being overwhelmed with the amount of information they received at their child's hearing aid fitting appointment. However, 84% of families stated that, in retrospect, they would still want to receive comprehensive information regarding hearing aid care at the fitting appointment. Moreover, families noted that they preferred to receive information via multiple mediums (e.g., verbal, demonstration, written, video, etc.) and across multiple points in time.

Muñoz and colleagues3,9 also identified many psychosocial-emotional factors that affected wear time. They noted that caregivers of children with disabilities are more likely to experience depression, grief, and difficulty coping with their child's health issues and that 46% of mothers who reported symptoms of depression also reported that their depression made it difficult to take care of responsibilities at home and work. Only 36% of respondents in their 2015 study9 reported that their hearing health care professional helped them manage their emotions relative to their child's hearing loss. Additionally, 29% were concerned about others’ thoughts regarding their child's hearing loss, and 73% reported concerns about how they would manage their child's feelings about hearing aid use. Moreover, caregivers commonly reported that they wished they were better connected with other families of children with hearing loss so they could support one another.

6. Wear Time Really Matters!

Several studies have explored the relationship between wear time and listening and spoken language outcomes. Bruce Tomblin and the OCHL team10 found better language outcomes for children who used their hearing aids more than 10 hours per day relative to those who used their hearing aids for less than 10 hours per day. More specifically, children who used their hearing aids for at least 11.5 hours per day had standardized language scores that were approximately one-half of a standard deviation better than children who used their hearing aids for less than 10 hours per day.

Similarly, Park, et al.,4 found that the age at which a child achieved full-time CI use (i.e., at least 80% of waking hours) was a strong predictor of receptive and expressive language at 3 years. In fact, the age at which full-time CI use was achieved was a stronger predictor of language outcomes than the age at implantation. Every child who achieved full-time CI use by 24 months had normal language development at three years of age. Furthermore, Easwar, et al.,11 found a significant association between CI wear time and speech perception.

5. Eyes Open, Ears On Goals: What Gets Measured Gets Done!

In consideration of the challenges involved with supporting full-time hearing technology use along with the research exploring the factors associated with hearing technology use, Hearts for Hearing has created Eyes Open, Ears On, a program with the primary objective of supporting families achieve full-time use of hearing technology. The program has five general components: (1) goal setting, (2) education, (3) retention strategies, (4) coaching and advocacy, and (5) continual assessment and adjustment.

For goal setting, we took a page out of the University of North Carolina book and have developed wear time goals based on the number of hours a child is expected to be awake as a function of her/his age. Full-time use is defined as 80% of expected waking hours, and age-specific goals are shown in Figure 1. Of note, Muñoz and colleagues3 provide great scripts for introducing data logging and data logging goals to families. Families must understand that full-time hearing aid use is a big challenge for infants and young children, and professionals should assure families that we are partners in their journey of optimizing their child's development. We will work together to identify wear time goals, identify barriers to and solutions for full-time, evaluate areas of need and support, provide support and resources as needed, and celebrate successes together. We are currently in the process of determining the optimal frequency to track wear time progress and discuss data logging with families relative to wear time goals.

4. Family/Caregiver Education: Knowledge Is Power!

To eliminate many of the barriers to full-time hearing technology use, pediatric hearing health care providers must ensure families are fully informed on several topics, including an understanding of hearing loss, hearing technology care, use, and maintenance, unaided and aided auditory function, hearing technology benefits and limitations, the connection between wear time and developmental outcomes, strategies to manage a child's behaviors that affect wear time, and considerations about the emotional aspects surrounding childhood hearing loss. The Eyes Open, Ears On program contains multifaceted educational components, including:

  • Anatomy and physiology of the auditory system with a focus on the parts and functions of the ear that are affected by hearing loss
  • Understanding the audiogram and the Familiar Sounds Audiogram
  • A description of a child's unaided and aided auditory performance, including simulations of hearing loss (see Sensimetrics, Audioscan Verifit, etc.), the unaided and aided Speech Intelligibility Index, and the Situational Hearing Aid Response Profile
  • A discussion and demonstration of proper use, care, maintenance, and troubleshooting of hearing technology
  • A discussion of research that shows the relationship between wear time and outcomes
  • A discussion of auditory brain development and the research showing the impact of auditory deprivation on brain development
  • Videos showing the listening and spoken language abilities of other children with similar hearing loss

Again, this information should be provided in multiple mediums (verbal, written, demonstration, video, etc.) and multiple times throughout the early intervention period. The exact frequency and mode of delivery required to optimize wear time have yet to be determined. Listening and Spoken Language Specialists (LSLS) see families frequently during the first years of a child's life and are consequently well-positioned to be a primary source of this information and support for families.

3. Reinforcing Retention

As noted above, many families reported confusion regarding optimal strategies to achieve retention of hearing technology. Figure 2 provides examples of products that may be used to aid in the retention of hearing technology. Professionals should ensure these products are recommended and available to families as needed. Professionals should also routinely query families about retention issues and brainstorm approaches that are most likely to address the specific challenge the family is encountering.

During the infant and toddler stage, children are more likely to remove their hearing technology to curiously explore their devices or to punctuate a tantrum. Pediatric hearing health care professionals should equip families with behavior modification and management strategies so they are prepared and able to effectively manage temper tantrums and meltdowns and minimize the effect of these outbursts on wear time. Conscious Discipline, parent-child interaction training, love, and logic are all examples of approaches that can be effective in managing the emotional well-being of young children. The pediatric hearing health care team should be well equipped (either through training or the addition of an Infant Mental Health Specialist to the collaborative care team) to provide training that enables families to incorporate the strategies of these programs into the care provided for their children. Professionals should recognize the power of acknowledging to families how challenging it is to keep hearing technology on the ears of an active infant or toddler so caregivers do not feel like they are personally failing. Nearly all families will fight the retention battle during some point of the infant-toddler stage. The phase will pass, and every minute spent keeping a child's hearing technology on her/his ears will pay big dividends in future developmental outcomes.

2. Coaching and Advocacy

Caregiver coaching is one of the most important aspects of pediatric hearing health care. Early and accurate fitting of hearing aids and cochlear implants is critical, but a child's listening and spoken language skills will not be optimized unless she/he uses that technology during all waking hours and is provided with a language-rich listening environment. An LSLS is uniquely equipped to coach caregivers to support full-time hearing technology use and the provision of a robust model for spoken language development. Caregiver coaching is an expansive topic that cannot be adequately summarized within the scope of this article. However, comprehensive caregiver coaching should include active listening, health coaching, use of content delivered via multiple mediums and at appropriate health literacy levels, principles of behavioral change theory, motivational interviewing, consideration for a variety of adult learning styles, energetic intentions, etc. Pediatric hearing health care professionals should be aware of the need for referral to support caregivers who are experiencing depression or grief that cannot be supported by the provider's skillset. Pediatric hearing health care professionals should also be aware of the ethics associated with inaction so appropriate referrals may be made when a child's needs are being neglected.

1. Assessments and Adjustments

The pediatric hearing health care team should continually evaluate each family's needs and progress to ensure the child is on track to maximize her/his listening and spoken language potential and to determine the supports and resources necessary to optimize a child's development. Many parents may feel unprepared to adequately manage hearing technology, so professionals should evaluate the caregivers’ comfort level with hearing technology. Many great questionnaires exist to assess caregiver hearing technology management abilities, including the Parent Hearing Aid Management Inventory,9 the Early Device Questionnaire,12 and the Practical Hearing Aid Skills Test.13

Parents are also more likely to facilitate full-time use of hearing technology if they are confident in their skills to manage their child's needs related to her/his hearing loss. Ambrose, Appenzeller, and DesJardin14 developed the Scale of Parental Involvement and Self-Efficacy – Revised (SPISE-R) to evaluate parents’ beliefs, knowledge, confidence, and actions relevant to supporting their child's hearing device use and language development. Professionals should consider administering the SPISE-R and at least one of the hearing device questionnaires above to evaluate caregivers’ needs and provide resources and supports to meet those needs.

Research has also shown that caregivers may struggle to support their children's needs because they are struggling with depression or other emotional difficulties. The Depression Anxiety Stress Scales (DASS) is a measure designed to evaluate the negative emotional states of depression, anxiety, and stress.15 Professionals should consider routine inclusion of the DASS or a similar measure to identify psycho-emotional challenges that may serve as barriers to a child receiving the support she/he needs from caregivers. Again, professionals should provide that support as needed and recognize when to refer to other professionals when the needs of the family exceed the skillset of the hearing health care provider.

Finally, achieving full-time hearing technology use is very unlikely if the caregivers’ basic needs of food, water, shelter, overall health, and safety are not being met. If a family is food insecure, which is a reality for almost one-quarter of American households, full-time use of hearing technology understandably becomes less likely. If domestic abuse exists within the home, full-time hearing technology use becomes less likely. Professionals should consider the completion of questionnaires that determine whether basic life needs may serve as a barrier to full-time hearing technology use. Ideally, the pediatric hearing health care team should include a mental health professional (i.e., counselor or social worker) who can evaluate basic life needs of families and identify resources to help meet those needs as necessary. When serving children with hearing loss, we should consider the entire family to be our patients. Gold standard pediatric hearing health care is holistic in its assessment and intervention.

In closing, full-time use of hearing technology is a challenge with infants and toddlers, but it's not an insurmountable one. Research has shown significantly better listening and spoken language outcomes for children who use their hearing technology during all waking hours, especially during their formative years of development. Professionals should continuously evaluate and support the needs of families to achieve full-time hearing technology use. Eyes open, ears on!


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