Without clearly defined roles and responsibilities, important tasks in schools—such as hearing instrument listening and maintenance checks—don’t get done. Adhering to federal law, public schools need to delegate responsibilities and provide measures such as personnel, training, equipment and time to ensure adequate hearing instrument monitoring and maintenance.
Children who are deaf or hard of hearing are heterogeneous, and the effects of hearing loss on them are variable. Areas impacted by even minimal hearing loss include receptive and expressive language skills, speech production, academic achievement, pragmatic skills and self-concept.1,2 To combat the negative effects of hearing loss, federal regulations have been created and implemented to meet the needs of children who are deaf or hard of hearing. School districts are mandated to identify and assess hearing loss in school-age children, provide appropriate aural rehabilitation services and ensure that hearing aids worn by school-age children are functioning properly. As a result of improved federal regulations, more deaf and hard-of-hearing students are enrolled and mainstreamed in public schools.
In a mainstream classroom, a majority of learning takes place through listening and speaking modalities. Children spend 45% of the school day engaged in listening activities.3 Under these circumstances, even a minimal hearing loss can be educationally significant. The important goal of amplification—maximizing the use of residual hearing—cannot be overstated. However, several studies4-8 show that school-age children’s hearing instruments often malfunction, and no recent information exists to suggest that the issue of frequent hearing instrument malfunction among school-age children has been resolved. This issue is of significance for any educational program using an auditory approach in a mainstream classroom. As Potts & Greenwood7 point out, “If a child is to realize maximum auditory potential, amplification must provide reliable auditory input.”
Recognizing the need to monitor hearing instrument function, many schools have established systems for monitoring hearing instruments. Reichman & Healey9 found that a majority of schools have formal systems for monitoring hearing instruments. However, 54% of those systems were not effective in ensuring proper hearing instrument function. An adequate monitoring and maintenance system was one that included daily monitoring of hearing instruments and auditory trainers, loaner amplification with one-day availability and in-service training for teachers. Potts & Greenwood7 investigated the validity of a daily program for monitoring hearing instruments. Results indicated that daily monitoring programs could reduce the incidence of hearing instrument malfunction. In the same study, the authors concluded that “monitoring programs often miss problems that may significantly interfere with the goal of optimum amplification.”7
Ideally, most children who have a hearing loss receive habilitation services from a multidisciplinary team that includes an educational audiologist, speech-language pathologist, teacher of the deaf and hard of hearing, social worker, physical therapist, occupational therapist and school nurse. Of these professionals, the educational audiologist is the most knowledgable in ensuring the proper fit and function of hearing instruments. However, educational audiologists seldom provide monitoring services due to a shortage of educational audiologists nationwide. According to the American Speech-Language-Hearing Association (ASHA) Guidelines10, a ratio of one full-time audiologist for every 12,000 preschool through secondary students is recommended to provide comprehensive audiologic services. Based on this ratio, Anderson & English11 estimate that there is a need for more than 4000 educational audiologists in the schools.
Educational audiologists employed by school districts are often overburdened and are limited in their scope of practice by high caseload numbers and the number of schools to be served. Johnson12 suggests that it is not cost-effective for audiologists to carry out daily visual and listening checks on all children’s hearing aids; however, “an efficient use of time would involve the audiologist overseeing a district-wide hearing aid monitoring program involving the cooperation of other school personnel.”12
English13 reports that 98% of educational audiologists supported the responsibility of “ensuring that at least one person at the mainstream site would assume the responsibility of helping the hearing-impaired student with the daily hearing aid inspection, after receiving a basic instruction in monitoring and trouble-shooting problems with amplification.” When educational audiologists are absent, school districts often rely on other staff members, such as speech-language pathologists, to keep current on any audiological concerns and to follow up on audiological services.
Speech-language pathologists employed in educational settings appear to be appropriate candidates to monitor hearing instruments. The educational background for speech-language pathologists suggests they should have the expertise for providing assistance with amplification. In order to receive the Certificate of Clinical Competence (issued by ASHA), speech-language pathologists must complete professional course-work and obtain clinical hours in the collateral field of audiology. Clinical experience may include screening, evaluation and/or treatment of children and adults with a variety of hearing disorders, counseling, auditory training and speech reading.
Despite this training, many studies have shown speech-language pathologists lack the knowledge and educational background to provide assistance with amplification. Mosely et al.14 surveyed speech-language pathologists on demographic characteristics and their perceived adequacy of pre-professional training on providing services to children with hearing loss. The results suggested a “weakness in areas related to clinical experience with deaf individuals and the need for additional knowledge in such areas as emotional and vocational ramifications of deafness, evaluations of speech and language skills of children with hearing loss, availability and use of sensory aids, and administration of standardized and non-standardized tests in the client’s preferred communication modality.”14
In another survey of speech-language pathologists, 69% of respondents felt that their coursework and clinical practicum in the area of hearing instruments were inadequate.15 In the same study, 81% of respondents felt that classroom and clinical practicum training in hearing instruments is necessary for speech-language pathologists. Results also showed 47.7% of respondents had clients who wear hearing instruments. When tested on their knowledge of hearing aids, the average percentage of correct responses was 78.8%, with a range of 17-100%.
Woodford16 administered a written and practical examination on hearing instruments to 102 speech-language pathologists. Results indicated that speech-language pathologists lack much of the knowledge and skill necessary to provide adequate services in the area of amplification, and “the performance deficit is particularly evident in the practical aspect of checking hearing aid function, suggesting that the training provided places little emphasis on ‘hands on’ experience.”16 The findings also showed increased scores relative to each individual’s amount of experience and instruction. This indicates that speech-language pathologists tend to expand their amplification knowledge and skill base when, and if, the need arises.
Davis et al.17 surveyed public school personnel regarding their perceptions of children who are deaf or hard of hearing, their experience in working with that population and the need for in-service training on hearing impairment. When asked if they felt comfortable dealing with amplification, 54% of speech-language pathologists felt “slightly comfortable.” Eighteen percent of speech-language pathologists answered “no; would like help.” Only 2% answered “not my responsibility.” Various professional groups were also asked to respond to a question concerning problems that they, as professionals, have encountered with hearing instruments. Fifty-seven percent of speech-language pathologists reported problems with monitoring hearing instruments, and 25% reported that keeping hearing instruments in good repair was a problem. In this sample, many speech-language pathologists requested information about hearing instruments and their care, realistic expectations for hearing instrument use and more complete audiometric data on the individual children they service. The authors’ concluded that their findings suggest “a general disinterest in hearing aids, indicating a poor understanding of the role of amplification in the development and achievement of hearing-impaired children.”17
Educational speech-language pathologists play a vital role in service delivery to children who are deaf or hard of hearing. They are knowledgeable in a wide range of issues related to a child’s communicative development, and therefore should also have knowledge of the benefit and function of hearing instruments. A lack of understanding relative to hearing instruments may compromise treatment efficacy and negatively impact a hearing-impaired child’s academic achievement.
The present survey was designed to assess speech-language pathologists’ perceptions of preparedness and technical knowledge in working with hearing instruments. The survey differs from previous research in two ways: 1) Surveys were completed by educational speech-language pathologists employed within the State of Minnesota only. (Of the aforementioned studies, only one was conducted in the Midwest [specifically Iowa]), and 2) The most recent study in this subject area was conducted in 1994.
A 26-item survey was developed to gain understanding about speech-language pathologists perceptions and working knowledge of hearing instruments. Several questions were designed to obtain demographic information and assess perceived preparedness relative to amplification. Textbooks18,19 and websites (e.g., www.utdallas, www.audiologyawareness, www.earaces) were used as resources in the development of technical questions on various aspects of hearing aid function, hearing aid batteries and troubleshooting. Fill-in-the blank, multiple choice, yes-no and true-false formats were used throughout the survey. Six of the 14 technical items questioned participants on their knowledge of hearing aid batteries, because batteries are often the cause of hearing instrument malfunction. Problems with batteries can easily be rectified by a speech-language pathologist who has adequate training and supplies.
Surveys were mailed to 115 speech-language pathologists in educational settings throughout the State of Minnesota. All educational speech-language pathologists listed in the Minnesota-Speech-Language-Hearing Assn.’s (MSHA) Membership Directory (1999) were used, and the 115 participants were randomly selected. Initial contact with subjects was made when each subject received a cover letter and survey via mail. A follow-up reminder was mailed to each subject following initial contact, and follow-up procedures were implemented to ensure optimal response rates.
A total of 63 surveys were completed and returned, representing a 55% response rate. Survey results are summarized below using the following categories: demographic information, perceived professional preparedness relative to hearing instruments, monitoring hearing instrument function, technical knowledge of hearing instruments and hearing aid batteries.
- Demographic Information: The participants’ graduation dates from a masters program in the field of speech-language pathology were grouped in five-year periods between 1965 and 1999. Survey respondents were represented evenly in terms of graduation dates, with 35% graduating from 1965-80, 50% graduating from 1981-95 and 15% from 1996-99.
- Half (51%) of the participants were uncertain as to the number of clinical hours they obtained in the area of audiology. Prior to 1999, ASHA required graduate programs in speech-language pathology to require students to obtain 35 clinical hours in the area of audiology. It is logical to assume that those who were uncertain met the minimal clock hour requirements prevailing at that time.
- On average, participants reported having 1.8 children who are deaf or hard of hearing (according to the State of Minnesota criteria) on their caseload per year (Table 1). Many speech-language pathologists do not receive pertinent information from a student’s audiologist regarding the student’s hearing status (Table 2). However, according to survey results, most speech-language pathologists would like to receive audiologic information (Table 3), although about one-fifth (18%) reported no desire to receive information from a child’s audiologist.
- Perceived Professional Preparedness Relative to Hearing Instruments: When responding to the question of whether or not participants felt their graduate school experience prepared them with sufficient knowledge to effectively service students who wear hearing instruments, half (51%) of the participants responded “yes.” Those professionals who had graduated more recently tended to report that they were more prepared to provide effective hearing instrument services. One participant who answered “no” commented that “more hands-on with hearing aids would have been beneficial.” A participant who answered “yes” indicated that she would have to do some “refresher work” should the need arise. Another participant who responded “yes” noted, “I feel comfortable with my initial training in this area and have attended some additional in-services in this area.” Other comments included: “Since I have never been responsible for hearing aid maintenance, I have not updated my skills in that specific area” and “If I were assigned that role I would immediately seek additional training.” Finally, one participant responded that she did not feel as though her graduate program prepared her with sufficient knowledge to effectively service students who wear hearing instruments. Rather, she “learned those techniques on the job”.
- Only one-third of participants reported attending conferences or in-services in the area of amplification/hearing instrument maintenance in the past five years. When asked a question regarding their comfort level of trouble-shooting a hearing instrument, only one-third felt comfortable (Table 4). One participant answering “slightly uncomfortable” added “even after training.”
- Monitoring Hearing Aid Function: Over half (59%) of the survey participants reported having an amplification trouble-shooting protocol to follow if a child’s hearing instrument is suspected of not functioning properly. When asked to report the school professional who performs hearing instrument listening checks for students using amplification, participants named a wide array of school personnel (Table 5 ). Fourteen percent of participants reported that they are the ones, as educational speech-language pathologists, to perform hearing instrument listening checks.
- Over half (57%) of participants reported not having a troubleshooting kit at their disposal. A traditional troubleshooting kit would include a drying agent for removing moisture, pipe cleaners, battery tester, hearing aid stethoscope, spare batteries and an extra receiver.18 Several participants reported only having access to some of these items. For example, one participant circled only a battery tester and a hearing aid stethoscope. Another participant responded having access to “batteries only.”
- When asked the frequency of hearing instrument listening checks, participant answers ranged from daily to two times annually (Table 6). Only about one-third of participants reported that hearing instrument listening checks occur daily. When asked if the “Ling 6 Sound Test” (i.e., used to determine a child’s detection and recognition of the sounds /a/, /u/, /i/, /sh/, /s/ and /m/) is used, a very small percentage (6%) of participants responded “yes.” Given a baseline, frequent administration allows educational speech-language pathologist to determine if a child’s hearing instrument is negatively affecting a child’s auditory abilities.20
- Technical Knowledge of Hearing Instruments: More than half (51%) of the participants did not know that hearing instruments cannot make speech clearer. The majority (89%) of respondents knew the goal of amplification is not to restore normal hearing. All of the participants knew that hearing instruments help more children than just those with significant hearing loss. In general, one-third of participants were familiar with appropriate hearing instrument trouble-shooting measures. Most (79%) respondents knew that feedback is caused when amplified sound leaks out of the ear canal and is re-amplified by the hearing instrument and that the “T” position on a hearing instrument stands for telecoil/telephone (also 79%). A majority (76%) of survey participants knew that hearing instruments should be turned off to prevent feedback during insertion and that any form of moisture, even perspiration, could damage a hearing instrument (76%). About half of the respondents were able to correctly select reasons why hearing instruments can cut on and off or fade. The overall average percentage of correct responses on all technical questions about hearing instruments was 76%.
- Hearing Aid Batteries: Almost all (94%) respondents knew that the statement “Excessive battery drain generally means a defective aid” is true. The majority of participants knew that removal of dead batteries should occur right away because of the possibility of leakage and damage to a hearing instrument. One-third (29%) of participants did not know that, when a hearing aid battery starts to lose power, it will shut off abruptly, make a motor-boat sound or start to squeal. In general, survey participants were not familiar with factors involved in the life of a hearing instrument battery. The average percentage of correct responses on all hearing aid battery questions was 61%.
Woodford16, through the administration of written and practical examinations in 1987, found speech-language pathologists lacked the knowledge and skill necessary to provide adequate services in the area of amplification. In 1989, Lass et al.15 found that speech-language pathologists correctly responded to hearing instrument informational items with an average 78.8% correct, indicating some deficiencies in knowledge of and exposure to hearing instruments.
The present survey’s findings, similar to the Lass et al.15 findings, suggest that the educational programs of speech-language pathologists continue to have deficiencies relative to understanding hearing instrument function and hearing aid batteries. The average percentage of correct responses on all technical questions of hearing instruments was 76%; the average percentage of correct responses on all hearing aid battery questions was 61%.
- Defining roles: Under ASHA’s scope of practice for speech-language pathology, speech-language pathologists are to conduct pure-tone screening and tympanometry screening for hearing loss identification purposes, collaborate in assessment of central auditory processing disorders (CAPD) when issues of speech and language are in question and provide aural rehabilitation services. School-related audiology services might include the identification and evaluation of hearing loss, audiologic evaluation, management of amplification, consultation with other members of a multidisciplinary team, management of classroom acoustics and aural rehabilitation. Other professionals involved in servicing children who are deaf or hard of hearing include teachers, social workers, school nurses, occupational therapists and physical therapists.
- In consideration of all the professionals working with a child who is deaf or hard of hearing, there is not a set standard for who is responsible for making sure hearing instruments function on a daily basis. This survey’s findings indicate that only 14% of educational speech-language pathologists view hearing instrument maintenance as their responsibility. Without clearly defined roles and responsibilities, important tasks—such as hearing instrument listening checks—don’t get done. Adhering to federal law, public schools need to delegate responsibilities and provide measures such as personnel, training, equipment and time to ensure adequate hearing instrument monitoring and maintenance.
- More preparation at the graduate level: Ideally, graduate programs training speech-language pathologists should address these apparent deficits by providing more instruction in the area of amplification and hands-on experience with hearing instruments. Previous studies’14-16 findings indicate speech-language pathologists do not receive adequate preparation for this task at the graduate level.
- The present survey’s findings show participants felt that their classroom preparation and clinical practicum in the area of hearing instruments were inadequate. Only half of the participants believed their graduate experience (both course-work and clinical practicum) provided them with sufficient knowledge to effectively service children who wear hearing instruments. Thirty-six percent of participants responded that they felt uncomfortable trouble-shooting hearing instruments. Topics that should be focused on include types of hearing instruments, hearing instrument components, batteries, realistic expectations with hearing instruments, hearing instrument maintenance and trouble-shooting. In addition to increased subject matter on amplification in the classroom, graduate students in speech-language pathology may benefit from more applied experience with hearing instruments via clinical practicum. Adequate preparation at the graduate level, both in content and applied experience, would aid speech-language pathologists as effective hearing instrument monitors.
- Multiskilling: As mentioned earlier, it is not cost-effective for educational audiologist to perform daily hearing instrument listening checks. Instead, as Johnson has stated, audiologists need to train other school personnel and oversee hearing instrument monitoring programs: “Educational audiologists must rely on the cooperation of support personnel to successfully meet the auditory needs of school-age children.”12
- Speech-language pathologists are excellent candidates for two reasons. First, they have some educational background in the area of audiology. Secondly, they have a great deal of contact with children who are deaf or hard-of-hearing children, as they may already service this population in aural habilitation. It is impossible for educational audiologists to perform daily hearing instrument checks on every child who uses amplification in an entire school district. Thus, sharing monitoring responsibilities with adequately trained professionals in the collateral field of speech-language pathology appears to be an effective way to ensure children’s hearing instruments are being monitored.
- Advanced technology: Amplification technology has made great strides in the past decade, including the widespread use of cochlear implants and high performance hearing instruments. The majority (70%) of survey respondents received their masters’ degree prior to 1990. Only 33% of participants reported attending conferences or in-services in the area of amplification/hearing instrument maintenance, implying that speech-language pathologists may need more help in keeping attuned with advances in amplification technology. Without attending up-to-date conferences or in-services that concentrate on this area, speech-language pathologists may find it increasingly difficult to appropriately service children who are deaf or hard of hearing.
Speech-language pathologists, like educational audiologists, fulfill an essential—and oftentimes difficult—role in the educational and social development of school-age children. Their professional skills and education in the areas of dealing with speech and language problems are, in most areas, excellent. However, as more children are identified with hearing loss at earlier ages and more amplification devices are prescribed for these children, an effective plan for monitoring and maintaining the devices needs to be adopted. Educational audiologists and speech-language pathologists will need to work more closely, utilizing multiskilling and continuing education, in order for children to receive the full benefits from amplification devices. Additionally, professional educational programs at the graduate school level should reflect the importance that hearing instruments, cochlear implants, soundfield systems and other amplification devices play in the hearing and communicative development of school-age children.
Kristine French, MA, is an educational speech-language pathologist in Edina, MN. Faith Loven, PhD, is an associate professor of Communication Sciences and Disorders at the Univ. of Minnesota Duluth.