Dr. Ross on Hearing Loss
When a Hearing Aid is NOT Enough: Consider other types of Hearing Assistance Technologies
by Mark Ross, Ph.D.
Now don't get me wrong: I think hearing aids are wonderful. I hate to think what my life would be like without them. But sometimes, and in some situations, either you're not wearing them (like when you're in bed, coming out of the shower, etc.) or they need to be supplemented by another type of assistive device. That's where hearing assistance technologies come in. Keep in mind that the devices I'm talking about are not hearing aids and they are not used instead of hearing aids.
Were there times that you stayed at a hotel without your hearing spouse (your hearing "ear")? How did you wake up in the morning when you couldn't hear the phone or the knock on the door? How would you have known if there was a fire if you couldn't hear the audible alarm? Or, let's say, you have your hearing aids on and you are watching TV at home. But the kids are in the next room listening to their stereo, the dishwasher is going in the kitchen, and your neighbors are having a noisy party. Sure you can turn the TV volume up, but not only would this not make the sound clearer, but you may drive your spouse out of the room, alienate your neighbors and provoke your kids to turn up the stereo even louder.
These are not far-fetched examples. As most hearing aid users will testify, even with the most sophisticated of instruments, there are still situations where hearing-related difficulties occur. So while hearing aids are marvelous devices, they can only do so much. They can't restore normal hearing and they can't help you when you're not wearing them. Some sort of hearing assistance technology can add to your communication capabilities and sound awareness. But this will be possible only if you're aware that these devices exist, that you know what they do and where to get them, and most importantly, if you're determined to take the initiative in order to get the help you need. You can't disguise a hearing assistive device; when you use it, everyone (gasp!) will know you have a hearing loss (as if all the important people in your life already didn't know!).
Hearing assistance technologies come in two forms. In one type, they are designed to convert sound or keystrokes into a visual or vibratory stimuli, or a written text. These are called signaling or text display devices. In other words, they provide an alternative for the sound. The second type is designed to enhance the sound you are receiving. These are called assistive listening devices, and they work by picking up the sound closer to its source (thus reducing the effects of distance, noise, and reverberation) and transmitting it directly to your ears (or hearing aids). In recent years, there has been an impressive proliferation of both types of devices, many more than I can include in this paper. What I'd like to do here is provide you with a general overview of what devices are available and how they work. At the conclusion of this paper, I'll inform you where and how you can get further information.
The most important point to keep in mind as I describe the various devices is your personal analysis of situations in which your hearing aids are less, or not, effective. The examples I gave above will illustrate this point. To wake up in a hotel, you would could use either an alarm clock that triggers a light or a vibrator (placed under your pillow), or a sound-activated light that blinks when the telephone rings or when someone knocks on the door. To be sure that you wake up in the event of a fire, you can request a visual smoke alarm. (Incidentally, hotels are required by law to provide you with these devices, and others such as amplified telephones and TTY's if you ask for them.) And to improve TV listening, you could utilize an Infra-Red (IR) system that will transmit the TV sound to an IR receiver. These come in all shapes and sizes and you can pick the one that is most suitable;some work in conjunction with your hearing aids, and some are self-contained. You yourself are the best person to judge when and where you think you can benefit from such gadgets. So as I go through various ones listed below, think about your own experiences and consider whether you might be helped by one or more of these hearing assistance technologies.
Hearing Enhancement Devices
Large Area Assistive Listening Devices
These are the most popular of all hearing assistance technologies. You may already be familiar with them. They are the ones used in theaters, movie houses, auditoriums, and houses of worship. There are three basic types: FM radio, Infra-Red (IR) light, and a looped wire around the room (Induction Loop). They can all work quite well, but each has its own unique advantages and disadvantages. They all pick up the sound at the source (the movie sound track, or from one or more microphones) and transmit the signal to special receivers that you wear. Their difference lies in the fact that one technology or other may be more appropriate for certain types of situations. For example, an IR system provides privacy since the light wave stays in the room where it is generated, but it is a bit more difficult to install and ensure good coverage in the listening area. An FM radio system is relatively easy to install and will provide good coverage in the listening area, but is more susceptible to outside radio interference and does not provide privacy (you could stand outside of a Broadway show and record the "original cast" performance!). The induction loop system is the most difficult to install, but most convenient for users who have hearing aids that include a telephone coil (these are tiny "induction" coils that pick up the electromagnetic energy emanating from the induction loop; more about these later).
I can't sufficiently emphasize how wonderful these systems can be. I personally would not attend any performance or lecture unless I can be assured that the venue is providing an assistive listening device. Fortunately, I have the law on my side. The Americans with Disabilities Act requires all places of public accomodations (excepting houses of worship) to make them available. But, and it is a big but, you have to ask for them. It's also a good idea to call in advance and verify if they are available (and if the batteries are charged, etc.). If you have a hearing loss, even a minimal one, and whether or not you wear hearing aids, let me strongly encourage you to try one of these assistive listening devices. If the system is working well (unfortunately, this is not always the case), the difference it can make in your understanding and enjoying a performance is truly astounding. Many, many people have told me that when they used such an assistive listening device that for the first time in years they were able to appreciate a sermon or comprehend all the dialogue in a show. Other people report that even though they could understand the dialogue without an assistive listening system, with one they could achieve comprehension with much less strain, less effort, and less resulting fatigue.
You should see a sign by the box office or lobby noting that "hearing assistive devices" are available. You may need to leave some ID, but they are not permitted to charge you a rental fee. Several types of special receivers are available, and this applies to both FM and IR technologies. Some are designed to be worn with headphones (or earbuds), and you can wear them either over your hearing aids or take your aids out to wear them. If you have telephone coils in your hearing aids (and if you don't know if you do, check with your audiologist), you can plug a neckloop (a wire loop that is placed over the head and around the neck) into the earphone jack on the receiver and listen through your hearing aids. The neckloop transmits an electromagnetic signal that is picked up by the telephone coil in the hearing aids.
TV Listening Systems
Essentially, these work on the same principle as large area listening systems, but on a smaller scale. The sound is picked up at the source and transmitted via radio, light, or electromagnetic waves right to your ear. In the usual type, you either locate the microphone by the TV loudspeaker or plug a wire into the "audio-output" jacks in back of the television set. These wires connect to a small IR or FM transmitter which broadcasts a radio or light signal to the same type of special receivers used with large-area systems. Some of the receivers contain all the electronics in the headset, others fit on the body or dangle from the ear (a stethoscope type). Instead of personal receivers, it is possible to transmit the radio signal to small external loudspeakers that are placed closed to the listener (this would be when the person cannot manage, for any reason, a personal receiver).
There are many other ways of improving TV audio reception. Some technophiles enjoy building their own connections, using small amplifiers and a direct wire connection to their hearing aids or to earphones. Other people prefer a small induction loop on the floor which they access through the telephone coils (the "T" coil) in their hearing aids. There are also radios which can be tuned to the network TV audio. For my own use, I plug into the audio-output jack of my TV set, connect the wire to a small amplifier into which I plug a neckloop. I then listen through my hearing aids switched to the "T" position. Works well for me.
When you use any kind of TV listening device, you should be able to set your own loudness independent of everyone else. That makes everyone happy. If you have been turning up the volume of the TV set in order to try to improve your understanding, what you've been doing is endangering marital harmony and annoying your neighbors (and I'm only half-joking). While this may have helped your understanding a bit, you can gain much more comprehension through a TV listening system. Considering the important role that television viewing plays in our personal lives, we should not underestimate the value of improving TV audio reception.
Ever sit in a meeting and have problems picking up the people at the far end of the table? For some people, those whose jobs or social activities require their presence at frequent meetings, this can be quite a problem. This is the situation that a conference microphone is designed to help. Usually, it is centered among the participants, perhaps a bit closer to those who are seated further away from you. What the microphone does is pick up their speech and transmit it to a listener wearing a special receiver. If this sounds familiar, it should. In a sense it is doing what the large-area and the TV listening devices do: picking up sound closer to the source and transmitting it to you.
Conference microphones are usually fairly small and can operate either on an FM or IR principle. They can be battery or AC powered, and they can include extra microphones on long cords to further enhance reception. Since they are designed to pick up sound emanating from as much as 20 feet way, I've seen them used as podium microphones as well. This permits the speaker to move around the podium and still be heard (though I still prefer a lapel microphone clipped to the talker). Some people will use them in the middle of a dining room table; this can also work well, provided that the diners will agree to be somewhat disciplined in their conversation (one at a time, please!).
Personal FM System
This is my personal favorite. FM listening systems have been used in educational settings for hearing-impaired children for about 30 years. These can best be conceptualized as FM radios, with a transmitter "broadcasting" the desired signal to an FM receiver worn by the listener. While they could have helped adults as well, FM systems never gained much acceptance by the grown ups. Why? To inconvenient to use was the usual comment. This excuse is no longer applicable. Modern FM receivers are incorporated in some behind-the-ear hearing aids. In other words, the hearing aid can function as an FM receiver as well as a personal hearing aid. You can set it to receive the FM signal alone (good in noisy places), microphone alone (where it functions just as a normal hearing aid), or both together. The FM microphone/transmitters of these newer systems are about six inches long and an inch wide, or about the same size as the remote control of some programmable hearing aids. Several companies are now including directional characteristics into the FM microphone, for improved signal detection capabilities in noisy situations. That is, the FM microphone/transmitter picks up sound more efficiently at the point of focus, and de-emphasizes sounds arriving from other directions.
The advantage of these systems is that they can function as a remote "third" ear, one that you can locate close to the source of the desired sound. Want to hear your wife at dinner in a noisy restaurant? Have her clip the microphone/transmitter to her blouse or slip it over her neck. Having trouble understanding your husband while he's driving (no, you [don't] want him to face you!)? Have him put the microphone/transmitter in his pocket. Walking the streets of a noisy city? Have your partner wear the FM microphone/transmitter. Want to hear the TV set in the hotel better? Place the microphone right by the TV speaker (yes, you can do this at home too). Attending the obligatory noisy office reception? Take it with you and hold it close to the speaker's lips. It takes bit of an assertive attitude to adopt this latter suggestion, but if you really do want to hear better in these situations, and you must attend them, try it. (It's also a great conversational starter - and sometimes stopper! Some paranoid types think they're being recorded).
One last point about personal FM systems: they are an effective way of directly increasing the level of the speech signal relative to the noise, the speech to noise ratio. And of all the factors underlying the comprehension of speech by a person with a hearing loss, this ranks as one of the most important (another one is where the hearing aid makes previously unheard sounds audible - but this is another topic). FM systems do this by being placed closer to the sounds you're interested in hearing - very simple but yet very profound in its impact. Hopefully, in the not too distant future, we'll see these FM microphone/transmitters reduced to the size of a ball-point pen and capable of focusing in on one person talking in the midst of a crowd. "Trinaural" hearing may then be a reality. (If a person has two bad ears why not use a "third" ear as a compensatory measure?)
The extent and variety of telephone options for people with hearing loss is truly impressive. In assistive devices catalogues, there are pages and pages of descriptions of various kinds of special telephones. If you're having difficulty communicating on the telephones, the chances are that you will find something in these pages that can help you. In all candor, however, the degree and nature of your hearing loss will set the ultimate limits of the effectiveness of any type of amplified telephone - or any other type of assistive listening devices, for that matter. In such instances, the use of a text display, such as a TTY would be indicated (see below).
There are telephone handsets that not only amplify, but that can also be set to provide variable degrees of high frequency amplification. There are those that automatically reset to zero after you hang up the phone (to keep from blasting the next user, who may happen to have normal hearing) and those that work on a "push to talk" principle (useful in noisy situations). Small and portable "in-line" amplifiers, connecting between the handset and the base, can be used to amplify the telephone signal. Some in-line amplifiers come with "frequency equalizers" to allow modifications of the amplified speech signal and also include an audio output jack. By plugging in a neckloop, a severely hearing-impaired user can use the telephone coils in the hearing aids to listen with both ears. I know a few adventurous souls who plug the output from an in-line amplifier directly into their hearing aids using the direct audio input connection on their behind the ear hearing aids. There are also answering machines that include an audio-output jack; this permits two-ear hearing with a neckloop. Given the quality of some of answering machines around, this may not be an insignificant advantage!
By law, all wireline and cordless telephones (not "cell" phones) manufactured or imported into the United States in recent years must be hearing aid compatible (HAC). What this means is that the telephone handset must generate a tiny electromagnetic field around the earpiece. Originally, this electromagnetic field was simply a by-product of the operation of the telephone; its function was to create the sound by vibrating a diaphragm in the handset. Some fifty years ago, it was learned that people wearing hearing aids could directly access the information in this electromagnetic field by inserting a small coil of wire (an "induction" coil) in their hearing aids. This coil, now termed "telephone" coil or "T" coil, converts the electromagnetic field to an electrical current. This current is amplified by the hearing aid in the same way that the electrical current produced by a microphone is amplified. While telephones can now be fabricated that shield the electromagnetic field, or operate on a different principle, including such a field has proven to be beneficial to many people wearing hearing aids. As a bonus consideration, the "T" coils in hearing aids can also be used to access assistive listening devices as well, as commented on above.
When a person uses a telephone coil, the microphone of the hearing aid is deactivated. This simple act makes it much easier to talk on the telephone, since not only is external noise eliminated but the volume control can be turned up as much as desired without causing a squeal (acoustic feedback). Since telephone coils take up space, they are less feasible in the smaller hearing aids, particularly the ones that fit directly in the ear canal. For the most part, however, people wearing canal type of hearing aids can place the telephone right over their ears (and hearing aids). If this produces a squeal from the hearing aid, it is possible to stick a thin foam cushion over the telephone earpiece; often, this will reduce the acoustic feedback and permit direct telephone access.
My advice to someone having difficulty understanding on the telephone is not to give up. If you have the basic residual hearing capacity, there is likely some adaptation that can be made to improve your functional ability. But you do have to willing to try and experiment with different options. Work with your audiologist as you go through the possibilities. If your residual hearing is simply insufficient, then you can still communicate adequately with one of the TTY options.
Signaling and Text Display Systems
We're all very well aware that people with hearing losses have difficulty hearing! Steps to enhance the audible signal, to make better use of a person's residual hearing, make perfect sense and their justification requires no elaboration. The need for signaling and substitution systems (converting sound or key strokes into another mode) is not quite so apparent, even for the people with the hearing loss. It's not that they're not aware of problems; it's just that a non-auditory solution does not immediately come to mind. Once we raise the possibility, the utility and contribution of a non-auditory solution then appears so logical as to make us wonder why we didn't think of it before. In the next few pages, I shall describe in a general way some of the signaling and text display systems that are now available to help people with hearing loss in very specific ways. If you recognize an area of difficulty, and if you think you can be helped by one of the types of devices I describe, talk it over with your audiologist. He or she may be able to either acquire the device for you or, certainly, advise you where you can get it.
Signaling and Warning Systems
I've already alluded to vibratory and visual alarms earlier in this paper. There are a large number of these wake-up alarms available. Some work by activating a vibrator, others flash a blinking bright light; while still others respond to sound and trigger a light or a vibrator. I have a favorite wrist watch which I use as a vibrating alarm (just came out a year or so ago). I've also used it to remind me when I've had to take pills every four hours, since I can't hear the dinky little chime that comes with traditional wristwatches.
The telephone or doorbell rings and you don't know someone is calling you or knocking at the door? There are different ways of hooking a light into the phone line; when the phone rings, the light flashes. You can set it up to flash in the living room, even though telephone is in the kitchen. You can hook a small transmitter to the doorbell, with a receiver triggering a light or a loud buzz in each room of the house (works through the house wires). When I go to a hotel, I ask for a door-knocker light (among other things). This is stuck on the inside of the door and lights when someone is knocking.
A visual smoke alarm is a must for people with hearing loss. The sound signal generated by smoke alarms may not be sufficient to wake them up. Some alarms come with both visual and audible signals, and should serve for most everybody. They are as simple to install as the ordinarily sound alarms. I would also recommend that you ask for them whenever you are staying in a hotel. Unfortunately, some of the visual smoke alarms in the hotels are not tied into the central fire alarm system; a fire anywhere else in the hotel (other than your room) will not activate these alarms. Some hotel chains are more sensitive to these problem than others, and I suggest that you verify the status of the visual smoke alarm whenever you check into a hotel.
Hearing-impaired parents who have young children are often very poor sleepers. I've known of parents in the past who tied strings to their child's crib, so that they would know when their child was crying. There are easier ways. Now we can place an intercom next to the crib with light-flashing receivers in the parent's room. To integrate all of these systems (door, telephone, fire, baby-cry, etc.) there are base stations which convert each sensor into a different stimulus (one, two, three flashes, etc.). The receivers can be worn on the wrist and deliver a vibratory or a light signal.
Worried about missing the approach of emergency vehicles when you're driving? You can hook an all weather microphone on the rear window or inside the trunk of your car. This will trigger warning lights from an indicator resting on your dashboard when an emergency vehicle is approaching with its siren on. As a matter of fact, this may be a freebie: the equipment and installation of this equipment can be reimbursed in any new GM, Ford, and Chrysler vehicle. This program is called EARS for Emergency Alert Response Systems. And along the same line, but not free, is a turn signal indicator that will let you know whenever you've left the turn indicator on for longer than 15 seconds (without the brakes being engaged). What happens is that a dash light will flash and buzzer gets louder and louder the longer the turn indicator stays on.
This brief overview is simply meant to introduce you to possibilities and not be a comprehensive description of what's out there. As I pointed out earlier, it's up to you to consider the overall scope of your communication problems and needs and then work with your audiologist to see how you can best resolve them.
Text Display Systems: Telephones
The classic text display system is the TTY, the teletype system. About 35 years ago, a deaf physicist figured out how to connect TTY's through a telephone modem. This opened up the world of telecommunications to deaf people, and it's hard to think of a more significant development in recent years for deaf people (TV closed captioning is another, see below). Just to clarify terminology, this is the same device that is sometime called TT, for text telephone, or TDD, for telephone devices for the deaf. Rather than spending our time trying to learn new acronyms, it now seems to be accepted to go back to the original designator, TTY.
A TTY system looks a bit like a typewriter with a built-in acoustic coupler for the telephone (a direct electrical connection to the telephone line is used for permanent hook-ups). They come in all shapes and sizes, the smallest ones about the size of computer notebook. If you are receiving the phone call, a light will flash to signal you. You would answer the phone by typing in, for example, "hello, this is mark, ga" (for go ahead). The person would then type the message to you, which you would either read on a small screen or on a paper copy. To communicate this way, both the sender and the receiver require a TTY.
If you are a late deafened adult with perfectly acceptable speech, you don't want to take the time to type all of your messages. Besides the person you want to talk you may not have a TTY. In this case, you can use a telephone relay service. This is a national program, available in all states through an 800 number. You can look up the number in the first pages of every telephone book. What you do is call the relay service and tell the relay operator, who serves as a communication assistant (CA), that you want to make a voice carry over (VCO) telephone call to particular number. The CA will call the number and tell the person that you are calling. The CA will let you know, by typing, that the connection has been made. You then speak directly to your party. Your party, in turn, talks to you through the CA, who types the messages that you read on your TTY (or special VCO telephone). It works the other way too. The normally hearing person can call you through the relay operator. So even if you can't hear a sound, telephone communication is still possible. (Many deaf people are now also using their computers and the internet for real-time "conversations", with a likelihood that this form of communication will exponentially increase in future years - and for everyone, not just deaf people).
Text Display Systems: TV Closed Captioning
If you purchased a TV set in the last four or five years, chances are that it includes a chip that provides access to captioning. Click on the menu on the remote (or directly on the TV set) and cycle through it until you see the closed captioning command. Routinely, it is turned "off"; turn it "on". When you do, you'll see a written version of the speech (and other information about sounds occurring) appearing on the screen. Not all programs are captioned, but more and more will be as the regulations of the new law on telecommunications comes into force.
Some programs are captioned in "real-time". This means that a typist, usually a trained court reporter using special software to convert the phonetic input into English orthography, is typing away as the program proceeds. Because a human being is involved, there is a slight delay between the spoken and written versions of the same verbalizations. Accuracy, while quite high, is not one hundred percent. Other programs are captioned "off-line". This means that the typist has an opportunity to preview the program and type in the dialogue. In these instances, the dialogue appears simultaneously with the spoken version. If you are watching a movie on TV, try the captioning command; if it is a recent movie, chances are that it is captioned. And if you use the VCR to watch movies, be sure that the movie is closed captioned. There are two symbols that designate whether a video is closed captioned: one is a "CC", and the other looks like a TV screen with a squiggle curving down from the right hand side.
Many hard of hearing people, who do not feel that they need to read captions while watching TV, are amazed how much more they get when they can simultaneously read while listening. Often, in the interests of "realism", actors interrupt or speak over one another, often in the presence of loud background sounds. The captioning provides information for these people that they are simply unable to get through listening alone. I know that I, for one, will not take out a movie from a video store unless it is closed captioned. So try it, you'll like it!
This has really been a brief excursion in the area of hearing assistance technologies. There are many more devices and possibilities than I can possibly include here. As a matter of fact, a few years ago I edited an entire book on this topic. The "take-away" messages of this paper are:
You can also obtain information about hearing assistance technologies by writing to Self Help for Hard of Hearing People, 7910 Woodmont Ave, Suite 1200, Bethesda, MD 20814. Include a stamped self-addressed envelope, and they will send you a list of companies that sell hearing assistance technologies and from whom you can request catalogues. (You can also request from SHHH other brochures on hearing loss from a consumer perspective.)
This article was supported, in part, by Grant #RH133E30015 from the US Department of Education, NIDRR, to the Lexington Center, Jackson Heights, NY.