Counseling Parents for Hearing Aid Management

By Karen Muñoz and Michael P. Twohig

This article is a part of the July/August 2024, Volume 36, Number 4, Audiology Today issue.

More than 6,000 infants are born with permanent hearing loss each year (Centers for Disease Control and Prevention, 2021) and are referred to early intervention. Infants are often fit with hearing aids in the first weeks of life to support spoken language development and school readiness (Joint Committee on Infant Hearing, 2019), and 10 or more hours of use per day has shown better language outcomes (Tomblin et al, 2015). Parents are central to the intervention process, and when they receive comprehensive and coordinated care, children can thrive. 

Even though using well-functioning hearing aids during most waking hours benefits children, data logging shows that many young children use their hearing aids fewer than five hours per day (Gosnell et al, 2023). Parents have reported that they experience struggles that interfere with hearing aid use (Muñoz et al, 2016) and have reported that they never check how the hearing aids are working or only check if they have concerns (Muñoz et al, 2019). 

Parents understandably experience challenges with hearing aid management. Most parents have typical hearing (Mitchell and Karchmer, 2004) and are unfamiliar with hearing loss,
hearing aids, and hearing technology. Parents have shared that feelings of frustration, uncertainty, and being overwhelmed have interfered with day-to-day hearing aid tasks (Muñoz et al, 2016; Nichols et al, 2022). Internal experiences, such as distressing thoughts and emotions, can get in the way of understanding information, decision-making, and taking action.

Development of an effective therapeutic relationship is a fundamental element for supporting parents in the behavior changes needed to increase audibility for children who use hearing aids.

Identifying and Addressing Internal Challenges

Providing information and teaching skills to manage hearing aids may not be enough to support 10 hours of wear time per day. Parents may also need help getting started with new routines and navigating challenges they experience as they are learning and adapting to a reality they were not anticipating. Evidence-based counseling is an intentional approach that can facilitate a partnership between audiologists and parents. By first identifying underlying issues, audiologists can help parents find effective solutions and provide support as needed using evidence-based strategies from motivational interviewing (MI) (Rollnick et al, 2008) and acceptance and commitment therapy (ACT) (Hayes et al, 2011). Development of an effective therapeutic relationship is a fundamental element for supporting parents in the behavior changes needed to increase audibility for children who use hearing aids.

Basic Counseling Skills 

Communication that incorporates basic counseling helps build trust and foster engagement in a shared process and exploration of concerns and solutions. Skills, such as asking open-ended questions, provide an avenue to understanding underlying issues, help parents feel heard, and are therapeutic by reducing the power of their troubling thoughts and emotions. Expressing empathy and showing caring through attentive nonverbal communication, and validating how parents are feeling, further support parents’ ability to engage in a shared process. 

TABLE 1 provides an example of dialogue to uncover underlying issues. Note the use of a series of open-ended questions to probe for deeper understanding, use of validation and reflection to acknowledge how the parent is feeling, and summarizing when no more issues are uncovered. This process helps the audiologist partner with the parent, where they are in the process, and together  determine targeted next steps. 

Motivational Interviewing

MI is a style of communication based on guiding rather than directing parents to support behavior change. Strategies include having parents voice their motivations or solutions they feel will work for them, rather than the audiologist providing a solution. MI strategies can help identify ambivalence (e.g., about hearing aid use), support information sharing and joint planning that matches parents’ current needs and skill level, and guide goal setting and progress monitoring. 

TABLE 2 provides an example of dialogue using two MI strategies to share information. Elicit-provide-elicit prioritizes what the parent wants to talk about rather than having the audiologist’s agenda dominate. Chunk-check-chunk has an emphasis on sharing digestible chunks of information and checking understanding throughout information sharing. These strategies help audiologists effectively partner with parents in their learning process.

Acceptance and Commitment Therapy

ACT focuses on a process called psychological inflexibility, which is characterized by difficulty taking actions important to the individual when they are having difficult internal experiences (e.g., thoughts and emotions). Audiologists can use ACT strategies to help parents increase awareness of distressing thoughts and feelings, decrease the impact of those internal experiences, and increase the ability to take actions that support what is important to them (e.g., put hearing aids on their infant) even when they are having difficult internal experiences. ACT strategies help audiologists address difficult thoughts and emotions that clients are experiencing using empirically supported methods. 

Audiologists can work with parents on making room for their difficult emotions and thoughts (e.g., feeling worried about how others will react and acknowledging that the thoughts do not need to get in the way of putting the hearing aids on). They can also work with parents on navigating situations in daily life while experiencing difficult emotions and thoughts (e.g., test the thought by noticing how people react to the seeing the child wearing the hearing aids). This work “sidesteps” internal experiences that are not easily changeable. 

TABLE 3 provides an example of using ACT strategies to help a parent act while feeling worried about how others might react to the hearing aids. The audiologist talks with the parent about their distressing thoughts and suggests an experiment to help the parent disentangle thoughts from actions (cognitive defusion). This experiment helps the parent move forward in their ability to act while having a distressing internal experience. In this example, the audiologist helped the parent break down the steps using a SMART (specific, measurable, achievable, relevant, timebound) goal for the situation. This is a conversation that takes place over time as the parent learns to overcome their challenge. 

Implementation Considerations

It is common for audiologists to experience barriers implementing counseling skills in practice, and audiologists have been found to avoid discussions about emotions (Ekberg et al, 2014). Factors audiologists say interfere include uncertainty about their role, feeling there is not enough time, and lacking confidence in how to have conversations about thoughts and emotions (Grigsby et al, 2024). 

Audiologists are well positioned to help parents gain confidence with hearing aid management.

Not talking about parents’ internal challenges can have unintended consequences and result in low hours of hearing aid use persisting over time because emotional challenges have not been addressed. Parents’ internal experiences will be there whether the audiologist talks about them or not; however, when the audiologist partners with parents to understand underlying issues and support coping, the challenges are less likely to interfere with hearing aid management tasks. 

There are tips that can help integrate counseling strategies in clinical practice. Notice the balance of the conversations; the parent should be talking about half the time. If the audiologist is dominating the conversation, it may not reflect a shared process. Have a plan to purposefully ask how the parent is feeling and what they need. Use data logging as a shared tool to help identify if there is a need to explore hearing aid use challenges. Monitoring data logging over time helps the audiologist and the parent know if there is a problem and provides objective information about effectiveness of solutions that have been implemented. Small steps in progress are to be celebrated. What is important is the process of working together toward a common goal.

Knowing that auditory experience impacts spoken language development (McCreery and Walker, 2021) underscores the critical role of supporting parents in becoming effective partners in the intervention process. Audiologists are well positioned to help parents gain confidence with hearing aid management. 

Additionally, partnering with parents helps them teach other caregivers, engage in daily management even in challenging situations, and ultimately teach their child how to manage their own hearing aids and self-advocate.