I have just returned from 7 weeks traveling and giving workshops. I was in 4 countries, 6 time zones, and gave workshops in 7 cities. I learned a great deal in my travels. It will not surprise anyone to hear that things are done differently in different parts of the world. I had the opportunity to meet with audiologists, speech-language pathologists, teachers of the deaf and hard of hearing, auditory-verbal therapists, physicians, and parents. Everybody was open to new ideas and discussion in all cities was wonderful. Some of the countries I visited had extensive services, others did not.
Hearing aids and cochlear implants
In the US, technology may or may not be available because of affordability issues. Hearing aids and FM may be available through Early Intervention. In NY, where I did most of my work, there has not been a financial means test to receive technology, but many other states have a financial means test. After age 3, when children age out of Early Intervention, technology is the responsibility of families. In most states, families on welfare can receive hearing aids, but for families not receiving welfare, hearing aids are not covered. Occasionally hearing aids are covered by health insurance, but usually only for a few hundred dollars – no where near the cost of hearing aids. Cochlear implants are almost always covered by insurance.
Australia has a national audiology program that provides whatever a child needs in hearing aids, cochlear implants and FM system through the age of 26. WOW!! No family has to worry about money to receive technology. The advantages of this are obvious. School staff reported that when an FM broke down, they did not have the ability to send it for repair. They had to wait for the family to come and collect it and bring it to the audiology center. This seemed like a problem to them, but from my point of view, it was wonderful that every child has an FM system. Audiologists also reported that since families did not pay for the equipment some did not value it as much. But kids could have technology to hear.
New Zealand also has good services but not as good as Australia. Hearing aids and cochlear implants are covered through age 18. FM systems are covered at discretion of the audiologist.
In Malaysia, families are responsible for hearing aids. Malaysia has state hospitals which receive a certain number of cochlear implants per year. When funding runs out, no more implants. Each year, they have to wait to see how much funding they will receive, depending on the government’s budget. Families who cannot receive a CI from a state hospital have the option of going to a private hospital and paying to receive the implant. At a workshop I gave for staff at the state hospitals, one of the audiologists asked me about a difficult decision he had to make. He had one CI left for the year and had two candidates. The first was a one year-old with a bilateral profound hearing loss and the other was a three year-old with a severe loss in one ear and a profound loss in the other. He asked me how I would decide which child could have the implant. After considering running out of the room, we discussed options. My first choice was to beg the Health Ministry for another CI. They said that was not possible. We had just discussed “critical periods” and I said, first I would not want to make that decision and second, I thought I would give it to the three year-old who was at the end of the first “critical period” for developing listening skills, and that I would give the one year-old the first implant next year. We also discussed investigating the families to be sure both would do everything that needed to be done to maximize performance.
In Indonesia the situation is different. There are no audiologists. Audiology services are provided by audiology physicians who are ENT’s. There is no state funding for technology and families must find money for any technology that is needed. If funding is limited, children will not have access to technology. I do volunteer work in Vietnam with the Global Foundation for Children with Hearing Loss. In Vietnam, there are audiology technicians who provide audiology services. Families who work for the government may be able to get cochlear implants paid for by the government. All other technology needs to be paid for by the family. Families have asked me if I thought they should sell their land to buy a cochlear implant for their child. Another awful question to be asked.
Speech perception testing
A significant part of the audiological evaluation, especially with technology, is the measurement of speech perception. Most of the speech perception tests available are in American English. Some tests have been recorded in Spanish. In Indonesia, one of the audiology physicians has had the Hint-C translated and standardized into the Indonesian language. I spent a lot of time talking with all the clinicians about developing speech perception tests. The Australians are recording the current tests with an Australian accent. I made suggestions to the audiologists in Malaysia and Indonesia about how to develop tests. We talked about starting off collecting “first words”, seeing if they could be analyzed for phonemes in the language, proceeding from there to testing normal hearing children and then moving on to children with hearing loss. In Indonesian, there is a limited number of monosyllabic words so bi-syllabic words would need to be used. It was very exciting that there was enthusiasm for developing tests in a variety of languages.
Different types of technology
In countries like Malaysia, Indonesia and Vietnam, technology manufacturers offer levels of technology that are different than those offered in the west. Devices are available with “fewer bells and whistles” at reduced cost for families that cannot afford the most current technology. While my first reaction was to question this policy, I came to understand that providing technology at a reduced cost is, in fact, the only way most families will be able to afford technology. Those of us who have fit technology for many years know that there are many young adults who are deaf, who are wearing older technology and who are doing wonderfully, so that technology without all the “bells and whistles” may be fine for many children.
We worry in this country about services for our children when schools do not have educational audiologists. Well, New Zealand has only one educational audiologist in the entire country. Australia has none, and the concept of educational audiology – services provided in schools, was completely foreign in South East Asia. Monitoring children in schools is left to school personnel.
Australia and New Zealand have good speech-language-listening therapy services available for children with hearing loss. There are certified auditory-verbal therapists and the numbers are growing. No auditory-verbal educators have yet been certified yet in those countries. Malaysia and Indonesia have speech-language pathologists but not auditory verbal practitioners yet. Vietnam has clinicians trained by the Global Foundation for Children with Hearing Loss to provide auditory verbal practice but no one is yet certified. Since the certification examination is not available in their languages, taking the examination is difficult.
Thinking about services in the US
We need to be grateful for the services that we have in this country. Most children can receive cochlear implants through insurance. Unfortunately, hearing aids are not available through insurance for most families. There are not sufficient auditory verbal practitioners for all the children with hearing loss but children are receiving services from speech-language pathologists. Educational audiologists are available in some school districts but not in many. Teachers of the Deaf may be available, but most do not provide preview and review services leaving out children missing some of what they need. Families might wish they had the level of technology services available in Australia, but we have many more services than are available in South East Asia. We need to be grateful for the services we have, but we need to fight for all the additional services we need for our children – educational audiology, auditory verbal therapy, available technology for all children who need it, full teacher of the deaf services with auditory verbal educators at school. We need to work with current organizations such as A. G. Bell Association, Hands and Voices, and parent groups in every state, to work on getting our children the services they need.