counseling counseling is a vital part of the aural rehab process. effectiveness of counseling is...

Counseling

• Counseling is a vital part of the aural rehab process.

• Effectiveness of counseling is correlated to compliance with recommendations.

Why Effective Counseling is Important

Because there are challenges in attaining the goal of infants using their hearing aids full time:

• Parents need to understand how important hearing is to brain development

• Parents need to provide auditory stimulation during all waking hours (and know why this is important)

• Keeping hearing aids on an active toddler‘s head can be a challenge


Goal: full time hearing aid use (12+ hrs per day)

• BUT studies show that 40% of children wear their hearing aids 4 hours or less per day

• Only 10% achieve full-time hearing aid use


If a baby only wears hearing aids for 4 hours per day, then it will take 6 years for his or her brain to receive as much auditory stimulation as a normal hearing child gets in one year.

Source: Achieving Effective Hearing Aid Use in Early Childhood

Counseling

Counseling starts when you are explaining the results of the hearing assessment to the child’s parents.

Breaking Bad NewsIt helps if you can break the news gently – i.e. over 2 sessions.

• 1st session: I have a suspicion, we’re going to have you come back for further testing…

• 2nd session: The results are consistent with the first…




• This instills more confidence




• This instills more confidence

• May soften the blow

Confidenceo You have to be confident in your test results to project

confidence during counseling.

o Avoid messages like “Our test results suggest hearing loss” or “I think your child might have a hearing loss”. Don’t hedge.

o It's OK to bring a patient back for a 2nd or 3rd ABR if that's what you need to be confident in your results.

Giving the ResultsPrepare the room.

o Make sure tissues are handy.

o Parents should be seated comfortably.

o You should be at the same eye level as the parents or lower – never higher.

o Try to make sure that there will be no interruptions.

Giving the Results1. Make and maintain eye contact with both parents.


2. Announce that you are going to explain the test results – get parents spoken or unspoken permission to do so.



3. PREFACE “I’m sorry to have to be the one to give you this news, but...” or “I know this is not the news you were hoping for, but..” or “I have some difficult news”.



3. PREFACE “I’m sorry to have to be the one to give you this news, but...” or “I know this is not the news you were hoping for, but..” (empathy) or “I have some difficult news”.

4. Give your diagnosis. For example “___ has a severe hearing loss in both ears. This is a permanent hearing loss and he/she is going to need hearing aids”.



3. PREFACE “I’m sorry to have to be the one to give you this news, but...” or “I know this is not the news you were hoping for, but..” (empathy) or “I have some difficult news”.

4. Give your diagnosis. For example “___ has a severe hearing loss in both ears. This is a permanent hearing loss and he/she is going to need hearing aids”.

Stop there! That is a lot of information to absorb. Give the parents much time as they need to absorb this. Let them dictate the next step.

Silence

o We are conditioned that silence is awkward/uncomfortable in social situations. This is not so when delivering bad news !

Silenceo We are conditioned that silence is

awkward/uncomfortable in social situations. This is not so when delivering bad news !

o The parents don’t experience silence this way.

Silenceo We are conditioned that silence is

awkward/uncomfortable in social situations. This is not so when delivering bad news !

o The parents don’t experience silence this way. It is not silent in their heads.

o Talking too much is the biggest mistake that clinicians make when delivering news about a diagnosis.

Silence

You will find this odd at first, but when you get used to it, it will seem very natural.

Respect

o The family is allowing you, a stranger, into their lives at this very vulnerable time.

Respect

o The family is allowing you, a stranger, into their lives at this very vulnerable time.

o This is a privilege

Respect

o Respect is a 2-way street.

Respect


o “Positive, unconditional regard. Assume good will.” (English, 2008, Oticon Pediatric Symposium)

Respect


o “Positive, unconditional regard. Assume good will.” (English, 2008, Oticon Pediatric Symposium)

o How might you seem like you’re looking down on a family ?o By not listening to what they have to say

(interrupting them).o By invalidating their concerns “It could be worse”.o By commenting negatively about something (such

as the child’s behavior – now is not the time!).

Crying

Expect one or both parents to cry, even if you thought they already expected the diagnosis

Crying

“Audiologists need to be prepared to deal with the emotional ramifications of the news they deliver”

(parent of deaf/hard of hearing child)

Crying

• Crying is a natural reaction and is not to be discouraged. It is a way for the parents to release their stress/emotions.

• Offering a tissue is an unspoken way of saying you’re OK with them crying.

Crying

What about the clinician. Should you cry ?

Crying

It’s normal to feel a bit sad, but there is also optimism because you know you are doing what is best for the child, and that this is something they can overcome.

Being Positive

Jane Madell: “We need to be optimistic about what is possible for hearing loss and believe it! Today, everything IS possible for children with hearing loss.”

Source: Audiology Online, 2013.

Breaking Bad Newso We tend to feel that we have to give parents all the

answers and solve the problem.



o You will not be good at counseling if you put this kind of pressure on yourself. You may find that you will actually get better at counseling when you try to do less.




o Avoid being the rescuer.




o Avoid being the rescuer.

o Encourage parents to talk about their feelings, fears and emotions.

Grief

The 5 stages of grief (Elisabeth Kübler-Ross):

1. Denial

2. Anger

3. Bargaining

4. Depression

5. Acceptance

For audiology, I would add guilt.

Grief

“Welcome to Holland” by Emily Perl Kingsley

Parent’s Concerns(even if unspoken)

• Are you sure?

J Am Acad Audiol. 2007 Sep;18(8):675-87. Development of an instrument to evaluate audiologic counseling skills.English K, Naeve-Velguth S, Rall E, Uyehara-Isono J, Pittman A.

http://www.ncbi.nlm.nih.gov/pubmed/18326154

http://www.ncbi.nlm.nih.gov/pubmed?term=English%20K%5BAuthor%5D&cauthor=true&cauthor_uid=18326154

http://www.ncbi.nlm.nih.gov/pubmed?term=Naeve-Velguth%20S%5BAuthor%5D&cauthor=true&cauthor_uid=18326154

http://www.ncbi.nlm.nih.gov/pubmed?term=Rall%20E%5BAuthor%5D&cauthor=true&cauthor_uid=18326154

http://www.ncbi.nlm.nih.gov/pubmed?term=Uyehara-Isono%20J%5BAuthor%5D&cauthor=true&cauthor_uid=18326154

http://www.ncbi.nlm.nih.gov/pubmed?term=Pittman%20A%5BAuthor%5D&cauthor=true&cauthor_uid=18326154


• Are you sure? • Did I cause this somehow?









• Are you sure? • Did I cause this somehow• Will my child talk?









• Are you sure? • Did I cause this somehow? • Will my child talk?• What do I do now?









• Are you sure? (show ABR waveforms as you’re doing test)• Did I cause this somehow? (can’t choose our genes; only

preventable hearing loss is NIHL)• Will my child talk?• What do I do now?• Shouldn’t I get a second opinion?









• Are you sure?• Did I cause this somehow? • Will my child talk?• What do I do now?• Shouldn’t I get a second opinion? • How many children have you tested?









• Are you sure? • Did I cause this somehow? • Will my child talk?• What do I do now?• Shouldn’t I get a second opinion? • How many children have you tested? • Can this be fixed? Is there a surgery or medicine to fix this

problem?









• Are you sure?• Did I cause this somehow? • Will my child talk?• What do I do now?• Shouldn’t I get a second opinion? • How many children have you tested? • Can this be fixed? Is there a surgery or medicine to fix this

problem?• Will my baby have to wear a hearing aid?









• Are you sure? • Did I cause this somehow?• Will my child talk?• What do I do now?• Shouldn’t I get a second opinion? • How many children have you tested? • Can this be fixed? Is there a surgery or medicine to fix this

problem?• Will my baby have to wear a hearing aid?• Will my other / future children also have hearing loss?









• Are you sure? • Did I cause this somehow? • Will my child talk?• What do I do now?• Shouldn’t I get a second opinion? • How many children have you tested?• Can this be fixed? Is there a surgery or medicine to fix this

problem?• Will my baby have to wear a hearing aid?• Will my other / future children also have hearing loss?• How will I communicate with him/her?








Relationships

Having a child diagnosed with hearing loss can be a strain on a marriage.

Non-Compliant Parents

o "I try to put the hearing aids in but he or she does not want to keep them on“



o "I don't want her to become dependent on the hearing aids“




o "he wants to be cool and if he wears his hearing aids at school he will be teased“





o "she wears her hearing aids at school but she really doesn't need them at home".





o "she wears her hearing aids at school but she really doesn't need them at home".

o “he hears better without his hearing aids than with them”

Negotiation

• The only way to deal with these road blocks is to establish a common ground with the child's parents

Negotiation

• The only way to deal with these road blocks is to establish a common ground with the child's parents

• That common ground is always "we all want to do what is best for your child"). THIS IS THE KEY!


“Parents who appear to be denying their child’s HI are often viewed by clinicians as foolish and stubborn - - -

- - - when they should be viewed as loving parents who, for the time being, cannot accept” this news…

(Kricos, in Rehabilitative Audiology Children and Adults, Chapter 9, page 281)

Trust

• Effective counseling will enable you to earn the family’s trust.

• Not instantaneous.

3 Components of Trust

1. Technical competence

2. Communication competence

3. Agency

(English and Montano, Audiology Now 2012)

Trust

Technical Competence

• You have to appear like you know what you’re doing

• Some very competent experienced audiologists don’t always come across that way

• An inexperienced clinician may come across as being very competent.

Trust

Patient-centered communication:

• Listen to what they have to say

• Try to understand their point of view

• Make family feel like you’re giving them all of the information they need. Don’t pull any punches.

• Caring attitude. You don’t want to make them feel like they’re just another family.

Trust

Agency

• Putting the child and family first, ahead of all other concerns such as time and money.

• Making all of the child’s needs a priority.• Not just the hearing aid fitting• The child’s development, education, social and

emotional well being.

Trust

Factors associated in family’s ratings of trust:

1. Time spent with the family.• Research shows that every minute spent with the

family is associated with an increase in trust.

Source: Fiscella K, Meldrum S, Franks P, et al. Patient trust: is it related to patient-centered behavior of primary care physicians? Med Care.2004;42:1049–1055

Trust

Factors associated in family’s ratings of trust:

1. Time spent with the family.• Research shows that every minute spent with the

family is associated with an increase in trust.

2. Verbally exploring the family’s experience concerning their child’s hearing loss.

Source: Fiscella K, Meldrum S, Franks P, et al. Patient trust: is it related to patient-centered behavior of primary care physicians? Med Care.2004;42:1049–1055

Accepting Technology

• Technology is not the issue.

• Parents use technology all the time. Cell phones, computers, etc. Hearing aids are less complicated than those things.

• Acceptance of the hearing loss is the issue.


Other factors:

• Parents overwhelmed

• Cultural factors

Reasons Children Take their hearing aids out

0-4 months:

• Earmold not fitting?

• Feedback?

• No benefit (e.g. future CI candidate)


First 12 months:

• Curiosity/ exploring their own body

• Usually starts at about 6 months of age


Toddlers (13-30 months):

• Testing out their independence (this is when they learn to say “no”.

• For attention (even bad attention is attention).


Preschoolers (31-59 months):

• This is when children want to do things themselves, for example dressing themselves.

• It can be a battle of wills

Note: This is the age when children learn to put in their earmold and turn their hearing aid on.

Ear Gear

SafeNSound

Stickers / Toupee Tape

Phonak Stick n Stays

Headbands / Caps

www.silkawear.comwww.hearinghenry.com

http://www.silkawear.com/

http://www.hearinghenry.com/

Informational Counseling

Parents should know:

• What their child’s audiogram looks like and what it means.

• The hearing abilities of their child with and without hearing aids in various situations.

• How to troubleshoot a hearing aid.

Etiology

• One of the first things parents will ask you is what caused their child’s hearing loss?

• This is a medical diagnosis but you should be prepared to list some possible causes.

During Pregnancy and Childbirth:

• Birth defects of the head and neck• Connexin-26• Cytomegalovirus (CMV)• Genetic Syndrome• Herpes (genital)• Low birth weight• Ototoxic Medications• Oxygen deprivation• RH incompatibility• Rubella (measles)• Severe Jaundice• Syphilis• Toxoplasmosis

In Infants and Children:

• Autoimmune disorders• Explosions or repeated loud noises• Head Injury• Heredity• Meningitis• Middle ear problems (repeated)• Mumps (usually one ear)• Ototoxic medications such as:

vancomycin, gentamycin, cisplatinum, carboplatinum

Tips

• If necessary, state that a child needs 10,000 hours of hearing experience to develop proficiency at a language (hearing is a first order event for language acquisition).

• A child with hearing loss may need 3-4 times the hearing experience to become proficient at language.

• How long is this going to take if he or she only uses the hearing aid ½ hour per day?

“Invisible Handicap”

"Adult Speak": How Adults Sounded to Me as a Hard of Hearing Child

o Speaks to the importance of incidental hearing.

o When a child only hears when someone speaks directly to them, they are only getting 10-15% of the information that they need to learn. This is why the technology is important!

o Overhearing builds vocabulary, it gives children grammar, it increases their general knowledge.

“Invisible Handicap”

Psychology

Don’t be afraid to access psychology services. They can be invaluable.

Examples:

• Behavioural psychology

• Counseling for anxiety / emotional problems (teens/preteens go through emotional changes, hard of hearing children even more at risk).

Psychology

Children who have hearing loss are more likely to have psychological/emotional problems:

• may feel isolated

• may be teased

• may fear that they will lose all their hearing

Support of other Parents

• Parents are sometimes the best support person for another parent, especially the parent of a child who is slightly older.

• They can talk about their feelings and how the older child has coped with challenges at school, etc...

• Some of the best counseling takes place in the waiting room.

Deafness

• Deaf parents will want to know if their child is deaf.

• The power of the word deaf. It has more meaning than just talking about degree of hearing loss (i.e. deaf culture).

Tools to Support Counseling

• Speech Intelligibility Index (SII)

• Hearing Loss simulators


Speech Intelligibility Index (SII)

• Audiologists have always shied away from using a percent score to explain a person’s hearing abilities.

• However, clients have been asking for this for years.

• However, the SII is becoming more and more popular.



• Can be used to estimate speech intelligibility for various input levels with or without hearing aids.

• Frequencies that are more important for speech intelligibility are given more weight.

• Is available on Verifit systems, which are in most clinics.



• Good predictive value for word recognition, phonological working memory and vocabulary (better than pure tone average).


Hearing Loss simulators

• There are several on the market, many free.

• Some use the client’s actual hearing loss, some offer a selection of audiograms.

• Gives a very powerful demonstration of what it might sound like to have a certain type of hearing loss.

• Also available for auditory neuropathy, cochlear implants.


Handouts

• Great for some families, but most will be looking this up on the internet.

• Have some handouts that you can offer.

• Most families appreciate a list of websites that you think provide some good information.

counseling counseling is a vital part of the aural rehab process. effectiveness of counseling is...

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