Listening Fatigue for Children with Hearing Loss (CHL)

Jane Madell
May 15, 2018

Today’s blog is written by Hilary Davis, AuD; Ben Hornsby, PhD, Stephen Camarata, PhD, and Fred Bess, PhD from Vanderbilt University. This is an important topic and they are doing wonderful research in this area.


What is fatigue?

Fatigue is something most everyone has experienced. Despite its omnipresence, fatigue can be difficult to define as there is no agreed upon “gold standard” definition. However, fatigue is often described as a mood state—a feeling of tiredness, weariness, sleepiness, exhaustion, or lack of energy. In addition, feelings of fatigue are often accompanied by problems with concentration and memory, attention, emotion and stress.


Negative consequences of fatigue

In healthy individuals, fatigue is typically short-lived and often remedied with short breaks or rest. Individuals with more chronic health issues, however, often experience more severe problems with recurrent and long-term fatigue. In adults, fatigue-related problems with attention, focus, memory and mental processing can lead to an increase in accidents in the workplace, reduced productivity and an increase in reported problems with mental distress. Fatigue-related issues affect children as well. Children suffering with long-term fatigue increased risk for academic problems, miss more school, and report increased stress compared to typical healthy peers. Overall, quality of life and work or school performance can be significantly impacted when an individual is attempting to cope with the negative effects of severe, recurrent fatigue.


Does listening cause fatigue?

For most healthy individuals without hearing loss, listening and understanding is generally effortless in most conditions. However this is not the case for people with hearing loss. Individuals with hearing loss are more likely to report that difficulty hearing at work causes them to increase their attention and concentration at work. This leads them to report they are “too tired for normal life activities” after the work day ends. Similarly, research suggests that CHL must increase listening effort, when trying to listen to, and understand, speech compared to those without hearing loss. That is, they must put forth more mental effort to focus on the spoken message. This leaves them with fewer cognitive resources for completing other important mental tasks, like remembering what was just said in a sentence, maintaining attention on the teacher and ignoring classroom distractions.

Thus, CHL not only have the inherent disadvantage of reduced access to auditory information they are also at risk for increased listening effort and stress. The hard mental effort required to manage and overcome these difficulties can be fatiguing for children with hearing loss. This is clearly a challenging position for CHL—a situation that can compromise a child’s ability to learn in a typical classroom environment, where high noise levels, interactive lessons, and multi-tasking are part of the day-to-day routine.


Fatigue in the Classroom and at Home

Photo Credit: Alamy Stock Photos

As CHL are at increased risk for fatigue, it is important to be able to identify potential signs of fatigue when working with this population. Below are some common behaviors, reported by teachers and parents that can be helpful in the identification of listening-related fatigue as well as the need for intervention:

  • Child falls asleep in the car on the way home from school/takes naps after-school
  • Child has changes in behavior following a long day of listening activities
  • Child “zones out” during the school days
  • Child takes off devices at the end of the day
  • Child has difficulty following instructions
  • Child exhibits reduced attention and motivation

Although no standardized intervention has been evaluated for alleviating fatigue in school-age CHL, we offer the following common sense suggestions for those working with this population:

  • Allow for brief listening breaks throughout the school day
  • Consider classroom acoustics and child’s placement in classroom
  • Schedule “down time” without listening activities
  • Consider impacts of amplification (i.e. hearing aids, cochlear implants, and/or FM/Roger systems)


How can fatigue be measured?

Listening-related fatigue can have a broad and significant impact on children and adults, and as such, it is important that we be able to measure it reliably. Methods for measuring fatigue are as varied as the definitions for the term. The following three methods have been used by our laboratory, and others, to measure fatigue.

  • Subjective measures: measuring fatigue with the use of interviews, questionnaires or rating scales
  • Behavioral measures: measuring fatigue as a performance decrement over time
  • Physiological measures: measuring fatigue-related changes in physiologic (brain and/or body) activity

The Listening and Learning Lab at Vanderbilt has used these techniques to learn much about the complexities of fatigue associated with listening for CHL. Please see our website (URL listed below) for a full listing of publications and presentations from our lab on this topic and for other useful information about listening-related fatigue.


Measuring Subjective Fatigue:

Vanderbilt Fatigue Scale for Children with Hearing Loss (VFS-CHL)

Previous work has suggested that generic fatigue scales may not be optimal for detecting and quantifying listening-related fatigue in CHL. Importantly, none of the available scales include items that are weighted for listening related effort or fatigue. Having a sensitive measure is a prerequisite for developing interventions to help CHL who struggle with listening-related fatigue. The primary goal of this project is to develop a valid, reliable, measure of listening-related fatigue for CHL.

We plan to create 3 versions of a scale designed to target listening-related fatigue in CHL from different perspectives: 1) a parent version, 2) a teacher/school provider version, and 3) a child version.

Below are a few quotes from CHL, their parents, and educators that highlight the issue of listening-related fatigue from their perspective. Comments like these motivate work in our laboratory to find ways to better measure and develop interventions to reduce listening-related fatigue in CHL.


“My child comes home from school exhausted. She goes into her room, turns off the lights, and takes off her implants. She needs 30 minutes to decompress—then she’s able to come back out and talk to the family.” –parent of a CHL


“When I get tired of listening to things, I just tell my friends, “I’m tired of listening to you, I’m gonna turn you down. If you need me, tap me.” And I just do that for fifteen, thirty minutes.” –teen with hearing loss


“If I’m working on a specific auditory task, I like to get the kids in the morning. At the end of the day, their ability to focus with their [cochlear] implants only becomes nearly impossible.” –Elementary-school SLP


To develop our measures, we have held several focus groups to learn about listening-related fatigue from the perspective of the child, their parents and their teachers/school providers. We held separate focus groups and one-on-one interviews with CHL to discuss their experiences.

Young CHL (age 10 and younger) had trouble understanding the concept of listening-related fatigue and identifying listening situations that led to fatigue. This was the case even when their parents reported observing behaviors suggestive of listening-related fatigue, such as removing their hearing devices (e.g. hearing aid, cochlear implant) at the end of the day, or needing to nap or quiet time after school. Findings like this highlight the importance of getting input from multiple sources when evaluating fatigue in CHL.

We have used the focus groups and interviews to identify common themes and important issues related to listening-related fatigue. Parents, teacher/providers and children confirmed that a strong association exists between difficult listening situations and the development of listening-related fatigue.

Respondents identified common negative consequences of listening-related fatigue (i.e., general feelings of tiredness, increased anxiety and frustration in, and social withdrawal from, difficult listening situations). They also identified common coping strategies for reducing or preventing fatigue. Some strategies were positive (e.g., taking a listening break between challenging settings) while others were not optimal (e.g., turning off or turning down their amplification device in an important listening environment). Using these themes as a guide, we developed a pool of potential items that tapped into physical, social-emotional, and cognitive aspects of listening-related fatigue. These items were reviewed by a panel of adults and children (and their parents) with hearing loss, other experts in the area, and research lab members. Based on their comments, items were modified or excluded, to improve quality.


Additional Data and Help Needed

We’ve collected some preliminary data and the initial results are promising. However, additional data are needed and we need your help to complete this work!

This version will be completed by parents, school service providers working with children with hearing loss aged 6-17 (educational audiologists, speech-language pathologists, general educators, deaf educators, and special educators), and children with hearing loss.


If you are interested in helping with online data collection, please email [email protected]. If you would like more information about our current studies and publications, visit the Listening and Learning Lab website at




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