Listening to Podcasts

Podcasts started to become more commonplace around 2005. Now we hear about them frequently and are reminded of their popularity when we see people walking and exercising with their earphones plugged in—listening to podcasts. Podcasts have become so popular!

Today, I will discuss how people with cochlear implants may enjoy them, too.

As a pure listening activity, podcasts allow people to listen while being occupied with other activities. Consequently, one may assume that podcasts are not a feasible listening activity for people with hearing loss (including those with cochlear implants).

Podcasts are often more challenging for auditory comprehension compared with audiobooks or recorded articles.  There are a number of reasons why that is the case:

• Hosts are usually not professional readers; therefore, their speech may be difficult to comprehend. In many instances, the reader is speaking too fast for someone with hearing loss to follow.
• Because podcasts are often given in a spontaneous manner, they may contain more pauses, repetitions, corrections, false starts, and hesitation. This may frustrate listeners with CIs.
• The sound quality in podcasts may not necessarily be as high quality as other recorded options. Indeed, there is a wide range of quality in the podcasts relative to the recordings and editing.
• Background music or other noises can make auditory comprehension difficult.
• When the podcast is a conversation between two people, listeners must distinguish between the two (or more) speaker voices, voices which may have different speech characteristics. This may complicate listening and make it more difficult than understanding a single speaker. There can be rapid transitions from topic to topic in such conversations, adding to the challenges of following and understanding the discussion.

So, why even try? What makes podcasts valuable?

 These are a number of reasons people like podcast:

• Podcasts use a different and exciting presentation of a topic and allow for a deeper level of content compared with radio.
• Comparing podcasts and newspaper articles, podcasts may present information in a less formal and processed way, allowing listeners more space to form an opinion and encouraging them to draw conclusions.
• Podcasts may be less structured and more like natural and even intimate monologues or conversations; they provide the listeners with a less filtered and more authentic experience.
• Listening to podcasts provides listeners with a glimpse into the personality of the hosts; listeners can relate to them. Moreover, when the host invites somebody to join the episode, it allows the listeners to experience a dynamic between them and the host.
• There are many podcasts covering many categories making it easy to find a podcast to connect with.
• Podcasts can be used as auditory training material for advanced CI users who are able to comprehend speech on other recorded materials such as (some) TED talks (without captions), audiobooks and recorded articles. 

• Begin by listening to video-podcasts where you can also rely on speech reading and captions when needed.
• Find podcasts that have captions or transcripts. Use the transcript and captions to support your understanding while listening, or read the transcript before starting to listen to the podcast. It will make the experience not only beneficial in terms of auditory training, but also rewarding and fun.
• Choose to listen to podcasts with speakers who have clear and highly intelligible speech and who are speaking at a slow pace.
• Select podcasts with high sound quality and a minimum amount of background noise.
  Choose topics that you have some knowledge about; having some background will support your comprehension and help you to enjoy it, even if you miss some words.
• If you can slow down the speaking speed, try to do that; reducing the speed to 75% of the original speaking speed may be helpful.
• Listen in a quietest room and use an assistive listening device to stream the sound directly to your processor(s).

A good podcast to start with

• Presented by a professional reader with highly intelligible speech speaking at a relatively slow speaking rate
• Excellent sound quality
• Although there is background music, it is played only during the first two minutes and the last 45 seconds of the podcast
• Captions and transcript are available!

https://www.leonardoenglish.com/podcasts/leonardo-da-vinci

Good luck!

"I used to think that I wasn’t able to understand some people because they weren’t speaking clearly, or sometimes because I wasn’t focusing on what they were saying. I didn't realize that my difficulty was often due to background noise. I didn't realize how noisy the world is.”

A dear patient of mine recently shared the above comment with me. After so many years of encountering this issue, I decided to write about it.

Understanding the Impact of Noise

How do you solve the problem of noise? Is it not obvious for people with cochlear implants (CIs) how to organize their acoustic environment to reduce the impact of noise on their ability to understand spoken communication? Why don’t family members and friends take care to reduce noise and be more considerate? Why is it not enough to note that CI users (or anyone with hearing loss) has considerably more difficulty hearing in noise than people with typical hearing and that to understand speech, the signal must be significantly louder than noise in the environment? Why don’t people understand that noise causes those with significant hearing loss to be tired and impatient and that they generally prefer to be in a quiet environment?  

What is Considered “Noise” is Subjective

Noise is subjective. What is perceived as noise by people using CIs may not be considered noise by people with typical hearing. For that reason, those not bothered by environmental sounds may not know to mitigate sounds to enhance CI users' communication. The Wikipedia entry defines noise as "an unwanted sound considered unpleasant, loud, or disruptive to hearing."

Noise can cause discomfort to people with CIs (as well as those using hearing aids). It may be challenging for CI users to separate the sounds they wish to hear from background noise. Therefore, they may perceive any sound that does not belong to the auditory stimulus they wish to focus on as disruptive noise. Compared to typically hearing people, CI users are likely to experience many more sounds in various situations as noise.

People with typical hearing often enjoy having a conversation sitting in the park, surrounded by the sounds of water flowing, birds chirping, and children playing. CI recipients in the same situation may find holding a conversation in the same situation to be a struggle. While people with typical hearing may experience a particular situation as pleasant, their CI user friends might experience the same situation as noisy and stressful. The gap between the two groups' experiences can be so significant that people with typical hearing may have no idea that their CI user friends' situation is so challenging.

Noise at Home

These gaps may also reflect various situations at home. For example, while getting ready for a family dinner the following could contribute to noise in the listening environment:

• TV located 16 feet from the dining table playing at a low volume
• Microwave on
• Refrigerator running (seems just a little noisy but contributes)
• Someone at the sink is washing dishes

Given the above scenario, many people with typical hearing would sit down at the dinner table oblivious to the noise and not even bother to turn off the TV. People with CIs might well feel surrounded by unbearable noise. In many instances, a CI user would not be able to manage a conversation and they might also be confused because they are struggling to hear as well as being unable to identify the source(s) of the various noise contributors.

There are people with typical hearing who have a higher sensitivity to noise than the general population. Still, they—unlike many CI recipients—would be able to locate the noise sources and quiet them (or at least complain about them).  Someone without significant hearing loss might say, for example: "The noise of your neighbor’s lawn mower is driving me crazy!”  And then someone might close the window.

What can we do?

People with typical hearing should ask about listening difficulties and listen to their CI user friends' complaints about disturbing and disruptive sounds. They should understand that these sounds are not something that people with CIs can "live with;" they should not say but “this is noise.” When communicating with people with CIs, those with typical hearing should adopt acoustic standards based on their CI user friends' judgment. At the same time, CI users should explore their daily acoustic environments, to maximize their skills in recognizing sounds that interfere with their communication and manage them.

How can we do it?

People with typical hearing: Ask your CI user friends about their acoustic experience.

• Do you find this location too noisy?
• Would you prefer to look for a quieter place?
• Listen to, and respect, any comments

People with typical hearing can listen to the "silence”

• What sounds do you hear?
• Where do these sounds come from?
• Is it possible to diminish the sounds you hear? Is it possible to remove them completely?
• Is it possible to keep away the noise sources away from where the conversation is taking place?
• Should you move the group and chat in a quieter place?

People with CIs:  Try to listen carefully to the noise in the environment.

• Stand near different appliances and learn to recognize the noise they produce
• Ask friends with typical hearing about sounds that you hear but cannot identify
• At home, close windows and doors when there are noise disruptions from outside or from another room in the house
• While having a conversation, chose a location that is as far away from from noise sources as possible

Concluding Thoughts

When communicating with CI recipients, people with typical hearing should be sensitive to how sounds in the environment may impact others and thereby develop a concept of “noise” that is sensitive to their CI friends’ needs. Collaborating with friends and family to create comfortable communication environments may be challenging for everyone as those with typical hearing may not understand the noise problems being encountered nor how to address them while the CI user may not be able to accurately identify why they are having a problem. Collaborative exploration and mutual efforts may help reduce communication gaps and achieve better communication for all.

In the early years of cochlear implantation and throughout the 1990s, adults who had experienced early deafness (either born deaf or having lost hearing during early childhood), were generally considered unsuitable candidates for cochlear implantation. This perspective was guided by research on children. Research demonstrated the significant impact of a child's age at implantation; children implanted at a younger age, on average, have better outcomes. The expectation was also driven by outcomes of adult CI recipients who lost their hearing as adults, findings which have consistently demonstrated diminished outcomes with longer duration of hearing loss among the population whose hearing loss was within the CI candidacy range.

Perspectives on CI in Adults with Childhood Deafness has Changed

In the early 2000s, there were important technological improvements in cochlear implants, such as advances in processing strategies and electrode array designs. Patient outcomes in this population of early deafened adults—once thought to be poor candidates—improved and CI candidacy guidelines were expanded. Many more adults with early deafness received cochlear implants. Studies from the 1990s rarely demonstrated open-set perception skills among adults with early deafness (i.e., few could repeat words or sentences without speech reading). Studies on this population a decade later demonstrated significant speech perception skills that allowed many recipients to perceive words and sentences presented in open-set tests. At the same time, there was variability in speech perception outcomes among these adults which made it difficult for clinicians to provide a simple answer to the often asked question "How will I benefit from cochlear implantation?"

Variability Explained

Adults with early deafness are a heterogeneous group. Studies have sought to explain the variability in CI outcomes for individuals and individuals’ personal characteristics. The variables found to be positively correlated with speech perception outcomes were:

• Consistent use of the CI
• Higher number of hours of CI usage each day
• Better speech intelligibility and speech perception skills prior to cochlear implantation
• Mainstream education that emphasized use of spoken language
• Spoken language as the main communication mode pre-implantation

Age at time of CI and duration of deafness were not found to be significantly correlated with speech perception outcomes in this group of adults—contrary to what has been found for children with congenital deafness and for adults with post-lingual deafness. The type of cochlear implant (i.e., manufacturer) was also not found to be correlated with outcomes in this group of adults.

Quality of Life Effects

Improved speech perception outcomes are only one aspect of how someone may benefit from cochlear implantation. For people with early deafness, relying solely on speech perception to evaluate CI benefits is problematic for two reasons:

• Variability and the wide range of results among this group of CI users
• Although many of these early deafened adult recipients fail to reach open-set speech perception skills, most still use their CI regularly and enjoy it.

A growing number of studies are focusing on the contribution cochlear implants to an individual’s quality of life. This is consistent with the World Health Organization's perspective that an evaluation of a health intervention should include assessment of the degree to which it improves one’s ability to carry out activities of daily living and contributes to overall quality of life. Studies indicate that most adults with early deafness believe that their CI has made a significant contribution to their quality of life. An important study funded by American Cochlear Implant Alliance explores this topic in detail https://www.acialliance.org/page/QOLMeasures by developing and testing new measures of quality of life associated with cochlear implantation.

CI recipients note that they:

• Are more aware of environmental sounds
• Benefit from improved speech comprehension
• Benefit from speechreading that is more accurate and less labored
• Are more confident and independent while communicating in everyday situations
• Feel less stress and more control while engaging in social activities
• Feel less lonely
• Have become more involved in hearing-based activities such as listening to music, watching TV, and talking on the telephone

Importantly, most studies did not find a significant relationship between quality of life benefits and and speech perception outcomes. This further supports the finding that the benefit many adults with early deafness enjoy from their CIs is not necessarily a function of their speech perception results.

Concluding Thoughts

To answer the question "How do adults with early deafness benefit from a cochlear implantation?" we need to appreciate the challenges faced, as well as the diversity, of this group of people. For these CI recipients, evaluating benefit based solely on objective auditory measures does not provide a full indication of outcomes and satisfaction. We must also assess the contribution in terms of quality of life benefits. The cochlear implant enhances communication and social functioning, contributes to one’s sense of well-being, and often improves overall quality of life. Quality of life should be part of any pre- and post- implantation assessment and should also be considered in an individual’s rehabilitation program. Considering communication and quality of life while also respecting the adult population’s diversity and the range of personal variables associated with CI outcomes will allow more adults with early deafness to benefit from a cochlear implantation later in life.

Further Reading

Craddock L, Cooper H, Riley A, Wright T (2016). Cochlear implants for pre-lingually profoundly deaf adults, Cochlear Implants International, 17(1), 26-30.

Florli F, Turchetti G, Bellelli S, Fortunato S, Bruschini, Barillari MR, Berrettini S (2017). Cochlear implants in prelingually deafened oralist adults:speech perception outcomes, subjective benefits and quality of life improvement. Acta Otorhinolaryngologica Italica, 37(5), 412-422.

Lammers MJW, Versnel H, Topsakal V, van Zanten GA, Grolman W (2018). Predicting performance and non-use in prelingually deaf and late-implanted cochlear implant users. Otology& Neurotology, (39),436-442.

Most T, Shrem H (2010). Cochlear implantation in late-implanted adults with prelingual deafness. American Journal of Otolaryngology, 418-423.

O’Gara SJ, Cullington HE, Grasmeder ML, Adamou M, Matthews ES (2016) . Factors affecting speech perception improvement post implantation in congenitally deaf adults, Ear & Hearing, 37(6), 671-679.

Straatman LV, Huinck WJ,  Langereis MC, Snik AFM, Mulder JF (2014). Cochlear implantation in late-implanted prelingually deafened adults: changes in quality of life. Otology & Neurotology: 35(2), 253–259.

Within the space of a few months, telecommunication in COVID-19 has become the main way to communicate with the people in our lives. Face-to-face communication has been replaced by video-chatting and phone calls. In today's post, I'll discuss telephone use and ways to reduce communication difficulties.

Phone calls have always been a challenge for many people with hearing loss including those who use a cochlear implant.

We usually read and write about what cochlear implant users can to successfully hold telephone conversations.  For example, we may advise someone to use technologies that work in concert with a CI and/or to use Assistive Listening Devices (ALDs), or to make phone calls while in a quiet room. There are a number of ways for someone with hearing loss to improve their likelihood of having a successful and enjoyable telephone conversation and I will discuss these in depth in this post.

When you begin practicing using the phone, choosing the right partner is one of the most important things to do. You would most likely choose someone you know well and feel comfortable with, someone who is patient, and someone who is willing to help you. Regardless, talking on the phone can be a real challenge, even for CI users use the phone regularly. In order to make it easier and avoid some of the obstacles, you might want to discuss what helps you ahead of time with your phone call partners.

So, this post is written for your phone conversation partners to provide them with practical tips and guidance that may help the person with a cochlear implant.

Here are some points to think about, and some requests that someone may want to bring to the conversation partner’s attention:

• In order to talk on the phone with your CI user friend, move to a quiet room, keep the closed to reduce background noise, and avoid interruptions.
• Do not call your CI user friend while driving unless you are equipped with a high-quality headset with a microphone adjacent to your mouth. Even then, it would be best to wait until you have reached your destination (if possible).
• Do not call your CI user friend while walking down the street or if you are in a noisy or echo-prone space. Noise that is insignificant for you, can make the call difficult for your CI user friend
• If your CI user friend calls you when you are somewhere noisy and you cannot move to a quiet room, describe the situation and let them decide whether to hold the conversation or have you call back later.
• Do not talk to your CI user friend when you are on speaker phone, as the CI user will hear you from a distance along with disruptive background noises.
• Speak just a bit slower than usual.
• Help your friend by Noting the reason and/or the topic of the conversation. Having that information will help him or her to follow your remarks.
• If you want to tell a long story, it may be best if you could break it into short passages to allow your friend to stop you if information is not accurately understood.  
• Always encourage your friend to ask for clarification if (s)he needs that. Be patient and repeat yourself as needed. If there is a certain word that wasn’t understood even after repetition, you may want to express yourself using other words or phrases.
• If you are having difficulty understanding your CI user friend, do not hesitate to ask for clarification. You may want to ask him or her to repeat what was just said, say it another way, or even spell the word you did not understand.
• If you provide information that includes names of people or places, or you are scheduling an appointment, allow your CI user friend to verify that they understood the name correctly. You may want to send the details by email or text to avoid misunderstandings.

Good Luck! Your patience will help your friend develop the confidence and skills to be comfortable making phone calls.

“Hearing people can be so mean” noted one of my patients during a session. We were talking about a reaction that she sometimes experiences when she asks an acquaintance "What did (s)he just say?" Questions intended to help someone understand what is being discussed are sometimes perceived by typically hearing friends as being overly probing.  The young woman discussing this issue was born deaf and she remembers often asking for help by asking such questions. She prefers paying the price of being judged by some people as having bad manners to being out of the loop.

Others with hearing loss may experience similar conflicts. We expect people to be more sensitive, considerate, and aware of the difficulties people are encountering but too often even friends and family fail to appropriately respond. Professionals sometimes use the "earplugs experience" as a demonstration of what it’s like to have hearing loss. In reality, the experience of being deaf or hard of hearing is so much more complicated. It sounds trivial to ask people with hearing loss to simply explain their needs to friends and others around them. But they may not know where to start because of the lack of understanding regarding what it means to be deaf.

This post is about self-advocacy and the importance of people with hearing loss being proactive about explaining the difficulties they encounter as well as their needs as people who are deaf or hard of hearing people. This includes anyone with hearing loss, regardless of the technology they use.

My comments and recommendations are drawn from many years of working with adult CI recipients and learning about their experiences and interactions with the "hearing world."  These are topics that should be explained when practicing self-advocacy and educating your friends and family about your needs as someone with hearing loss.

·       The influence of a noisy environment. Did you know that many people with typical hearing think that a noisy environment has no impact on the ability of someone with hearing loss to hear? It may be assumed that people with hearing loss cannot hear the background noise. Clarification is needed.  Noisy environments make hearing and understanding even more difficult for people with hearing loss compared to people with typical hearing. In order to gain the same level of speech understanding, people with hearing loss need a better signal to noise ratio (e.g., the difference between the noise and the speech needs to be greater, favoring the speech level). Though people with typical hearing can often understand speech when speech signal level is the same as the noise level (or even a bit softer), people with hearing loss generally cannot understand speech unless the volume level is significantly higher than the noise. Knowing that would enable others to understand:

o   Why you're asking them to turn down the TV volume

o   The need to not sit near the air conditioning or to a working dishwasher when having a conversation with you

o   Why you are encouraging friends and family to choose quiet restaurants

o   Why you are often too busy or have other plans when invited to events in noisy places. Assistive Listening Devices (ALDs) that require your friends/ family/colleagues cooperation can be extremely helpful since they may provide you with a better signal to noise ratio by decreasing the level of the surrounding noise and increasing the level of the speaker's voice. It's important to note that during many daily situations, noise levels are too high for people with hearing loss meaning that they are forced to lose a lot of the auditory information and invest a large level of effort in trying to compensate for their limited auditory perception.

·       The influence of the number of speakers in a conversation. As the number of speakers increases, the ability of deaf and hard of hearing people to follow the conversation decreases.  People with hearing loss may not be able to rely solely on auditory information and may need visual cues (e.g., speech reading). In a conversation with more than one person, person may need to locate each speaker visually in order to supplement what he is hearing with speech reading. When people are not speaking one-at-a-time, understanding may be impossible. Having visual cues to supplement the auditory signal becomes even more important when a conversation is taking place in a noisy environment. Knowing that would let your friends understand why:

o   You prefer to meet with a group of friends in a bright place and not in a dark one

o   You need to position yourself such that you are able to see all of the speakers’ faces

o   You are asking people to remove their hands from their face while talking

o    Overlapping conversations leave you out of the loop.

·       The amount of effort that's required for keeping up with the conversation. Many people with typical hearing are unaware of how exhausting it can be for someone with hearing loss to follow a multi-speaker conversation in a noisy environment. You can read about listening fatigue in my previous post https://www.acialliance.org/blogpost/1334356/311879/Listening-Effort-and-Fatigue-Part-1

·       Dealing with communication gaps and misunderstanding.  Did you know that many people with typical hearing believe that speech reading replaces what someone with typical hearing perceives via listening alone?  People sometimes believe that deaf and hard of hearing people have a unique ability to derive the whole meaning of what has been said by focusing on a speaker's face. Clearly this is false belief that should be addressed. It is not possible to completely perceive speech sounds in the absence of hearing them. People with typical hearing are not aware of the various strategies deaf and HOH people use in order to understand speech based on incomplete auditory input. They do not know that in order to understand whether somebody said "doll" or "tall" you need to use linguistic context since speech reading alone would not be helpful in recognizing which of the words were spoken.  People with typical hearing are often not aware of the fact that people with hearing loss do a lot of guessing. For example, they might need to guess the name of a person they were introduced to because they did not perceive it completely;  they might guess what had been said in conversation with more than one person since they might miss some of what had been said. They might smile and nod in the wrong places. These are typically done daily, and such guesses may lead to misunderstanding.

As people with typical hearing are exposed to a lot of auditory information—without even knowing they were listening to it—much of this information may not be perceived by a person with hearing loss. Parents of young deaf children are usually instructed by professionals to mediate the environment for their young children in order to:

·       Encourage their listening skills

·       Expand their knowledge and curiosity

·       Improve their orientation and their sense of involvement.

Many of these young children continue to seek this kind information as adults, reaching out to their friends, colleagues, spouses and relatives.

When your friends better understand the challenges you face, they are likely to be much more cooperative and helpful when you ask: "What did (s)he just say?"