Pediatric audiology is a complex profession. In addition to diagnostic responsibilities, pediatric audiologists need to provide and monitor habilitation services including selecting and fitting technology and counseling services to the families and the children they serve. Audiologists are case managers. So what are the components of their jobs?
Diagnosing hearing loss
First, we need to diagnose degree and type of hearing loss. This is obvious, but critical if we are to appropriately perform the rest of our job. Is the hearing loss medically treatable? What has to be done before we proceed with habilitation?
Sharing information with the family
In many ways, making the diagnosis is the easy part. Once the diagnosis is made, families have to understand what it means. We need to be careful not to use jargon. Who, besides us, knows what a severe bilateral sensorineural hearing loss means? We need to transmit information in a way that helps families understand the seriousness of the diagnosis, what the effect will be on learning and on brain development, what the choices about treatment are, and what we are recommending. On day one, most families are not in a position to understand much. They are traumatized by the fact that there is something wrong and will only hear part of what we say. We need to know what they understand and know what we need to do to help them move on.
Once families are ready to move on, we can select appropriate technology. Hopefully, this will happen within a few weeks. Lots of things must be taken into account, including the degree and type of hearing loss. But technology consideration also needs to include decisions about the child and what the family can handle. If a child does not have good head control, how will we keep the hearing aids on without whistling? Should parents’ desire for the smallest possible hearing aid trump the need for good acoustic accessibility? In my view – audibility is key. The only thing that matters is making sure sound is audible. Lots of things to decide.
It is not enough to select a hearing aid and fit it using real-ear technology. Real-ear tells us what is reaching the eardrum, but not what is reaching the brain. We MUST be certain that the child is hearing everything she needs to hear – that means hearing throughout the frequency range at soft levels. How are we going to be certain that a child is hearing at 20 dB at 4000 Hz (so we know he hears “s”?) We need to test it. IF YOU DON’T TEST, YOU DON’T KNOW!! You cannot assume that because hearing aids are set according to the manufacturer’s specs they are appropriate for this child. Remember, manufacturer’s specs are general, not specific to the child in front of you.
Arrange for the child to receive appropriate therapy
Yes, this is our job. Hearing aids, in and of themselves, are only a start. Children and families need therapy to learn to use audition to develop speech and language. Yes, we need to tell families that there are different options for therapy – but we also need to tell them that not all are equal. They need to understand that developing auditory skills is time locked – we cannot do it later. Extensive research has demonstrated that it has to happen early.
Assuring full time use of technology
Eyes open, ears on!! Families need to understand that it is not okay to take hearing aids off when out in public, when visiting grandma (who is sad that Johnnie needs hearing aids), or when Johnnie gets cranky. If a child wears hearing aids 4 hours/day, it will take him 6 years to hear what a child with typical hearing hears in one year. Telling this fact to parents often helps them to understand the importance of having ears on all day long. Some new hearing aids have the ability to tell us how many hours they are actually used. This can be a very helpful counseling tool.
As audiologists, we need to follow up on how the child is performing with their technology, and if it is not optimal (20 dB throughout the frequency range), change it. If you don’t test, you don’t know. Test speech perception regularly. And check what is happening in therapy and in school. When I ask a parent what is happening in therapy, I really want to know. If parents don’t know, that means they are not involved, which means they cannot carry out therapy activities at home. Not a good plan since children with hearing loss need intensive language exposure all day every day. Therapy, even it if is daily, is only 30-60 minutes. Kids need much more. For school-aged kids, ask how they are doing in school. Are they on target in every subject? Are there areas of weakness that need to be developed? Who is doing preview and review of academic subjects so the children can learn with their typical hearing peers? It there are problems we need to find a solution.
Providing support to children
Children with hearing loss will eventually realize that they are different from their peers. They need hearing aids or cochlear implants, they are taken out of class for therapy or tutoring, they have to go to appointments after school instead of playing baseball. At some point, they may be getting teased by classmates. We need to be sensitive to how our kids are doing and ask how they are. How is school? Anyone bullying anyone? Are they bullying you? How do you feel about hearing aids? Is it hard to wear them in school? By asking the questions, we can open a dialogue. When a child comes in and says he does not want to wear his hearing aids or FM, he is really saying that he does not want to have a hearing loss and this means there are things to talk about. Support groups for kids are one of my favorite activities. They love meeting other kids with hearing loss who understand their issues.
Be knowledgeable about your field
We are in an exciting field that changes almost daily. Criteria for who is a cochlear implant candidate changes frequently. A child who is struggling with hearing aids may be a candidate for a cochlear implant now. Consider making the referral. If a child is not learning well, consider a psychoeducational referral. Keep learning what is new and use the information daily.
Ask for help
None of us know everything. If we have a child who is not a star, let’s ask colleagues if they have any ideas for how things might get better. A new pair of eyes can be very helpful and we really have only one responsibility – to help the kids we work with be the best they can be. Let’s just do it.