1. Counseling Counseling is a vital part of the aural rehab process. Effectiveness of counseling is correlated to compliance with recommendations.

2. 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

3. Why Effective Counseling is Important 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

4. Why Effective Counseling is Important 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.

5. Source: Achieving Effective Hearing Aid Use in Early Childhood

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

7. Breaking Bad News It helps if you can break the news gently – i.e. over 2 sessions. 1 st session: I have a suspicion, we’re going to have you come back for further testing… 2 nd session: The results are consistent with the first…

8. Breaking Bad News It helps if you can break the news gently – i.e. over 2 sessions. 1 st session: I have a suspicion, we’re going to have you come back for further testing… 2 nd session: The results are consistent with the first… This instills more confidence

9. Breaking Bad News It helps if you can break the news gently – i.e. over 2 sessions. 1 st session: I have a suspicion, we’re going to have you come back for further testing… 2 nd session: The results are consistent with the first… This instills more confidence May soften the blow

10. Confidence oYou have to be confident in your test results to project confidence during counseling. oAvoid messages like “Our test results suggest hearing loss” or “I think your child might have a hearing loss”. Don’t hedge. oIt'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.

11. Giving the Results Prepare the room. oMake sure tissues are handy. oParents should be seated comfortably. oYou should be at the same eye level as the parents or lower – never higher. oTry to make sure that there will be no interruptions.

12. Giving the Results 1.Make and maintain eye contact with both parents.

13. Giving the Results 1.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.

14. Giving the Results 1.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”.

15. Giving the Results 1.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..” (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”.

16. Giving the Results 1.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..” (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.

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

19. Silence oWe are conditioned that silence is awkward/uncomfortable in social situations. This is not so when delivering bad news ! oThe parents don’t experience silence this way.

20. Silence oWe are conditioned that silence is awkward/uncomfortable in social situations. This is not so when delivering bad news ! oThe parents don’t experience silence this way. It is not silent in their heads. oTalking too much is the biggest mistake that clinicians make when delivering news about a diagnosis.

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

22. Respect oThe family is allowing you, a stranger, into their lives at this very vulnerable time.

23. Respect oThe family is allowing you, a stranger, into their lives at this very vulnerable time. oThis is a privilege

24. Respect oRespect is a 2-way street.

25. Respect oRespect is a 2-way street. o“Positive, unconditional regard. Assume good will.” (English, 2008, Oticon Pediatric Symposium)

26. Respect oRespect is a 2-way street. o“Positive, unconditional regard. Assume good will.” (English, 2008, Oticon Pediatric Symposium) oHow might you seem like you’re looking down on a family ? oBy not listening to what they have to say (interrupting them). oBy invalidating their concerns “It could be worse”. oBy commenting negatively about something (such as the child’s behavior – now is not the time!).

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

28. Crying “Audiologists need to be prepared to deal with the emotional ramifications of the news they deliver” (parent of deaf/hard of hearing child)

29. 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.

30. Crying What about the clinician. Should you cry ?

31. 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.

32. 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.

33. Breaking Bad News oWe tend to feel that we have to give parents all the answers and solve the problem.

34. Breaking Bad News oWe tend to feel that we have to give parents all the answers and solve the problem. oYou 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.

35. Breaking Bad News oWe tend to feel that we have to give parents all the answers and solve the problem. oYou 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. oAvoid being the rescuer.

36. Breaking Bad News oWe tend to feel that we have to give parents all the answers and solve the problem. oYou 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. oAvoid being the rescuer. oEncourage parents to talk about their feelings, fears and emotions.

37. 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.

38. Grief “Welcome to Holland” by Emily Perl Kingsley

39. Parent’s Concerns (even if unspoken) Are you sure? J Am Acad Audiol.J Am Acad Audiol. 2007 Sep;18(8):675-87. Development of an instrument to evaluate audiologic counseling skills. English KEnglish K, Naeve-Velguth S, Rall E, Uyehara-Isono J, Pittman A.Naeve-Velguth SRall EUyehara-Isono JPittman A

40. Parent’s Concerns (even if unspoken) Are you sure? Did I cause this somehow? J Am Acad Audiol.J Am Acad Audiol. 2007 Sep;18(8):675-87. Development of an instrument to evaluate audiologic counseling skills. English KEnglish K, Naeve-Velguth S, Rall E, Uyehara-Isono J, Pittman A.Naeve-Velguth SRall EUyehara-Isono JPittman A

41. Parent’s Concerns (even if unspoken) Are you sure? Did I cause this somehow Will my child talk? J Am Acad Audiol.J Am Acad Audiol. 2007 Sep;18(8):675-87. Development of an instrument to evaluate audiologic counseling skills. English KEnglish K, Naeve-Velguth S, Rall E, Uyehara-Isono J, Pittman A.Naeve-Velguth SRall EUyehara-Isono JPittman A

42. Parent’s Concerns (even if unspoken) Are you sure? Did I cause this somehow? Will my child talk? What do I do now? J Am Acad Audiol.J Am Acad Audiol. 2007 Sep;18(8):675-87. Development of an instrument to evaluate audiologic counseling skills. English KEnglish K, Naeve-Velguth S, Rall E, Uyehara-Isono J, Pittman A.Naeve-Velguth SRall EUyehara-Isono JPittman A

43. Parent’s Concerns (even if unspoken) 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? J Am Acad Audiol.J Am Acad Audiol. 2007 Sep;18(8):675-87. Development of an instrument to evaluate audiologic counseling skills. English KEnglish K, Naeve-Velguth S, Rall E, Uyehara-Isono J, Pittman A.Naeve-Velguth SRall EUyehara-Isono JPittman A

44. Parent’s Concerns (even if unspoken) 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? J Am Acad Audiol.J Am Acad Audiol. 2007 Sep;18(8):675-87. Development of an instrument to evaluate audiologic counseling skills. English KEnglish K, Naeve-Velguth S, Rall E, Uyehara-Isono J, Pittman A.Naeve-Velguth SRall EUyehara-Isono JPittman A

45. Parent’s Concerns (even if unspoken) 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? J Am Acad Audiol.J Am Acad Audiol. 2007 Sep;18(8):675-87. Development of an instrument to evaluate audiologic counseling skills. English KEnglish K, Naeve-Velguth S, Rall E, Uyehara-Isono J, Pittman A.Naeve-Velguth SRall EUyehara-Isono JPittman A

46. Parent’s Concerns (even if unspoken) 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? J Am Acad Audiol.J Am Acad Audiol. 2007 Sep;18(8):675-87. Development of an instrument to evaluate audiologic counseling skills. English KEnglish K, Naeve-Velguth S, Rall E, Uyehara-Isono J, Pittman A.Naeve-Velguth SRall EUyehara-Isono JPittman A

47. Parent’s Concerns (even if unspoken) 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? J Am Acad Audiol.J Am Acad Audiol. 2007 Sep;18(8):675-87. Development of an instrument to evaluate audiologic counseling skills. English KEnglish K, Naeve-Velguth S, Rall E, Uyehara-Isono J, Pittman A.Naeve-Velguth SRall EUyehara-Isono JPittman A

48. Parent’s Concerns (even if unspoken) 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? J Am Acad Audiol.J Am Acad Audiol. 2007 Sep;18(8):675-87. Development of an instrument to evaluate audiologic counseling skills. English KEnglish K, Naeve-Velguth S, Rall E, Uyehara-Isono J, Pittman A.Naeve-Velguth SRall EUyehara-Isono JPittman A

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

50. Non-Compliant Parents o"I try to put the hearing aids in but he or she does not want to keep them on“

51. 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“

52. 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“

53. 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".

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

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

56. 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!

57. Non-Compliant Parents “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)

58. Trust Effective counseling will enable you to earn the family’s trust. Not instantaneous.

59. 3 Components of Trust 1.Technical competence 2.Communication competence 3.Agency (English and Montano, Audiology Now 2012)

60. 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.

61. 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.

62. 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.

63. 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

64. 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

65. 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.

66. Non-Compliant Parents Other factors: Parents overwhelmed Cultural factors

67. Reasons Children Take their hearing aids out 0-4 months: Earmold not fitting? Feedback? No benefit (e.g. future CI candidate)

68. Reasons Children Take their hearing aids out First 12 months: Curiosity/ exploring their own body Usually starts at about 6 months of age

69. Reasons Children Take their hearing aids out Toddlers (13-30 months): Testing out their independence (this is when they learn to say “no”. For attention (even bad attention is attention).

70. Reasons Children Take their hearing aids out 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.

72. Ear Gear

73. SafeNSound

74. Stickers / Toupee Tape Phonak Stick n Stays

75. Headbands / Caps www.silkawear.com www.hearinghenry.com

76. 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.

77. 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.

78. 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

79. 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

80. 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?

81. “Invisible Handicap” "Adult Speak": How Adults Sounded to Me as a Hard of Hearing Child oSpeaks to the importance of incidental hearing. oWhen 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! oOverhearing builds vocabulary, it gives children grammar, it increases their general knowledge.

82. “Invisible Handicap”

83. 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).

84. 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

85. 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.

86. 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).

87. Tools to Support Counseling Speech Intelligibility Index (SII) Hearing Loss simulators

88. Tools to Support Counseling 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.

89. Tools to Support Counseling Speech Intelligibility Index (SII) 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.

90. Tools to Support Counseling Speech Intelligibility Index (SII) Good predictive value for word recognition, phonological working memory and vocabulary (better than pure tone average).

91. Tools to Support Counseling Speech Intelligibility Index (SII)

92. Tools to Support Counseling 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.

93. Tools to Support Counseling 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.