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ASSISTIVE TECHNOLOGY FOR INDIVIDUALS WHO ARE DEAF AND HARD OF HEARING Objective: 1. 2. 3. 4. Discuss type of devices and reasonable accommodations. Gain insight through hands-on experience. Relate accommodation to employment outcomes. Discuss unique funding issues and alternative resolutions. Presenters: Christine Day SPS Unit Supervisor Woodrow Wilson Rehabilitation Center Susan Hansborough Senior Audiologist Woodrow Wilson Rehabilitation Center Mary Nunnally Deaf and Hard or Hearing Services Program Coordinator Department of Rehabilitative Services 1 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology INTRODUCTION Technology continually changes -- Counselors cannot be the “technology experts” for all disabilities. When working with individuals who are deaf or hard of hearing, ask the following questions: What are the communication barriers? Assess communication in general and on the job. Think in terms of auditory cues in our environment. o Telephone o Alarm clock o Door knock o Fire/smoke o Alarm o Verbal communication Questionnaires for communication needs are an excellent assessment tool. There are several types available. One is located at the end of this section. Which device is appropriate? Review the “general” definitions of each device Experiment -- obtain devices for consumer to utilize on “trial basis” Consumer preference -- visual, tactile, auditory What resources are available? Program Coordinator, Deaf and Hard of Hearing Services 804-662-7614 (V/TTY) 800-552-5019 (V) 800-464-9950 (TTY) Audiologist at Woodrow Wilson Rehab Center 540-332-7086 (V) 800-345-9972 (V) 800-811-7893 (TTY) Virginia Department for the Deaf and Hard of Hearing 804-662-9502 or 800-552-7917 (V/TTY) Deaf/Hard of Hearing Services Unit Supervisor (WWRC) 540-332-7236 (V/TTY) 800-345-9972 (V) 800-811-7893 (TTY) Regional Rehabilitation Counselors for the Deaf 2 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology FUNDING SOURCES Department of Rehabilitative Services Technology Assistance Program (TAP): The Virginia Department for the Deaf and Hard of Hearing (VDDHH) distributes telephone equipment to individuals in the state who are deaf, hard of hearing, deafblind, hearing impaired/visually impaired, or speech disabled. Eligibility is based on the hearing or speech disability and financial need. VDDHH also manages TAPLOAN, which provides individuals and organizations with the opportunity to evaluate equipment available through TAP, prior to purchase, for up to 30 days. TAPLOAN also allows people who have purchased equipment through TAP to borrow the same or similar equipment while their own equipment is being repaired. TAPLOAN sites are located throughout the Commonwealth. Most TAP equipment is on state contract, which offers a potential reduced cost for any state agency. Check with VDDHH or DRS Deaf and Hard of Hearing Services before purchasing any related telephone equipment. Central Virginia Lions Hearing Aid Bank: Reconditioned hearing aids are provided for individuals with a hearing loss. Eligibility is based on financial need to anyone in the state of Virginia. Program is a fund of last resort. For detailed information, contact (800) 407-4327 or (804) 285-8245 http://www.lions24b.org/cvlhab.htm Consumer Service Fund: Assistive technology can be purchased through this fund which is financial need based. Program accepts applications quarterly. Program is a fund of last resort Civic Organizations: Many civic organizations have assisted in the purchase of assistive technology for individuals with disabilities in financial need that do not qualify for any other program Assistive Technology Loan Fund Authority (ATLF): The ATLFA makes loans and loan guarantees to people with disabilities for equipment and technology that increase independence, quality of life and employment opportunities. Loans are made through this program in partnership with SunTrust and feature easier loan approval criteria, flexible terms and favorable interest rates. Loans not approved by SunTrust Bank may qualify for an ATLFA guaranteed loan. Many families on fixed incomes, or who have credit problems related to their disability, have qualified for loans through the ATLFA. Care Connection for Children (CCC): Care Connection for Children is a statewide network of centers of excellence for children with special health care needs (CSHCN) that provide leadership in the enhancement of specialty 3 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology medical services; care coordination; medical insurance benefits evaluation and coordination; management of the CSHCN Pool of Funds; information and referral to CSHCN resources; family-to-family support; and training and consultation with community providers on CSHCN issues. http://www.vahealth.org/specialchildren/cssprogram.htm TYPES OF DEVICES Assistive Listening: FM System Infra-red System Induction Loop Personal Amplifier Hearing Aid with FM Sound-field FM Hearing Aid Accessories Amplification: Behind-The-Ear In-The-Ear Canal Aid Completely-In-the-Canal (CIC) CROS Aid Bi-CROS Aid Programmable Aid Analog Aid (old technology rarely used) Digital Aid (today’s standard) “T-Switch” Hearing Aid Accessories Direct Audio Input Bone Conduction Aid BTE/FM Aid Alerting Devices: Visual Tactual Auditory Specialized Equipment Amplified Stethoscope Digital Blood Pressure Monitor 4 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology Emergency Systems Telecommunications: Amplifiers Binaural Headsets Hearing Aids w/ Telephone switch and/or Bluetooth Hearing Aid Accessories TTY/TDD Uniphone (VCO) Voice Carryover Phone Fax machine Wireless Pagers / PDAs Text messaging CapTel Video Telephone Video Relay Computers: Computer Assisted Note Taking Computer Aided Real-time Translation Communication Software/Networks Video Telephone Television: Telecaption Decoders Decoder Chips Assistive Listening Device Hearing Aid Accessories Captioned Videos/DVDs 5 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology Clocks and Wake Up Alarm Systems Sonic Boom Alarm Clock with bed shaker AlertMaster 6000 Alert Wireless Doorbell and Telephone Signaler Sonic Shake for Travel Telephone Products VCO Phone Crystal Tone Amplified Phone Dialogue CL-40 Amplified Phone Easy Recall Answering Machine for Voice and TTY 6 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology Wireless TTY’s PocketComm Pocket Speak & Read VCO Compact TTY/C Pocket VCO & PocketComm 7 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology Wireless Technology ALD for Cell Phones NEW! Artone Bluetooth Neckloop www.etoengineering.com T-Coil Loopset for Nokia Cell phones HATIS Freedom Mach I Hearing Aid Compatible Cell Phones • • • Try before you buy. Not all labeled “HAC” phones would work for you. Most cellular phone providers have some phones and accessibility for hearing disabilities Per FCC, by February 18, 2008, fifty percent of all digital wireless handsets offered must meet the hearing aidcompatibility requirement 8 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology Wireless Technology Text Pagers & PDA’s T-Mobile Sidekick 3 Blackberry 8700g E-mails TTY Messages Instant Messages Relay Service Internet Access Signal coverage continues to improve 911 Not Ready yet 9 Treo 700W Smartphone Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology Assistive Listening Devices Basic FM System Pocketalker TV Listener Amplified Stethoscope ALD – New! Portable Clipboard www.puredirectsound.com Portable InfoLoop http://www.ovalwindowaudio.com/infoloop.htm 10 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology Two Ways of Video Calls Video Phone using TV Web Cam using Computer How Video Relay Works 11 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology Assistive Listening Devices (ALDs) ALDs are electronic devices used along with or instead of hearing aids to overcome problems of background noise and distance from the speaker: The microphone that picks up sound on hearing aids is on the aid itself. That means it is at or near the wearer’s ear. When there is background noise present in a listening situation, turning up the hearing aid volume means increasing the level of the background noise as well as loudness of the speaker’s voice. This often reduces the benefit of wearing the hearing aid. When speakers are at some distance, turning up the volume of a hearing aid may not be sufficient to enable adequate reception of their voices. Use of ALDs can often greatly reduce these problems because: The microphone that picks up the sound in an ALD system is at or near the speaker’s mouth. Therefore, turning up the volume on one’s hearing aid (if used with an ALD) or on the ALD receiver will increase the loudness of the speaker’s voice more than the ambient background noise. The negative effect of the background noise is greatly reduced. Because the microphone is at the speaker’s mouth, the effect of distance on the understanding is greatly reduced when using an ALD system. The voice of a speaker coming through an ALD system sounds as if the person were standing at the shoulder of the listener, even when the speaker is at some distance. Using ALDs properly in many situations will prevent or greatly reduce communication problems. Knowing the advantages and disadvantages of various ALD systems and knowing how to use them properly enables the person with a hearing disability to anticipate problems in various situations he or she may encounter and to plan when and how to use them to minimize communication hassles. There are many conditions at work where listening can be made easier through the use of an ALD. Some common problems that arise due to a hearing disability at work are the inability to fully participate at staff meetings or more informal discussions, difficulty understanding during training sessions or lectures, and problems using the telephone. The use of ALDs may be helpful in each of these situations. An Assistive Listening Device usually contains a microphone, transmitter, receiver/amplifier and earpiece. ALDs are more effective than hearing aids in noisy environments because the microphone that picks up sound on an ALD is positioned close to a speaker’s mouth. This means that the effects of background noise are greatly reduced compared to that experienced through hearing aids. Also, the closeness of the microphone to the sound source (speaker’s mouth) eliminates sound distortion and weakened signal which results 12 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology from distance between the source and the receiver, adding clarity to the sound (speech). ALDs create a listening environment, which makes a speaker’s voice louder and background noise quieter. There are a variety of ALDs for a variety of listening situations. Below are several commonly used ALD systems: FM Systems: A FM system consists of a transmitter, microphone and one or more receivers with earpieces. A FM system is “wireless”. Sound is sent from a transmitter to receiver by radio waves. A FM system does not require wiring between the sound source (microphone) and receiver. FM systems can allow up to 500 feet between speaker and listener with no loss of integrity in the transmission of the speaker’s voice. These units are portable and can use rechargeable batteries. The FM signal will travel through walls which can cause security concerns when discussing private information. To use the FM system, the person who is hard of hearing gives the transmitter and microphone to the “speaker”. The speaker holds the microphone in front of his or her mouth or attaches it to clothing three to six inches from their mouth. The FM user listens to the speaker through an earpiece or “T- switch” and neckloop connected to the FM receiver. Infra-Red Systems (IR): Infra-red systems use light waves rather than radio signals to transmit sound. Similar to a FM system, IR is also wireless (meaning there are no wires between the transmitter and the receiver). The speaker uses a microphone that is connected to a transmitter. The listener has a receiver to pick up sound with an earpiece (some IR units combine the receiver and earpiece into one unit). The IR system produces a very clear signal. Because it is a light ray, however, this signal is susceptible to interference from either natural or incandescent light. Therefore infra-red is often only used in theaters or rooms that are heavily draped or without windows. IR signals do not travel through walls and require a direct “line of sight”; therefore they offer security within the room. Unlike the FM system, the infra-red transmitter does not operate on batteries. Transmitters or “emitters” are usually attached to walls; however, smaller, moveable units are available for home use and sit atop the television or stereo. For a large area, the transmitter can be plugged into the public address (PA) board, when an existing PA system is already in use. The infrared receiver is powered by battery, and the user should not be more than 30 to 50 feet from the transmitter. Induction Loop Systems: An Induction Loop system consists of a coil of wire surrounding a listening area. This wire is connected to an amplifier that controls the volume of the sound transmitted through the loop (wire). One or more microphones, plugged into the amplifier are positioned within the room to be used by persons in any part of the room wishing to speak. Speech 13 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology signals are amplified and circulated through the loop. The resulting electromagnetic energy radiating from the loop wire is picked up and amplified in the telecoil or “T-switch” in listeners’ hearing aids or by an induction receiver. Loop systems can be permanently installed in a room or remain portable. The closer to the loop the listener is seated, the better the signal. Low power equipment such as computer terminals or florescent lighting can cause interference with a loop system. Neckloops are used as individual connectors to FM, Infra-red or personal “hard wire” systems. The neckloop allows the person using hearing aids with a good built-in telecoil to benefit from “customized” amplification of their own hearing aids. Personal Amplifiers: Personal amplifiers are “hard wired” systems, and consist of a receiver/amplifier connected to a microphone by wire. The speaker holds or wears the microphone. The listener keeps the receiver, and controls the level of sound by adjusting the volume dial on it. They are available in monaural or stereo and some have individual volume/tone controls for each ear. Personal amplifiers are ideal for one-on-one conversations when the speaker and listener can be located near one another, as in a counselor/consumer interview. Extension cords are available in lengths of up to twenty feet or more, but may introduce a safety or nuisance factor. The microphone of a personal amplifier can also be placed near the speaker of a TV or radio to afford easier listening. Earpiece Options: The earpiece can be any one of a variety of devices. For example, a neckloop for users with a hearing aid with a telecoil (T) switch, a silhouette (plastic strip worn between the mastoid bone and a behind-the-ear aid with a “T-switch”), and earmold with snap receiver (used with no hearing aid), a walkman type headset (used with no hearing aid, and in-the-ear or canal hearing aid), or an “earbud” (a small speaker covered by spongy material) placed just at the opening of the ear canal. Sound-field FM System: Small, wireless, high-fidelity public address systems that are self-contained in a classroom or other type rooms. The room is amplified through the use of one to five walls or ceiling mounted loudspeakers. The teacher or speaker wears a wireless FM microphone transmitter that sends speech via a radio signal to an amplifier that is connected to the loudspeakers. This enables the speaker’s voice to be heard over the ambient background noise. It has proven to be very beneficial to individuals with hearing loss (even minimal hearing loss), central auditory processing deficits, and ADD/ADHD. This technology is also available in a personal system that has a small speaker that is placed near the individual and can be carried from room to room. 14 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology ALERTING DEVICES (SYSTEMS) Alerting devices can be essential at work to inform the client when a significant event is occurring in the environment. An alerting device can produce a visual (flashing light), tactual (vibration) and/or auditory (very loud) signal that is activated by a loud sound or manipulation of equipment. Any employee expects the safety and security of knowing when the fire or smoke alarm is sounding, that the phone is ringing or that someone needs their attention. The employee with a hearing disability is no exception. Visual Cueing: For blinking lights, both transmitters and receivers are plugged into 110-volt electrical outlets or wired directly into the building’s wiring. Receivers containing the lights are situated wherever the consumer may need to go at any time during the workday within the building. Vibro-Tactile Cueing: If the consumer needs to move substantially within the workplace or even outside, portable systems are available. Using a vibrotactile device, transmission is via FM waves. Transmitters are battery powered and placed as near the sound source as possible. The consumer carries receivers. Often a receiver is worn on the wrist or is attached to clothing. When the transmitter is stimulated (by the smoke alarm or ringing phone, etc.), the receiver begins to vibrate. A coded light will indicate which sound source has triggered the vibration. Auditory Cueing: By changing the frequency and/or volume of: telephone ringers, doorbells, alarm clocks, as accommodating to an individual’s need. Auditory cueing can be used alone or in combination with visual or tactile cueing. Specialized Equipment: There are a number of commercially available emergency systems that present both visual and audible signals for fire/smoke alarms. Some can be connected easily while others require electricians for proper installation. Prices vary considerable form $100 to $400 per unit. TELECOMMUNICATION DEVICES For the person with normal hearing, being able to use the telephone at work is seldom an issue. However, for the person unable to hear clearly or to hear at all, take accurate information, or place an emergency call, telephone accommodation is a primary consideration. Telephone Amplifiers: To improve hearing on the telephone, many types of phone amplifiers are available. Some are more helpful than others are and some are much more expensive than others are. Because one type of 15 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology amplifier is more expensive than another, it will not necessarily be the most helpful. Different Varieties of Phone Amplifiers: Small, inexpensive ($10 to $40) “in-line” amplifiers give minimal amplification, but are often adequate for the user with a mild to moderate hearing disability. This type of amplifier is connected between the body of the standard telephone and the receiver. Depending on the make of amplifier, this system may or may not accommodate multi-line phones. To use this system, dialing may not be done from the handset. The “in-line” amplifier can be battery operated or powered by the telephone. Another inexpensive ($10 to $30), but often completely adequate phone amplifier is the portable amplifier that attaches to the receiver of the standard telephone. The portable phone amplifier can be easily carried in a pocket or purse and is powered by an AA battery or 675 hearing aid battery. This type of phone amplifier is also useful for the person with a mild to moderate hearing disability. It can be used on single or multi-line telephones. Telephone receiver handsets with built-in amplifiers are commonly selected by individuals needing phone amplification. They can provide a 10 to 18 dB gain (usually sufficient for a moderate to severe hearing loss) and attach by replacing the existing handset on the standard telephone. Should the user have a hearing aid with a telephone (or “T”) switch, the “T” switch can enhance the effect of this type of amplification, by increasing the gain as well as eliminating background noise. This type of telephone amplifier cannot be used when dialing is done from the handset. Some amplified handsets will accommodate multi-channel phone lines, others will not. Amplified Telephones: Amplified telephones with frequency response selections can help the person with moderate to severe hearing disability. These systems are more costly (usually several hundred dollars) and may not work with multi-line phone systems. Phones may also be amplified when optional equipment is available with some personal amplifiers and receivers from infrared and FM systems. Amplification of this type can help people with moderate to severe hearing disability. The use of these systems, hearing aids and neckloops allow the user to use both ears for hearing when wearing two hearing aids with “Tswitches”. Walkman type headsets or earbuds can also give binaural hearing when aids are not used. Often people who have been unable to hear on the phone in the past, by listening with both ears and phone amplification, are able to use the phone adequately. It may take some practice to build phone skills and a sense of confidence about using equipment they have been unable to use. 16 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology Text Telephones (TTY) also known as Telecommunication Devices for Deaf (TDD): For the late deafened individual, unable to hear on the telephone, Text Telephones (TTY) are available. A TTY is a modem that looks much like a small typewriter and is used with or instead of a telephone. A visual display of the conversation is produced rather than voice or auditory signals, by tones emitted through phone wires. The “sender” types the message. The message is displayed on a light emitting diode (LED) screen at the receiving end and may also be printed on paper if the TTY has a printer option. A TTY (or compatible telecommunication equipment such as a computer with a modem) is required at both ends of the telephone conversation. Some models of the TTY have a paper printer, automatic answering machine, direct dialing from the key board of the TTY with a directconnect feature which allows the user to by-pass using a standard telephone in unison with the TTY. Less expensive TTY models simply display the message on a small LED screen, as the message moves from right to left across a 20 character display panel. Telecommunications Relay Service (TRS): When a TTY call is placed and no TTY is at the destination of the phone call, a TRS is necessary, and available through all states as mandated by the Americans with Disabilities Act. A relay service allows a person with a TTY to place a phone call to a person who does not have a TTY, and vice versa. When a phone call is placed through a relay service by someone using a TTY, an intervening operator is contacted and given the name and telephone number of the person to be called. The operator reads this information on a TTY screen. The operator then calls the person for whom the call is intended. The operator speaks or “voices” the TTY message to the receiver. The operator to the person originating the phone call then types this person’s verbal response on the TTY. CapTel: CapTel (Caption Telephone) is a voice carry-over telephone and relay service used by individuals who are deaf or hard of hearing. A CapTel phone is programmed to interface immediately with a contracted relay service. When a call is placed using a CapTel phone, the number dialed is routed through the contracted relay service. A relay operator types the conversation to the CapTel user which is viewed on the small digital screen located on the CapTel. The caller is then able to use their own voice when responding in the conversation. Voice Carryover: For TTY users who choose to speak their message rather than type it out on the TTY with the relay operator speaking for them, there is the Voice Carry Over option within the TRS. This speeds up the conversation considerable and adds a more personal flavor to the message. It also encourages use of a TTY by persons who would not use one previously since VCO eliminates the need for typing skills. 17 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology Uniphone: Combination telephone and TTY with voice carryover (VCO) capabilities. Other features may include visual flasher, amplified handset. Video Telephone: Using a commercially available web-camera and high speed internet connection, telephone calls are made person-to –person. Individuals are able to see and hear each other, allowing for total communication styles (auditory, signing, speechreading). Video Relay: VRS makes it possible for sign language users to converse in their native language with the person they are calling. With this feature, users can express real emotions and feelings (similar to a person-to-person conversation) and benefit from increased communication speed. To make a VRS call, individuals use a computer or a television and a video device to connect to the VRS provider of their choice. Once a connection is made, a professionally trained video relay interpreter begins translating the user’s sign language into spoken language or text for the other (hearing) party. When the other person responds, the operator translates his or her words back into sign language for the VRS user. COMPUTERS AND TELEVISION Computer Assisted Notetaking (CAN): Computer Assisted Notetaking (CAN) is a relatively new option for communication access for individuals with profound hearing disability who receive limited benefit from hearing aids and ALDs. This visual alternative to receptive speech communication requires a transcriber able to “type” quickly on a computer keyboard, summaries of what is being verbalized in any given situation, usually meetings, lectures or classroom presentations. What is transcribed can be viewed on computer monitor or projected onto a larger screen/wall, depending on how many individuals need to use this service in a specific setting. An additional benefit is the potential for creating a hard copy of what has been transcribed for review. Computer Aided Real-time Translation (CART): Computer-Aided Real-time Translation (CART) got its start in the captioning of live television programs -mostly national news and sports events. More and more of these programs, including local news, are being captioned at the present time. This technology, through the operation of skilled stenocaptioners, allows the viewer with a hearing disability to read almost all words in a given situation, a few seconds after they are spoken. The ability to provide this important service has developed through the willingness on the part of trained court reporters to expand their skills to include stenocaptioning, not only for TV captioning, but also for use in situations where CAN had been used before. The advantage of CART over CAN is that CART produces a verbatim transcription of everything said in a meeting, in the classroom, etc., while also 18 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology providing a printed hard copy. Persons with severe to profound hearing disabilities generally prefer the CART to the CAN and other communication options for a variety of reasons. Like CAN, one or many consumers can use the CART system at once. The major drawback to both of these systems is the lack of trained, qualified persons to provide these services to meet the level of demand. The costs for CART services can be prohibitive but are moving downward with the increase in the market. Rehabilitation personnel can take the cue from this concept by transcribing commonly asked questions onto computer software to be used when communicating with people who have hearing impairments in the office setting. This not only saves time for all involved; it can decrease frustration and demonstrates sensitivity to the needs of these individuals. Captioned Videos & DVDs: When information or training is done via video tapes or DVDs for employees, it is important to remember those tapes/DVDs need to be captioned to allow the employee who is unable to hear and understand what is said to “read” what is said. TV Listening Devices: These can be coupled to the television and hard of hearing individual using wireless FM or IR technology. The transmitter is plugged into the TV, video or DVD player, or cable box and the transmitter is worn as a head set by the listener. The listener can adjust the volume control on the receiver to a comfortable level, allowing the sound to be heard clearly. Most have a volume and tone control that can be adjusted by the user. It does not affect the volume setting of the TV for normal hearing listeners. BEST PRACTICES IN CHOOSING AMPLIFICATION Have a complete audiological evaluation: By a licensed Audiologist Conducted in a sound booth Should include: case history; otoscopic examination; testing with tones and words; counseling about degree, type, and communication difficulties resulting from the hearing loss; realistic expectations of amplification; an understanding by the audiologist of your listening environments and specific hearing problems. Obtain medical clearance from your medical physician, those under 18 must be seen by an otolaryngologist (ENT). To rule-out a serious health condition that needs medical or surgical treatment Can not sign a medical waiver if certain conditions exist Thoroughly discuss the pros and cons of each style of hearing aid: 19 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology What are you capable of manually handling? What are you capable of maintaining? What will provide the best hearing results? What are you the most comfortable wearing? A word of caution about CICs (completely-in-the-canal): they have fewer advanced features than larger styles, are the most expensive, have the poorest maintenance record, and have been shown to provide the lowest customer satisfaction ratings. Discuss levels of technology in amplification that are currently available: Don’t expect to understand it all, but do your best. Your dispensing audiologist should gladly provide this information so that you understand what you’re getting in this expensive purchase. Low Technology: Analog (rarely dispensed); Entry level digital with basic features (The Chevy) Mid Technology: Mid level digital with some sophisticated features (The Honda) High Technology: Digital with all advanced features (The Lexus) Discuss cost of amplification and what is included: Follow-up visits, warranty period, loss and damage, cost of extended warranty, cost of minor repairs Consider the need to purchase hearing aid insurance Find out the cost of the 30-day trial period It is your privilege to compare costs with other dispensers. The price tag can vary tremendously. Just make sure you’re comparing apples with apples! Following the fitting, urge your clients to contact the dispenser with any problems that they may be experiencing! The initial settings may need to be tweaked for a better fitting A period of “learning to use the hearing aid” is necessary for all new users, and may take as much as 6 months Initially, use the aid in easy listening environments then move to more demanding listening situations Consistent use of amplification is a requisite for successful adjustment. Wear it daily! 20 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology TYPES OF AMPLIFICATION Behind-the-ear (BTE): This type of hearing aid is worn behind the ear and tends to be more powerful than hearing aids worn within the ear. However, a BTE can also be fitted for a mild hearing loss. These aids require separate, attachable ear molds. This type of aid is often best for greater losses, as they can provide greater power and more circuit features. The BTE also has larger switches for easier control. A behind-the-ear hearing aid can also be used with a direct audio input whereby sound is transmitted from a microphone along a wire that connects to the hearing aid. This is useful not only to better hear a speaker’s voice, but also to assist in modulating the wearer’s own voice. In-the-ear (ITE): Usually this type of hearing aid fits entirely within the bowl portion of the ear canal opening and wearers often feel it is less visible than the BTE aid. Power is more limited compared to the BTE style and is usually not appropriate for severe or profound hearing loss. Canal Aid: This aid is smaller than the ITE in that it fits only in the opening of the ear canal but it is completely visible. It appeals to some individuals because it is less bulky and is slightly less conspicuous than the ITE. The batteries required for this aid are very small and some individuals may have difficulty handling them. Because of their size, the batteries do not last as long as the ITE and BTE. Most hearing losses, except for severe to profound, can be fitted with this style aid. 21 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology Completely-in-the-Canal (CIC): This is the smallest, most cosmetically appealing hearing aid. It is also the most expensive, most difficult to fit properly, has the highest repair record, and the least amount of circuit features. Some individuals are not able to successfully use this style of amplification due to unusual ear canal shape/size, excessive temporomandibular joint movement, discomfort, severity of the loss, excessive feedback, or difficulty manipulating the small size. CICs have become popular because they are worn deep in the ear canal and are the least visible. They are too small to allow for a telecoil. Because of the difficulty in fitting this aid properly and the extra effort required in maintaining it, recommendations for such fittings should be made cautiously. CROS (contralateral routing of the signal) Aid: For unilateral losses. This is a two piece hearing aid, with a transmitter worn on the poorer ear, which sends signals to a receiver positioned on the normal ear. The wearer has a better audibility of sound on both right and left sides with the use of this type of aid. Bi-CROS Aid: For use with an asymmetrical hearing loss where one ear is non-functional or cannot be fitted with amplification. This aid is much like the CROS aid; however, the receiver is also an amplifier. The transmitter worn on the poorer ear sends signals to the receiver worn on the better ear, which hears from the opposite ear and through amplification within its own aid. This allows the wearer to hear sound originating from either side of the head. Programmable Aid: This has become the standard. It is necessary for the dispenser to have sophisticated computer hardware and software, and training in working with these instruments. Programmable aids come in BTE, ITE, Canal, and CIC styles. The superiority of these instruments lies in their flexibility to acoustically shape the output to match the hearing loss. Programmable aids can have either analog circuits or digital signal processing. Analog Aid: This is older, less sophisticated hearing aid technology that amplifies and shapes the frequency response through filters and other electronic components. With this technology, all sounds are amplified and advanced signal processing to improve speech understanding in background noise, is not possible. These aids have limited circuit adjustments, making them less flexible. Non-programmable, analog hearing aids have become obsolete in recent years. Digital Aid: These are the most technologically advanced hearing instruments on the market and first appeared in 1995. They continue to evolve to higher quality and fourth generation digitals are now in the marketplace. They have become the standard and >85% of all aids dispensed are digital. Digitals are similar to programmable aids in their computer requirements for fitting. These aids are more flexible than the 22 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology programmable aids because the acoustic signal is transformed to digital coding and then manipulated to fit the hearing loss. The sound is of superior fidelity with very low circuit noise. Several advanced signal processing features are only available in digital instruments. Some examples include; feedback suppression, noise reduction, speech enhancement, adaptive directional microphones. The cost of this technology is very expensive. Some digitals have fewer features and will cost less. That’s why it is important to know the specific characteristics of the hearing aid when you are comparing prices. All digitals are not equal! The “T-Switch: “T-switches”, or more accurately, telecoils, on hearing aids have been available, but under utilized for years. The “T-switch” improves telephone communication and allows the user to be connected to numerous ALDs, which include large area audio loop systems, neckloops, or some hearing aid accessories. The electro-magnetic field created by the “T-switch” helps to hear the desired speaker and greatly reduces background noise. “T-switches” are available on BTE, ITE and usually canal style hearing aids. Hearing Aid Accessories: Devices to be used with a hearing aid that enhance hearing ability in specific situations. These devices cannot be used independently. Some examples of hearing aid accessories include; remote control, direct audio input boot, auxiliary microphone, induction silhouette, neck loop, Bluetooth receiver, Smart Link with FM transmitter and receiver. Direct Audio Input (DAI): A special circuit available in many hearing aids that allows direct connection to certain assistive listening devices as well as stereos, television, and radio. The hearing aid is coupled to the other device by a “boot” that slips on the end of the aid. A frequently used accessory that is used with DAI is an auxiliary microphone that can be held by the communication partner of the hearing impaired individual. This allows their voice to be heard much more easily particularly in the presence of background noise. Hearing Aid with FM: A receiver is located within the casing of BTE hearing aids. A distant speaker can use a transmitter. This hearing aid makes using a FM system much easier than carrying a separate receiver for the user. Because the FM signal is received directly through an individual hearing aid, it will be adjusted to the hearing loss more precisely than using a separate FM system. Bone Conduction Hearing Aid: A hearing aid in which the amplified signal directly stimulates the inner ear via a bone vibrator placed on the mastoid process. The bone vibrator can be coupled to a body aid via a cord or a BTE hearing aid attached to the headband. These aids are rarely used because of poor sound quality and reserved for individuals with chronic draining ears or those without an ear canal or pinna (outer portion of the ear that’s visible). A surgical procedure has been developed in recent years that allows for the use 23 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology of a bone anchored hearing aid (BAHA) for individuals who cannot use typical aids. The BAHA offers superior sound quality to the traditional bone conduction aid. Cochlear Implant: This is a surgically implanted multi-channel electrode housed within the cochlea. A microphone to pick up sound is located in a BTE hearing aid. An individual receiving a cochlear implant must be carefully screened. There are specific criteria including severe to profound bilateral hearing loss with poor speech understanding. The price for this procedure varies from about $40,000 and up. Extensive aural rehabilitation may be needed after surgery. DESCRIPTIONS OF HEARING AID FEATURES Programmable: The hearing aid is connected to a computer and the internal hearing aid chip is adjusted appropriately for a specific hearing loss. Programmable instruments are significantly more flexible and precise in their adjustments. Nearly all hearing aids dispensed today are programmable. Multi-channel: Think of channels as equalizers on a stereo system. They are bands of frequencies that can be adjusted independently. In hearing aids, they may number from two to twenty. The more channels, the more precisely the aid can be programmed for each specific hearing loss. Multi-memory: Think of a memory as an environment (ex. Noisy, quiet, restaurant, party, music, etc.). The aid is programmed to process sound differently in each environment for improved speech understanding or comfort. Some aids have up to four memories. Access to the different Memories can be either manual (you push a button on the aid) or automatic. Entry level aids may only have two memories while more sophisticated aids may have four or five. Adaptive Memories: The hearing aid will automatically shift between memories depending upon how the environment changes. This feature is particularly useful for clients who have limited manual dexterity or cognitive functioning; don’t have their hands free to manually change the memories; or work in demanding environments (background noise, reverberant rooms, changing work conditions, etc.). Newer hearing aid models may have a combination of an adaptive setting and fixed settings. Acoustic Feedback Suppression: A hearing aid has the potential of "whistling" when a high level of amplification is needed. The aid produces a loud tonal signal similar to what you have heard in public address systems when the microphone gets too close to the loudspeakers. This phenomenon is call acoustic feedback. Some hearing aids have circuits that suppress acoustic feedback. A notched filter is the most basic method of suppressing feedback but the drawback is a reduction in gain which can reduce audibility of the high frequencies that are 24 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology needed for speech clarity. A model with many channels (15-20) will only reduce the gain in the offending channel causing the feedback, while a model that only has a few channels (2-8) will reduce gain in frequencies that may not be causing the feedback resulting in reduced clarity of speech. The most sophisticated method of feedback reduction is with a “phase inverter”. The aid detects feedback then produces the same sound 180 degrees out-of-phase. The two sounds cancel each other out and eliminate the feedback. Noise Suppression: Many hearing impaired individuals have difficulty listening in noisy situations. Certain types of electronic circuits in hearing aids are used to amplify the signal of interest while suppressing the surrounding noise. The processing chip in the digital hearing aid can identify steady state background noise and reduce the gain in the specific frequency channels where the noise while maintaining gain in the important speech frequencies. Best results occur in digital hearing aids with the most channels and those with adjustable suppression amounts (off, light, moderate, strong). Directional Microphone (multiple microphones omni and directional): Some hearing aids have more than one microphone, which can filter out some of the background noise -- allowing you to actually hear speech better in noisy situations. These are referred to as “directional mics.” It’s one of the most effective and important features on hearing aids. If hearing in noise is a problem, this feature is a “must”. Some directional mics require the user to turn it on by touching a button on the hearing aid. Other models will turn on automatically when noise is present. Some have a fixed null position (area of reduced amplification) such as behind the user. More sophisticated models have an adaptive microphone null position that changes from the side of the user to behind the user depending on the location of the loudest noise. The most sophisticated is an automatic, adaptive mic that is independent in all channels. Each channel can have its own null position allowing for noise reduction from many sources. Telephone Coil: A telecoil (T-coil) is nearly standard in most BTEs and is an option on some in-the-ear custom made hearing aids. T-coils “hear” magnetic signals, such as the signal transmitted by most phones, representing an audio signal. The T-coil is an important way to “couple” your hearing aids directly with audio sources such as the TV, telephones, and assistive listening devices. However, the smaller the aid is, the less likely it is to have a telecoil. When you couple your hearing aid directly to an input signal, you automatically eliminate background noise, you maximize the signal, and you get the best sound signal possible directly to your hearing aid. Some hearing aids have automatic T-coils that “turn-on” by themselves when a telephone is placed up to the ear. However, sometimes the T-coil is not strong enough and a tiny magnet must be placed on the telephone receiver to successfully engage it. 25 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology FM/Smart Link Compatible: Hearing instruments that can be used with the Smart Link FM system. Not all manufacturers and not all models are compatible. If it is compatible then it can be added later and it is not necessary to purchase it with the hearing aids. DataLogging : A valuable client counseling and follow-up tool. DataLogging provides access to your client’s real life use of amplification (number of hours worn per day, percentage of time used in each memory, volume control setting) and proposes optimal corrections. Echoblock: Removes reverberant components of the signal that may occur in auditoriums, churches, large stores, houses with tall ceilings, big windows, and hardwood floors. Sound Localizer: Circuitry available in some advanced models that imitates the curves and contours of the pinna in order to enhance localization. This helps in detecting the location of a sound source as well as listening in noise. Wind Noise Management: Reduces the microphone turbulences caused at the inlet. Noise suppressor identifies the characteristics of the remaining noise and suppresses it. Low Battery Warning: The hearing instrument signals the wearer that the battery is low by producing an audible (only to the wearer) beep. Warranty Period: Period of time the manufacturer will repair a malfunctioning hearing instrument from normal wear and tear at no charge to the consumer. It is usually 1-2 years. Extended warranty coverage can be purchased. Loss/Damage Deductible: Most manufacturers will give one or two-year loss/damage coverage. Damage is something that is not caused by normal wear and tear, in other words, abuse. Examples include, a dog chewing up the hearing aid, putting the aid through the washing machine, driving over the aid with a car. Most high performance instruments have a deductible for replacements of about $150.00 per instrument and manufacturers will only make one replacement per instrument. 26 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology CHECKLIST OF HEARING AID FEATURES Manufacturer, Model, Style: _____________________________________ Price Quote: _________________________________________________ Dispensing Facility: ____________________________________________ FEATURES # of Channels: # of Fixed Memories: BASIC 1 (Circle feature levels) INTERMEDIATE ADVANCED 2-8 9-14 MOST ADVANCED 15-20 1 2 3 4 # of Adaptive Memories: None 2 3 4 Microphones: Omni only Fixed Directional Adaptive Directional Adaptive Directional & independent in all Channels Noise Reduction: None Off / On Off/light/moderate Off/light/mod/strong Feedback Suppression: None Notched Filter Notched Filter Phase Inverter Telephone Program: None Acoustic Program Telecoil/T-coil & Mic Automatic T-coil EchoBlock: None Yes Wind Noise Reduction: None Yes Sound Localizer: None Yes Wireless FM Compatible: No Yes Warranty/Loss&Damage: 1 Year 2 Years 3 Years 4 Years Notes: 1. Acoustic Telephone Program does not block out noise in the environment, cannot be used with assistive listening devices and is susceptible to feedback. 2. Most manufacturers’ warranty/loss&damage coverage is 1 or 2 years but longer policies can be purchased. 3. Hearing aid developments are continually occurring, therefore, this information is time sensitive. (10/06) 27 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology WOODROW WILSON REHABILITATION CENTER ALD NEEDS QUESTIONAIRE NAME:____________________ WWRC# ____________ DATE ____________ Has difficulty hearing: ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ (WITH or WITHOUT hearing aids [circle one]) A smoke alarm An alarm clock The telephone ring Knocks at the door A stove or microwave timer In a quiet room with only one person talking In a small group of people On the telephone at home On the telephone at work or other people’s homes The television The radio or stereo While riding or driving in a car At work with my boss or co-workers In a classroom At church At the movies In a restaurant or cafeteria In a large auditorium A baby crying from another room Other situations______________________________________ Devices that are already owned include: ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ One or two (circle one) hearing aids Style:____________ Age of aid(s):_________ (average lifespan is 5-6 years) With telephone switch (T-coil) Uses hearing aid regularly Does not use hearing aid because____________________ Does not have hearing aids but would like to try them Telephone amplifier Type:________________________ TV listening device Type:________________________ Alerting lights _____For the telephone _____For a door _____For an alarm clock Vibrating alarm clock TDD Closed caption decoder Other______________________________________________ Primary mode of communication: ASL English Speech Hearing poor ____ ____ ____ ____ 28 fair ____ ____ ____ ____ good ____ ____ ____ ____ Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology WEB RESOURCES Audiology: www.asha.org – The American Speech & Hearing Association is a national professional association for speech-language pathologists (SLPs) and audiologists (As). Provides information for professionals and consumers on topics of current interest and the Certificate of Clinical Competence (CCC) for SLPs and As. www.audiology.org – The website of the American Academy of Audiology which is a national professional association for audiologists dedicated to providing quality hearing care to the public. Offers professional development, education, research and increases public awareness of hearing disorders and audiologic services. www.audiologyawareness.com – Audiology Awareness Campaign information site. AAC was organized by five professional audiology organizations with one main goal in mind: helping people with hearing loss. www.audiologyinfo.com – Audiology information network of resources. www.healthyhearing.com – a world leader in hearing information. www.nidcd.nih.gov/ – Request a free copy of Information Resources for Human Communication Disorders Directory published by the National Institutes of Health. It is a well-organized, useful guide of national organizations that focus on health issues related to hearing, balance, smell, taste, voice, speech and language. Organizations: www.agbell.org – an international, non-profit, membership organization that promotes better public understanding of hearing loss in children and adults. First year of membership is free to parents who have children with hearing loss. Provides newsletters, journals and information relating to oral education. www.alda.org - Website for Assoc. of Late Deafened Adults, a self-help group that provides information to those that have lost their hearing post-lingual. www.cochlearamericas.com - Official website for the Cochlear Corporation, the largest and one of three manufacturers of cochlear implants. www.nad.org/ - National Association of the Deaf provides services and support for deaf individuals and their families. Includes local chapter links and articles. 29 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology www.hearingloss.org – Website for the Hearing Loss Association of America, formerly Self Help for Hard of Hearing People. http://tap.gallaudet.edu/ - contains information on Gallaudet’s Technology Access Program. Worksite Accommodation: www.jan.wvu.edu/soar/hear.html - SOAR (Searchable Online Accommodation Resource) website to provide information about compliance with ADA in the workplace for individuals with hearing loss as well as many other types of disabilities. www.jan.wvu.edu/media/deaf.html - Work-site individuals who are deaf or hard of hearing. accommodation ideas for www.eeoc.gov/facts/deafness.html - Questions and answers about deafness and hearing impairments in the workplace and the Americans with Disabilities Act provided by the Equal Employment Opportunity Commission. Vendors: www.ameriphone.com – listing of products available from Ameriphone (TTY’s, VCO’s, etc.) www.audioenhancement.com – On-line catalog of assistive listening devices geared towards classrooms. www.cardionics.com - Manufacturer of the E-Scope amplified stethoscope with models that can be used with hearing aids. Also, it has the capability to provide visual representation of respiration and heart sounds on a PDA. www.harc.com - On-line catalog of products for the deaf and hard of hearing. www.harriscomm.com – On-line catalog of products for deaf and hard of hearing: equipment, novelties, books, videos, pagers. www.hatis.com/ - HATIS connects hearing aids with cellular phones, telephones and other listening devices to allow people with hearing loss to use any telephone anywhere. www.hitec.com/ - assistive communication products for deaf, hard of hearing, speech impaired, mobility impaired and vision impaired individuals. www.phonak.com - A renown hearing aid manufacturer that offers various forms of FM and Bluetooth technology to be used with hearing aids. 30 Linking Virginia’s Resources Together Woodrow Wilson Rehabilitation Center (Fall 06) Deaf and Hard of Hearing Technology www.potomactech.com/ - find sweatshirts, t-shirts, TTY’s and other accessories for individuals who are deaf or hard of hearing. www.soundbytes.com – hearing enhancement products for deaf and hard of hearing individuals. www.weitbrechtcom.com – on-line catalog of products for deaf, hard of hearing and speech impaired individuals. 31