Children's Use of CROS Hearing Aids Irving Shapiro,
PhD
\s=b\Ten children with unilateral hearing loss, aged 7 to 17 years, who were fit with contralateral routing of signal (CROS) hearing aids were followed up for three years to assess the suitability of this type of hearing aid fitting on children. The determination of the success of the fitting was based on follow-up visits, chart review, and response to a questionnaire sent to the parents. The fitting was considered to be successful if the child accepted the aid and if parents and teachers observed substantial improvement in academic performance and/or social behavior. Seven children were considered to be successful users of their CROS aids; one was unavailable for follow-up; one did better with a BICROS aid; and one did not do well with amplification. Our experience suggests that children with unilateral hearing loss can benefit from CROS amplification.
(Arch Otolaryngol 103:712-716, 1977)
person with a unilateral hear¬ loss has a unique set of prob¬ lems to his ability to hear and understand speech, which differs from that of a person with a bilateral
Theingrelated
hearing loss. The unilateral listener usually has no difficulty when he is communicating with only one person in a relatively quiet environment. However, under more adverse listen¬ ing conditions, he encounters prob¬ lems. Harford and Barry1 described
the complaints of patients with uni¬ lateral hearing loss as (1) having increased difficulty in hearing in groups and noisy surroundings, (2) having difficulty in hearing when people speak on the poorer hearing side, and (3) having problems in local¬ izing sound sources. They reported experimental evidence that accounted for publication April 7, 1977. From the Center for Communication Disorders, Harbor General Hospital, Torrance, Calif, and Department of Surgery, UCLA School of Medicine, Los Angeles. Presented at the fourth annual meeting of the Society for Ear, Nose, and Throat Advances in Children, New Orleans, Nov 17, 1976. Reprints not available.
Accepted
for some of the problems encountered when speech is presented to the contralateral ear in unilateral listen¬ ing situations." These findings showed that the intensity of the speech signal is attenuated approximately 6 dB across the head, thus providing a lessintense signal at the hearing ear. The signal arriving at the better-hearing ear is distorted because the higher frequencies are attenuated more than the lower frequencies, thus resulting in poorer speech intelligibility. Final¬ ly, discrimination is impaired second¬ ary to an unfavorable signal-tocompeting noise ratio when the speech is presented to the poorer-hearing ear and the better ear is exposed to a
competing signal. Fowler,' in recognition of the prob¬ lems experienced by the patient with a unilateral hearing loss, proposed that some kind of hearing aid arrangement be devised by either air
conduction or bone conduction so that the sounds from the deaf side could be transmitted to the good ear. Miller4 reported a procedure wmerein he used a low-gain, ear level, air conduction hearing aid on the poorer ear of a patient with a unilateral hearing loss and routed the signal through a length of plastic tubing behind the head to the better-hearing ear. This arrange¬ ment afforded great improvement in the ability to hear low-intensity speech from the poor-ear side and to localize the source of speech. In the same year, Harford and Barry1 described a hearing aid arrangement that they called CROS, an acronym for "contralateral routing of signals." Their arrangement differed from Miller's in that they used a pick-up microphone on the poor-ear side that was connected to a hearing aid on the good-ear side by wire. They found that the success of the CROS fitting was highly influenced by the social and professional communicative needs of their adult subjects; and that, generally, better acceptance was ob¬ served when there was some hearing
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loss in the better ear also. They felt further study was required before the suitability of CROS amplification for children could be determined. Harford and Dodds reported on the follow-up of patients for whom CROS aids were recommended. They sug¬ gested that the status of the hearing in the better ear was the most impor¬ tant factor in a successful CROS fitting, with better results obtained wThen there was some hearing loss in the better ear. A trial period with CROS amplification appeared to be the best predictor of how a person would function with the aid. However, Harford and Dodds did not encourage the use of CROS with children. They based their reservations on the follow¬ ing considerations: (1) Inasmuch as the trial period was believed to be the major factor in predicting success with the aid, they questioned whether a child would be able to evaluate his experiences reli¬ ably with CROS. They also suggested that children would be subject to adult biases and influences regarding the benefits of such amplification. (2) Since children's activities are more structured than adults, it might be possible to counteract negative environmental factors by such maneu¬ vers as preferential seating in the classroom. (3) Motivation has been shown to be important in success with CROS fittings. They questioned whether the difficulties resulting from a unilateral hearing loss would be of sufficient magnitude to children to produce such motivation. (4) They also questioned whether the degree of handicap resulting from a unilateral hearing loss would out¬ weigh the negative aspects of wearing a hearing aid. They did suggest, howyever, that some high school-aged students might be old enough to benefit from CROS amplification. Others have indicated that children can and do benefit from the use of CROS hearing aids. Miller0 used a '
body-type hearing
aid in
a
CROS
arrangement for a group of 13 chil¬ dren, aged 7 to 13 years, who had
unilateral hearing loss. Observations of the children were made over a onesemester period. Of the 13 children, 12 had a favorable adjustment to the aid. Schoolwork improved greatly, the chil¬ dren did not need the television or radio turned up as loudly at home, and
Table 1.—Air Conduction Thresholds, Speech Reception Thresholds (SRT), and Speech Discrimination Scores (SDS) for Children Fit With CROS Hearing Aids*
Frequency
Patient/Age, yr/Sex 1/7/F 2/7/M 3/8/F
they reported having a greater aware¬
4/8/M
of environmental sounds. The children, their parents, and their teachers were reported to be pleased with the results of using this type of ness
5/9/M 6/9/M
amplification.
Matkin and Thomas7 reported on a three-year clinical study of the use of CROS with children aged 5 to 16 years. They concluded that CROS fittings could be made successfully with children, but that less success was achieved with teenagers and those with unilateral losses. Navarro and Vogelson* described a procedure for evaluating a CROS
9-year-old boy. They compared sound-field speech arrangement
on
SUBJECTS AND METHODS The clinical records of children seen for evaluation at this center from 1973 to 1976 were reviewed. Only those children who had unilateral hearing loss and were fit with a CROS hearing aid were included in the study. We did not include those children who were fit with BICROS or Power-CROS hearing aids, because these children did not have the same kind of hearing problems as the unilaterally hearing-impaired. The study group in¬ cluded four boys and six girls, aged 7 to 17 years.
0.25 15 60 5 NR 15 85 60 10 NR 10 30 70 5 NR 40 75 NR 10 NR 15
7/9/F 8/10/F 9/16/F 10/17/F
*NR, no response at audiometrie limits; DNT, tSpeech detection threshold. Table 2.-Nature of
Follow-Up
0.50 15 65 0 105 15 85 75 0 NR 10 25 95 15 NR 40 90 NR 10 NR 10
1.0 20 60 5 100
2.0 10 55
4.0 10 50
8.0 20
SRT 10
15
5 NR 10 60 100 40 NR 5 35 85 50 NR 15 65
10 NR 15 55 80 60 NR 15 55 70 65 NR
55 0
10 80
0 NR 0 55 95 65 NR 5 40 75 50 NR 20 95
NR 10 NR 0
NR 0 NR 5
NR 5
100 5 NR 10 20 90 15 NR 35 85 NR 10 NR 0
SDS% 100 12 DNT
NR 10 85
DNT 96
60f
DNT 80
0 NR 0
DNT 92
25
96
75t
DNT
20
92 DNT 100 CNT CNT 100 CNT 100
NR
30
25 80* NR 10 NR 0
NR
NR 5
did not test.
With Children Fit With CROS
Hearing
Aids
a
discrimination obtained with and without the aid. Greatly improved speech discrimination was found un¬ der the aided condition. The boy's parents reported improved social be¬ havior at home, and teachers reported substantial academic improvement as a result of the use of CROS amplifica¬ tion. The authors concluded that CROS hearing aids could be of value with children. The question of the suitability of CROS hearing aids for children remains unresolved. The purpose of this report is to share our experiences with the use of CROS amplification with children and to contribute to the resolution of this question.
hearing aid
Ear
In kHz
Patient
Posttrial Period Visit
i
Follow-up Visits
+
+
Additional
Hospital Chart Review
Response
to
Questionnaire +
None
10
A child was considered to be a candidate for a CROS hearing aid if there were normal or near-normal hearing in one ear and a hearing loss in the other ear greater than 30 dB HL, which was not suitable for conventional monaural amplification. In addition to the hearing loss, there had to be some indication that the child was experi¬ encing problems that could be attributed to unilateral hearing loss. Usually, this meant that the child was having difficulty in school. Thus, some of our children who had unilateral hearing loss, but did not report having any substantial problems, were not fit with amplification.
Procedure All the children were examined in a tworoom double-walled audiometrie test suite on instrumentation calibrated to American National Standards Institute 1969 norms. The audiologic evaluation included the measurement of air- and bone-conduction
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thresholds, speech reception thresholds, and speech discrimination. Speech audiom¬ etry materials included the Central Insti¬ tute for the Deaf W-l spondee word lists; the Northwestern University auditory test No. 6; and for one Spanish-speaking child, the Spanish speech audiometry tape pro¬ duced by the Los Angeles Foundation of Otology. The suitability of the CROS fitting was based
on
the results of
period using
a
a
one-month trial
low-gain, low-powered
ear
level CROS aid. The results of the trial period were evaluated on the bases of the following criteria: (1) Did the child use the aid in school, and did the teachers report a noticeable improvement in the child's attentiveness and school performance? (2) Of somewhat less importance, but still of some significance, did the child wear the aid at home, and did the parents observe any improvement in the child's listening behavior? (3) Did the child accept the aid, or
How many days
a
week does your child
1
Less than five
k
Five
wear
the hearing aid?
More than five How many hours per day does your child ________
5
wear
the hearing aid?
Less than five More than five
Does your child
k
Yes
1*
No
the aid in school?
wear
Sometimes Does your child ______
the aid at home?
wear
Yes
_No 4
Sometimes
How does your child
k _________
1
seem
to hear when
wearing the aid?
Better than without the aid
Same
as
without the aid
Poorer than without the aid
Do your child's teachers
see
any difference in how your child
performs when
wearing the aid? 3
Better than without the aid
1
Same
as
without the aid
Poorer than without the aid _
1
Don't know
Questionnaire that
was
sent to
parents and distribution of responses for five questionnaires returned.
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Has there been any wear
change in
your child's school
grades since
he/she began
to
the hearing aid?
k
Better
_______
Same
Poorer
1
Does your child like to
wear
the aid?
3** Yes ________
________
Doesn't
care one
way
or
the other
No
Who puts the hearing aid
'4
The child
1
The parent
No
on
your child?
one
_
Have you had to bring the hearing aid in for repairs? _______
If yes, how many times?
Twice for each aid
No
2
Would you
Yes
suggest that other children with the
child's get the
same
same
type of hearing loss
as
type of hearing aid?
_5__Yes _No ________
Don't know
*This child
was no
**One child liked to
longer attending school, but she wear
the aid at
school, but
wore
the aid at home.
not at home.
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/22/2015
your
was the child forced to use it? We explored these questions at the follow-up appoint¬ ment after completion of the trial period. Our recommendation as to whether or not to procure the aid was based on the answers to these questions. In addition, we sent an 11-item questionnaire to the parents, in which we explored how the child was functioning with amplification. In three cases, where the child did not return for later follow-up appointments, we were able to derive an impression of the child's use of the aid from notes in the hospital chart when the child was seen by other hospital services.
RESULTS
Table 1 shows the results of the
audiologic evaluation for the ten chil¬ dren included in the study. Four of the
children had hearing levels in excess of 20 dB at one or more of the frequen¬ cies in the 500- to 2,000-Hz range in the better ear. Five children had measurable hearing in the poorer ear, but none of these was considered suitable for conventional amplifica¬ tion. The remaining five children did not have any measurable hearing in the bad ear. Table 2 summarizes the types of follow-up we had with these children. All of the children except patients 5 and 8 were seen for the posttrial period follow-up evaluation. Five of the children were seen for additional follow-up appointments after their posttrial period visit. Information on three of the children was available from review of their hospital charts, where notes regarding their hearing aid use were made by other hospital services. For patient 8, this was the only follow-up available to us. How¬ ever, there were multiple chart entries reporting her regular continuing use of the aid. For eight cases we had two or more follow-up sources; for one case, number 5, we had none; and for one case, number 8, we had only the hospital chart to which we could refer. On the basis of our evaluation of these results, seven of these ten chil¬ dren were successful users of CROS amplification. The criteria for success¬ ful use included regular hearing aid use in school, improvement in academ¬ ic performance as reported by parents and teachers, and acceptance of the aid by the child.
Three children were not considered to be successful users of their CROS aids. Patient 4 did not do well with the
CROS fitting. He was an 8-year-old boy with mild mental retardation and slight aphasie involvement, in addi¬ tion to the hearing loss. However, when the hearing aid fitting was changed to a BICROS arrangement, his acceptance of the aid and his academic performance improved greatly. Patient 7 we classified as a failure. She did well with the aid during the trial period, but then was unavailable for follow-up. She re¬ turned one year later with a history of not having worn the aid because it was broken. Results of examination showed that the problem was that she did not know how to adjust the aid. Further work with this child did not result in improved functioning with amplification. One child, patient 5, may not have been a failure. However, since he was unavailable for follow-up, we had no way of determining how he was functioning with the hearing aid. The Figure shows the questionnaire that was sent to the parents, and the distribution of responses to the ques¬ tions. Of the ten questionnaires sent out, five were returned. The pattern of responses suggested that the chil¬ dren wore their aids primarily at school and only sometimes at home. Teachers believed that the children appeared to hear better with the aids, and school grades improved wnth hearing aid use. Most of the children put on the aids themselves, but there was an equal division between those who liked to wear the aid and those who did not. Three of the five reported that they had to bring the hearing aid in for repairs. In most cases, this was because of cord break¬ age. All of the parents indicated that they would recommend this type of hearing aid for children who had similar kinds of hearing loss. COMMENT
Although
it
was
that
suggested
greater acceptance of CROS amplifi¬
cation is found when there is some hearing loss in the better ear1 and that teenagers are less accepting than younger children,7 we found no corre¬ lation between age, hearing level in r'
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the better ear, and acceptance of CROS amplification in our admittedly small sample of young patients. One of the major components in the treatment of hearing-impaired chil¬ dren is an ongoing, regular program of audiologic follow-up. We have been discouraged by the lack of parental cooperation in this matter for this group of children. Whereas our young patients with bilateral hearing loss appear regularly for their follow-up visits, the children with CROS aids, as a group, were notably lax in keeping follow-up appointments. We have hy¬ pothesized that the reason for this may be that the child with a unilateral hearing loss does not behave as a particularly handicapped child. In ad¬ dition, the improvement obtained with the hearing aid may not be readily apparent in the home environ¬ ment. Therefore, the motivation to accept the inconvenience of returning to the hospital for follow-up appoint¬ ments may be lacking. We believe that children with unilateral hearing loss should be considered for CROS amplification when there are problems that are attributable to the hearing loss and the poor ear is unaidable. It may be appropriate to recommend that the aid be used primarily at school, with home use left up to the child's desires. Finally, we recommend that a clearly defined program of follow-up be established prior to the purchase of the aid, so that performance can be monitored on an ongoing basis. References 1. Harford E, Barry J: A rehabilitative approach to the problem of unilateral hearing
impairment: The contralateral routing of signals (CROS). J Speech Hear Disord 30:121-138, 1965. 2. Tillman TW, Kasten RN, Horner JS: Effect of head shadow on reception of speech. Read before the American Speech and Hearing Association convention, Chicago, 1963. 3. Fowler EP: Bilateral hearing aids for monaural total deafness. Arch Otolaryngol 72:41\x=req-\ 42, 1960.
4. Miller AL: A loss helped
case
of
unilateral aid. J Speech
severe
by a hearing Hear Disord 30:186-187, 1965.
hearing
5. Harford E, Dodds E: The clinical application of CROS. Arch Otolaryngol 83:455-464, 1966. 6. Miller AL: Body type hearing aids for unilateral hearing losses. J Speech Hear Disord 32:268-269, 1967. 7. Matkin ND, Thomas J: The utilization of CROS hearing aids by children. Maico Audiological Library, vol 10, No. 8, 1972. 8. Navarro MR, Vogelson DO: An objective assessment of a CROS hearing aid. Arch Otola-
ryngol 100:58-59,
1974.
PhD
\s=b\Ten children with unilateral hearing loss, aged 7 to 17 years, who were fit with contralateral routing of signal (CROS) hearing aids were followed up for three years to assess the suitability of this type of hearing aid fitting on children. The determination of the success of the fitting was based on follow-up visits, chart review, and response to a questionnaire sent to the parents. The fitting was considered to be successful if the child accepted the aid and if parents and teachers observed substantial improvement in academic performance and/or social behavior. Seven children were considered to be successful users of their CROS aids; one was unavailable for follow-up; one did better with a BICROS aid; and one did not do well with amplification. Our experience suggests that children with unilateral hearing loss can benefit from CROS amplification.
(Arch Otolaryngol 103:712-716, 1977)
person with a unilateral hear¬ loss has a unique set of prob¬ lems to his ability to hear and understand speech, which differs from that of a person with a bilateral
Theingrelated
hearing loss. The unilateral listener usually has no difficulty when he is communicating with only one person in a relatively quiet environment. However, under more adverse listen¬ ing conditions, he encounters prob¬ lems. Harford and Barry1 described
the complaints of patients with uni¬ lateral hearing loss as (1) having increased difficulty in hearing in groups and noisy surroundings, (2) having difficulty in hearing when people speak on the poorer hearing side, and (3) having problems in local¬ izing sound sources. They reported experimental evidence that accounted for publication April 7, 1977. From the Center for Communication Disorders, Harbor General Hospital, Torrance, Calif, and Department of Surgery, UCLA School of Medicine, Los Angeles. Presented at the fourth annual meeting of the Society for Ear, Nose, and Throat Advances in Children, New Orleans, Nov 17, 1976. Reprints not available.
Accepted
for some of the problems encountered when speech is presented to the contralateral ear in unilateral listen¬ ing situations." These findings showed that the intensity of the speech signal is attenuated approximately 6 dB across the head, thus providing a lessintense signal at the hearing ear. The signal arriving at the better-hearing ear is distorted because the higher frequencies are attenuated more than the lower frequencies, thus resulting in poorer speech intelligibility. Final¬ ly, discrimination is impaired second¬ ary to an unfavorable signal-tocompeting noise ratio when the speech is presented to the poorer-hearing ear and the better ear is exposed to a
competing signal. Fowler,' in recognition of the prob¬ lems experienced by the patient with a unilateral hearing loss, proposed that some kind of hearing aid arrangement be devised by either air
conduction or bone conduction so that the sounds from the deaf side could be transmitted to the good ear. Miller4 reported a procedure wmerein he used a low-gain, ear level, air conduction hearing aid on the poorer ear of a patient with a unilateral hearing loss and routed the signal through a length of plastic tubing behind the head to the better-hearing ear. This arrange¬ ment afforded great improvement in the ability to hear low-intensity speech from the poor-ear side and to localize the source of speech. In the same year, Harford and Barry1 described a hearing aid arrangement that they called CROS, an acronym for "contralateral routing of signals." Their arrangement differed from Miller's in that they used a pick-up microphone on the poor-ear side that was connected to a hearing aid on the good-ear side by wire. They found that the success of the CROS fitting was highly influenced by the social and professional communicative needs of their adult subjects; and that, generally, better acceptance was ob¬ served when there was some hearing
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loss in the better ear also. They felt further study was required before the suitability of CROS amplification for children could be determined. Harford and Dodds reported on the follow-up of patients for whom CROS aids were recommended. They sug¬ gested that the status of the hearing in the better ear was the most impor¬ tant factor in a successful CROS fitting, with better results obtained wThen there was some hearing loss in the better ear. A trial period with CROS amplification appeared to be the best predictor of how a person would function with the aid. However, Harford and Dodds did not encourage the use of CROS with children. They based their reservations on the follow¬ ing considerations: (1) Inasmuch as the trial period was believed to be the major factor in predicting success with the aid, they questioned whether a child would be able to evaluate his experiences reli¬ ably with CROS. They also suggested that children would be subject to adult biases and influences regarding the benefits of such amplification. (2) Since children's activities are more structured than adults, it might be possible to counteract negative environmental factors by such maneu¬ vers as preferential seating in the classroom. (3) Motivation has been shown to be important in success with CROS fittings. They questioned whether the difficulties resulting from a unilateral hearing loss would be of sufficient magnitude to children to produce such motivation. (4) They also questioned whether the degree of handicap resulting from a unilateral hearing loss would out¬ weigh the negative aspects of wearing a hearing aid. They did suggest, howyever, that some high school-aged students might be old enough to benefit from CROS amplification. Others have indicated that children can and do benefit from the use of CROS hearing aids. Miller0 used a '
body-type hearing
aid in
a
CROS
arrangement for a group of 13 chil¬ dren, aged 7 to 13 years, who had
unilateral hearing loss. Observations of the children were made over a onesemester period. Of the 13 children, 12 had a favorable adjustment to the aid. Schoolwork improved greatly, the chil¬ dren did not need the television or radio turned up as loudly at home, and
Table 1.—Air Conduction Thresholds, Speech Reception Thresholds (SRT), and Speech Discrimination Scores (SDS) for Children Fit With CROS Hearing Aids*
Frequency
Patient/Age, yr/Sex 1/7/F 2/7/M 3/8/F
they reported having a greater aware¬
4/8/M
of environmental sounds. The children, their parents, and their teachers were reported to be pleased with the results of using this type of ness
5/9/M 6/9/M
amplification.
Matkin and Thomas7 reported on a three-year clinical study of the use of CROS with children aged 5 to 16 years. They concluded that CROS fittings could be made successfully with children, but that less success was achieved with teenagers and those with unilateral losses. Navarro and Vogelson* described a procedure for evaluating a CROS
9-year-old boy. They compared sound-field speech arrangement
on
SUBJECTS AND METHODS The clinical records of children seen for evaluation at this center from 1973 to 1976 were reviewed. Only those children who had unilateral hearing loss and were fit with a CROS hearing aid were included in the study. We did not include those children who were fit with BICROS or Power-CROS hearing aids, because these children did not have the same kind of hearing problems as the unilaterally hearing-impaired. The study group in¬ cluded four boys and six girls, aged 7 to 17 years.
0.25 15 60 5 NR 15 85 60 10 NR 10 30 70 5 NR 40 75 NR 10 NR 15
7/9/F 8/10/F 9/16/F 10/17/F
*NR, no response at audiometrie limits; DNT, tSpeech detection threshold. Table 2.-Nature of
Follow-Up
0.50 15 65 0 105 15 85 75 0 NR 10 25 95 15 NR 40 90 NR 10 NR 10
1.0 20 60 5 100
2.0 10 55
4.0 10 50
8.0 20
SRT 10
15
5 NR 10 60 100 40 NR 5 35 85 50 NR 15 65
10 NR 15 55 80 60 NR 15 55 70 65 NR
55 0
10 80
0 NR 0 55 95 65 NR 5 40 75 50 NR 20 95
NR 10 NR 0
NR 0 NR 5
NR 5
100 5 NR 10 20 90 15 NR 35 85 NR 10 NR 0
SDS% 100 12 DNT
NR 10 85
DNT 96
60f
DNT 80
0 NR 0
DNT 92
25
96
75t
DNT
20
92 DNT 100 CNT CNT 100 CNT 100
NR
30
25 80* NR 10 NR 0
NR
NR 5
did not test.
With Children Fit With CROS
Hearing
Aids
a
discrimination obtained with and without the aid. Greatly improved speech discrimination was found un¬ der the aided condition. The boy's parents reported improved social be¬ havior at home, and teachers reported substantial academic improvement as a result of the use of CROS amplifica¬ tion. The authors concluded that CROS hearing aids could be of value with children. The question of the suitability of CROS hearing aids for children remains unresolved. The purpose of this report is to share our experiences with the use of CROS amplification with children and to contribute to the resolution of this question.
hearing aid
Ear
In kHz
Patient
Posttrial Period Visit
i
Follow-up Visits
+
+
Additional
Hospital Chart Review
Response
to
Questionnaire +
None
10
A child was considered to be a candidate for a CROS hearing aid if there were normal or near-normal hearing in one ear and a hearing loss in the other ear greater than 30 dB HL, which was not suitable for conventional monaural amplification. In addition to the hearing loss, there had to be some indication that the child was experi¬ encing problems that could be attributed to unilateral hearing loss. Usually, this meant that the child was having difficulty in school. Thus, some of our children who had unilateral hearing loss, but did not report having any substantial problems, were not fit with amplification.
Procedure All the children were examined in a tworoom double-walled audiometrie test suite on instrumentation calibrated to American National Standards Institute 1969 norms. The audiologic evaluation included the measurement of air- and bone-conduction
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/22/2015
thresholds, speech reception thresholds, and speech discrimination. Speech audiom¬ etry materials included the Central Insti¬ tute for the Deaf W-l spondee word lists; the Northwestern University auditory test No. 6; and for one Spanish-speaking child, the Spanish speech audiometry tape pro¬ duced by the Los Angeles Foundation of Otology. The suitability of the CROS fitting was based
on
the results of
period using
a
a
one-month trial
low-gain, low-powered
ear
level CROS aid. The results of the trial period were evaluated on the bases of the following criteria: (1) Did the child use the aid in school, and did the teachers report a noticeable improvement in the child's attentiveness and school performance? (2) Of somewhat less importance, but still of some significance, did the child wear the aid at home, and did the parents observe any improvement in the child's listening behavior? (3) Did the child accept the aid, or
How many days
a
week does your child
1
Less than five
k
Five
wear
the hearing aid?
More than five How many hours per day does your child ________
5
wear
the hearing aid?
Less than five More than five
Does your child
k
Yes
1*
No
the aid in school?
wear
Sometimes Does your child ______
the aid at home?
wear
Yes
_No 4
Sometimes
How does your child
k _________
1
seem
to hear when
wearing the aid?
Better than without the aid
Same
as
without the aid
Poorer than without the aid
Do your child's teachers
see
any difference in how your child
performs when
wearing the aid? 3
Better than without the aid
1
Same
as
without the aid
Poorer than without the aid _
1
Don't know
Questionnaire that
was
sent to
parents and distribution of responses for five questionnaires returned.
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/22/2015
Has there been any wear
change in
your child's school
grades since
he/she began
to
the hearing aid?
k
Better
_______
Same
Poorer
1
Does your child like to
wear
the aid?
3** Yes ________
________
Doesn't
care one
way
or
the other
No
Who puts the hearing aid
'4
The child
1
The parent
No
on
your child?
one
_
Have you had to bring the hearing aid in for repairs? _______
If yes, how many times?
Twice for each aid
No
2
Would you
Yes
suggest that other children with the
child's get the
same
same
type of hearing loss
as
type of hearing aid?
_5__Yes _No ________
Don't know
*This child
was no
**One child liked to
longer attending school, but she wear
the aid at
school, but
wore
the aid at home.
not at home.
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/22/2015
your
was the child forced to use it? We explored these questions at the follow-up appoint¬ ment after completion of the trial period. Our recommendation as to whether or not to procure the aid was based on the answers to these questions. In addition, we sent an 11-item questionnaire to the parents, in which we explored how the child was functioning with amplification. In three cases, where the child did not return for later follow-up appointments, we were able to derive an impression of the child's use of the aid from notes in the hospital chart when the child was seen by other hospital services.
RESULTS
Table 1 shows the results of the
audiologic evaluation for the ten chil¬ dren included in the study. Four of the
children had hearing levels in excess of 20 dB at one or more of the frequen¬ cies in the 500- to 2,000-Hz range in the better ear. Five children had measurable hearing in the poorer ear, but none of these was considered suitable for conventional amplifica¬ tion. The remaining five children did not have any measurable hearing in the bad ear. Table 2 summarizes the types of follow-up we had with these children. All of the children except patients 5 and 8 were seen for the posttrial period follow-up evaluation. Five of the children were seen for additional follow-up appointments after their posttrial period visit. Information on three of the children was available from review of their hospital charts, where notes regarding their hearing aid use were made by other hospital services. For patient 8, this was the only follow-up available to us. How¬ ever, there were multiple chart entries reporting her regular continuing use of the aid. For eight cases we had two or more follow-up sources; for one case, number 5, we had none; and for one case, number 8, we had only the hospital chart to which we could refer. On the basis of our evaluation of these results, seven of these ten chil¬ dren were successful users of CROS amplification. The criteria for success¬ ful use included regular hearing aid use in school, improvement in academ¬ ic performance as reported by parents and teachers, and acceptance of the aid by the child.
Three children were not considered to be successful users of their CROS aids. Patient 4 did not do well with the
CROS fitting. He was an 8-year-old boy with mild mental retardation and slight aphasie involvement, in addi¬ tion to the hearing loss. However, when the hearing aid fitting was changed to a BICROS arrangement, his acceptance of the aid and his academic performance improved greatly. Patient 7 we classified as a failure. She did well with the aid during the trial period, but then was unavailable for follow-up. She re¬ turned one year later with a history of not having worn the aid because it was broken. Results of examination showed that the problem was that she did not know how to adjust the aid. Further work with this child did not result in improved functioning with amplification. One child, patient 5, may not have been a failure. However, since he was unavailable for follow-up, we had no way of determining how he was functioning with the hearing aid. The Figure shows the questionnaire that was sent to the parents, and the distribution of responses to the ques¬ tions. Of the ten questionnaires sent out, five were returned. The pattern of responses suggested that the chil¬ dren wore their aids primarily at school and only sometimes at home. Teachers believed that the children appeared to hear better with the aids, and school grades improved wnth hearing aid use. Most of the children put on the aids themselves, but there was an equal division between those who liked to wear the aid and those who did not. Three of the five reported that they had to bring the hearing aid in for repairs. In most cases, this was because of cord break¬ age. All of the parents indicated that they would recommend this type of hearing aid for children who had similar kinds of hearing loss. COMMENT
Although
it
was
that
suggested
greater acceptance of CROS amplifi¬
cation is found when there is some hearing loss in the better ear1 and that teenagers are less accepting than younger children,7 we found no corre¬ lation between age, hearing level in r'
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the better ear, and acceptance of CROS amplification in our admittedly small sample of young patients. One of the major components in the treatment of hearing-impaired chil¬ dren is an ongoing, regular program of audiologic follow-up. We have been discouraged by the lack of parental cooperation in this matter for this group of children. Whereas our young patients with bilateral hearing loss appear regularly for their follow-up visits, the children with CROS aids, as a group, were notably lax in keeping follow-up appointments. We have hy¬ pothesized that the reason for this may be that the child with a unilateral hearing loss does not behave as a particularly handicapped child. In ad¬ dition, the improvement obtained with the hearing aid may not be readily apparent in the home environ¬ ment. Therefore, the motivation to accept the inconvenience of returning to the hospital for follow-up appoint¬ ments may be lacking. We believe that children with unilateral hearing loss should be considered for CROS amplification when there are problems that are attributable to the hearing loss and the poor ear is unaidable. It may be appropriate to recommend that the aid be used primarily at school, with home use left up to the child's desires. Finally, we recommend that a clearly defined program of follow-up be established prior to the purchase of the aid, so that performance can be monitored on an ongoing basis. References 1. Harford E, Barry J: A rehabilitative approach to the problem of unilateral hearing
impairment: The contralateral routing of signals (CROS). J Speech Hear Disord 30:121-138, 1965. 2. Tillman TW, Kasten RN, Horner JS: Effect of head shadow on reception of speech. Read before the American Speech and Hearing Association convention, Chicago, 1963. 3. Fowler EP: Bilateral hearing aids for monaural total deafness. Arch Otolaryngol 72:41\x=req-\ 42, 1960.
4. Miller AL: A loss helped
case
of
unilateral aid. J Speech
severe
by a hearing Hear Disord 30:186-187, 1965.
hearing
5. Harford E, Dodds E: The clinical application of CROS. Arch Otolaryngol 83:455-464, 1966. 6. Miller AL: Body type hearing aids for unilateral hearing losses. J Speech Hear Disord 32:268-269, 1967. 7. Matkin ND, Thomas J: The utilization of CROS hearing aids by children. Maico Audiological Library, vol 10, No. 8, 1972. 8. Navarro MR, Vogelson DO: An objective assessment of a CROS hearing aid. Arch Otola-
ryngol 100:58-59,
1974.
