Mental Health
Practitioner's Guide
Samuel
Trychin Ph.d.
Major editorial and content review and suggestions were contributed
by KAREN LINDBERG, Chairperson, SHHH Mental Health Committee.
Other helpful suggestions were provided by members of the
SHHH Mental Health Committee.
The section on Psychological Testing was written by CARREN STIKA, PH.D.
Consultation on Assistive Technology was provided by JANET TRYCHIN, M.A.,
CCC-A.
Introduction
Section One: Who We Are Talking
About
Section Two: Demographics of Hearing
Loss
Section Three: Identifying People
Who Are Hard of Hearing
Section Four: The Impact of Hearing
Loss
Section Five: Intervention Strategies
Section Six: Other Intervention
Strategies
Section Seven: Psychological Testing
Section Eight: Other Conditions
Related to Hearing Loss
Appendix A: National and Local
Resources
Appendix B: References
Appendix C: Communication Guidelines
MENTAL HEALTH PRACTITIONER'S GUIDE
Providing Mental Health Services to People Who
Are Hard of Hearing
INTRODUCTION
Hearing loss affects the delivery of mental health services
in several ways. First, the services must be accessible, meaning
that people who have difficulty with or cannot use the telephone
without there being special accommodations in place, may be severely
limited in their ability to enter into the service delivery system.
Second, once in the system, they have to be able to understand
what is being said to them by office personnel and service providers.
Third, professionals engaged in assessment, diagnosis, and treatment
need to understand the psychosocial issues that frequently accompany
hearing loss--both for those who have it and for their family
members. A frequently observed complaint of people who are hard
of hearing who have sought mental health services is that they
had to devote considerable time, that they were paying for, to
educating their therapist or counselor about the issues associated
with hearing loss.
This manual is written in an attempt to fill an existing void
in the delivery of mental health services. That void is the lack
of information about the mental health needs and concerns of
people who are hard of hearing and those who are late-deafened,
i.e., deafened after language acquisition. Programs that provide
information about the mental health needs and concerns of people
who are deaf and rely on sign language for communication have
been available for some time. Federally funded research on issues
in general concerning people who are hard of hearing and late-deafened
date back only to 1991 and research on their mental health needs
only to 1994 with the establishment of the Research and Training
Center for People Who are Hard of Hearing and Late-Deafened at
CSPP-San Diego. As far as we know at this writing, there are
no other training programs for mental health professionals that
provide systematic and comprehensive information about the mental
health needs of this population.
The goal of this manual is to provide mental health professionals
with information about hearing loss and its effects to enable
them to provide effective services to people who are hard of
hearing and late-deafened.
SECTION ONE: WHO WE ARE TALKING
ABOUT
One problem for mental health providers is that there is often
not a clear distinction about whether the client is functioning
as deaf, late-deafened, or hard of hearing. Often, not understanding
the importance of distinguishing between these categories, people
who are hard of hearing will refer to themselves as being deaf.
The problems faced by people who are deaf may be quite different
from those faced by people who are hard of hearing. More importantly,
the solutions to those problems will probably be quite different,
even between those who are deaf and rely on sign language as
contrasted with those who are oral deaf and do not use sign language.
For example, many culturally deaf people do not view their deafness
as a problem. Recommending ways for them to hear better, such
as, surgery or using assistive listening devices will not be
acceptable to them. Virtually all people who are hard of hearing
or late-deafened see their hearing loss as a problem and will
be more willing to entertain suggestions for increasing their
ability to hear and understand. The term hearing impaired itself
is the cause of much confusion because it does not provide information
about the sub-group to which the individual belongs. Because
of the differences in the problems and their solutions among
these groups, it is important to have criteria to define them,
even though there are always cases that do not neatly fit into
any of these categories.
A. Defining the populations
There are several systems available that provide ways of classifying
people who do not have normal hearing.
1. Audiological classification
Audiologists use a unit of measurement called the decibel
to determine thresholds of hearing for tones of varying frequencies.
These tones are measured in Hertz (Hz) and vary from 125 Hz (low
pitch) to 8,000 Hz (high pitch). The tones are presented at loudnesses
varying from zero to 120 decibels. The following categories are
derived from assessing hearing in this manner.
-
normal hearing--tone thresholds between zero and 15
decibels (db)
-
minimal hearing loss--tone thresholds between 16 and
25 decibels (db)
-
mild hearing loss--tone thresholds between 25 and 40
db
-
moderate hearing loss--tone thresholds between 41 and
55 db
-
moderate to severe hearing loss--tone thresholds between
56 and 80 db
-
severe hearing loss--tone thresholds between 81 and
90 db
-
profound hearing loss--tone thresholds above 90 db
One advantage of this classification system is that it provides
an objective and verifiable assessment of whether or not the
individual has a hearing loss and, if so, a measure of its severity.
A second advantage is that it also provides information about
the type of hearing loss--conductive, sensorineural, or mixed.
Conductive hearing losses are caused by problems in the outer
or middle ear that prevent the normal transmission of sound to
the inner ear (cochlea). They are often remediable by medication
or surgery. Fitting hearing aids is usually easy because all
that is necessary is amplification of the sound. Sensorineural
hearing loss results from permanent damage to the hair cells
of the cochlea and is not treatable, except for cochlear implants
in the most severe cases. Amplification will not completely alleviate
the hearing problems, because there is uneven ability to hear
sounds in the various frequencies. Usually, high frequency sounds
are lost or, at best, poorly received, resulting in difficulty
in understanding speech. Mixed hearing loss has both conductive
and sensorineural components.
A major disadvantage of this classification scheme is that
several of the terms used are quite misleading. Mild and moderate,
for example, imply that these levels of hearing loss do not represent
much of a problem for the person who has them, when, in fact,
all levels of hearing loss present significant problems. The
American Speech, Language, and Hearing Association (ASHA) is
currently in the process of changing the labels of these categories
in order to resolve this problem. A second disadvantage is that
these categories do not provide information about how these levels
of hearing loss effect the day-to-day functioning of the individuals
so classified. Two individuals with the same audiometric profile
may function quite differently--one functioning very well and
the other functioning poorly. This fact indicates that other
factors also need to be taken into account in placing a specific
individual into one of the categories. The following is one attempt
to provide additional criteria for inclusion into the categories
of hard of hearing and late-deafness.
2. Functional classification
people who are hard of hearing:
have some degree of hearing loss varying from mild to profound.
can acquire their hearing loss at any age at between birth
and late adulthood.
have some residual hearing that can benefit from hearing aids
or other assistive listening devices.
rely on their native language, e.g., English, Spanish, etc.
for communication.
in most cases, do not know sign language.
are usually not affiliated with the deaf community.
function primarily within the "hearing world" in
terms of family, friends, and work relationships.
people who are late-deafened:
have a severe to profound hearing loss.
acquire their hearing loss after the development of speech,
i.e., at about three years of age or any time thereafter into
adulthood.
derive little or no benefit from hearing aids or other assistive
listening devices.
rely on their native language, English, German, etc. for communication.
may or may not know sign language.
may or may not be affiliated with the Deaf Community.
function primarily within the "hearing world" in
terms of family, friends, and work relationships.
People who are culturally deaf:
have severe to profound hearing loss.
are often born deaf or acquire deafness early in life.
derive little or no benefit from hearing aids or other assistive
listening devices.
rely on sign language, usually American Sign Language, for
communication.
are usually affiliated with the Deaf Community.
function primarily in the Deaf Culture in terms of friends
and, sometimes, family, but often work in a "hearing"
job setting.
One major problem with the above functional classification
system is that there is overlap between the categories. Some
individuals do not fit neatly into any one category, because
they share characteristics of several, e.g., those people who
are hard of hearing by most criteria, but know sign language.
An increasing number of people have had cochlear implants--electronic
devices placed in the cochlea to replace damaged hair cells that
have resulted in deafness. These people are deaf in the ear that
has been implanted when the unit is turned off, but hear when
it is on.
A second problem is that the terms hard of hearing,
deaf, and late deafened carry surplus meaning in
the larger culture and may evoke stereotypic images that may
not hold for a given individual within any of these categories.
For example, many people associate hard of hearing with
advanced age and tend to disregard hearing ability as a possible
factor in evaluating a younger person's performance or style.
Many associate impaired speech with deafness and find
it difficult to believe that a person who has clear speech, as
do most people who are hard of hearing, cannot hear well.
3. Classification based on communication requirements and
preferences
In this kind of system people are classified based on the
amount of residual hearing they have and on the communication
requirements necessary for them to understand the message being
conveyed to them. For example, some people can function well
with hearing aids, while others need hearing aids plus other
assistive listening devices. Some who are deafened depend on
some form of sign language, while others depend upon speech reading.
Many people who are deafened later in life depend on visual representation
of their language--English, Spanish, Japanese, etc.--through
use of hand writing, computers, real-time-captioning, etc. This
kind of classification system might appear as follows:
Relies on residual hearing
can understand using hearing aids,
can understand using hearing aids with an ALD, e.g., FM system,
can understand by using an ALD system,
can understand using a cochlear implant,
can understand using a cochlear implant with an ALD,
Relies on visual representation of native language
can understand by reading (on a computer screen, TTY, Fax,
etc.) what is being said,
can understand using real-time-captioning (CART),
can understand by speechreading,
can understand by speechreading and cued speech,
can understand using an Oral interpreter,
Relies on manual communication
can understand using Signed English,
can understand using American Sign Language,
can understand using fingerspelling,
can understand using tactual, manual communication,
Such a system is not currently in use, but would, if adopted,
eliminate some of the problems of the other classification systems.
The knowledge that a person defines herself as being hard of
hearing, for example, does not provide sufficient information
to determine the communication method she needs in order to understand
what is being said. By clearly specifying the communication method
that is required for a given individual, this kind of uncertainty
is avoided. Many people belong to both Self Help for Hard of
Hearing People, Inc. (SHHH) and the Association for Late-Deafened
Adults (ALDA)--national self help organizations Knowing the specific
communication requirement for a person with such a dual membership
eliminates the ambiguity about what assistive system he or she
would need in attending a meeting of either group.
SECTION TWO: DEMOGRAPHICS OF
HEARING LOSS
One of the puzzling features of working with the population
of people who are hard of hearing is that it has been given such
little attention considering the magnitude of the problem and
the effects of hearing loss on people's lives. Virtually everyone
in the United States has hearing loss, lives with someone who
has it, works with someone who has it, or has a friend or relative
who has it. It is difficult to find someone who has never experienced
the effects of hearing loss either in themselves or talking to
someone who has it. Given the size of the population, every mental
health provider must have encountered people who are hard of
hearing in the course of their practice. Experience indicates
that this condition is usually either overlooked or not considered
to be a significant factor. Knowing the demographic facts of
hearing loss can be helpful in increasing awareness that it is
often present and that it may be of critical, clinical importance.
The following demographic information is from the 1991-92 National
Health Survey.
1. Overall
Hearing loss combined with tinnitus (ringing or other sounds
in the ears) is the second most prevalent chronic public health
problem in the United States. As a chronic public health problem,
hearing loss is exceeded only by rheumatism and arthritis in
terms of the number of people affected. According to the 1990-91
Vital and Health Statistics report from the National Health Survey,
there are approximately 20 million people in the United States
who report trouble hearing. The National Institute on Deafness
and Communication Disorders uses the figure of 28 million people
and may be a more accurate estimate of the true number because
of under-reporting in the National Survey. This estimate represents
about one out of every ten people in the general population.
Of the 20 million people in the survey reporting trouble hearing,
only 421 thousand or 2.2 percent are deaf. The remaining 19.5
million people are hard of hearing.
Hearing loss is on the rise in the United States. Compared
to the 1970-71 Vital Health and Statistics survey, hearing loss
has increased in prevalence by 24 percent. The population of
the United States is now proportionately older than it was then,
but there is still an increase of 14 percent when the data are
adjusted for age. These statistics also show that the severity
of hearing loss has also increased from 1971 to 1991.
2. By age
Forty three percent of the people reporting hearing trouble
are 65 years of age or over; while children ages 3-17 account
for only 4.8% of that population.
The onset of hearing loss shows a definite age factor with
6 percent reporting onset before the age of three, 15 percent
reporting onset between the ages of three and 18, and 79 percent
reporting onset after nineteen years of age.
3. By gender
Males, at 59 percent, are over-represented among persons reporting
trouble hearing. Males represent only 47 percent of the population
reporting normal hearing.
4. By ethnicity
Caucasians are over-represented (90 percent) among people
reporting trouble hearing, but as a group, they are older than
other ethnic groups. When the data are age-adjusted, the percentage
reporting trouble hearing are more similar in the black and hispanic
ethnic groups. There is also a possibility that trouble hearing
is under-reported in some ethnic groups, resulting in a lower
prevalence rate.
5. By economic status
Nineteen percent of people reporting trouble hearing have
family incomes under $10,000 per year, while only 11.1 percent
of those reporting normal hearing have family incomes that low.
6. By education level
Thirty percent of people reporting trouble hearing have less
than twelve years education compared to 20 percent of those reporting
normal hearing.
7. By employment status
Almost forty percent of those reporting hearing trouble are
not in the labor force compared to 20 percent of persons reporting
normal hearing. Forty one percent of those reporting hearing
trouble are in service and blue-collar occupations compared with
27 percent of people reporting normal hearing.
8. By limitation of activity due to chronic conditions
About twelve percent of people reporting no trouble hearing
indicate they experience limitation of activities. Thirty percent
of people who have trouble hearing report limitation of activities.
Fifty percent of a subgroup of people who have trouble hearing
who report they cannot hear and understand normal speech report
limitation of activities.
In summary, the demographic data indicate that there are a
variety of negative effects on people's lives when hearing loss
is present in terms of economic status, education, and daily
activities.
SECTION THREE. IDENTIFYING
PEOPLE WHO ARE HARD OF HEARING
The vast majority of people who are hard of hearing in the
United States do not take steps to effectively deal with their
hearing loss. We believe that many of them are not aware that
they have a hearing loss. Because so few people who are hard
of hearing openly admit to it, it is important that service providers
recognize the signs that it may be present. The following presents
a variety of ways of identifying the presence of hearing loss.
1. Hearing aid identification
Only about six million people in the United States have hearing
aids. That means that most of the people who have trouble hearing
do not have hearing aids. There are many reasons for this. Many
don't recognize that they have the problem because, for most
people, hearing loss has a gradually progressing development.
They do not notice the difference between normal hearing and
a slight hearing loss in the beginning stages. Later they do
not perceive the difference between a slight hearing loss and
a mild hearing loss, and so on. The person may have a substantial
level of hearing loss and not be aware they have it, instead,
blaming others for not speaking clearly or complaining that the
TV or radio is not working properly..
Others do not acquire or wear hearing aids because they deny
they have it or deny that it is a problem for them. Still others,
are unaware that hearing aids will be of help to them or have
previously been fitted inappropriately with an aid which did
not help them. For some, a hearing aid does not help, and they
do not use them.
Many people simply do not have the financial resources to
purchase hearing aids, or even be able to afford an audiological
assessment. For others, getting an audiological assessment and
purchasing hearing aids is low on their list of priorities due
to other more life-threatening conditions, mental health problems,
family or relationship crises and so on.
Many hearing aid users have in-the-canal or in-the-ear hearing
aids which are often not visible to casual observation. Sometimes
the hearing aid(s) may be hidden from view by long hair, kerchiefs,
etc.
As a result of these factors, whether or not a hearing aid
is apparent is not a reliable indicator of the presence of hearing
loss. Neither, is self-report a good indicator. But, there are
behavioral signs that may indicate the presence of hearing loss,
particularly if several of these signs are manifested.
2. Signs and symptoms of hearing loss
When a person repeatedly exhibits the following signs, particularly
when more than one occur in combination, the possibility of hearing
loss should be considered.
Asking people to repeat frequently
Giving inappropriate responses to what is said
Failing to respond when spoken to
Having difficulty understanding in group situations
Blaming people for not speaking clearly
Being defensive about communication problems
Staring at a speaker's mouth
Turning the head to one side to favor a better ear
Having a strained expression around the eyes
Having a puzzled expression when listening
Talking too loudly or too softly
Avoiding or withdrawing from social situations
Turning up radio or TV much too loud
SECTION FOUR: THE IMPACT OF
HEARING LOSS
The effects of hearing loss on the people who have it and
on those with whom they interact has not been addressed in the
training programs of service providers from a wide variety of
professions. It is only in the 1990's that the first federal
grants have been focused on the needs, concerns, and issues of
people who are hard of hearing and those who communicate with
them. This chapter focuses on the impact of hearing loss on those
whQ have it and on those with whom they interact.
A. Hearing Loss As A Communication Disorder
In the national Public Health Survey hearing loss appears
under the category Communication Disorders. It is listed
there because communication difficulties are the primary problem
for the majority of people who experience hearing loss. And,
it is listed there because the communication problems related
to hearing loss affect both the person who has it and those with
whom he or she communicates. Hearing loss is a systems issue
involving both speakers and listeners in the following ways:
the listener and speaker both experience problems when communication
breaks down,
the listeners and speaker both contribute to communication
breakdowns, and
the listener and speaker are both part of the solution of
communication problems.
B. Problems Associated With Hearing Loss
1. Communication problems frequently reported
When traveling around the United States providing workshops
for people who are hard of hearing and family members, we always
ask them about the problems they encounter that are related to
the hearing loss. The problems listed here are those universally
mentioned independent of the life circumstances, age, or gender
of the person reporting.
The following list is a sample of the problem situations frequently
reported by people who are hard of hearing. Not every hard of
hearing person experiences all of these situations as problematic,
but, as a group, hard of hearing people report them as being
difficult. In these situations they may hear the voice and know
that someone is talking, but be unable to understand what the
person is saying.
following conversations in a moving car
understanding what is said at family dinners at holidays
understanding when several people are talking
understanding on the telephone
knowing what is being said in medical situations
understanding voices outdoors in wind or traffic noise
hearing alarm signals, doorbells, telephone ringing
understanding speech on the TV or radio
understanding when people whisper
understanding someone speaking from another room
understanding when they can't see the speaker's face
understanding in poor illumination
understanding unclear speech
understanding when unaware that a person is talking to them
understanding a policeman when stopped for traffic violation
understanding what is said at movies, plays, classes, lectures
This list indicates that the effects of hearing loss are pervasive
and constant in the person's life.
The following is a list of the most frequently reported complaints
of family members who interact with the person who is hard of
hearing.
difficulty remembering what to do to be understood
difficulty in finding ways to get the person to understand me
the hard of hearing person turns the TV or radio much too loud
having to repeat what I'm saying a lot
having to act as an interpreter for the hard of hearing person
when it's obvious the person is not understanding someone else
when we become frustrated or irritated with each other
when the hard of hearing person doesn't pay attention
not knowing whether I've been understood
sometimes everything is understood, at other times, nothing
the person is becoming too dependent on me
conversation is reduced in frequency and duration
reduction in social contact with friends and family
loss of spontaneity in our communication
not traveling or gotng to new places
not doing things we enjoyed previously
This list indicates the variety of ways that hearing loss
can adversely affect the people who live with or regularly interact
with the person who has the hearing loss.
2. Reactions to communication problems frequently reported
Another way to examine the effects of hearing loss on people
is to inquire about how they react or respond when the inevitable
communication problems occur. Many of the reactions that are
frequently reported do not help to resolve the communication
difficulty and many serve to make the situation worse, such as,
becoming angry and blowing up at the speaker.
a. reactions frequently reported by people who are hard of
hearing:
frustration
anger
depression
anxiety
guilt
embarrassment
shame
muscle tension
fatigue
headaches
increased blood pressure
stomach problems
bluffing--pretending to understand
withdrawing from the situation
dominate the conversation
decreased self-esteem/confidence
difficulty thinking clearly
inability to concentrate
The person speaking to the individual who is hard of hearing
also reacts when it is obvious that communication has broken
down. Speakers also report the reactions listed above by the
people who are hard of hearing. The following are some additional
comments frequently reported by family members that deserve special
mention.
b. reactions to communication problems frequently reported
by family members
frustration--at not knowing what to do to be understood
guilt--feeling that misunderstandings are their fault
embarrassment--when they know he is misunderstanding someone
confusion--caused by the variability in the person's ability
to understand what is being said
irritation--caused by having to repeat a lot
anger--caused by the person's failure to pay attention
overwhelmed--by the person becoming too dependent
3. Mental health risks associated with hearing loss
Dealing with loss is a major issue when providing mental health
services to people who are hard of hearing and late-deafened.
The experience of loss occurs for both the people who have the
hearing loss and for those close to them. For people who are
hard of hearing or late-deafened the underlying sense of loss
may be related to the feeling of, "no longer being the person
I once was." Some examples of manifestations of this sense
of loss are:
loss of ability to fully participate socially
loss of ease of communication
loss of intimacy in relationship(s)
loss of ability to contribute vocationally
loss of income
loss of the sense of physical security
loss of ability to enjoy music, plays, movies, or other leisure
activities
loss of independence
For family members the underlying sense of loss may be the
feeling that this is no longer the person I knew before or this
relationship is no longer the same as it once was. This sense
of loss may manifest itself in the following examples:
loss of ease of communication
loss of intimacy in the relationship
loss of shared activities
loss of freedom
loss of income
loss of trust
Hearing loss can result in a variety of additional mental
health-related complaints for people who are hard of hearing
and for those who frequently interact with them. The following
are examples of the kinds of mental health issues that can be
caused or exacerbated by hearing loss.
a. emotional:
depression
anxiety
guilt
anger
shame
b. cognitive:
low self-esteem
worrying
inattentive
difficulty concentrating
easily distracted
blaming/paranoid
c. interpersonal:
withdrawal
bluffing
dominating conversations
loss of intimacy
non-assertive
argumentative
wary/tentative socially
d. behavioral:
seemingly eccentric behavior
self-limitation of activities
substance abuse
overfunctioning
e. physical:
fatigue
stress reactions
eating disorders
sleep disorders
sexual problems
However, it is wise to be cautious when attributing mental
health problems to an individual's hearing loss. There are three
possibilities for any mental health related complaint reported
by a person who is hard of hearing or a family member:
a. the complaint, e.g., depression, is caused by the hearing
loss. If the individual did not have the hearing loss, he would
not be depressed.
b. The complaint, e.g., depression, is exacerbated by the
hearing loss. If the individual did not have the hearing loss,
he would still be depressed, but having the hearing loss makes
the depression worse.
c. The complaint, e.g., depression, is unrelated to the hearing
loss. If the person did not have the hearing loss, he would be
just as depressed.
Identifying which of these is the case requires an in-depth
assessment of the history of the complaint along with the history
of the hearing loss, assessment of other factors in the person's
life, and knowledge of the mental health risks associated with
hearing loss as listed above.
4. Factors contributing to mental health problems
a. relationship issues:
lack of family support
loss of friends
interpersonal problems at work
b. damage to self-image:
loss of sense of competency
loss of sense of acceptability by others
loss of sense of control or influence over the environment
c. anxiety about the future:
in terms of career
in terms of relationships
in terms of losing one's remaining hearing
in terms of losing one's independence
d. loss of valued activities and experiences
movies, theaters
music
social events with friends
family gatherings
telephone use
e. grief associated with losses:
for person who is HoH
for family members
f. dependency issues
for person who is HoH
for family members
The mental health complaints of many people who are hard of
hearing are due to the communication problems related to their
hearing loss. In these instances, the most efficient intervention
is helping them prevent and reduce those communication difficulties
through communication skills training, use of assistive technology,
and information about resources. Others will have mental health
complaints whose origins are independent of the hearing loss,
but that are exacerbated by the communication difficulties associated
with it. Helping this group to learn strategies for preventing
and reducing communication breakdowns will accdmplish two things.
First, it will increase treatment accessibility, i.e., they will
understand more of what is being said during treatment sessions.
Second, it will allay that portion of their distress that is
related to their communication difficulties.
C. Information Gaps
1. Consumer's lack of knowledge
The majority of people who are HOH and their family members
are living with a mystery.
a. the problems they experience are often not associated with
the hearing loss:
communication problems
psychological problems
social problems
b. they do not understand how the ear works and how it malfunctions
c. they are unable to functionally interpret their audiogram
d. they do not know the causes of communication breakdowns:
speaker
environmental
listener
e. they do not know the crucial difference between not
understanding and misunderstanding
f. they do not know about assistive alerting and listening
equipment available, self help groups, and/or other national
and local resources
g. they do not know how to alter their communication behavior
in order to prevent or reduce communication breakdowns
2. Professionals lack of knowledge
Professionals who provide services to people who are hard
of hearing and their families often do not have necessary information.
a. Their services are not accessible to people who are hard
of hearing.
b. They often do not recognize that the client has a hearing
loss.
c. They may have had training and experience in providing
services to people who ar culturally deaf, but more likely have
had no training related to hearing loss at all.
d. They often do not realize the relationship between the
hearing loss and the reported mental health issues.
D. Developmental Issues
1. Hearing loss and age of onset
a. early onset:
Because the acquisition of language and educational foundations
requires ability to understand what is being said, early detection
of hearing loss and intervention are essential. Children who
do not hear normally who are in environments in which information
is presented aurally are at high risk for educational failure
and social skill deficits. Such people, later in life may have
major difficulty in forming relationships and establishing careers.
b. later onset:
People who acquire hearing loss later in life are more concerned
about keeping and nurturing already formed relationships and
maintaining and advancing in careers.
People who acquire hearing loss at more advanced age may have
additional difficulties due to the interaction of hearing loss
with other conditions, such as, impaired vision or motor problems.
They are more at risk for losing their sense of independence
and influence over their environment.
2. Hearing loss as an on-going developmental process
The onset of most cases of hearing loss is gradual and progressive.
What is an adequate adjustment at a lower level of hearing loss
may not suffice as the person's hearing loss becomes more severe.
Therefore, coping with hearing loss is often an on-going learning
process for many individuals and their families involving a continual
readjustment of communication behavior. As the hearing loss becomes
more severe they may have to alter features of the home or work
environment, and learn to use additional listening devices.
People who have had cochlear implants require an adjustment
period to learn to process and understand speech and other sounds
through these electronic devices. The length of this adjustment
period varies from individual to individual, and individuals
also vary in how well they are ultimately able to process auditory
information through these devices.
The individual with the hearing loss may have difficulty adjusting
to the loss of even more hearing and may face another crisis
in self-identity. If the person loses virtually all of their
hearing the whole family unit may be facing a crisis situation
in attempting to deal with the completely altered communication
situation resulting from late-deafness.
SECTION FIVE: INTERVENTION STRATEGIES
Important considerations in providing services to people who
are hard of hearing and their family members are:
how accessible those services are to people who are hard of
hearing, and
the information the provider should know about hearing loss.
Both of these factors relate to treatment effectiveness and
also to the issue of establishing credibility.
A. Basic Intervention Strategies
1. Accessibility
One sure way to establish credibility with people who are
hard of hearing is to have the equipment and services necessary
for enabling them to access your services and to understand what
is said to them in your offices. Examples of such equipment and
services are listed here.
a. Devices and services
Telephone access epuipment and services are necessary
for people who are hard of hearing to call your office for an
appointment, call your hot line service in case of emergency,
or for enabling patients to make calls from your office, e.g.,
calling taxis, etc. Types of telephone access equipment and services
are as follows
A TTY is a unit obtainable from the telephone company that
connects to a standard telephone and enables the user to type,
rather than speak, messages transmitted over the telephone line.
The user then reads incoming messages on a screen rather than
listening to them over the telephone receiver.
A relay system is useful for those who cannot hear over the
telephone, but do not have a TTY or are speaking to someone who
does not have a TTY. A telephone company, relay operator has
a TTY and transmits typed messages orally or types spoken messages.
An amplified telephone is a telephone that has a volume control
on it so that the listener can boost the volume of the incoming
message.
Assistive listening devices (ALDs) that work with,
or independently of, hearing aids and serve to amplify a speaker's
voice in order to:
minimize interference due to background noise,
decrease the effects of distance on ability to hear, and
increase understanding of what is being said.
An assistive listening device consists of a microphone that
picks up the speaker's voice, a transmitter that sends the sound
picked up by the microphone, a receiver that picks up the transmitted
sound, a volume control mechanism that enables the listener to
regulate the amount of sound received, and an earpiece, such
as an earbud or headset, that places the sound received at or
in the listener's ear.
Types of assistive listening devices available are:
personal amplifier--a single unit containing all of the above
components and usually held by the listener who points the microphone
towards the speaker's mouth. It is powered by a nine volt battery.
FM system--a two-component system consisting of a microphone
and transmitter held or worn by the speaker and a reciever and
ear piece held or worn by the listener. The signal is transmitted
via FM radio waves. It is powered by a nine volt battery.
infra-red system--a two component system consisting of a microphone
and transmitter (called an emitter) and a receiver and ear piece
held or worn by the listener. The infra-red emitter is stationary
and receves power from being plugged into an electrcal outlet.
The signal is transmitted via infra-red light waves.
induction loop system--consists of a microphone feeding into
an amplifier. The signal is sent out through a wire (called a
loop). The listeners turn their hearing aid switch to "t"
(telecoil) or use a special loop receiver to pick up the sound.
The signal is transmitted via an electromagnetic field established
between the loop and the telecoil in the hearing aid. The amplifier
is powered by plugging it into an electrical outlet.
Personal amplifiers and FM systems are probably the best ones
for use in one-on-one communication situations, such as individual
counseling or psychological testing. The clinician who is hard
of hearing may also benefit from use of the previously mentioned
equipment.
For further information about assistive listening devices
contact Self Help for Hard of Hearing People, Inc. (see Resource
section).
Alerting devices that inform the user that a sound
signal is present in the environment by means of a flashing light,
or a vibratory stimulus.
Types of alerting devices are those that respond to:
ringing alarm clocks, telephones, fire alarms, doorbells,
etc.
a baby's cry
a knock at a door
Visual input systems for people who are unable to understand
speech sounds.
Types of visual display are as follows:
Computer assisted real-time captioning (CART)
computer monitor
TTY LED readout
Large print TTY
handwritten notes
e-mail and on-line services
Hand written notes can be difficult to read when a great quantity
of communication is needed. Use of a computer or TTY offering
uniformity and high contrast for letters can minimize the individual
differences in people's handwriting.
Interpreters
Types of interpreters are as follows.
Oral interpreters are trained to provide a readable, visual
representation of what is being said by clearly mouthing the
words so that they are relatively easy to lip read.
Sign language interpreters use their hands, bodies, and facial
expressions to convey manually what is being spoken. Most people
who are hard of hearing do not use sign language, but some do.
American Sign Language (ASL) and Signed English are different,
and it is necessary to determine which is preferred by someone
requesting a sign language interpreter.
Cued-speech is a method that uses hand and finger movements
to supplement speech-reading. It is used rarely.
b. Signage
It is very important that the office has prominently displayed
signs informing people of the availability of these devices and
services. It is also wise to include information about their
availability in your advertisement of services in telephone directories
and other promotional literature.
c. Staff training
It is essential that all office staff who come into contact
with patients, e.g., secretary, billing clerk, nurse, etc. are
adequately trained to:
identify people who are hard of hearing,
communicate effectively with people who are HoH, and
use and troubleshoot assistive equipment
d. Environmental modification
It is also important to ensure that the environment is accessible
by:
having proper lighting
reducing background noise
providing ALDs, or
providing visual input, e.g., CART large print TDD, etc.
ensuring adequate acoustics
using proper seating arrangement:
minimizing distance between speakers and listeners
2. Information about hearing loss
For practitioners who advertise a specialty in serving people
who are hard of hearing, it is important to be familiar with
some basic audiological concepts and procedures. Having a basic
text in audiology available for reference is probably a good
idea. In general, it is necessary to ascertain the following
information.
a. onset factors
As discussed previously, age of onset is important because
early onset of hearing loss can contribute to the inadequate
development of language, rudiments of education, and social skills.
A second onset issue is how rapidly the hearing loss occurred.
For people whose hearing loss occurred virtually overnight and
is severe to profound there will be a crisis for them and their
families that needs to be managed. Inability to communicate effectively,
actual or potential loss of employment, related organic problems,
and uncertainty about the cause of the hearing loss can produce
an overwhelming anxiety for everyone involved.
The majority of people who are hard of hearing have had a
gradual, progressive loss of hearing over a number of years.
For them, there may not have been a distinctly recognizable crisis
period, but they have had a long time in which to develop and
strengthen a variety of bad habits, such as bluffing, which can
be highly resistant to change.
b. severity of the hearing loss
As indicated previously, the labels given to the various severity
levels of hearing loss are unfortunate in that the terms mild
and moderate are often taken to mean that the hearing
loss so designated is not of great consequence. All hearing loss
produces problems in understanding for the individual who has
it, depending on the circumstances in which he or she is attempting
to communicate.
c. unilateral hearing loss
Most people who are hard of hearing have bilateral hearing
loss, meaning that both ears are affected. Some individuals have
unilateral hearing loss, meaning that only one ear is affected.
Individuals with unilateral hearing loss have difficulty localizing
the source of a sound and separating background noise from speech
or other signals they are trying to hear. Confusion is caused
by their ability to hear sounds presented from the side of their
good ear and inability to hear sounds coming from the side of
the bad ear. They are often accused of being inattentive, slow
witted, or worse. When talking on the telephone with the good
ear to the phone, they are unable to hear anything said to them
other than what comes over the telephone.
d. type of hearing loss
Conductive hearing loss is caused by problems in the outer
or middle ear that prevent adequate transmission or conduction
of the sound signal to the inner ear. Usually these conditions
are treatable medically and respond well to amplification by
hearing aids or other assistive listening devices. Sensorineural
hearing loss is caused by damage to the hair cells in the inner
ear and is not treatable medically other than by cochlear implants.
Sensorineural hearing loss can be difficult to accommodate with
amplification and is often associated with poor speech discrimination.
People with sensorineural hearing loss are usually the ones who
say, "I can hear you talking, but I don't know what you
are saying."
It is necessary to be knowleageable about other aspects of
hearing loss as well as audiological variables. In making accurate
appraisals for diagnosing and treatment planning and for carrying
out an intervention it is essential to:
know the problems faced by people who are HOH and their families
as discussed previously
know how these problems relate to mental health issues
know local and national resources (see Resources section)
have reliable hearing health professionals for referrals
Knowing the problems and reactions frequently reported by
people who are hard of hearing and their family members is essential
in accurately assessing whether or not:
a. the mental health complaint(s) are produced by the communication
difficulties stemming from the hearing loss, or
b. the mental health complaints are exacerbated by the hearing
loss, but also need to be treated independently of it, or
c. the mental health complaints are due to mental illness
and the hearing loss needs to be accommodated to render the person
accessible to treatment.
3a. Providing accurate information--myths and misconceptions
There are a variety of misconceptions or myths related to
hearing loss that interfere with successful treatment and adjustment.
Disabusing people of several commonly held myths or misconceptions
about hearing loss can be most helpful.
a. the hearing aid myth
The basic misunderstanding associated with hearing aids is
that they are somehow analogous to eyeglasses, i.e., they return
hearing to something close to normal. People who believe this
think that all that is necessary to solve communication problems
associated with hearing loss is to wear hearing aids. This is
simply not true. The basic problem with hearing aids is the location
of the microphone that picks up sound; it is on the hearing aid
at the wearer's ear(s). That means that when the wearers turn
up the volume on the hearing aid to make a speaker's voice come
in louder, all other sounds in the environment are also increased
in volume. Therefore, when background noise is present, as is
almost always the case, turning up the volume to better hear
the person speaking is self-defeating. Recent developments in
hearing aids allow them to filter out certain frequencies of
background sound, but no hearing aideliminates the negative effects
of background noise. The best we can say is that the benefits
of hearing aids are situation specific--they are usually very
useful in quiet environments, but much less useful in noisy environments.
Hearing aids are necessary for most people who have hearing loss,
but should not be considered as a final solution to communication
problems.
b. the lip-reading (speech-reading) myth
Another misconception is that people automatically become
good lipreaders when their hearing fades. This is far from being
true, and it usually requires special training for people to
become adept at reading lips and other body cues to what is being
said. Speechreading classes are helpful in this regard for many
people. But, even an expert speechreader needs to be able to
clearly see a speaker's face in order to understand what is being
said. Visual problems, poor illumination, inability to see the
speaker's face will decrease the effectiveness of speechreading.
Most people who are hard of hearing will not even be able to
get 40 percent of what is being said by speechreading alone.
c. the severity of hearing loss myth
This is the very dangerous misconception that mild or moderate
hearing losses are not very significant in terms of being able
to understand what people are saying. In~fact, all severity levels
of hearing loss produce problems in understanding, and the categories
of mild and moderate are misleading because they imply that the
impact of these levels of hearing loss is not to be considered
as being serious.
d. the "They're out to get me." myth
Many people who are hard of hearing hold the faulty assumption
that when people fail to meet their needs communicatively, that
these people are insensitive, inconsiderate, or worse. The fact
is that most people do not have a clue about what to do to communicate
with people who are hard of hearing. When informed about what
to do, they quickly forget and revert back to the way they habitually
communicate--which is exactly what we should expect them to do.
Rather than holding these faulty assumptions, it is much more
adaptive to know that people need to be taught and frequently
reminded about what they need to do to be understood.
e. The selective hearing myth
A misconception frequently heard from people who relate to
those who have hearing loss is that, "He can understand
me when he wants to." This stems from the fact that most
people who are hard of hearing can understand very well under
certain circumstances (quiet room, one-on-one conversation, close
to speaker) and not at all under other circumstances (noisy room,
multiple speakers, at some distance from the speaker) . Because
most people are unaware of the many factors that interfere with
understanding what is being said, they attribute failure to understand
to inattention or poor motivation to hear. This is most often
not the case.
3b. Providing accurate information--Epuipment and other
help
Most people who are hard of hearing and their family members
have never been informed about the assistive devices (referred
to under accessibility issues above) that can vastly improve
understanding speech and being aware of important environmental
sounds. Providing information about these assistive devices can
dramatically and immediately improve the quality of people's
lives. Providing them with hands-on experience with these devices
is the most effective way to demonstrate their benefits. Professionals
in the community, e.g., audiologists or speech therapists may
be able to provide such information to clients. Local chapters
of Self Help for Hard of Hearing People, Inc. also have members
who are knowledgeable about this equipment and can be contacted
for helping to demonstrate it.
4. Helping establish effective communication behavior:
Preventing or reducing communication problems related to hearing
loss requires communication behavior knowledge about what
to do and how to do it in ways that will elicit cooperation
from others. Many people who are hard of hearing do not have
this knowledge and skill and suffer unnecessarily as a result.
It can be most helpful to determine clients' status in this area
by:
a. determining whether they know and can follow the guidelines
for effective communication (see Appendix C).
b. determining whether they are able to inform others about
the fact of their hearing loss without being apologetic and without
making the other person feel uncomfortable.
c. determining whether they can effectively inform others
about what to do to be understood, such as saying, "I need
you to face me when you speak."
d. determining whether they can remind others when they forget
to speak louder or to slow down in ways that will not make them
feel defensive.
e. determining whether they model the communication behavior
they desire from others, e.g., they speak clearly and at a moderate
pace themselves.
SECTION SIX: OTHER INTERVENTION
STRATEGIES
Most of the intervention strategies currently in use by mental
health professionals are applicable to people who are hard of
hearing. Many are useful in helping people who are hard of hearing
learn to alter their communication behavior, request communication
behavior changes in others, and feel better about themselves.
Some of those found useful in this context are as follows.
1. Relaxation Training/Biofeedback
Many people who are hard of hearing report high levels of
stress, often manifested by chronic muscle tension. Stress levels
can be especially severe in communication situations. Relaxation
training and biofeedback has been found useful in treating tinnitus
in some people.
2. Cognitive therapy
People who are hard of hearing may hold specific thought and
belief structures that interfere with their ability to cope effectively
with their hearing loss. For example, some believe that they
are totally responsible for communication because they are the
ones that have the hearing loss that produces communication failures.
When they believe they are 100 percent responsible for communication,
they usually will not inform others about what they need them
to do in order to be understood. When they accept the fact that
communication responsibility is mutually shared between the person
speaking and the person listening, they are more likely to make
their communication needs known.
3. Communication Skills Training
In our experience most people who have hearing loss do not
know what communication behavior changes to request from other
people. They often do not know what communication behavior changes
they themselves need to make. Furthermore, just informing them
is insufficient in enabling them to effect such changes. They
need to learn to identify what they need. They need opportunity
to practice making requests for change. They need to receive
feedback on their performance. This requires a communication
skills training program. Our experience indicates that when people
who are hard of hearing and their family members participate
in a group or class with other people who share their experiences,
improvement is often rapid and enduring. This is especially true
when the focus of the group or class experience is on strategies
for preventing or reducing communication problems related to
hearing loss. People who attend these sessions with a spouse
or other family member usually experience better results than
those who attend alone.
4. Assertiveness Training
Even when people who are hard of hearing know what it is they
need others to do to be understood, they may convey their needs
in ways that offend other people and make them defensive. When
people are defensive, they are usually resistant to complying
with requests. This results in their unwillingness to make necessary
changes in communication behavior, and communication problems
continue or worsen. Many people who are hard of hearing need
help in learning how to communicate their needs in ways that
increase the probability that others will comply with their requests.
5. Grief Resolution
The relationship between grief and loss is well established.
When people who have hearing loss and/or those who live with
them have not dealt with the grief they experience related to
the loss of hearing, they are often unable to move forward in
dealing effectively with the hearing loss. Furthermore, the issue
of loss may resurface periodically as the individual's hearing
loss progresses.
6. Individual/Couples/Family Therapy
Because hearing loss is primarily a communication disorder
for many people and affects both speakers and listeners, couples
or family treatment is often more efficient and productive than
individual treatment. Both sides need to learn how the hearing
loss affects the other person. Both sides will need to alter
their behavior in order to prevent or reduce communication problems.
7. Group Therapy
Many people who are hard of hearing will have difficulty following
discussion in a group therapy situation. The anxiety generated
by difficulty in understanding what people are saying in such
a situation may far outweigh the benefits of the treatment. Asking
other group members to face the person who is hard of hearing,
raise their voices, when talking about private and sensitive
issues, and remember to use the microphone of an assistive device
may produce an undue burden on them. Of course, these would be
standard procedures if the group were composed entirely of people
who are hard of hearing and their family members.
SECTION SEVEN: PSYCHOLOGICAL TESTING
Psychologists who tests with persons who have hearing loss
must take into consideration the many factors that can potentially
influence the results obtained. Most standardized psychological
tests rely on audition and verbal expression, and, as such, test
results can be significantly effected by the person's linguistic
competency or comprehension of questions asked.
When hearing loss occurs during early childhood, language
development is almost always effected. Research is beginning
to indicate that this is true even for individuals with mild
and moderate hearing losses, particularly if amplification was
not provided from the onset: Use of verbally-based standardized
tests with these individuals may not give an accurate picture
of their level of functioning, and, instead, may measure the
extent of their language deficiency and restricted vocabulary.
Individuals who acquire hearing loss later in life are often
not good judges of when they have or have not understood what
has been said. In a testing situation, they may not be aware
of having misinterpreted directions or having not heard a question
asked. Individuals who acquire hearing loss later in life may
also be reluctant to ask for questions to be repeated, in order
to avoid embarrassment or because they do not want to draw attention
to their communication difficulties.
Psychologist who test persons with hearing loss are not the
only ones who need to be familiar with the potential pitfalls
of testing individuals who are hard of hearing. Mental health
professionals and vocational rehabilitation counselors also need
to be aware of these limitations, as they often request psychological
testing to assist in treatment planning. If these service providers
understand the potential sources of difficulty in testing persons
with hearing loss, they will be in a better position of (1) developing
a referral that can help guide the psychologist doing the testing,
or (2) evaluating how much trust to place in test results obtained
and the recommendations provided.
There are no "hard" rules about testing individuals
who are hard of hearing, nor are there specific tests which should
or should not be used. The population of individuals with hearing
loss is a heterogeneous group. Therefore, certain psychological
tests which may be inappropriate to use with one individual may
be appropriate for use with another. To increase the validity
of tests used with individuals who are hard of hearing, the following
information should be gathered and assessment considerations
made:
Information about the hearing loss:
SECTION EIGHT: OTHER CONDITIONS
RELATED TO HEARING LOSS
The psychological, social, and economic effects of communication
problems resulting from hearing loss are the main concern of
most people who have hearing loss. However, some individuals
with hearing loss have conditions that produce additional problems
that need to be dealt with in their own right. Some of the more
frequently occurring conditions requiring special consideration
are as follows.
1. Vertigo/Dizziness
For many people who experience dizziness, the problem is a
change in the vestibular system--part of the inner ear responsible
for balance and body orientation in space. Meniere's disease
is an example of a hearing loss-related condition that includes
symptoms of fluctuating hearing, prolonged periods of violent
dizziness, nausea, difficulty concentrating, and memory problems.
Some people with Meniere's disease lose all of their hearing
virtually overnight. For further information see the Vestibular
Disorders Association in the Resource section at the end of this
booklet.
2. Neuromas
Neuromas are tumors on the auditory nerve. Often, they are
life threatening, and their surgical removal is required. Facial
and/or other paralysis may result from this surgery, sometimes
resulting in paraplegia. The surgery also results in complete
loss of hearing. There is a tendency for tumors to recur, requiring
repeated surgeries over time. The attendant psychological effects
are numerous and severe. For further information see the National
Neurofibromatosis Foundation and the Acoustic Neuroma Associations
in the Resource section at the end of this booklet.
3. Tinnitus
Tinnitus is a ringing or other noise in the ears or head that
often occurs in the absence of an external stimulus. It can be
intermittent or constant and it may be experienced as mildly
annoying to highly distressing--the effects of tinnitus can be
psychologically devastating. While many people who have hearing
loss do not have tinnitus, more than 90 percent of people with
tinnitus also have hearing loss. For further information see
the American Tinnitus Association in the Resource section at
the end of this booklet.
APPENDIX A: NATIONAL AND LOCAL RESOURCES
A. Organizations
Acoustic Neuroma Association
P0 Box 12402
Atlanta, GA 30355
(404) 237 8023
Acoustic Neuroma Association of Canada (ANAC)
P0 Box 369
Edmonton, AB, T5J, 2J6
Canada.
Alexander Graham Bell Association for the Deaf (AG Bell)
3417 Volta Place, NW
Washington, DC 20007
(202) 337 5220
American Tinnitus Association (ATA)
P0 Box 5
Portland, OR 97207-0005
(503) 248 9985
Association of Late-Deafened Adults (ALDA)
11038 N. Pleasant Hill Rd.
Dakota, IL 61018
AT&T National Special Needs Center
2001 Route 46
Parsippany, NJ 07054
(800) 233 1222
Cochlear Implant Club International, Inc. (CICI)
Box 464
Buffalo, NY 14223-0464
(716) 838 4662 V/TDD
Hearing Dogs for the Deaf and Hard of Hearing
The San Francisco SPCA
2500 16th St
San Francisco, CA 94103
(415) 554 3020 V
(415) 554 3022 TDD
International Federation of Hard of Hearing People
Christopher Shaw, General Secretary
P.O. Box 13
Abbots Langley
Hertforshire, WD5 ORQ
National Captioning Institute (NCI)
5203 Leesburg Pike
Falls Church, VA 22041
(703) 917 7600
National Court Reporters Association (NCRA)
8224 Old Courthouse Road,
Vienna, VA 22182-3808
(703) 556 6272 V
(703) 556 6289 TDD
National Information Center on Deafness (NICD)
Gallaudet University
800 Florida Ave, NE
Washington, DC 20002
(800) 451 8834
National Institute on Deafness and Other Communication Disorders
(NIDCD)
NIDCD Clearinghouse
1 Communication Avenue
Bethesda, MD 20892
(800) 241 1044 V
(800) 241 1055 TDD
National Neurofibromatosis Foundation, Inc.
141 Fifth Ave, Suite 7-S
New York, NY 10010-7105
(800) 323 7938
Self Help for Hard of Hearing People, Inc. (SHHH)
7910 Woodmont Ave, Suite 1200
Bethesda, MD 20814
(301) 657 2248
Vestibular Disorders Association (VEDA)
P0 Box 4467
Portland, OR 97208-4467
(503) 229 7705
B. Hearing Health Professional Organizations
Academy of Rehabilitative Audiology (ARA)
ARA National Office
P0 Box 26532
Minneapolis, MN 55426
(612) 920 6098
American Academy of Otolaryngology-Head and Neck Surgery
1101 Vermont Ave, NW, Suite 302
Washington, DC 20005
(202) 289 4607
American Speech-Language-Hearing Association
10801 Rockville Pike
Rockville, MD 20852
(301) 897 5700 V or TDD
C. Manufacturers and Vendors
Audiometrics, Inc.
710 Standard Street
Longview, TX 75604
(800) 237 0716
Clarion, by
Advanced Bionics, Corp.
12740 San Fernando Road
Sylmar, CA 91342
1 (800) 678 2575 V
1 (800) 678 3575 TDD
Cochlear Corporation
61 Inverness Dr. E., Ste 200
Englewood, CO 80112
(800) 523 5798
(303) 790 9010
Comtek Communications Technology, Inc.
357 West 2700, South
Salt Lake City, UT 84115
(801) 466 3463
Hear Your World
1421 Edgecliffe Dr.
Los Angeles, CA 90026
(800) 964 3271 V TTY
(213) 661 2010
Phonic Ear, Inc.
3880 Cypress Dr.
Petaluma, CA 94954-7600
(800) 227 0735
(707) 769 9624
Harris Communications
6541 City West Parkway
Eden Prarie, MN 55344
(612) 906 1180
Walker Equipment Corp.
Hwy 151 South
Ringgold, GA 30736
(800) HANDSET
(706) 935 2600
Williams Sound
10399 West 70th Street
Eden Prarie, MN 55344-3456
(800) 328 6190
For a comprehensive listing of manufacturers and organizations
see
The Hearing Journal, Vol. 48, No. 12, Dec. 1995 (the 1996
Hearing
Health Industry World Directory Issue)
APPENDIX B: REFERENCES
D. Periodicals
The Volta Review
AG Bell, Assoc.
3417 Volta Place, NW
Washington, DC 20007
Hearing Health magazine
P0 Drawer V
Ingleside, TX 78362
(512) 776 7240
Hearing Loss
The Journal of Self Help for Hard of Hearing People, Inc.
7910 Woodmont Ave, Suite 1200
Bethesda, MD 20814
Journal of the Academy of Rehabilitative Audiology (JARA)
Circulation Manager
P0 Box 26532
Minneapolis, MN 55426
E. Books
Clark, J.K., and Martin, F.N. (1994) Effective Counseling
in Audiology: Perspectives and Practice.
Prentice Hall, Englewood Cliffs, NJ 07632, 319 pages
Davis, Julia, Ed. (1990) Our Forgotton Children: Hard of
Hearing Pupils in the Schools. 2nd Ed.
SHHH, 7910 Woodmont Ave, Suite 1200, Bethesda, MD 20814, 68 pages
($5.00 plus shipping)
Kricos, P.B., and Lesner, SA. (1995) Hearing Care For The
Older Adult.
Butterworth-Heinemann, 313 Washington Street, Newton, MA
02158-1626, 282 pages
Ross, Mark, Ed. (1994) Communication Access For Persons
With Hearing Loss.
York Publisher, 16781 Shagrin Blvd, Shaker Heights, OH 44120,
306 pages (ISBN 0-912752-35-1)
Trychin S. and Busacco, D. (1991) Manual for Mental Health
Professionals, Part one: Making Services Accessible to Hard of
Hearing People.
SHHH, 7910 Woodmont Ave, Suite 1200, Bethesda, MD 20814 ($20.00)
Trychin S. (1991) Manual for Mental Health Professionals,
Part two: Psychosocial Challenges Faced bv Hard of Hearing People
SHHH, 7910 Woodmont Ave, Suite 1200, Bethesda, MD 20814 ($25.00)
Trychin, S. (1993) Communication Issues Related To Hearing
Loss
SHHH, 7910 Woodmont Ave, Suite 1200, Bethesda, MD 20814 ($12.00)
F. Videotapes
Assistive Devices: Doorways to Independence. Cynthia
Compton.
Vancomp Associates, 2740 Gingerview Lane, Annapolis, MD 21401,
(410) 266 8157 (about $100.00 with an accompanying manual)
Getting The Most Out Of Your Hearing Aids. C. Everett
Koop.
SHHH Publications, 7910 Woodmont Ave, Suite 1200, Bethesda, MD
20814
($19.95 plus $4.25 Shipping)
Communication Rules. Samuel Trychin,
SHHH Publications, 7910 Woodmont Ave, Suite 1200, Bethesda, MD
20814
($40.00, accompanying manual $12.00)
Did I Do That? Samuel Trychin,
SHHH Publications, 7910 Woodmont Ave, Suite 1200, Bethesda, MD
20814
($40.00, accompanying manual $12.00)
Getting Along. Samuel Trychin and Marion Forgatch,
SHHH Publications, 7910 Woodmont Ave, Suite 1200, Bethesda, MD
20814
($40.00, accompanying manual $12.00)
APPENDIX C: COMMUNICATION GUIDELINES
