Improving the ratio between speech and noise may be accomplished by distancing oneself from the noise source and/or getting closer to the speech source. This is not always possible. Sometimes, we must stand next to the noise source (for example, when washing dishes). Sometimes, noise is coming from multiple directions and it's impossible to distance ourselves from it (for example, when sitting at a table in the middle of a restaurant).

Understanding and analyzing noisy situations can help improve coping in them
The more hearing care professionals AND people with hearing loss thoughtfully analyze the acoustic environment, the better we are able to explain the problems to others, who may then know how to meet the needs of someone with hearing loss.

One way someone with hearing loss can raise awareness about the challenges that noisy environments create for them and better explain their communication needs is to explore the specifics of the intensity (or loudness) of the noise they are encountering. For that, I encourage someone to download a sound level meter app(decibel meter/noise meter) and use it to experiment and learn about the acoustic environment at home, at work, and wherever someone regularly spends time. I find that people are often surprised to discover how much noise exists in seemingly quiet environments. For example, the noise generated by the large flame on my gas stove is 45 decibels. The refrigerator generates noise which can reach an intensity of 52 decibels.  The dishwasher generates noise of 55 decibels and the water stream in the kitchen faucet creates noise 70 decibels of noise. Of course, one can be cognizant of such noise when replacing appliances. 

Speech intensity for a normal conversation range between 55 and 60 decibels with loud speech reaching 70 decibels. This means that while you are washing dishes, it may well be impossible to understand speech—even if the person speaking is standing immediately next to you.

When standing next to the stove cooking and conversing with another person, the speech will be stronger than the gas flame noise by about 10-15 decibels. If there are no additional noises and you have good speech perception skills, you may understand them without much effort. However, as the speaker moves away from you, the speech intensity will decrease, making it more difficult to understand speech. The speech intensity you hear when you six feet from the stove will may be equal to the noise intensity (or even be weaker than the speaker) so speech understanding will become a real challenge.

Knowing the average speech level and the (measured) noise level in different situations can reflect your difficulty understanding a conversation. You can explain to family members and friends that any noise of the same or higher intensity than 60 decibels (the average speech intensity in a normal conversation), or even 50 decibels, significantly affects your ability to understand speech without speech reading. Therefore, if needed, they should position themselves so that you have easy access to their faces. The same applies to talking to you from a distance greater than 3-4 feet in a non-quiet environment.

Understanding the implications of basic acoustics in everyday situations can avoid misunderstanding and discomfort.  

Basic facts you should keep in mind:

• Knowing the noise levels in the car (about 65 decibels) can demonstrate to people why they should not call you while driving, especially while using the car's speaker option. In addition, being aware of the noise level while driving with you can encourage use of your assistive listening device

• Measuring noise intensity in different restaurants can help you make informed choices for the quiet options.  Restaurant noise can vary depending on table location, so you can ask in advance to sit at a corner table or a table away from known noise (such as the bar). 
  

Measuring noise levels in the environment can help you:

• Distance yourself from noise sources and reduce controllable noises
• Know when to use technology to improve understanding of speech in noise including ensuring noise reduction programs on your processor are optimized for listening in noisy situations and you are making use of suitable assistive listening devices.
• Explain to others the challenges you face in noisy environments to help them communicate with you more constructively, suitably, and considerately.
  A better understanding of the acoustic conditions will allow you to manage everyday situations to reduce the adverse effects of noise and help you enjoy better communication with less effort.
  

Further, your SLP was in contact with your audiologist at the cochlear implant center and kept you informed about technology advances and other relevant updates. She encouraged you to practice using assistive devices and accessibility technology. They supported you when you felt concerned and perhaps even frustrated. They answered questions from your family members, reflected on your progress, and assured you that they knew exactly where you were in terms of your hearing function, and if there were any changes in your hearing, they would notice.

After AR concludes, who can you turn to for support? What can you do to maintain your progress and continue to progress?

Obtain a written summary of your AR process and recommendations going forward from your SLP. The summary should include:

• Exercises to help you maintain your achievements over time and progress.
• Recommendations to share with the audiologist responsible for your care at the CI center. This summary should include specific and clear practice recommendations, including the conditions for practicing each task (e.g., quiet or noise, speech rate, listening with only the implanted ear, or both ears).
• Suggestions should be tailored to your ability at the end of the AR process and should be concrete and specific. For example, they might be:
  • Engage in a five-minute phone conversation every day with someone you're comfortable talking to. Be sure to ask the person questions, as well as answering their inquiries.
  • Listen with both ears at least twice a week to a written article—one minute with the written text and then two minutes without it.
  • Listen with both ears without subtitles to TED talks at a slow speech pace, one minute at a time. As you progress, move on to listening at a regular speech pace.
  • Continue practicing in comfortable acoustic environments.
  • Listen to conversations that aren't directly “aimed at you” for half an hour each day.
  • Expand the circle of people you explain your communication needs to.

These are examples that are specific to a particular CI recipient based on the exercises (s)he practiced during her AR timeframe, and the subjects included in the AR process.  These are general examples and do not necessarily apply to everyone who has completed AR.

Practice Helps a Recipient to be Aware of their Hearing Progress

Practicing challenging tasks that are appropriate for your abilities (but are not overly difficult) will help you stay tuned to your hearing outcomes. It will also help you to be aware of your progress (or lack of progress, or even decline). In many cases, a decline indicates maintenance problems or possibly issues with the sound processor.  Such issues can typically be corrected by the audiologist. 

These recommendations may seem simple at first glance, but ongoing commitment to practice and improvements in hearing outcomes are not a given. With clinician-guided AR, there's a commitment to dealing with challenging hearing and listening tasks. The AR dynamics and tangible progress contribute to motivation and willingness to cope with hearing challenges. However, even after AR is completed, it's essential to maintain one’s motivation to practice and continue to improve.

Schedule Periodic Mapping Appointments

Pursue regular mapping appointments and prepare for these by assembling relevant information and questions for the audiologist.  Such preparation was discussed in a prior post. https://www.acialliance.org/blogpost/1334356/357192/How-to-get-the-most-out-of-your-CI-Mapping-Appointment?hhSearchTerms=%22mapping%22&terms=

Follow the recommendations for maintaining your sound processor.  Poor maintenance can lead to a gradual deterioration in your hearing quality and can affect speech comprehension. The decline can be gradual, and you may not notice it. Some people notice such changes only after a significant degradation in their hearing. Practicing challenging hearing tasks help you recognize a decrease in your hearing. Optimal sound processor maintenance is part of ongoing rehabilitation.

Joining groups and being familiar with resources and organizations of people with hearing loss, specifically CI recipients, can provide valuable information and support.  Increasingly people are benefitting from online groups such as Cochlear Implant Experiences, which is moderat4ed by knowledgeable individuals and is a reliable source of information.  Some clinics maintain such groups and ACI Alliance can also help by connecting recipients with others. ACI Alliance resources (including articles and webinar) will keep you informed about various topics such as technology, accessibility, and knowing your rights. In addition, groups and organizations can support and encourage proactive and practical approaches that will help you navigate challenging communication situations. They may facilitate meetings (virtual and physical) with people who share similar life experiences and a willingness to contribute and collaborate.

Maintaining an optimistic, practical, curious, and courageous approach will support your continued progress. There may be ups and downs, and you might need to reach out to your clinician for advice and follow-up, but your awareness and overall positive approach will push you forward. Successful coping with hearing challenges and rewarding hearing experiences will boost your confidence and motivation to stay engaged in the auditory learning process to maximally benefit from your CI.

Summary

Understanding foreign-accented speech is particularly challenging for people with hearing loss. It may be challenging and seem impossible. However, communicating with non-native English speakers in a global world is inevitable. Although there may be some difficulty, many people are able to improve their ability to understand foreign-accented speech. Regular communication with people who have foreign accents can result in an improvement in understanding them over time. Using voice-to-text apps may be helpful and hopefully even more accurate in the future. Focused training can contribute to better coping and a better understanding of people who speak English with foreign accents.  

Further Reading

Bieber RE &  Gordon-Salant S (2017). Adaptation to Novel Foreign-Accented Speech and Retention of Benefit Following Training: Influence of Aging and Hearing Loss. The Journal of the Acoustical Society of America, 141, 2800.

Strori D, Bradlow AR & Souza PE (2021). Recognizing Foreign-Accented Speech of Varying Intelligibility and Linguistic Complexity: Insights from Older Listeners With or Without Hearing Loss. International Journal of Audiology. 60(2) 140-150.

There are a number of possible reasons why this is the case. People typically conduct their auditory training:

• While in favorable acoustic conditions (i.e., a quiet room and/or using streaming technology or assistive listening devices (ALDs)
  
  
• Listening to a single speaker
  
  
• Practicing speech understanding with speakers who have highly intelligible speech (i.e., professional narrators for audiobooks)
  
  
• Using structured materials designed specifically for auditory training
  
  
• Listening to speakers at a relatively slow speech pace
  
  
• At a time when they are totally focused on listening, which is not characteristic of everyday life circumstances

Such auditory skill development is primarily helpful in specific listening situations such as having conversations in a quiet room with one person or familiar people, interacting with people who speak very clearly, participating in discussions on known or expected topics about which the person has prior knowledge, and in favorable acoustic and communication environments.

Communication in Daily Life is Complicated 

These auditory skills might not be sufficient when conversing with people who are either less familiar to the listener, have less intelligible speech, or both.  Auditory skill development may not be as useful when a CI recipient is moving about in a room, or when conversations are held in noisy places. Another challenging situation is when two people converse in the presence of other people with the expectation that everyone has been able to join the conversation and has heard and understood what has already been said.

How do you transition from understanding speech in favorable conditions to understanding speech in life?

• Challenge yourself to understand more than one sentence at a time without visual clues. Gradually listen to several sentences without speechreading.
  
  
• Practice having a conversation with a familiar person when you are simultaneously involved in another activity like painting or folding laundry. Don’t make this overly difficult by practicing conversations while occupied with noisy activities (i.e., washing dishes or listening to music) since it may be too difficult, even for people with typical hearing. 

• When you are in a quiet room listening to videos or other auditory content on your computer or telephone, try the following:
  • Practice without streaming the materials directly to your speech processor
  • Sit six feet away from the sound source
  • Walk around the room while listening.  This is more challenging than listening and understanding speech while sitting in one place. This will help you gain experience in processing sound coming from different directions and at different intensities.
    
    
• Practice your understanding of voicemail messages. Ask friends and family members to send you short voice messages on your phone. If needed, slow the pace of such messages to help with understanding.  Apple has directions on how to do that on their phones.

Make Listening More Challenging

• Practice understanding children's speech. People with hearing loss often find it difficult to understand children's speech, which might be too soft or too fast or unclear. You can find many online videos of children talking. Choose videos with no or a minimum of bothersome background noise. You might turn on captions to help you practice understanding children's speech.
  
  
• Expand the circle of people you talk with on the phone, especially those who are less (or not) familiar to you.
  
  
• Practice understanding speech in real world background noise. Listen to speeches given by famous people. You can find videos of speeches from demonstrations or other events that often have background noise. Download captions ahead of time to support your understanding and use as necessary. 
  
  
• Try to understand lyrics in songs. This activity is training for understanding speech in background noise. (You can find lyrics to songs on the Web; view them and then listen without the text in front of you.)
  
  
• Learn to effectively use Assistive Listening Devices (sometimes called ALDs) and the special programs for listening in noisy situations available on your sound processor. 
  
  
• Practice listening to a conversation with multiple speakers, rather than listening to just one person. You can also use recorded interviews and dialogues. Listening to two people talking to each other is more challenging than listening to contents presented by one person. 
  
  
• Ask friends or family members to record themselves talking to each other and send the recording to you. It may be quite challenging, so ask them to speak relatively slowly and provide you with the topic of their conversation. 
  
  
• Learn how to use speech-to-text technologies to help you participate in more social activities.
  
  
• Try to be attentive and listen (almost) all the time!
  
  
• Try to understand public announcements 
  
  
• Practice your hearing ability even if you are not part of the conversation. Listen and try to understand discussions held near to you.  
  
  
• Eavesdrop and try to understand what people next to you are talking about on their phone.

Initially many of these activities are likely to be difficult and tiring. Over time they will become more natural, and you may even understand speech unintentionally and without extraordinary effort.

It takes time and practice, but setting high goals is always the first step!

Good luck.

What can you do to advance your progress during this early timeframe? You may be puzzled about what you should be doing.  Know that your hearing journey depends on many factors; your high motivation is one of them. The focus during the first weeks should be on adaptation and less on auditory practice.

Why is that? There are a number of reasons but the most important one is that in the first few weeks, recipients may have limited access to sound. Voices and other sounds may seem too soft, and very different from the sounds you once heard. Future mapping sessions will provide you with louder, clearer sounds.

What helps prepare you for the stage when you experiencing speech comprehension?

• Use your CI all day long
• Maintain the sound processor as suggested by your CI company (e.g., use the Dry and Store)
• Familiarize yourself with the sound processor so that you can easily change programs, settings, loudness, and connecting to other technology via Bluetooth and telecoil. Learn how the different programs are helpful in various settings. volumes).
• Experience different auditory environments but initially avoid very noisy situations. If you attend a noisy event, use your sound processor's lowest volume option.
• Use your CI exclusively (without a hearing aid) for at least one hour daily. Initially, do so in safe conditions (the least challenging communication and acoustic situations). You can start by taking off your hearing aid and using your CI alone while you're at your home alone or with a few family members. Avoid going without your hearing in demanding communication settings like the workplace, theater or social event.

Adapting is a Key Part of the Process

It may seem like you are doing nothing with your new CI, but adaptation to hearing through the CI is not trivial. Many CI users, especially during the initial stage of CI use, experience hearing as a flood of auditory stimuli. This is the case even though exposure to sounds may still be limited. The enhancements in sound experience typically occur later.

It is essential (and yes, easier said than done), that you experience and explore different sounds without self-judgment. Ask your friends and family members not to test you. Remember that what you hear during the first weeks is not what you will hear later.

What happens after your second or third mapping?

You are still at the initital stage of your hearing journey. You may consult your audiologist on his or her recommendation on when they recommend starting to consciously practice speech comprehension. 

Some possible strategies to try:

• Listen intentionally to the sounds around you and explore different acoustic environments. You might sit under a tree and listen to birds, or on a bench in a playground and listen to children's voices (without trying to understand them yet). Listen to the voices of your family members. Are you able to differentiate between them? Listen to the sounds in the house, such as running water, cooking, and appliance noises.
• What sounds do you like? Are there sounds that bother you? Note that at this early stage, weak or uncomfortable sounds may become comfortable and feel more balanced. Adapting to the quality and volume of the sounds can happen spontaneously. Patience pays off.
• If some sounds are still bothering you, remember to share that with your audiologist at your next appointment.
• If you wish to listen to music, do so carefully knowing that music will sound better in the future. Optimism, patience (again), and practice (in the future) will make it work.

Speech understanding

• Note that you are still in the first few weeks after your initial switch-on. Can you identify specific speech sounds, such as S, Sh and Z sounds? Can you differentiate between singular and plural words (e.g., cat/cats, pack/packs, bag/bags, road/road).
• Can you identify color names from a spoken series of colors? Car brands? Names of your family members or work colleagues? Can you understand simple sentences? 

In previous posts, you will find tips for your auditory trainer.  

You may already be able to log into different computer self-training apps and try to follow audiobooks. For many people, it may be too early to understand recorded speech. When using recorded speech, slow it down if possible. More tips for advanced self-training ideas may be found here.  And here.

Noise Sensitivity

In the early stages after turn-on, even people who are able to understand some speech without speechreading (or lip-reading) may be sensitive to noise and have difficulty understanding speech in noisy situations. Maintain a quiet acoustic environment when practicing, and use streaming technologies or assistive listening devices.

In Summary

Take the time that you need, become an attentive listener, embrace every achievement, and work in a hierarchical way. If possible, reach out to a Speech-Language Pathologist to help you determine an auditory learning program. Above all, maintain a positive attitude.

Good luck!

The exchange made me think of my experiences with patients who are adult CI recipients.

Part of my job as a therapist is to help patients acquire new auditory and communication skills. Just as important is assisting adults to utilize those skills and apply them to diverse situations in life to maximize their ability to negotiate the world. After someone has acquired a particular auditory skill, I try to guide them to use their new abilities in other ways and in different situations that they previously thought were beyond their capability or may have been afraid to try.

People who are not receiving formal auditory learning services (with a professional expert in auditory skill development) should consciously focus on expanding their auditory abilities and utilizing them in various daily life situations.  For example:

If you can hold a simple conversation in a quiet room with a familiar person without lip-reading (speechreading), you may be able to:

• Talk on the phone under certain conditions
• Understand two people with clear speech talking to each other close to you—even if you are not part of this conversation. (Also called “overhearing.”)
• Understand the voice instructions of your car navigator
• Converse with the person sitting next to you in the car (at least some of the time)
• Hold a conversation while being occupied in another (not noisy) activity 
• Understand voice messages sent to you by people you know well (You can slow down the speaking pace of the recording to help)
• Respond to simple questions while you were not being attentive to the speaker, provided the speaker is close enough to you and there is minimal noise in the room. If that is not yet possible, try practice this task intentionally

What might help you develop the skills to successfully master more challenging listening situations?

• Understand the conditions that affect your ability to understand speech. Learn to recognize the effects of less than ideal listening situations on speech perception of variables such as noise (some types of noise are more disturbing than others), distance from the speaker, fatigue (yours), speaker's speech intelligibility, familiarity with speaker, and prior knowledge of the conversation content. 
• Planning your practice. Consider the variables that  may affect your speech comprehension and build a graded training program in increases difficulty over time.
• Share your challenges and goals with the partners who will help you practice. 
• Don’t be afraid to make mistakes. Skill-building is often accompanied by insecurity and fear of failure. Choose people you feel comfortable with to try out challenging situations and encourage them to give you real-time feedback. This will help you learn and gain confidence in your abilities.
• Use streaming technology available with your sound processor (or assistive listening devices or ALDs) when conversing in the car, talking on the phone, watching TV, participating in video conversations, and other situations.
• Intentionally change old listening habits. People who have experienced long periods of hearing loss may restrict their attentiveness and limit listening to specific (comfortable) situations. They may simply ignore speech that is not directed to them, not listen when they are missing words, and avoid social activities. These listening habits may hold back progress and benefits of the CI. Putting yourself in more varied hearing situations and communication settings will provide you with opportunities to find solutions to challenges and acquire more advanced listing skills.
• Have high expectations. Believe that improvement is possible. Know that hearing has many uses, and the main challenge is to implement your hearing abilities in as many situations as possible. Pursuing your goals and meeting them will strengthen your belief in the cochlear implant technology and in yourself.

Good luck!

• Use your CI regularly—during all waking hours 
  
  
• Develop your hearing skills in CI-only mode. You can start by choosing situations you can handle without hearing through your hearing aid, such as those times in which there are no challenging communication requirements and less pressure on you to not to make mistakes or miss important information.
  
  
• Listen to environmental sounds. You will likely find that your CI provides you with access to sounds that you miss via your hearing aid. Learn to recognize home and outdoor environmental sounds so they become meaningful and not ignored. 
  
  
• Listen to speech through your CI

• The CI allows you access to more speech sounds such “s,” “sh,” and “z.”  
• The CI provides cues that cannot be perceived solely by lip-reading and in many instances, not even by lip-reading with the hearing aid. For example, try to distinguish between the words "phase" and "vase” using lipreading.
• Listen to the differences between voices and try to recognize the voices of family, friends, and colleagues.
• As you become more comfortable with your CI only hearing, you should practice your speech perception and speech understanding skills. If you work with an audiologist or speech-language pathologist), they may be able to refer you to suitable materials to practice at home. If you practice independently, you can use the materials found on the CI companies' websites and other materials that were mentioned in previous posts. 
•  Several times a week (or more!) of self-practice in CI-only mode will make the difference!

What can you expect to happen?

• Your hearing outcomes will improve over time.
  
  
• You will feel more oriented by understanding the sounds around you.
  
  
• You will be able to more efficiently make use of the various programs on your sound processor and take advantage of them in various acoustic environments.
  
  
• You will feel that lipreading is less tiring, and you'll be less affected by the speech intelligibility of others including coping with rapid speakers or those with accents.  
  
  
• You may manage be better able to locate sound sources.
  
  
• If you develop the ability to understand speech without lipreading, you may be able to hold more challenging telephone conversations than those you could have carried out in the past using your hearing aid. Streaming sound to both your hearing aid and CI bilaterally or using assistive listening devices may be helpful.
  
  
• When listening to music, you may find that your CI helps you to understand words in songs.
  
  
• You will be better able to understand speech in noisy situations.
  
  
• When taking off your CI and using your hearing aid alone, you will feel that your hearing is lacking—not just in terms of volume but also in terms of speech understanding. The CI contribution to your communication and quality of life will be evident. 

In Conclusion

People with usable functional hearing in the non-implanted ear may face a challenging process of getting used to and utilizing the sound provided by the CI.  Effective auditory learning using CI-only mode will result in improved overall hearing and listening skills, the best possible bilateral hearing, and an improved quality of life.

• Have a mapping appointment at the recommended timeframe
• Confirm that you are knowledgeable about the programs on your sound processor and the situations in which they can improve your listening outcomes
• Change the filter/microphone cover. If need be, instructions on this and other aspects of maintenance are on your CI company's website.
• Ensure that you have the spare parts you may need such as cable(s) and filters/microphone covers (depending on your specific sound processor). Also check on your supply of batteries. Rechargeable batteries, if applicable, do sometimes need to be replaced.
• Have your hearing outcomes tested in the non-implanted ear and ensure that your hearing aid is adjusted to work maximally for you.
• Consulting with your audiologist and/or surgeon as to whether a second implant may be beneficial.
• Update yourself on the availability of a new speech processor and whether you are eligible to upgrade your old one via your insurance plan. Talk to your CI manufacturer to ensure your manufacturer is considered an in-network provider. The CI company can help with that process.
• Learn about new voice-to-text apps.
• Check to determine if there are assistive listening devices (ALDs) that can improve your understanding and ease your listening efforts when watching TV, talking on the phone and listening to content through your computer.
• Consider the ways in which a remote microphone (RM) device might help you in understanding speech in noise and from afar.
• Trying to listen and hold a conversation on the phone (if you haven’t done so yet).
• Listen to music. Even if your early experience of listening to music with your CI was disappointing and you gave up, you may want to try again. With practice and the advanced technology available today, you may find that you do enjoy music.

To summarize

Keeping your CI equipment in good working order and making sure it operates optimally can make a difference in your hearing outcomes. Striving for the best bilateral hearing and taking advantage of advanced technologies available on your sound processor, as well as using assistive listening devices and speech-to-text apps, can add significantly to your quality of life. Challenge yourself by experiencing and participating in new hearing-related activities. Over the long term, consistent CI use and best maintenance practices (with newer technology), can provide you with improved hearing and communication.  

We wish you all good wishes for the New Year!

I dedicate this blogpost to some of my fearlessly perfectionist patients. Being a perfectionist is challenging. Even if we are aware of this aspect of our personality and try to mediate it, being a cochlear implant recipient and going through rehabilitation can add an additional emotional burden to our life.

Adult CI candidates and recipients in the early stages of CI-usage typically have various assessments and evaluations in which they get “low” scores. Who feels comfortable getting a score as low as 30%? Most of us would not and those who most feel negative about their evaluation outcome are those who go about their lives as over-achievers or perfectionists.

Progress after cochlear implantation can be slow and confusing. The test conditions can affect test “grades.” One of my patients noted "I have 90 percent correct in quiet but only 60 percent in noise. What does that say about me?” Another asked “How come I have only 40% correct for short (monosyllabic) words? Did I fail the test?"

The Problem with Perfection

For perfectionists, outcomes that they view as poor can be almost unbearable. They want to see progress and forward movement. They know improvement requires listening practice but repetitive exercises can be frustrating. Use of drills that involves repeating sentences and words provides clear right or wrong feedback, which may push them to stop practicing—especially if they find themselves making mistakes over and over again.

When you are dealing with these challenges alone without a professional’s oversight and encouragement, there may be no one to explain the meaning of the scores. Without a clinician’s support, it may be difficult to recognize improvement and achievement beyond numerical scores. This can be tough to bear alone. People need to find ways to challenge themselves without being frustrated; frustration can lead to a recipient abandoning rehab that could help them.

People who are perfectionists should avoid using practice materials that evoke a sense of being tested and graded. Self-practice software and apps that give true/false feedback and scores may discourage more than help. Therefore, training materials and methods that would not induce this kind of stress can be a much better option.

Dealing with Perfection in Auditory Rehab

Although pursuing perfection is the way to success for many, we also need to remember that auditory learning and improving listening skills is a gradual process that takes time. As with any kind of training, we should adjust the exercise materials and training tasks to someone’s level and carefully consider the starting point.

For example, if someone chooses to practice auditory comprehension by listening to audiobooks, I encourage them to get started by listening to short articles that are read clearly and at a slower speaking pace. You can find such on English learning sites for people who learn English as a second language.

You can also use recorded articles or text-to-speech software and apps.

When choosing recorded stories, take care to not use content with background music or environmental sounds initially; save those for the future when someone becomes a more advanced listener. Initially, choose texts with simple, everyday language. Investigate hearing comprehension while practicing different language levels.

I recommend that someone start listening as they follow the written text. Then, as someone becomes accustomed to the presenter's voice and speaking style, they can move forward by first reading one or two sentences and then listening to them without looking at the text. The more progress made, the more sentences someone will be able to repeat after reading them; this process helps develop auditory memory as well as developing listening skills.

Summary

The more that someone leans towards perfectionism, the harder it may be for them to deal with a situation in which they are not entirely successful. My advice is for such individuals to curb use of auditory training that relies on scoring as the only measure for progress. It is essential to find and use training materials that gradually increase the following:

• Complexity of the materials with which they are coping (e.g., daily conversation versus literary language)
• Complexity of the practice task (e.g., repeating versus understanding)
• Complexity of the presentation of the auditory stimuli (e.g., fast, regular, or slow-paced speech; in quiet versus in background noise)

If a CI recipient finds it too difficult to deal with the imperfection inherent to practice materials, change the process to fit the person. Find training materials that (s)he feels comfortable with, work hierarchically, and give the process time. Additionally, the recipient may benefit from keeping a journal to track their experiences over time. Doing this will provide perspective on progress. Most importantly, it will allow the individual to better enjoy the process and celebrate achievements.

Good luck!

Even if you went through cochlear implantation 5 or more years ago, this question is still relevant. And the answer is “yes.” It is likely that you can take steps to improve your hearing outcomes and utilization of your CI.

The main goal for most people seeking a cochlear implant is to experience improved hearing and daily communication. However, your CI can give you more than an undefined “improvement.” You may still be hesitant to pursue some hearing-dependent activities, or you may have thought that certain experiences were not for you because of your hearing problem. You may also believe that progress with a CI stops after several years, and that further improvement is not possible. In fact, this isn't true—people can still make progress years after they received a cochlear implant.

Some areas in which progress is possible include:

• Talking on the phone. Some people are hesitant about talking on the phone without captioning. Such hesitancy applies even to certain people who have succeeded at understanding speech without lip-reading (and have used their CI for years). Using a voice telephone without captioning may be initially challenging but you may be able to gradually learn to listen effectively on the phone. https://www.acialliance.org/blogpost/1334356/347956/Tips-for-People-Who-Converse-with-CI-Recipients-on-the-Telephone

• Listening to music. Even if you were initially disappointed with your music perception after you received your CI, it is possible for this perspective to change. Your hearing perception today is different from what it was immediately following your activation and even after a few years.  You may wish to try again and also utilize some of the practice tools others have found helpful. There are many materials available on listening to music with a CI; the following webinar provides important tips to help CI recipients enjoy music.  https://www.audiologyonline.com/audiology-ceus/register_account/35602

• Optimizing use of the options for listening in different environments on your sound processor.  Ask your audiologist or CI manufacturer representative to help. You can, for example, your audiologists for a program that may improve your music experience or your ability to hear better in a large meeting space. You may wish to explore a program for a challenging daily situation. Most CI recipients have several programs on their sound processor but use only one of them. Trying other programs may help you to maximize the opportunity possible with the technology. 

• Ensure that your sound processor mapping is up-to-date. The frequency of how often you need to see your mapping audiologist varies by individual. Your audiologist can also help to ensure you using your technology effectively. The following blog discusses how to get the most out of your mapping sessions:  https://www.acialliance.org/blogpost/1334356/357192/How-to-get-the-most-out-of-your-CI-Mapping-Appointment

• Use assistive listening devices (ALDs) to improve your access to the voice(s) you want to hear. Using ALDs can enable more CI users to talk on the phone and/or keep up with video calls. Using ALDs can help you better understand your yoga instructor, improve your understanding of TV programs, and more. Using ALDs not only can improve your understanding—they can also can decrease your hearing efforts. If you already purchased ALDs such as a TV streamer or a remote microphone (available from your CI manufacturer) and do not use it, give it another chance. You may find hearing much more accessible and comfortable. CI company reps can help with technology that your purchased from them.

• Familiarize yourself with the variety of speech-to-text technologies available on the various video platforms (such as Zoom and Microsoft Teams). There are also apps for the phone. These can help communication in different settings—in person or over a virtual call.  Many people with hearing loss are challenged when faced with a speaker wearing a mask.  Phone apps can provide a reasonable (though not absolutely accurate) representation) of speech to help you through a difficult situation.  These apps may be helpful in many situations including listening to lectures or speaking to your physician. 

• Define your difficult situations and communication needs and talk about them with family and friends. Good communication depends on collaboration of all of the partners—there is a limit to what you can do on your own. In many situations, the help and cooperation of family members, co-workers, and friends will make a difference. Everyone should share the responsibility for meeting your communication needs and make an effort to maximize your communication.
https://www.acialliance.org/blogpost/1334356/334221/Hearing-people-can-be-so-mean

• Stay up-to-date with new sound processor technological advancements and with what is known about the benefits of bilateral implantation.

• Challenge your listening skills with auditory training.  Consider seeking guidance from a rehabilitation professional with specialized CI auditory training and/or by monitoring changes in your hearing. Make use of self-training materials (such as those available on the CI companies' websites) or elsewhere.  Listen to audiobooks, TED Talks, and podcasts without captioning.

For guidance: https://www.acialliance.org/blogpost/1334356/Cochlear-Implant-Rehabilitation-for-Adults

https://www.acialliance.org/blogpost/1334356/366153/How-can-you-practice-and-improve-your-listening-skills-during-the-social-distancing-timeframe

It’s never too late for auditory improvement. Taking advantage of technology, setting new expectations and working toward achieving them may help you to make better use of your cochlear implant and improve your quality of life.

Good luck!

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!

At the end of April 2020, I realized that COVID-19 added an additional challenge for people with CIs—daily use of cochlear implants by many of my patients had decreased. A short survey I ran in a Facebook group for deaf and hard of hearing people supported my hypothesis, demonstrating that this trend was not specific to people with CIs and was also common among adults with hearing loss using hearing aids.

The reasons are logical. Spending most of our time at home, communicating with a limited number of people, and having few (if any) social activities had affected motivation and need for some people to use their hearing devices regularly and throughout the day. A prior post discusses this topic.

Consistent use of one’s cochlear implant(s) is especially critical for new CI users, individuals who are still adjusting to their new hearing and learning to use their CI to understand speech. Staying at home and having minimal social interactions means that people do not have sufficient opportunities to practice and improve their new auditory skills.

What can you do to develop your hearing skills at home?

Using assistive listening devices (ALDs) may be helpful as they can help someone to maximize their quality of the signal through a computer, cell phone, and/or television. ALDs can dramatically decrease the interference via environmental sounds. If someone does not yet have an assistive device, it is important to practice listening in a quiet room with a closed door.  Others at home should avoid making noises as competing sounds may impede performance and make it difficult for someone to concentrate on listening tasks. 

Ten challenging (and fun) listening activities that may be pursued at home:

1.   Ted Talks. Choose an exciting talk, add subtitles, slow down the playback speed, and you are ready to go! 0.75 playback speed may be the best. The slower option of 0.5 may be too slow, making speech sound smeared and unclear. 
2.  News. There are news websites that allow the viewer to read and listen at the same time. You can choose to practice your speech understanding using news websites designed for English learners in which the news is presented at a slower speaking pace. On www.newsinlevels.com you may practice your listening skills at three different language levels. Simple, straightforward language is easier to understand than more complicated language since it is easier to fill in the gaps of words you might have missed. Newsineasyenglish.com is another site that allow someone to listen at a slow or fast speaking pace. 
3.   Voice-reader/read aloud apps. Text-to-voice apps allow someone to listen to various written materials; in many apps, you can make adaptations and choose the voice you prefer (male or female) and the speed that works best for you.
4.   Listen to songs. Listen to your favorite songs repeatedly. Start with listening while you follow the written text. Then try to understand some words without it text. Different versions of the same song may challenge you with varying levels of difficulty. Read more here .
5.   Listening to podcasts with transcripts. Try to listen to podcasts in small segments, with repetition and using transcripts as needed. If it is possible to listen to the podcast via YouTube, you will be able to slow down the speech rate, as mentioned above.
6.   Phone Calls .  If you feel like you are almost there and want to improve your telephone skills, then this is the time!  Enlist people who will be cooperative and patient and ask them to help you in achieving your desired outcome. Send them general instructions, like the ones listed here.  Be aware of the variables that may affect your difficulty or success in making a phone call. This will allow you to adapt the challenges you face to your current ability. Training that is tailored to your specific needs will help you succeed and provide the confidence you need to continue practicing and making calls.  You may find relevant instructions here.
7.   Listen to your own speech. You can record yourself reading sentences and stories, and then listen to the recording. Listening to yourself speak in daily life helps your progress, and this is one way of training yourself to do it.
8.   Using auditory training apps. You can work on improving your listening skills in various contexts such environmental sounds, speech sounds, words, sentences, music, and telephone use.  There are many computerized auditory training programs; one of the most extensive (and free) programs is Angelsound™. The CI manufacturers offer auditory training programs which are available on their websites. 
9.   Video calls. Ask friends and family members you usually text with to have a weekly video call with you. Ask them to sit in a quiet room while talking with you, use a headset with a microphone, and ensure that there is plenty of light on their face allowing you to have additional assistance from seeing their face. If you can already understand simple sentences without speech reading, they can ask you simple questions while covering their mouth or turning off their camera. It is recommended that both of you use computers, not your cellphones.
10. Seek a support group in your area or online. To read more about the potential benefits of a support group for adult CI users, review this post.

Try to reserve one hour every day specifically for auditory training and be sure to use your CI for at least eight hours a day; more is better. Consistent use and auditory practice will yield the best results.

Good Luck!

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.

I suggest looking differently at your mapping sessions. Think of them as an opportunity to share your listening experience with your audiologist and to improve your hearing with your CI. You already know that hearing with a cochlear implant is not perfect and it can be a struggle in many situations. What you might not know is that your audiologist has adjustments that (s)he can make in your map to make it easier for you and to improve your hearing outcomes.  But your audiologist needs to better understand what you are experiencing.

Before writing about what you can talk about with your audiologist, I want to emphasize the importance of coming to your appointment with all the external parts in optimal condition. For example, check and change the cable and microphone covers if your device has these parts and if it is needed (follow the manufacturer's maintenance recommendations).  If you don’t know how to do this, bring the spare parts to the session and your audiologist will teach you how to change them. Another tip is to write down answers to the following questions and take it with you. This will help you provide the information in the most organized and efficient way and it will also serve as documentation for your next mapping session.

It is important that your audiologist knows about the following:

1. Listening experience. Do you enjoy listening with your CI? Do you like the quality of the sounds? Do you ever find the sound unpleasant? If so, in what places/situations/times? Are there specific speech sounds that bother you?
   
   
2. Distinguishing between sounds. Are there speech sounds that sound the same or very similar for you? Include examples.
   
   
3. Hours of use. How many hours per day do you use your CI? Do you consistently use it on weekends? Do you use it when you are alone at home? It would be helpful if you make a one-week log with a detailed description of your daily CI use.
   
   
4. Times when you prefer to not use your CI. Are there certain situations in which you prefer not to use your CI? If so, when?
   
   
5. Impact on your energy level. Does using you CI affect your energy level? Does it ever make you tired?
   
   
6. Facial stimulation. Do you ever have any facial sensation on the side of the implanted ear?
   
   
7. Tinnitus. Do you suffer from tinnitus? Does using your CI affect your tinnitus and if so how? Does it mitigate tinnitus or make it worse?
   
   
8. Loudness level. Do you feel comfortable with the loudness of sounds you get through your CI? Is it too loud or too soft? Is it altering?
   
   
9. Processor program use. Do you use all the programs you have for your device? Which ones do you use and in what situations?
   
   
10. Assistive Listening Device use. Do you use or consider using assistive listening devices (ALDs) such as RM (remote Microphone), FM or infrared systems? Does your device have enabled Bluetooth, and do you use it? Your audiologist can consult and update you about the different options available
    
    
11. Bilateral hearing. Are you using a hearing aid in your non-implanted ear? If you are and planning to purchase a new hearing aid, you may want to consult your audiologist about the selection. There are types and models of hearing aids that allow many CI users to enjoy connectivity between the hearing aid and their CI, streaming to both CI and HA as well as more convenient use of ALDs. Be sure that your hearing aid dispenser is aware of your needs. You may want to connect that professional to your CI audiologist to ensure that your care is coordinated. Are you considering going bilateral? Consider questions to ask your audiologist about this option. If you use two CIs, do you feel that your hearing is balanced?
    
    
12. Upgrades. Are you considering upgrading your processor?

Meeting with your audiologist is an opportunity for you to resolve hearing issues that you find difficult or impossible to resolve.  Approach your mapping session as an opportunity to improve your hearing experience in diverse ways by engaging fully with your CI professional, getting their advice, and being updated with relevant information on your technology.

Click here to download a PDF version of this article. 

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.

Adults who receive cochlear implants rarely are offered clinician-guided auditory rehabilitation after their surgery. They are often told that the process they will go through, in learning to access the new auditory signal via their cochlear implant, will occur spontaneously as they adjust to their new hearing.

This approach works for many people, especially if individuals had typical hearing as children and experienced hearing loss as adults and their period of deafness was relatively short prior to receiving a CI. However, this process of spontaneous adjustment does not occur for all adults. Learning to use the new signal from a cochlear implant is especially difficult for those who were deaf as children and received their CI as adults.

What impacts spontaneous auditory learning?

Spontaneous auditory learning during daily routines is impacted by various factors including one’s ability to understand speech while occupied with other daily activities, opportunities to listen at work and at home, and whether the individual has feedback on their mistakes. Being able to constructively address such feedback is key to helping an individual improve their listening skills.

Following cochlear implantation, people who had typical hearing for most of their lives learn to adjust to sounds that are different from what they remember as sound. Sounds may seem strange or confusing at the beginning but typically become meaningful over time. One’s auditory memory will help an individual interpret the sounds they hear. A recipient may experience some ups and downs during the first year following implantation especially if they have very high expectations regarding their improvement rate. Some people will struggle in complex communication listening situations such as listening in noise or listening with multiple speakers. In most cases, the CI recipient will learn to handle these challenges over time and with experience, their comprehension will improve.

Later Deafened CI Recipients

People who have lost hearing later in life will generally become acoustically attentive to their surroundings. Before implantation, given that their auditory function was limited, such individuals tend to have been selective in their auditory attention focusing mainly on speech directed at them. After a period of time using their CI, a late deafened person will typically find themselves unintentionally perceiving and reacting to speech and sounds around them. They will grasp words and sentences from the radio and TV, parts of a conversation held between colleagues without even looking at them, and many other auditory stimuli. "Yesterday I noticed that I was hearing without even trying" is an important milestone and a great accomplishment, one that most people can expect to experience after few months. As they become active listeners, they will naturally practice their hearing in many daily situations.

In addition, most people will continue to strive to hear better. They will challenge themselves to function as close as possible to the level in which they did before losing their hearing. They have the drive and the knowledge of what good hearing is, and they will find their own ways to achieve the most out of their CI, including the use of additional technologies as needed such as assistive listening devices, apps, and making full use of programming options on their sound processor.

Early Deafened Adults

In contrast to CI users who had typical hearing for much of their lives and lost their hearing as adults, there are a growing number of adult CI users who were deaf as children. For this group, the decision to pursue a cochlear implant entails some uncertainty. They may have questions that cannot be answered with certainty about their outcomes. Since they either have no memory of typical hearing (either because they never had it or it was for a short period time during early childhood), it is difficult for such individuals to know what to expect regarding CI outcomes.
For an early deafened adult, the acoustic information provided by a CI may be confusing, overwhelming, and exhausting. Some people are bothered by the sound level they receive from their CI and perceive it as “noise.” It takes time to learn to interpret both environmental and speech sounds and attach meaning to them.

Not only do such recipients need to learn to attach meaning to the sounds they are hearing, they must also deal with many sounds they may not have even known existed. In addition to adjusting to their new hearing, they will deal with some key questions:

• What constitutes typical hearing?
• What are the limitations of typical hearing?
• To what extent can a CI allow someone to function like a person with typical hearing?
• Will I be able to enjoy music?

With regard to music, some early deafened adults will be interested in listening to music including songs they may have learned about from others but have never actually heard.

New Listening Opportunities and Challenges

 This group of early deafened CI adults will need to learn how their ability to listen is affected by factors related to the environment, the speaker, the content and more. Like late deafened individuals, they should seek accommodations that may improve communication. They will need support and guidance in practicing tasks that previously seemed impossible to them, such as talking on the phone. Since most in this group are accustomed to concentrating on speech that is targeted directly at them, they will need to work to consciously change their old habits to become acoustically attentive to a larger sphere of sound. All of these challenges may be challenging especially if they attempt it without a clinician-guided auditory rehab program. 

The speech perception outcomes of adults with early deafness are typically lower than those of people who had generally typical hearing in the past. To understand speech without lipreading, CI adult users with early deafness rely heavily on contextual strategies. The differences show not only in their ability to perceive speech sounds and sentences in quiet but especially in their ability to understand speech in noise. If their use of auditory information was limited during most of their life, they may have great difficulty in processing auditory information. These tasks will be more difficult still with speech that is normal to fast-paced or require auditory memory skills.

Adult CI recipients with early deafness often struggle to learn how to identify speech sounds, separate several sounds that are occurring at the same time, and understand speech in noise. In addition. their auditory processing skills limit their speech understanding to a slow speech pace, and to tasks that do not overload their limited short-term auditory memory skills. This means that, over a long period of time, they would have to train their hearing and listening skills in accommodated conditions of quiet rooms, slowly paced speech, and individually-tailored training tasks. These conditions do not exist in most everyday situations, which is what makes their chances to experience spontaneous auditory learning nearly impossible.

Summary

Cochlear implantation is the beginning of a rehabilitation process that requires learning, adjustment, and training. There are CI users who will be able to negotiate the process using self-training resources with the support of their audiologist, family, and friends. They will adjust and quickly regain speech perception skills. These skills, combined with previous listening habits and cognitive and auditory abilities, will allow them to cope with the communication and acoustic challenges of everyday life.

Others will need the support provided through a clinician-guided auditory rehab program. Such programs allow an assessment of the patient’s speech perception, listening, and use of hearing in everyday life. Typically, such patients require individualized training before being able to say “yesterday I noticed that I was hearing without even trying.” Spontaneous auditory learning is possible for some of these patients. It’s a real breakthrough and a dream come true.

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.

The post is dedicated, with love and understanding, to the cochlear implant recipients who may be taking a break from their CIs during the difficult coronavirus timeframe.

•  Maintain a routine. During a timeframe of uncertainty, concern, and worry—such as that we are all going through right now—it is very important to maintain our routines.  Cook healthful foods, exercise, dress up, and even wear shoes. Your CIs and hearing are part of your routine.
• Stay connected! Stay involved! Every sound has its meaning. Stay oriented with what's going on around you.
• Be independent and strong. Feeling in control is always important, especially now.
• Do not indulge in silence. Despite the ease of falling into a routine of isolation and silence, force yourself to interact in normal ways. It can be difficult later to return to your good auditory functions and to effectively cope with a flood of auditory stimuli.
• Consider the effect of not using your cochlear implant to access sound on your family members. They have become accustomed to a certain level of communication with you. If you turn off, they now need to adjust to the fact that for several hours a day (or more) you may be disconnected. At a time like this, there is tremendous value in good communication, engagement, and partnership. Your attentiveness and communication are significant not only for you, but also for the people who live with you.
• Research on recipient utilization has demonstrated a correlation between the number of hours a day that adult CI recipients use their CI and their speech-perception abilities. It was found that during the first year of CI use, adults with good speech perception skills used their CIs for an average of 3 hours a day more than people with poor speech perception.

 Stay home, stay connected, enjoy your hearing, and be safe!

Naama

For further reading on this topic, please see: Schvartz-Leyzac KC, Conrad CA, Zwolan TA (2019). Datalogging statistics and speech recognition during the first year of use in adult cochlear implant recipients. Otology & Neurotology; 40 (7), 686-693.

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?"   

Today I would like to share some thoughts about learning to listen, which is not the same as learning to hear.

When people come across the phrase “auditory training,” one often associates this term with computer-based listening practice. Alternatively, one might have an image of someone sitting in front of a speech-language pathologist covering his/her her mouth and asking the person to repeat words and sentences or answer questions.

However, when I work with my patients as part of their auditory rehab program, my goal is to help them become better listeners. Listening is more than being able to hear and repeat auditory stimuli. Who are the ones who will eventually benefit the most from their CIs? I believe it is those with congenital hearing loss who have been transformed into active listeners as well as those who lost their hearing later in life and then managed to recover their listening skills.

Why is it that adults who can hear with their cochlear implant(s) don’t necessarily listen?

People, especially those who have never heard before, may be accustomed to the option of living largely in a quiet world. They may prefer to not use their hearing technology in noisy environments, especially when it is unlikely to that they will be having any significant verbal communication (e.g., when using public transportation). Before cochlear implantation, some people have removed (or turned off) their hearing aids in uncomfortable auditory situations so their tendency is to do the same thing with their cochlear implant. Although their audiologist may encourage them to use their CI throughout their day, they may retain old habits and not  use their hearing device(s) for a few hours each day.

Other people will use their CIs throughout the day but will listen only to what they perceive as directed to them, as they used to do before. That is, they would listen to people who are talking to them and would ignore any other auditory stimuli. Therefore, they would miss a lot of significant information. 

What types of auditory stimuli may be missed by CI users?

·         Side or background conversations: if these conversations occur in proximity to you, the speakers may assume that you could (or even should) understand what has been said. Or, when two people at your place of work are talking about their preferences regarding the New Year’s party date, they might expect you to express your opinion or at least to be aware of their view.  

·         A comment or a question that is not directed to someone specifically, but can be significant, such as: “Does everybody know they are going to close the parking lot earlier today?”

·         Information provided during over public announcement systems at work, in transit stations (airports, train stations)

·         Background music anywhere (and everywhere)

These examples demonstrate huge challenges in terms of auditory perception and speech understanding. However, being aware of these situations and trying to get the most out of them would result in more attentive listening; active attempts to resolve insufficient understanding; better sense of orientation and inclusion; and Improved ability to apply your auditory skills into your everyday life.

What can an adult CI recipient do to improve their listening skills?

·         Strive to actively use your cochlear implant(s) throughout the day. If you have difficulty doing that, share your experience with your professional team (audiologist, speech pathologist). Many issues can be resolved with mapping, use of assistive listening devices, and/or a clinically-guided auditory rehabilitation program.

·         Know that indirect communication is significant and try to make use of any opportunity to listen during your daily routines. Think about the gain you may derive by being more attentive and more involved.

·         Examine how you might Improve acoustic conditions in your workplace and home.

·         Adjust your location at work that so you maximize visual access to as many people as possible. Try not to sit with your back turned into the center of the room which may prevent you from being able to make eye contact with co-workers.

·         Attempt dual tasking by practicing speech perception and auditory understanding skills while undertaking other (quiet) tasks (i.e., cooking, painting). This may help improve ability to react to speech even when you are busy with another activity.

·         Develop personal weekly listening goals.  These might include listening to public announcements at one’s workplace or when using public transportation (possibly with a co-worker or friend helping), listening to conversations between two other people when this occurs behind you, or listening to the GPS navigator in your car. (Try this last one when driving a known route so as not to be dependent on 100% speech understanding.)

Mastering Learning to Listen

It is not trivial to expect someone with hearing loss, who has been accustomed to attending only to speech that is directed at them, to start listening to a surge of auditory input from all directions. Even some people who had nearly normal hearing in the past but have been deaf for many years sometimes become selective listeners—focusing on speech that is addressed to them. Nonetheless, ongoing listening is a challenge worth taking on.

A few days ago, when I asked one of my patients how he did during the prior week, he told me that he surprisingly understood a short conversation between two people in his workplace without seeing them. I was thrilled! I knew he had made an amazing breakthrough. He has become more attentive to spoken communication occurring around him and is now more involved and oriented. The benefits for a CI user who becomes a good listener is not limited to his/her auditory rehab sessions because (s)he can use their "auditory training" in so many situations every day. I know that from now on my patient will progress at a faster rate and will better enjoy to a much greater degree the contribution that his cochlear implants make to his quality of life. And that is the point of it all!

Many adults who experienced hearing loss later in their lives have memories of their favorite songs from the time when they had more hearing. These songs elicit feelings and reminiscences that relate to different times in their past, and songs that they long to hear again. 

People connect to songs through melody, words, or both.

The experience of listening to songs with a CI is challenging. The perception of music with the implant is imperfect. The main challenge is to recognize the melody but there are other challenges as well including:

• Isolating a specific sound in the presence of other sounds
• Distinguishing between various musical instruments
• Distinguishing between the vocalist(s) and musical instruments

To understand the lyrics of a song, you would need to be able to understand words in the presence of musical accompaniment, which is a very difficult speech perception task. Nonetheless, you may enjoy listening to songs with your CI—even if you have never listened to the specific songs before.

In this post we will describe some principles that may help you enjoy listening to songs.

Following the words of a song can also be difficult for people with typical hearing. In order to understand the lyrics, even people with typical hearing listen to a song multiple times or read the lyrics while listening to a song. Some people are less concerned about the lyrics and simply enjoy listening to songs without understanding all of the words.

It is more difficult to understand the lyrics of a song if:

• There are several vocalists, rather than one
• The musical accompaniment includes many instruments, rather than one or two
• The instrumental accompaniment is markedly louder than the singer, masking the vocalist’s voice
• The vocalist’s articulation is not clear
• The song’s tempo is fast
• There are few or no repetitions of lyrics
• The song lyrics are in a language other than yours

Word Pronunciation in Songs

The rhythm and inner structure of words in a song may change when it’s being sung. Do you know the word “slehey?” In the Christmas song Jingle Bells, we typically pronounce the word “sleigh” as “sleheigh.” (“Oh what fun, it is to ride, in a one-horse open sleigh”). Or in Leonard Cohen’s famous song Hallelujah, the last word in the chorus is pronounced “Halleluhuhuhu-jah.” That means what? Yes, that’s correct. And it's not trivial.

Some songs include a chorus of “na na na” including Freed from Desire by Pink and the second half of the song Hey Jude by the Beatles. In Hey Jude there is a four-minute vocal segment comprised mainly of “na na na.”

When people sing, they often need to stretch their breath until the end of the musical phrase. This can cause the last words, and especially the last sounds in the sentence, to sound weaker and less clear.

Practice Listening

Before starting your practice, choose a quiet place, close the door (and the window), and ask other people in your house to reduce background noises. In addition, it’s highly recommended to use an assistive listening device such as a streaming accessory. If you use a CI on one ear and a hearing aid on the other, don’t take your hearing aid off when you listen to music.

Now, let’s discuss choosing a song. People who listened to songs in the past may choose to listen to the songs they loved before. People who have never listened to songs before may start by listening to popular songs or to songs by popular artists. You may also ask relatives and friends for their recommendations—that’s a good way for you to participate in music with the people you spend time with.

After choosing a song to listen to (and considering the conditions mentioned above), print out the song lyrics. Although there are versions of songs which have the lyrics appearing in music videos, these are not necessarily the best versions for you to start practicing with.

Almost every popular song has several cover versions. Among many versions of the same song, note that the ones that were recorded during live performances may be more difficult to follow. Start by listening to the acoustic version of the song—one vocalist with one instrument, or even only the vocalist version without any musical accompaniment. Sometimes these versions are slower; that’s helpful when you’re listening to the lyrics. You can progress gradually. Listen to the same song in different versions with more than one vocalist. Also listen for the richer and more complex musical accompaniment until you reach the original version of the song. You may also find a version of the song melody without the vocal (i.e., singing). This can be an interesting experience too. At the end of the process, you can choose the version that you enjoyed the most.

Some CI users prefer to listen to male singers and others prefer to listen to female singers. It can be another criterion for you when choosing your favorite song version. If you find a vocalist who is easier for you to understand and who you particularly enjoy listening to, try listening to more of that artist’s songs.

Listen to the songs you love repeatedly until you learn some of their words by heart. This is a nice exercise for your memory. It will also allow you at some point to listen to that song without the lyrics in front of you in order to understand it as well as recognizing it spontaneously (even when you stumble upon it). And you may even sing it!

Now, let’s practice listening to Hallelujah (by Leonard Cohen) step by step:

Hallelujah (Leonard Cohen):

1. Imogan Heap, no musical accompaniment, with lyrics:
https://www.youtube.com/watch?time_continue=98&v=cNQu9rP7xwI

2. K.D. Lang accompanied by piano: https://www.youtube.com/watch?time_continue=82&v=8wT4hl7iIvc

3. Jeff Buckley accompanied by guitar:
https://www.youtube.com/watch?time_continue=9&v=y8AWFf7EAc4

4. Melody without singing:
https://www.youtube.com/watch?v=FSFpqWKvrHg

5. Leonard Cohen, official version, with vocal and instrumental accompaniment:
https://www.youtube.com/watch?v=ccGz-li_rgM

Good luck and have fun!
Naama

For additional reading about music appreciation with a cochlear implant:

https://www.acialliance.org/blogpost/1334356/265473/Music-Appreciation-Following-Cochlear-Implantation?hhSearchTerms=%22music%22&terms=

https://www.acialliance.org/blogpost/1334356/263351/What-s-Old-is-New-Again-if-We-re-Lucky?hhSearchTerms=%22Richard%22&terms=

https://www.acialliance.org/page/CIMusic

In the last post, Part 1 on fatigue, we discussed in detail why people with hearing loss may experience fatigue when listening. In this section, we will explore what happens when someone receives a cochlear implant, and what can be done to lessen fatigue associated with listening.

The auditory input provided by a cochlear implant is different from that which is provided by hearing aids. In addition to the extended frequency and intensity ranges provided by a CI, the cochlear implant converts the acoustic signal into an electrical signal and performs frequency and intensity compression's. Therefore, CI users should acquire new connections between auditory input and its meaning. These connections are acquired by learning to interpret the new signal and requires the listener’s attentiveness.

CI users cope with many environmental sounds that were not accessible to them before. Throughout the initial period of CI use, people strive to interpret and learn the meaning of sounds, which may require a lot of concentration. Understanding environmental sounds is rewarding as it improves one’s sense of orientation, safety, and independence. At the same time, these sounds that are now within the hearing range and have meaning, may distract CI users’ attention while they are trying to understand speech.

As was mentioned in the previous post, restricted auditory memory—especially among people who have never experienced typical hearing and older adults (who had typical hearing in the past)—also contributes to more difficult listening effort. Even when sounds are audible and speech perception has been greatly improved with cochlear implantation, listening can still be very demanding.

The process of adjusting to the CI is not always an easy one. In addition to extensive auditory learning, there is a process of experiencing and investigating the technology boundaries. Besides the feelings of gratefulness and relief, people might feel overwhelmed, frustrated and even disappointed. These feelings need to be addressed. This is a process of change, growth and re-organization that is not necessarily obvious. Coping with these challenges can be exhausting.

As CI users improve their ability to perceive speech, they may gradually and naturally become less dependent on speech reading. This is a great gift and an important achievement. On the other hand, people may report negative changes in their family and friends’ behaviors. They can even occur among colleagues at work. People who knew the person before he or she received a CI may now perceive them as having better hearing than they actually have. They challenge them by being less careful in making eye contact, talking to them from a distance, and speaking too fast. The consequences are an increased load and effort required by CI users to keep up.

What can you do?
• Try to arrange your schedule keeping in mind expected fatigue and level of alertness needed for specific activities. If need be, plan for a “time out” (i.e. taking a rest or removing the CI for a short time).
• Be aware of challenging environments that may cause stressful communication conditions. Some of these situations can be managed.
• Organize and accommodate the acoustic conditions at home and at any other relevant space to make them as comfortable as possible:

• Small room + closed door + covered walls + acoustic ceiling: YES
• Open space + open/no door + bare walls + high ceiling: NO
  

• Whenever possible, turn off or quiet appliances such as the dishwasher, air conditioner, microwave, fish tank.
• Try various sound processor programs or adjustments that may help you manage communication in challenging acoustic environments. It might take some time for you to investigate and understand your options but it is definitely worth trying.
• Use assistive listening devices in daily situations that are challenging for you such as lectures, phone calls, and meetings.
• Consider/improve your bilateral hearing.
• Share your experiences with your family and friends and guide them to support and help you communicate with them.
• There is a link between fatigue and motivation, so keep yourself highly motivated. It can be done by setting practical and meaningful goals (e.g., I wish to improve my understanding and active contribution in work meetings and/or family gatherings or I wish to go out to a nice quiet restaurant with friends). Your mood can also affect your motivation, your energy level, and your overall functioning. Try to focus on your gains rather than on your difficulty. This is easier said than done but with the right attitude and support, it is attainable. Focus on the rewards such as the intellectual and social benefits you gain rather than on the listening effort; this may help you to not feel fatigued.
• A guided auditory rehabilitation program may provide you with goals, motivation, and strategies (such as auditory training materials) that may improve your auditory skills as well as your ability to use other resources involved in the listening process.

We can summarize by saying that cochlear implantation enables access to expanded auditory information; some CI recipients may need to work hard in order to accommodate a life filled with new sounds. Such efforts may result in additional fatigue. Know that this is an integral part of the CI journey. Be patient, try to ease the burden by managing your daily environment, and share your experiences with those who can help you get through the process.

Good Luck!

Recommended Reading
McGarrigle R, Munro KJ, Dawes P, Stewart AJ, Moore DR, Barry & Amitay S. (2014): Listening Effort and Fatigue: What Exactly Are We Measuring? A British Society of Audiology Cognition in Hearing Special Interest Group White Paper, International Journal of Audiology, Early Online: 1–13.

Pichora-Fuller MK, Kramer SE, Eckert MA, Edwards B, Hornsby BWY, Humes LE, Lemke U, Lunner T, Matthen M, Mackersie CL, Naylor G., Phillips NA, Richter M, Rudner M, Sommers MS, Tremblay KL & Wingfield A (2016): Hearing Impairment and Cognitive Energy: The Framework for Understanding Effortful Listening (FUEL), Ear and Hearing, 37, 5S-27S.

Today we will talk about the fatigue associated with listening effort. Listening involves both auditory and cognitive processing. We hear with our ears but we listen with our brains and consequently people whose auditory input is of a lesser quality may expend more mental effort to listen. The fatigue may be described as a feeling of being tired, exhausted or having low energy or a low motivation to listen.

Fatigue associated with listening effort is reported by many people with hearing loss including those using cochlear implants. Statements such as these are not uncommon from people with hearing loss of all ages.

• I feel that my brain is working nonstop and it takes a lot of energy for me to listen.
• I am bursting with auditory stimuli that I cannot filter.
• My brain needs to process what I am hearing faster than it used to do before.

Such comments are more common with CI recipients who used hearing aids for many years (when they could have benefited more from cochlear implants) and also from those adults who had significant hearing loss at birth or early childhood and were implanted later in life.

People with hearing loss may refer to communication conditions as stress inducing situations since they require significant listening efforts and can potentially involve communication breakdowns and misunderstanding.

What kind of listening effort may be required of people who are deaf and hard of hearing? Why do CI users report fatigue associated with listening?

People with hearing loss may perform complicated auditory processing in order to understand speech because of imperfect auditory perception. They may work hard to: localize sound, identify who is speaking, distinguish speech from background sounds, and recognize speech sounds as well as cues for emphasis and intonation. They may rely upon visual information for speech reading to supplement what they are receiving auditory. In many real-life situations, accessibility to visual cues may be restricted due to imperfect lighting conditions, difficulty in localizing the speaker and other factors.

Consequently auditory and visual cues might not be sufficient and people with hearing loss may need to rely upon previous knowledge regarding a conversation. They may also draw upon their linguistic knowledge (e.g., Is this word likely to be a noun?) and on other kinds of supporting clues. If all of this isn’t difficult enough, they may need to process the spoken information rapidly—based upon the speaker's pace of speech or to stop the speaker to ensure they understood what was said. They also need to remember everything they heard already and use different cognitive and language skills to fill in the whole meaning.

People who have never experienced typical hearing, as well as older adults who had typical hearing in the past, may experience greater difficulties with recalling auditory input and this also contributes to their effort to communicate effectively. Since auditory memory skills are imperfect, the individual with hearing loss must put a great deal of effort into understanding speech—even when they can recognize single words

Consequently, fatigue can be an inevitable consequence of listening with hearing loss. What fatigue in adult CI recipients? How can we manage fatigue and improve quality of life for adults post CI? We’ll talk about it soon, on our next post.

You’ve been asked to be a personal auditory trainer

What do you need to know? 

You’ve been asked to be a personal auditory trainer by a friend or relative. What does that mean? What’s involved?

You will help them work towards better hearing and ease in communicating. You are going to have the very special opportunity to make an important contribution to your friend’s fascinating journey.

Here are some tips for you—a first time auditory speech perception trainer. I hope you find them to be both practical and applicable.*

• Pay attention to the space where you are practicing. During the early rehabilitation timeframe, it is important to keep the auditory training environment as quiet as possible. Practice speech perception in an enclosed space. Close the door and the windows and turn off any appliances that you can that create noise. If there is noise in the house, try to reduce it before starting to practice. It’s possible that you will not be aware of all these interfering noises because we often “tune them out unconsciously.” Hence you may be surprised to find out that your CI user friend is more sensitive to noises in the environment than you are. My advice is to look for a quiet room and adjust the conditions together with the trainee.
  
  
•  Begin by sitting no more than three feet from the trainee.
  
  
• The first step is to verify that the implant is working. Ask the trainee to turn off the hearing aid in the ear opposite to the CI ear and see if they hear the following sounds: /i/ /a/ /u/ /s/ /sh/ /m/. If the person has two cochlear implants, check each one separately.
  
  
• Encourage the trainee to be attentive to environmental auditory stimuli and help them to identify any sounds that they are hearing (e.g., car noise, a dog barking outside). When unplanned "auditory events" occur during the session (e.g., phone or door bell ringing, someone knocking on the door, an airplane, rain), raise the awareness of your friend to these sounds prior to your own reaction to them.
  
  
• Since the aim is to improve auditory speech perception, you should "hide your mouth" to avoid providing speechreading cues to the trainee. You will probably need to cover your mouth up to your nose. You can use a piece of paper or even better, a speech or acoustic hoop designed restrict visual cues without impacting the intensity or sound quality of one’s voice during therapy. Such hoops can be found online from CI company stores or from other educational institutions such as this one: https://cid.edu/professionals/shop/additional-cid-spice-acoustic-hoop/.  You can even make one yourself; there are instructions here: http://www.thespeechbubbleslp.com/2014/07/using-tension-hoops-in-speech-quick-tip.html
  
  
•  Speak a little slower than your normal speaking rate, and use comfortable speech intensity (do not raise your voice).
  
  
•  Expect that several repetitions of the stimuli will be needed.

Auditory training should become a part of the CI recipient's life routine, since auditory learning after cochlear implantation is a long-term process. Therefore, your long term commitment, patience, and positive support will be highly valued.

A number of earlier posts suggest specific practice routines. I urge you to go back and take a look at the following. These are perfect ways for a personal auditory trainer to work with an adult recipient.

• Constructive Communication
• Auditory training using your own word lists can be fun!
  
• How to Build your Own Auditory Training Word List
  
• How to Begin Talking on the Telephone with Your Cochlear Implant
  

* For individual assistance, questions and verification requests, please ask your friend to contact their audiologist or speech pathologist.

Favorite Home Practice Tools to Improve Speech Understanding:
Audio Books, Speech Sounds, and More

Audio Books: Why people like them for auditory practice

Audio books are widespread and accessible. They include wide-ranging topics and are available for non-fiction, biography and fiction and span many different languages and personal interests. Many adult CI recipients use audio books as a home practice tool to improve their speech understanding skills. Usually the narrator is a clear speaker who is reading at a normal speech pace (meaning not too fast). While listening to audio books, you can read along with the written text if you wish. These are significant positives, making the use of audio books the most common self-practice tool for adult CI recipients.

Audio Books: What’s their downside as a practice tool?

Anyone who has used audio books knows that there are also some negatives associated with their use as a practice tool. First, recorded speech sounds different from natural speech because the acoustic signal is restricted (contains fewer auditory cues) and therefore might be more difficult to process. Secondly, the content is sometimes recorded at a pace which may be too fast and overly challenging for a CI recipient—depending upon where they are in their rehab process. It may be technically impossible to slow down the narrator’s reading speed. (And if it is possible to slow the pace, this could cause distortion of the speech signal.) Some audio books have background music that make the speech even more difficult to understand. In addition, listening to audio books requires more than just good speech perception of everyday language as book text may use less frequently used vocabulary, longer sentences, and more complex syntax.

One can look at the use of audio books from two perspectives:

• On the one hand, for many people, they are too difficult to use, especially during the early rehabilitation timeframe (when the motivation to practice is the highest but auditory skills are still limited).
• On the other hand, they provide challenging practice. For individuals who are able to cope with the complexity they provide, audio books can be an effective and engaging practice tool.

More ways to practice your auditory skills

Speech sounds can be presented either solitary (/s/), as part of a syllable (/sa/), or in a single word context (bus). Good speech understanding does not always indicate that someone has excellent perception of speech sounds. For example, the last word in the following sentence can be perceived—regardless of one’s access to all of the acoustic information: "I bought a new _a_"(car).” If the CI user knew that the person talking had an old car that was always breaking down, he would have contextual knowledge that supports speech understanding even when all of the words heard were not understood.

So if words can be understood based on context cues, why is it so important to improve the accuracy of speech sound perception? In order to capture new words with minimal linguistic redundancy, you must be able to perceive the word's components. This is also true in cases of single word presentations or proper names when there is no context to enable someone to fill in the gaps. In addition, knowing which sounds you perceive less well, or which sounds tend to get mixed up with others (e.g., /b/ with /p/, /k/ with /t/) will help your audiologist fine tune and to monitor your CI.

Practicing understanding simple greetings, questions and simple sentences is easy to do and can be very rewarding when you implement these skills into your everyday life.

• You might practice recognizing the names of friends, co-workers and relatives.
• You may find it useful to practice single letters, numbers and other words that may help ("c like Charley") clarify words that you are having difficulty with.

Improving auditory memory skills and capacity may make it easier for you to follow sentences, conversations, and even lectures. You can use word lists that contain letters, numbers, and words related to different topics (i.e., shopping, food ingredients, packing for travel, city and country names) and practice different repetition tasks. Start with two words and gradually increase the number. You can also practice auditory memory by using sentences, such as understanding instructions with ascending complexity (1) take the book and put it on the table, (2) take the pencil and put it on the table, (3) take the pencil and put it on the book. More advanced practice could include recall of details from a short story or recipe, or how to get from your home to another location with specific directions.

Comprehensive practice of hearing skills might include the activities above and more. Many of these suggested activities rely upon the assistance of another person. In the next post, we will discuss some guidelines and tips for relatives or friends who assist you with your home training.

Good luck.

Naama

Why is it hard for cochlear implant recipients to hear on the telephone?

Acoustically, the telephone signal has a more limited frequency band than a typical speech signal, the phone instrument distorts voices, and there can be an echo and/or other noises that make comprehension difficult for anyone but most especially for people with hearing loss. These challenges combined with the inability to use speech reading when talking on the phone are significant barriers to fluent telephone conversations. The lack of eye contact that prevents you from receiving visual cues for speech reading also pertains to the person you are speaking to as he or she cannot see your facial expressions or other nonverbal cues either—cues that typically help someone to know that you did not grasp completely what was just said.

Hence it is important to tell the person you are talking to when you don’t understand. The other person may not be aware of your lack of understanding unless you tell them.

Telephone Tips When Starting Out:

1. Choose your partners carefully. This is good advice for life in general and is highly recommended when you begin talking on the phone with your CI. Begin with people who will be mindful and tolerant as a conversationalist as they will likely need to make adaptations for you. You probably know which friends or family members have relatively clear speech. You should ask for their help and guide them with some basic principles.
2. At first, you should be the initiator of phone calls. Call your partner(s) from a quiet room.
3. Use your preferred method of connecting from your processor to the telephone. There are several connection methods available including Bluetooth, telecoil, or another ALD (Assisted Listening Devices) that can help you. Ask your audiologist and make sure that you have been updated with every device that can work with your CI. I also recommend that you review our previous blog post by Erin Schafer on Assistive Listening Devices for Cochlear Implants.
4. If you don't use an ALD to connect to the telephone, take care to find the best position to hold the telephone receiver before you make a phone call. This position may be different from where you held the phone with your hearing aid.
5. Ask your practice partners to take your phone calls when they are also in quiet spaces. Ask them not to converse with you when they are driving a car, sitting in a restaurant, or using a speakerphone. Ask them to wait until they are in an ideal acoustical environment to talk.
6. Do not feel embarrassed to inform your partners that you did not understand what they just said! Remember that if you do not inform them at the moment when you missed something they said, there is an increased chance of further misunderstandings. Let them know in advance that they should expect that you will not understand every word.
7. Ask your partners for clarifications such as “I did not understand.” “Please say it again.” “Could you speak slower?" Guide them to use basic clarification strategies such as slowing down their speaking rate and conveying the message using other simple words rather than repeating precisely what they said before. When you miss a name of a place or a person and you are not sure you have understood the word in full, your partner could spell the word ("N" as in Nancy, etc.) or briefly describe the person or the place ("My sister Ann whom we visited last Sunday" or any other significant clue).
8. If the conversation includes instructions, information regarding meetings and so on, check back by repeating what was said and then writing it down.
9. One last tip is relevant if your speech is not perfectly clear (i.e., you have imperfect speech intelligibility). Speechreading is an important source of information for many people—not just those with hearing loss. People who have normal hearing may use speechreading in some situations without knowing they are doing it. These situations include understanding speech in noisy environments, especially when the listener is in conversation that is not their native language or they are listening to someone with lower speech intelligibility. If your speech intelligibility is lower than typical speech, a communication partner may need clarification on the telephone as well.
10. Remember, both of you will need to be patient and use the clarification strategies described above.
11. You might also try the telephone practice tools from the CI companies, all of which are available for free in the rehab areas of the company websites. These may help you develop the confidence to converse with a real person!

What is the right time to start telephone practice?

I suggest starting telephone practice only after you are able to understand short, simple sentences without speechreading. Some people can do this immediately after device activation, some are able after a few months, and others are ready only after a year of CI use. Not everyone implanted at a later age will be able to understand speech on the phone. Talking on the phone can be a challenging mode of communication for a CI recipient as it requires the person to have robust speech perception skills, to have pursued specific training and practice, and to have high auditory processing abilities (which may be based upon previous hearing experience).

Good luck and have fun!

Naama Tsach

The speech perception evaluations done as part of the follow-up for CI recipients are typically reflected by a percentage, which some people perceive as a “grade.” However, unlike grades in school, there are no standards and there is not a simple definition for what is a good grade. Some people would consider 30% on a test of understanding words in sentences in quiet as a huge success because they never had any auditory speech understanding before CI. Other people, after the same period of CI experience, would consider a score of 90% in quiet and 50% in noise as successful; those individuals might have had a pre-CI “grade” of 40% of words in sentences in quiet and 10% in noise. There are speech perception tests that simulate comprehension in more realistic conditions, such as recognition of common sentences in noise. Other tests are used to evaluate perception of speech sounds, words, and sentences in quiet conditions in closed set (i.e., multiple choice) or in open set (i.e., words or sentence repetition task). Recipients should always seek the help of their CI audiologist to help them understand their outcomes and what they mean in terms of personal improvement.

Objective Versus Subjective Assessments

One should take these scores with a grain of salt. Remember that they represent specific speech perception skills (those that are directly evaluated by these tests) and do not represent your overall CI outcomes. For example, a score of 95% word recognition in quiet conditions may not cheer up a CI user when they realize that a colleague approached them with a short question and they missed it. For others, a "lower" grade (of say, 40%) does not represent the significant advancement they’ve experienced in being able to combine speechreading with listening much more effectively—an advancement that makes them feel very positive about their decision to undergo cochlear implantation.

Therefore, if a recipient feels that numerical scores don’t seem consistent with their own perceived experience and (s)he then asks "Am I doing well?", one should consider other ways of representing a subjective evaluation.

How did hearing loss affect the person’s life before the cochlear implant?

The goal is to evaluate the contribution of the CI to one’s communication and how it is reflected in different situations in life. It's important to consider how hearing loss affected an individual before CI and what kinds of difficulties affected his or her decision to undergo cochlear implantation. For example, someone might contemplate:

• Could you understand some speech without speechreading?
• If you could, what restrictions did you have? Did you need to stay close to the talker, listen in a quiet room, and close the door?
• Did you understand certain talkers better than others?
• Did you ask people to slow down when they were speaking?
• Do you remember how much effort you put into having a conversation, especially with unfamiliar speakers?
• Do you remember how often you asked people to repeat or speak more slowly?
• Did you give up the chance to fully understand people, given the frustration in getting it right?
• Did people touch or tap you to get your attention? 

Assessing Quality of Life Changes

To assess the CI contribution to one’s quality of life and sense of successful CI use, an individual should consider improvements in the ease of communication, sense of security and orientation, and enjoyment in listening.

• Does the CI make it easier for the person to have a conversation?
• Can the person now understand a more rapid pace of speech?
• Does (s)he ask people to repeat less frequently?
• Does (s)he feel that it is easier to understand people whose voices were previously very difficult to understand, such as children or those with heavily accented speech?

If a person answers “yes” to some of these examples, it indicates benefit in daily situations that contribute to quality of life.

Satisfaction Isn’t Easy to Quantify

In addition to improvements in auditory speech perception, an individual may simply enjoy listening to the voices of beloved people, to street noise, animals and nature sounds, and music. These feelings of pleasure are priceless. It is true that there are people who will respond to daily greetings and understand simple questions, even without having any eye contact with the speaker. There are also CI recipients who will talk on the phone. However, they are not the only successful CI users. Everyone may define the benefits they derive from their CI and can feel satisfied and accomplished by them.

Satisfaction following cochlear implantation can be affected by the extent to which the CI enables someone to meet their own communication needs. These needs vary depending upon whether the recipient relies upon written communication at their work place or if they need to use spoken language extensively, whether an individual is working in a quiet or noisy environment, whether they use sign language with relatives and friends or not. The sense of self-accomplishment should mainly rely on the person’s recognition of the different contributions that a cochlear implant makes to their everyday life.
Keep in mind that the reason for someone to undergo cochlear implantation is typically to improve their quality of life, not to get As on tests. The auditory information provided by cochlear implantation provides much more than numeric results on clinical tests.

CI recipients should share their insights regarding benefits and expectations with relatives and friends as well as with their CI professionals. Accepting diversity, appreciating achievements, and continuing to improve hearing skills is all part of one’s CI enjoyment.

Naama Tsach
naama@acialliance.org

The improved access to sound provided by assistive listening devices is generally accepted for those who use hearing aids. This same benefit extends to cochlear implant users of all ages. Read Erin Schafer’s guest blog post and learn about how these technologies can be used in a variety of settings.

Erin Schafer Ph.D. is an Associate Professor at the University of North Texas in the Department of Audiology and Speech-Language Pathology. She teaches courses and publishes peer-reviewed research on the assessment and (re)habilitation of adults and children with hearing loss or auditory disorders. She is a Board Member of the Auditory Implant Initiative, serves as President of the Educational Audiology Association, and is Editor of the Journal of Educational, Pediatric, and (Re)Habilitative Audiology.

Thank you Erin, for this important blog post, which is an enriching addition to our blog resource library.

Naama Tsach PhD

Assistive Listening Devices for Cochlear Implants

The selection of assistive devices for users of cochlear implants has grown tremendously over the past 10 years with today’s devices offering more affordable, simpler, and easy-to-use wireless products to improve hearing in noisy situations, over the phone and to the television. Although I cannot speak to my personal experiences with these devices, I am able to share with you the findings of our recent published research as well as some practical uses of each device.

Improving Hearing in Noisy Situations

For many years, individuals with cochlear implants have been able to connect their sound processors to frequency modulation (FM) systems, which wirelessly transmit a signal from primary talker to the listener with the implant. These systems were helpful for improving speech recognition and listening ease, particularly in noisy environments. However, many FM systems are expensive, sometimes cumbersome to connect to cochlear implants, and are susceptible to interference from the environment. Many of today’s wireless accessories, however, use digital transmission, which is less susceptible to interference and, in many cases, is much more affordable. Examples of these accessories include the Wireless Mini Microphone and Mini Microphone 2+ that can be used with Cochlear processors (in partnership with GN Resound) and the Phonak ComPilot and RemoteMic accessories that can be used with Advanced Bionics processors. Although MED-EL is not offering wireless accessories, MED-EL processors may still be used with existing FM and digital transmissions systems available from Oticon, Phonak, and many other manufacturers.

According to our research, the Mini Mic is was able to substantially improve average speech recognition in quiet by 10% and in noise by up to 65% in 16 adults with Advanced Bionics implants when compared to performance with the cochlear implant alone. A more recent study that is in progress included two groups—a group of listeners with bilateral cochlear implants and a group of listeners with a cochlear implant on one ear and a hearing aid on the other. This study showed that, in both groups, use of the Mini Microphone 2+ was able to improve speech recognition substantially, and the benefit achieved with the Mini Microphone 2+ was similar to the benefit obtained with a higher-end remote-microphone system. Results of these studies provide evidence that the new wireless devices are beneficial. A 65% increase is a huge benefit!

Although use of these wireless accessories requires a cochlear implant user to adjust processor settings and to ask the primary talker to use a small microphone, the benefits are notable, particularly in noisy situations. This accessory will be helpful in the car, when the primary talker is at a distance (e.g., church or lecture), or at large family gatherings, parties, or other social situations.

Improving Hearing Over the Phone

Hearing over a mobile telephone may also be improved with new wireless accessories available from Cochlear (Phone Clip) and Advanced Bionics (Phonak EasyCall Accessory). Both of these wireless accessories connect to mobile phones via Bluetooth and allow users to communicate hands-free through the small device that is clipped near the user’s lapel. The benefit of using the Phone Clip was documented in a study including 16 adults with Cochlear sound processors where speech recognition was improved by 18% in quiet and 29% in noise when compared to performance in a test condition where the phone was held close to the processor microphone.

All listeners, including those with normal hearing, experience difficulty hearing over the phone when in noisy listening situations, such as parties, grocery stores, and restaurants, and sometimes these calls are really important! A trial period with a wireless phone device may offer a solution to some difficulties over the phone and result in more fluid conversations. Regardless of the manufacturer, all CI processors have a telecoil setting that can be coupled to telecoil-enabled mobile devices and landline phones to improve hearing and ease conversational difficulties.

Improving Television Listening

Signals from the television may be streamed directly to the ears of individuals with cochlear implants via new wireless accessories, such as the ComPilot and TVLink II for Advanced Bionics processors and the TV Streamer for Cochlear sound processors. These devices are fairly simple to set up and can provide substantial benefit. For example, we conducted a study with 16 adults with Cochlear sound processors who completed a test of auditory and visual recognition through a television. Their performance improved by 8% in quiet and 23% with noise in the background when compared performance with their cochlear implant alone.

The potential benefits of a streaming device for the television are obvious and may serve as a mediator for your household, especially if you like to turn up the volume quite a bit. Some individuals with implants have difficulty hearing the television, particularly when other sounds are present including the washing machine, dishwasher, water running, and children playing (or yelling in my house). A wireless device allows the user to hear the television at a normal and comfortable volume, regardless of the noise in the background.

I hope you will consider giving some of these new wireless devices a listen because many adults with cochlear implants have experienced great benefit from these devices. Happy Listening!

Erin C. Schafer, Ph.D.
University of North Texas

In my last post, we discussed building your own word lists. Now let’s review how best to use those lists in your home practice.

Repeating words read aloud can help reinforce your auditory memory. However, over time you may experience two shortcomings of this practice tool: (1) You may memorize the words after some practice and/or (2) The process may become boring.

After repeating words from your lists, try using them in other ways. Here are some tasks that might be performed using your word lists in enjoyable and challenging ways that will encourage you to practice your auditory skills. These tasks require you to use abilities other than auditory perception. You might use judgment, auditory memory, and your sense of humor. Tasks may require implementing world and linguistic knowledge, social understanding, and more. Therefore you should expect to find these tasks more challenging, even if you have already easily identified these words as they were presented to you from a list. Don’t hesitate to ask your practice partner for repetitions.

Speech perception tasks that involve understanding and thinking (not just identification of a single word from a known list) serves to better simulate the communication challenges you experience in everyday life. So now, after this long introduction, let’s move on to some practical examples.

Foods: Instead of simply reading the words, ask the person who is practicing with you to share their shopping list for his or her next supermarket visit. You can also ask them to read you a list of ingredients and then you could guess what might be prepared with those foods (e.g., "What might be prepared with vinegar, lemon juice, honey, mustard, salt and garlic?"). If there are words that you’ve not practiced before, include them anyway (and add them to your list).

Numbers: Instead of simply repeating random numbers, ask your trainer to read you useful telephone numbers and then feel free to add them to your contacts. Hey, how did you manage not having the phone number of the best pizza take-out in town? If you easily recognize one-digit numbers, ask them to read you phone numbers as a group of two 3-digit numbers (e.g., 202-354-097-1). If you can grasp two and three-digit numbers, ask them to read you prices of products. You can also ask them to occasionally tell you the wrong price so you will have to initially recognize the number you heard and then to decide whether it is correct as a price. You can ask your trainer to tell you about their relatives' ages, or even practice solving simple math problems using your auditory perception skills.

Letters: Instead of reading you random letters, ask your trainer to spell out the names of family and friends (or places around the world). After you cite the word, have the person tell you something you did not know about it. Another exercise might be to ask your trainer to spell out short words but to state the letters in reverse order. If you recognize letters very easily, your trainers can say more than one letter at a time, which can be great training for your working memory (e.g., a/I, r/p, l/a, n/e).

Find the word that doesn't match: Ask your trainer to say four words, each word separately or two at a time (e.g., train, bus, car, bicycle) and identify the word that doesn't fit.

Auditory perception of a word in a sentence: Your trainer could read simple sentences, including target words from your word training lists. You could use speechreading to help you grasp the entire sentence—except the target word or words will be voiced with a covered mouth—no visual information would be provided for these specific words. Prior to the sentence presentation, you need to define the semantic field (or topic of the target words. For example, days of the week: "I am taking Yoga class every Monday" and the covered word would be Monday. Or sports activities and days of the week: "I am taking Yoga class every Monday" with the covered words being Yoga and Monday. Or names of the states: "Which state has the larger population—Maryland or Ohio?"

Syntax and morphology: The first step would be to set the task words; then you could be asked to judge whether the covered word is in the correct form. For example, for have/has/had: "She have a birthday last week" or walk/walking/walked: "I saw him walking away".

These examples illustrate some of the ways you can practice identifying specific words in meaningful contexts while reinforcing auditory understanding in communicative situations.

Before we conclude, I want to address the important issue of preventing access to speechreading while practicing auditory skills. There are different ways to do so. For example, you could ask your trainer to sit or stand behind you. I personally do not recommend that particular approach because it precludes any eye contact between the person practicing and his/her trainer. This makes the exercise unrealistic and not very pleasant.

Rather, you may want to sit side by side and agree that during the training, you will not look towards the speaker's face. Tasks that require a combination of speechreading and auditory-only perception (such as in a sentences that should be presented visually with certain covered words), the speaker can use a sheet of paper to cover the lower part of their face. You should guide your trainer to do it in a way that will prevent visual information or speechreading but not distort the sound (i.e., avoid placing the paper on the mouth).

In future posts, I will offer more ideas for auditory training exercises involving not only single words but also complete sentences, telephone use, auditory memory skills, listening in different acoustic conditions, listening to different language materials, and more.

All that remains for me is to encourage you to continue practicing, being creative, and enjoy your auditory training!

Good luck!
Naama

This post was written at the request of a reader who noted:

I would like to involve my family in my auditory training by having them read words or sentences to me. Can you provide suggestions of home practice tools for this purpose?

This is a wonderful request that will help others looking for home practice materials.
I do have mixed feelings about this request. On the one hand, I believe that after receiving a cochlear implant, recipients of all ages benefit from working with a professional trained in auditory rehabilitation. Such professionals can help recipients choose and adapt auditory training materials to meet their needs. On the other hand, we know that most adults do not receive such support post CI and their auditory practice is likely to be done independently. Hence, I will do my best to guide you. I would also be more than happy to respond to any comments or inquiries from our readers regarding their experiences in using home practice techniques.

Our current goal is to create lists of words that could serve as a foundation of your auditory listening inventory and will later serve you when you create lists of sentences for further auditory training. So, let's roll up our sleeves and get to work.

Creating Word Lists

The first part is fun. Think of words that are most useful to you—at home, at work and in other everyday situations. Include important words such as names of relatives and friends, nouns, pronouns (i.e., I, we, you, she, her, them, it, this, that), verbs, auxiliary verbs (i.e., be, can, could, do, have, may, might, must, shall, should, will, would), adverbs, and adjectives. Include same verbs in different morphological forms (drive, drives, driving). For future practice, add common question words (i.e., what, why, where). In addition, include numbers (1-100), colors, and letters. Update the list occasionally with relevant words. At the end of this process, you should have a very long list from which you can build various auditory training lists.

Example of a (partial) List:

Bob, John, Kathy, Mom, Dad, Rockville, Maryland, yes, no, don't, what, how, when, why, who, do, does, are, is, want, take ,give, build, drive, clean, play, tired, happy, coffee, tea, water, soda, lunch, dinner, breakfast, egg, nuggets, guacamole, room, car, big, small, green, great, beautiful, one, two, A, B .

In addition to the word list, you should make a list of everyday phrases and greetings. These might include:

• Good morning
• What's up?
• Have a good one
• Thank you

Congratulations! You now have a very long list of working materials. The next step is to build your training lists. I will illustrate how to create lists of words that require different levels of auditory perception skills. Practicing speech perception of the same word in different environments (different word lists) will help you identify specific differences between speech sounds, which will enhance your word perception (even beyond the words that you have included in your original list).

Example #1: Word lists based on letters

1.  Beginner level (easy): w,s,b,I,k,m,o,q. To make it easier, you can divide the list into two groups.
   
2. For more advanced training you can use the following list of letters: a,c,e,f,i,j,h,l,m,o,u,r,t,v,w,x,b. Again, to make it easier, you can divide the list into two or three groups.
3. The following lists would demand even higher auditory perception skills: b,c,d,e,g,p,t,v or f,h,j,k,l,m,n,s,x

Example #2: Word lists based on food names

1.  Beginner level: Include words of different lengths and varying vowel patterns: avocado, tomato, cheese, egg, lettuce, rice, cucumber, corn, chicken, and cream cheese.
2. For more advanced training, you can use the following list of mid-length (two syllable) words: chicken, onion, nuggets, pizza, orange, lettuce, mango, pumpkin, ice cream, pasta, ketchup, and mayonnaise.
3. This next list would be even more difficult since it includes only short (one-syllable) words: soup, bread, rice, cream, bean, corn, egg, cheese, toast, beef, steak.
4. For an even greater challenge, you can use short words with very similar vowels sounds, such as: bean, cream, cheese, beef, mint.

Start with short lists of disparate words

When you adjust your practice materials to your auditory ability, note that the more similar the words (in their length, vowel and/or consonant sounds) and the longer the list, the greater the level of difficulty. Therefore, my advice is to start practicing using relatively short lists that include words that differ in as many parameters as possible, and then move on to longer lists that include words that are more similar to each other.

During practice sessions, you may have difficulty distinguishing between some words. Try practicing your auditory discrimination skills using specific words that are difficult (e.g., fun and sun). Ask your practice partner to read you the words and highlight the sounds that distinguish them (i.e., “f” and “s” in this example) by emphasizing or prolonging the first consonant. Repeat difficult exercises a week later and see if you have improved.

Share your experience with your audiologist

When you next visit your audiologist, share your experiences. (S)he may be able to explain why you have difficulty with specific auditory features and suggest how to move forward with your auditory training.
I hope that some of these tips will be helpful to you in getting started. Please feel free to send me any questions and I will do my best to assist you.

How can you use your word lists? In the next post I will share some practical uses for your lists. Hopefully you'll discover that auditory training can be fun.

Good luck!
Naama

Last month was my blog's first anniversary so I thought it would be a good time to sum-up what we have done over the past year. If someone had told me two years ago that I would write a blog on adult rehabilitation for the ACI Alliance, I would have never believed them. Yet, life presents us with opportunities and this blog has given me a new and unexpected way to express my love for my profession and my patients.

It all started when Donna Sorkin and I spoke about my experience with adult rehabilitation following cochlear implantation. Many of the people I had worked with had congenital hearing loss though some had lost their hearing later in life. Of the total population of CI recipients, 60% are adults. Unlike pediatric recipients, most adults do not receive auditory rehabilitation services as part of their rehabilitation process. Moreover, adult CI recipients have difficulty finding resources to support their rehabilitation journey.

18 Posts Published So Far

Consequently, in Donna's kitchen, this blog was born. Eighteen posts have been published to date, aimed to present a broad perspective and offer practical advice to enhance the challenges faced by a diverse population of adult CI recipients. This diversity includes wide-ranging expectations, rehabilitation needs, and outcomes.

I wrote about perception of environmental sounds, music appreciation, emotional effects and improvement in recipients’ quality of life. These topics demonstrate the various CI benefits and suggest that subjective evaluation of benefits made by recipients themselves, is as important as objective assessments of speech perception ability performed by professionals.

Some of the posts included practical advice on topics related to constructive communication with family, professionals and friends to facilitate support and cooperation following implantation. In addition, there were posts that presented the questions faced by audiologists in the process of evaluation of CI candidates, and issues regarding bilateral CI. Although I emphasized the importance of auditory rehabilitation provided by speech pathologists, tips for self- auditory training were also suggested. Linda Daniel, an audiologist and Auditory Verbal Therapist shared her moving experience in initiating a support group for adult cochlear implant recipients. Thank you Linda! Another writer we were privileged to host is musician Richard Reed, who lost his hearing later in life and was implanted after nearly 10 years of significant hearing loss. His touching story demonstrates some of the challenges, as well as achievements, he experienced during his unique rehabilitation journey. I take this opportunity to invite other writers to contribute to our blog.

Future Posts

What about future blog posts? The next posts will include instructions on how to develop your own training materials and use them in creative and fun ways. Other posts will discuss related topics such as speechreading, how to deal with noisy environments, and strategies to improve listening on the telephone. You are most welcome to suggest other relevant topics.

As both a speech pathologist and audiologist who previously relied on direct face-to-face communication, writing a blog is a very different kind of communication. Therefore, I would like to thank the readers who wrote to me; your questions and comments were thought provoking and you helped me focus on important topics of interest.

I would like to thank the extraordinary Donna Sorkin, who presented me with this exceptional platform, enabled me to freely express my professional insights and perspectives, and supported me all the way with her positive encouragements and suggested edits. I also want to thank Susan Thomas—without her dedication and technical support, I might be writing these posts only for myself.

Best wishes for a healthy and thriving 2017.

Naama Tsach
naama@acialliance.org

Our last blog post was by musician Richard Reed, who was late deafened and subsequently received a cochlear implant (What-s-Old-is-New-Again-if-We-re-Lucky). I would like to follow up on Richard’s touching personal account with some professional observations based on my work with adult recipients.

Many CI recipients experience initial frustration in appreciating music. Perception of the richness of music requires various auditory skills including being able to distinguish between sounds that are similar (but differ in their frequency and/or intensity) as well as the ability to follow rapid changes in the music. Cochlear implants cannot convey all of the characteristics of music due to the limited number of electrodes. Regardless of the type of listening device, the auditory system of people with severe to profound hearing loss typically cannot accurately represent the acoustic characteristics of music.

Music appreciation is not an assured outcome of cochlear implantation but many recipients do seek it as an additional benefit that adds to quality of life. The ability to appreciate and enjoy music depends on many individual factors such as age (teens often spend a lot of time listening to music), musical education (before or after the CI), life experiences, and personal preference. It is important to note that not every person with typical hearing enjoys music to the same extent. Some people prefer to read books, watch TV, or go to the theater rather than listen to music or attend concerts.

If you previously enjoyed listening to or playing music and consider musicality as a contributor to your quality of life, you may wish to pursue a specific practice program. According to studies and clinical observations, there are differences in enjoyment of music by CI recipients. Nonetheless, people can enjoy listening to music following cochlear implantation, even if it is not the same experience that they remember prior to losing their hearing (if late deafened) and receiving a CI.

Discerning melody is the most difficult challenge

The difficulty in perceiving music by CI recipients relates primarily to one’s ability to recognize the melodic components of music and isolate a specific sound in the presence of other sounds. For example, listening to a vocalist in the presence of instrumental accompaniment or distinguishing between different musical instruments playing at the same time are difficult tasks. Listening to classical orchestral music, large group ensembles, or lyrics with loud instrumental accompaniment can be frustrating experiences for CI recipients. However, since there are so many styles of music, you can be selective in your music choices and pursue those with strong rhythm, solos, or vocalists with an accompaniment of only one or two instruments. You may be encouraged by studies and personal accounts indicating that auditory training for music can result in improved music perception as well as greater music enjoyment.

What can you to improve your appreciation of music?

When dealing with music appreciation (and other topics related to rehabilitation following cochlear implantation), there are two key factors that affect individual’s satisfaction: (1) duration of CI use and (2) quality of therapy/practice. Longer periods of CI usage combined with specific music therapy and self-practice often results in higher levels of music enjoyment. With patience, persistency and hard work you can improve your appreciation of music.

Professional music therapists utilize systematic programs for individuals or small groups. Musical selections and music-making activities may be modified for participants' preferences and needs. Research on CI recipients, both adults and children, revealed positive effects of music therapy on self-esteem, communication skills, music perception, and music enjoyment.

Self-practice is less structured and can be undertaken independently in different ways. For example, you may choose your own materials and progress according to your own schedule and preferences. You can also use materials designed specifically for CI recipient music training. (I’ve provided some examples below.)

When you practice on your own, you should follow a few guidelines:

• Practice when you are well rested.
• Choose a quiet environmental with minimal background noise
• Ensure that you have the best possible sound system with appropriate volume. Use direct audio input, Bluetooth or assistive listening device to connect to your sound processor

Attentive Listening

Attentive music listening is more effective than simply being exposed to music. When you listen attentively, you can selectively identify musical characteristics. You may ask yourself:

• Do I recognize the rhythm?
• Have I noticed the dominant instrument change?
• Do I recognize what is playing now?

In the early stages, I recommend using videos that enable you to see which instruments are playing. When you become familiar with different pieces of music, ask yourself questions:

• Can I recognize the selection that I’m listening to?
• What feeling do I have while listening to certain music?
• Do I have a preference for a certain style?

Try to listen to different music styles, even those that you did not previously listen or did not enjoy listening to in the past. While listening to songs, you may ask yourself:

• When did the vocalist start or stop singing?
• Can I identify repeated words or phrases?
• Which is easier for me to listen to—a male or female vocalist?
• Are there specific singers I prefer to listen to? 

Read the lyrics while you listen to songs to further help you enjoy your musical training experience. These principles may help you adjust your practice. You may want to share your experience with friends who have typical hearing and ask them to recommend musical selections.

Where to Start Your Practice Program

Start by listening to simple musical pieces, including familiar music you remember from the past. It is preferable to listen to music accompanied by only one or two instruments versus a large band or ensemble. Many CI recipients prefer to start listening to instruments such as piano, cello, saxophone, bass and drums. Note that almost any song or musical piece can be performed as a one-instrument solo.

Choice of Songs

Begin by listening to songs which have one vocalist accompanied by a limited number of instruments. You may even fall in love with some new songs that you did not notice in the past. Select relatively slow tempo songs by singers who have clear articulation. Nursery rhymes and holidays songs that are familiar to you are often a good choice to begin with.

What practice materials are available to help improve your music appreciation?

The cochlear implant companies all have excellent music rehabilitation materials. I encourage you to explore their websites to find materials for your use.

Advanced Bionics rehAB http://www.abmusicrehab.com/EN/?err=login offers Musical Atmospheres, an interactive online program designed to help teens and adults with cochlear implants explore their music perception skills. It guides users through different musical features with increasing complexity (i.e., solos versus duets). This hierarchical training program invites you to experiment with a variety of tasks from basic (distinguishing between a human voice and the sound of musical instruments) to intermediate and advanced (i.e., identifying specific instruments, a vocalist's gender, or song lyrics).

Cochlear Americas offers HOPE Notes, a music rehabilitation tool developed by Richard Reed. (View Richard’s prior blog post to learn his story). HOPE Notes includes original and traditional songs and tunes, sometimes played in various ways to allow different listening experiences. The DVD includes captions that literally describe the music (Which instrument is now playing? Which chords are dominant?) This can be very helpful as you are learning to listen. I recommend using the DVD with the User Guide because it provides both theoretical and practical tips and most importantly—it encourages you to work on improving your music perception and appreciation. Richard's practical and positive approach, as expressed in the HOPE Notes tool, is both a source of support and an effective self-training program. The product is available for purchase from Cochlear. https://store.mycochlear.com/store/index.php/usb2c

MED-EL designed the first Spotify playlist for CI users. The playlist was created by MED-EL’s in-house musicologist, Johanna Pätzold, based upon research on music and cochlear implants. The list includes a variety of songs by various artists using different styles to enable as many CI users to enjoy using it and to motivate recipients to listen to music. The list includes popular and familiar songs, with emphasis on the vocals and with limited “special musical effects”. The list was created utilizing parental advisory guidelines, so it can be used as a family's playlist. The lyrics are available, allowing users to follow along.

It can be a motivating experience to use the MED-EL Munich Music Questionnaire to Record Music Listening Habits of People with Post-lingual Deafness after Cochlear Implantation. http://www.medel.com/en/rehabilitation-downloads/ The questionnaire provides an interesting perspective about changes in your music listening habits as well as a means of improving your awareness of your own music listening skills. You can fill out this questionnaire two months after your switch-on, then 6 months later, as a means of documenting your progress.

This is a brief introduction to the topic and an overview of CI company music rehab tools. More content is available on the CI company websites.

To sum up…Music was important to many people prior to losing their hearing. With your cochlear implant, hard work and dedication, you may be able to regain this important part of your life. Best of luck!

After losing his hearing due to an ototoxic antibiotic, musician Richard Reed was unable to appreciate music—or even have a so-called "normal" conversation—for nearly ten years. Then he had CI surgery in 2002.

At lectures and performances Richard demonstrates how music, voices, and nature sounds through his CI. Once again, he is playing organ and piano in Blues and Rock & Roll bands. He was inducted into the Rhode Island Music Hall of Fame in 2015.

It is my honor to share Richard's story in our blog.
~Naama

What’s Old is New Again if We’re Lucky

While searching our cluttered basement, I came across boxes full of reminders from my first- and worst- decade of late-deafened adulthood. Thanks to Cochlear Implant surgery and rehabilitation, I've been able to hear again, and quite well, for fourteen years. Why had I held on to this stuff? Why had I shlepped those musty memories along through three moves? There's no good reason. We let go when we're ready.

One carton was mostly wires wrapped around obsolete assistive listening devices and gadgets; another held hopeful articles on hearing loss breakthroughs and a small stack of my dismal audiograms. In the years before the deluge of virtual journalism, family and friends used to send me stories about grieving and loss. It's funny and poignant to see my long-gone mom's elegantly eccentric handwriting scrawled across a tragic tale: "Saw this and thought of you!"

One folder contained ads for Ginkgo Biloba and other tinnitus treatments and "cures", an expired warranty for state-of-the-art analogue hearing aids, and a thick catalogue offering amplified telephones as big as old phone books. Contemplating having to sort the contents into four piles (keep, toss, recycle or Salvation Army), I whispered sarcastically "This will be fun!" Then I smiled to realize that when I'd packed most of this stuff, I couldn't have heard myself say anything.

There were only two post-CI mementos in the lot: the first and only CD I ever bought, "Rubber Soul" by The Beatles and a hardcover copy of "Walden" by Henry David Thoreau.

I've written elsewhere about how foolish it feels in retrospect to have attempted The Beatles as my first post-CI music. Although very familiar and sorely missed, those songs were way too harmonically rich, their production too sonically dense. They're actually enjoyable again now, but it's strange that "Nowhere Man" is less than three minutes long. It seemed a lot longer a few days after CI activation. I tried listening to it two or three tortuous times, but knew right away it wasn't going to work. So I walked to the nearby library to look at audiobooks.

My father had been re-reading Walden before he died. I'd held on to his copy meaning to at least crack its cover, if not all of its secrets. But I hadn't taken the time to do either. Finding Walden among the Narragansett Library's audio books—knowing I had that old hardcover at home to read along with—felt like a sign from above.

It wasn't.

Like its ancient namesake pond, the 19th century tales in Walden are beautiful and deep. So it's probably best if their narrator doesn't sound like a 21st century robot chipmunk. Thoreau once said, "Read the best books first, or you may not have a chance to read them at all." A caveat for beginner CI users: Read along while listening to simple audiobooks at first, or you may not be able to listen for more than a paragraph or two. Returning to the library, I swapped Walden for The Witches by Roald Dahl. It was light-hearted. Its narrator used a few different accents which only sounded sillier in Early CI Robot Chipmunk English. Much better.

Fast forward back to the basement: those old boxes were heavy, literally and figuratively. At the very bottom of the pile was a mislabeled under-the-bed storage container full of sweeter memories: favorite cassette tapes from before I lost my hearing. Wow! There were a few thousand great old songs. And if I'm only able to enjoy hundreds and hundreds of them due to the inherent Lo-Fi of CI, that's still an amazing grace. I'm glad I hadn't tossed them out in a quiet fit of melancholy while still deaf.

Except for the sentimental things and the memories they trigger, all the information in those old boxes---the books and articles, the music on antiquated tapes, the obsolete technology of my land-line relay telephone, even my medical records—can now fit in a device smaller than one of those old cassettes. I was pondering that when the lights went out.

"Hey!" I yelled.

"Oops, sorry", I heard Emily shout from three basement rooms and a staircase away/ "I didn't know you were down there!"

Being able to hear my girlfriend's faraway voice didn't feel particularly special at the time. CI users grow accustomed to everyday aural miracles. It's only in remembering and writing it down now that I feel the weight of it, like a warm comforter on a cold night. I really should spend more time just being amazed.

"What are you doing?" Emily asked from the stairway.

"Looking for a cassette player," I replied.

Cochlear Implants and Adults with Congenital Hearing Loss –
It's worth considering!

My previous blog post described the process of expanding the boundaries of CI candidacy to include teenagers and adults who communicate with sign language, have minimal use of oral language, and little functional use of their residual hearing. The experience of providing cochlear implants to congenitally deaf adolescents refined our understanding of the different ways in which people benefit from cochlear implantation including subjective benefits that need to be evaluated using quality of life measures rather than more typically applied measures of language perception.

When the first congenitally deaf adult candidates arrived at our clinic, we already had experience in providing CIs to adolescents with congenital deafness. Although sometimes the motivation for teenagers was at least in part to please their parents, the interest of adults with congenital hearing loss in cochlear implantation was typically derived from a desire to improve their quality of life. Some of these adults had typically hearing spouses and/or children. Many struggled with academic and career issues related to their hearing loss. They wished to improve their ability to communicate with people with typical hearing—mainly by enhancing their speechreading. They wished to be able to perceive environmental sounds to a greater degree and to be more independent in their daily activities. Some expressed hope for understanding speech without speech reading, to be able to talk on the phone, and to enjoy listening to music. Some wanted to improve their speech intelligibility. They were excited about the benefits they might gain from the new technology and didn't want to miss the possibility to experience improved access to sound.

Some of those adults who expressed interest in CI had experienced important benefit from conventional hearing aids when they still had usable residual hearing; they hoped CI would advance access to sound as they remembered it. Most of these adults were involved in the Deaf community; however, unlike their teen counterparts, most were not concerned about social acceptance (or rejection) by the Deaf community.

While teenagers usually received ongoing support from their families (who attended mapping and auditory rehab sessions with them), adults were generally accompanied by a family member at the candidacy phase only and negotiated the post surgery rehabilitation process post implantation alone. Moreover, their ability to commit to a long intensive rehabilitation process, which might involve the loss of working hours among other things, was difficult.

Auditory stimulation prior to cochlear implantation is an important issue for adults with congenital hearing loss if they have not used amplification recently. The long-term lack of auditory amplification has to be taken into account when determining the appropriateness of CI, communicating realistic expectations, and providing appropriate rehabilitation.

Adult CI recipients with congenital hearing loss have benefited importantly from auditory rehabilitation provided weekly by an auditory rehabilitation professional. In my experience, some patients require support starting at the early stage of adjusting to the new auditory signal since they may experience the new sound as strange, unfamiliar or even unpleasant. The rehab professional can help determine whether the unpleasant sensations are within the normal range for a recipient's process of adaptation. In addition, s(he) can document progress and consult with the audiologist and surgeon.

Auditory training helps CI recipients learn to identify the differences between environmental and speech sounds and improve their listening skills. As recipients become more experienced, they often report hearing new environmental sounds, which is thrilling for auditory therapists as they witness the gradual development in their patients' listening attentiveness! Learning to recognize environmental sounds is an exciting experience that extends one’s world knowledge and improves a sense of involvement and orientation.

Adult CI recipients with congenital hearing loss can also learn to recognize some speech sounds. Recognition of specific speech sounds enables them to gradually acquire an auditory inventory of dozens of words and phrases. It is important to note that most of these recognition skills are restricted to structured and quiet rehabilitation settings. After a period of time, some of these recipients excitedly report that they are able to identify certain words and common phrases in real life situations (e.g., when their child calls Mom or Dad, when someone calls their given name, when co-workers greet them "good morning" or ask "What's up?" in a relatively quiet acoustical environment).

Another important achievement is continuous use of the sound processor. Many people with congenital hearing loss did not use their hearing aids consistently prior to the CI and others haven't amplification for years. The experience of continuous connection to the world of sounds can be an important benefit.

After several months, many CI recipients report enhanced speech reading and easier communication. They may report fewer requests for clarification, fewer misunderstandings, and an improved ability to understand people with imperfect or unclear speech. For example: "Suddenly I realized that I could speak with my young daughter's friends, who until recently had to seek my daughter's help when talking to me. Now they could communicate with me directly".

From my experience, CI rehabilitation goals for adults with congenital hearing loss typically do not include the improving the recipient’s own speech intelligibility nor achieving complete auditory speech understanding (based solely on the auditory modality). The rehabilitation of adults with congenital hearing loss focuses on:

• Taking advantage of basic acquired auditory skills in order to improve the perception of environmental sounds
• Facilitating oral communication
• Modifying old habits that often result in someone ignoring auditory stimulation, changing the pattern of behavior to more auditory attentiveness 

It is my feeling that post CI rehabilitation of adults with congenital deafness is like adding rungs to a ladder. In some instances, it can make the ladder more accessible for those who could have never before have climbed it. In other cases, it can make the climbing more pleasant and comfortable, thereby improving the climbers' opportunity to reaching even higher levels.

Good luck to you all.

Cochlear Implantation for Adults with Prelingual Deafness*

Deafness in Adults: Age of Onset Matters
Adult CI candidates who once had normal hearing and experienced hearing loss later, or had some degree of hearing loss in childhood that worsened over time, typically have spoken language skills including intelligible speech. In contrast, adults with congenital deafness (present at birth) who never derived significant speech perception benefit from conventional hearing aids, generally have less well developed spoken language skills. If they did not use amplification consistently, there is an even greater chance that their use of spoken language is more limited.

Despite the fact that the individuals in the described categories may have similar audiograms indicating bilateral profound hearing loss, their spoken language skills may differ significantly. Further, expected outcomes with a cochlear implant are also quite different.

Congentially Deaf Adults
The speech intelligibility of congenitally deaf adults may be poor. Spoken language may be hampered in other ways and listening ability may be quite limited. These CI candidates likely are unable to detect all speech sounds and many environmental sounds are not detectible. Many such individuals do not demonstrate spontaneous listening behaviors and will require speechreading and/or sign language, even in quiet. Repetition and a slower speaking rate may also be needed.

CI Outcomes for this Adult Population
In light of the above, it can be generalized that congenitally deaf adults will continue to need speechreading and/or sign language following cochlear implantation. Nonetheless, we cannot predict with certainty that they would not benefit from the auditory information they would derive from a cochlear implant. Some individuals with this hearing profile may even gain some open set listening with a CI.

Although cochlear implantation has advanced dramatically, device outcomes are impacted by many factors including patient characteristics. In assessing candidacy, it is important to consider:

• What are your expectations? Can a CI help you to fulfill some or most of these expectations?
• Will you undergo rehabilitation to help you realize potential benefits? 

With regard to rehabilitation, it is important to both follow through and find a means to customize a program to meet the person’s specific needs—both subjective and objective outcomes. Assessment of outcomes should include a range of possible benefits including access to speech, one’s own spoken language, environmental sounds and music. Changes in life circumstances may also affect communication needs. Such changes may include, for example, living with parents versus living independently; mainstream educational settings as opposed to supportive settings; moving into a workplace that does not fully accommodate hearing loss.; or expanded social interactions with a greater range of people.

A broader appreciation of possible benefits allows one to assess CI outcomes more accurately, particularly for this group of adults. Therefore, a consideration of CI candidacy should be undertaken without preconceived notions regarding potential benefits of the intervention on someone’s quality of life.

Our ability to understand this complexity is key to defining needs, goals and rehabilitation strategies which may augment the opportunity for a prelingually deaf adult to realize the full benefit of a cochlear implant over time.

In the next post we will discuss these potential benefits.

* Prelingual hearing deafness is defined as hearing loss present at birth or prior to the acquisition of language.

Part 2: Experiences of Older Deaf Children Using Hearing Aids

In the mid 1990s, parents of older deaf children observed the benefits of cochlear implants for young children. Many deaf children were using hearing aids with minimal benefit and were struggling, sometimes in mainstream classrooms. The negative impact of the child’s hearing loss on academic progress became more evident as the children moved into upper grades.

Parents recognized that communication and educational support typically decline as children get older—despite the fact that academic and social activities become more challenging. Though their children were not the ideal age for cochlear implantation, parents felt that their children deserved the opportunity to try new technology that could enhance communication and quality of life. The children themselves typically shared their parents' dreams. Many were integrated into mainstream school settings and experienced their hearing loss as a significant disability that CI could potentially mitigate, at least partially. Many CI teams, however, had concerns about making the intervention available to this population. It was clear that in order to achieve maximum benefit, older implanted children would need to be enrolled in intensive auditory rehabilitation programs designed to address their unique needs.

What have we learned from these later implanted pediatric recipients?

We learned that the speech perception skills of someone who is prelingually deaf and later implanted is a key indicator of expected auditory skills post CI. We also confirmed the effect of age at the time of CI as a key parameter in other auditory outcomes. Children who were implanted at a later age differed significantly from children who were implanted at an early age in various aspects including the course of the rehabilitation process, the pace of progress, and the eventual outcomes.

We also learned that later implantation can facilitate progress in communication skills. Over time, many of these older children experienced significant improvement in their communication function. Some gradually changed their communication habits from using primarily visually based communication with little meaningful auditory information to an auditory supported method of communication. Long term outcomes included enhanced speech reading including understanding speech without visual clues in certain situations, better speech intelligibility, music appreciation, increased ability to understand speech on the telephone, and improved perception of environmental sounds. Parents reported that their children were more self-confident in various social situations and functioned more easily in their regular classrooms.

Interest Increased from Families

Due to the positive impact of later implantation for mainstreamed children, we saw an increase in interest in CI from this population. Typically, candidates were children and adolescents who attended special classes for children with hearing loss. Many students communicated using sign language—either sign alone or total communication. Many had significant spoken language delays of 4 years or more and some had disabilities in addition to their hearing loss.

This new group of candidates challenged CI teams in many ways. Not only were they thought to be "too old" to benefit from CI, their oral language skills were often poor. There were questions regarding their ability to enhance their auditory abilities when their communication mode was not based upon listening and spoken language. There were also concerns regarding whether they would be sufficiently motivated to complete the needed intensive rehabilitation that would likely take many months, or even years.

The decision on whether a child was an appropriate CI candidate was even more complicated in instances in which there were additional disabilities. If candidacy was approved for a child with additional disabilities, it was critical that the family had realistic expectations regarding likely outcomes and the need for a unique course of follow-up rehabilitation. Clinicians and family members together needed to collaborate to build realistic rehabilitation goals. We also needed to gain the support of the child’s educational team and ensure that the classroom environment would be supportive.

In the program where I worked in Israel, we initiated efforts at the national level with the Ministry of Education to increase the educational support and rehabilitation resources provided to students with cochlear implants. We communicated and coordinated with school staff to establish a collaborative process during the candidacy evaluation stage and throughout the rehabilitation process. We visited schools to meet not only with educators, but also with a child’s classmates. We adopted an approach of acceptance and respect for the use of sign language. The message conveyed by the CI team regarding use of sign language by candidates and their parents was that CI does not exclude the use of sign language. For these later implanted children, it was important to encourage the children's continued use and further development of sign language skills. Accordingly, professionals from the CI team used signed Hebrew along with spoken language (total communication) with these candidates and CI users.

What insights have we gained from these later implanted children?

We learned that the amount of auditory language that an older candidate already has in place, as well as the frequency of using such language, is a factor in determining CI outcomes. Motivation is a highly influential variable regarding participation in CI rehabilitation. The CI recipient's cooperation with the rehabilitation demands and their willingness to take on proper maintenance of the CI cannot be taken for granted with older children or adolescents. Given the later age, cochlear implantation may conflict with their identity relating to hearing loss; such conflicts must evaluated to determine an appropriate path forward. Teenagers must address which community they identify with and whether a CI will present identity concerns. Do they identify as having hearing loss, being part of the Deaf community, or being part of a new paradigm allowing them to be deaf but functioning within the hearing world with CI?

Auditory rehabilitation is essential for progress; a lack of consistency in their auditory training program can interfere with progress. We also learned that collaboration between the CI team and the educational team is critical to the progress of the older child or teenage cochlear implant user.

Beyond all of the complexities and challenges, we learned that CI provides significant benefits for this group of candidates!

Important Benefits in Older Children Changed Minds

Implanted teens and children with the above age and communication characteristics were able to identify many environmental sounds and their awareness of auditory stimuli in their environment improved significantly. They reported meaningful enhancements to speech reading. In many cases, following intensive long-term auditory training, they were able to understand simple sentences without speech reading. This ability was usually restricted to quiet conditions, certain speakers, and short sentences on an identified topic. However, this was a groundbreaking experience related to auditory comprehension. Some of older recipients were able to reply to simple questions and react spontaneously to greetings in everyday situations. Some even managed to talk on the phone with their parents, usually when the conversations were relatively structured and on specified topics. Most of these recipients used their device regularly and were positive regarding their decision to pursue a cochlear implant.

With these insights, CI clinics began to open up their programs to this new population of older children and adults. This required a new approach for follow-up rehabilitation, which will be addressed in future posts.

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Quality of Life Benefits Are Not Just About Speech Perception Scores

Although the improvement in quality of life correlates with the improvement in speech perception, it is important to note that it is not restricted to a certain objective level of speech perception skills. Even people with relatively "poor" auditory skills can experience meaningful contributions to their quality of life.

The following examples illustrate two CI users who differ in their auditory functioning. Both are satisfied with the contribution that a CI made to their quality of life.

One person is grateful that the CI allows her to feel safer and more oriented to her surroundings. She wrote:

"I gained the ability to hear a variety of sounds and use them daily. I especially appreciate my ability to understand invisible sounds. The CI made a huge change in my life as I now can rely more on hearing and less on sight and touch. In the past, when I locked the car I've always been trying to open the door in order to check if it is locked. Today I don't need to check anymore. I can be at home on the second floor and figure out that my husband is washing dishes downstairs without seeing him. I can hear my children fighting and go to stop them. Before I had the implant nobody stopped their fighting." 

The other woman, who previously worked as a director of a large company, reported on a huge improvement in her ability to cope with group meetings. She is able to talk on the phone with family and friends, she can follow some TV programs (without captioning), and she enjoys listening to music.

It is clear that these two examples represent women with different auditory abilities, pre and post implantation. Yet, both of them use the CI regularly (even when they are at home alone). They both experienced an improved sense of well-being and significant benefit in daily situations in which they previously struggled before they received a cochlear implant.

Assessing Your Quality of Life Changes

To assess the contribution of the CI to your quality of your life, you might ask yourself some question comparing your pre-implant feelings to your current situation post CI. For example, before receiving a CI:
  
• What were the reasons you pursued a CI?
• In what ways has your hearing disability limited your daily life?
• Which specific situations were difficult for you to cope with before the implant (i.e., at home, work, or with certain people).
• Did you avoid certain situations and why?
• What strategies did you use in order to cope with these difficulties?
• Did you experience any stress or depression due to your hearing disability?

Now, post cochlear implantation, consider the following:

• Do you enjoy listening with your CI?
• Do you feel there is enhancement in communication (hearing, speaking, and speech-reading)? Can you define these situations?
• Do you feel more comfortable in social and communicational situations that used to be stressful prior the implantation?
• Do you feel more self-confident to do things you did not do in the past?
• Do you feel more independent?
• Do you feel that you have achieved the goals that you set for yourself prior to implantation? Which goals have already been achieved? Which goals have not yet been achieved?
• Are you satisfied with your CI?

Focusing on benefits can be a very empowering, constructive, and supportive method of action that may contribute to your perception of improved quality of life. Some studies note quality of life improvements as early as 9 months post implantation. However, the auditory outcomes continue to improve for the first few years. It is important to view the improvement in quality of life as a long-term process and expect the growth of benefits resulting from your CI to be reflected in various aspects of your life over time.

Further Reading:

Loeffler C et al. 2010. Quality of Life Measurements After Cochlear Implantation. The Open Otorhinolaryngology Journal, 2010, 4, 47-54 47 1874-4281/10. Bentham Open Access

Zaidman-Zait A. 2010. Quality of Life among Cochlear Implant Recipients. In: JH Stone, M Blouin, editors. International Encyclopedia of Rehabilitation.

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Emotional Impact of Cochlear Implantation

How does cochlear implantation impact people on an emotional level? Though it is difficult to find empirical data documenting the emotional effect of cochlear implants on adult recipients, this is an extremely important issue. How can one find information about emotional effects? One source is the abundance of online videos documenting the first moments of hearing after CI activation. In addition, there are published studies that assess quality of life benefits for adult CI users.

Most CI candidates and their families view videos posted on the Internet documenting the first sounds and words heard by adults and children at activation. Watching these videos, one can witness the tremendous excitement of the recipients and their families—often expressed with tears of joy and relief. Studies examining the effect of CI on adult quality of life document that there is general improvement and satisfaction over time.

But what happens in between? Relying on these two sources of information (i.e., videos and quality of life studies) might lead to the impression that the timeframe following CI is characterized mainly by a great happiness and that once a cochlear implant is activated, individuals experience a continuous increase in your quality of life. However, many CI recipients know from their personal experience that the reality is much more complicated. My experience with many adult CI users, has taught me that not everyone experiences the same level of joy when the implant is activated. Importantly, for some people, the first period of CI use is characterized by significant emotional challenges.

Let's start by stating the obvious; severe to profound hearing loss is not a life threatening condition. Adults' motives are not linked to health conditions in the same way that many other surgeries are but rather are driven by a desire for a better quality of life. This includes improved communication with family members and in the as well as better environmental orientation. These hopes may be dashed in light of difficulties that arise initially. The challenge of adapting to the CI and the gradual—not immediate—acquisition of auditory skills can cause intense emotional distress and disappointment. Emotional difficulties may be experienced by adults with wide-ranging hearing histories. In this post, I would like to share some experiences that I have witnessed.

Recipients Who Experienced Progressive Hearing Loss

People who lost their hearing progressively later in life might experience the sound provided by a CI as unpleasant (not "natural") and their speech perception via CI might not meet their expectations. They might not accept the time required to adjust to the CI. Their wish is to experience normal hearing again. It will take them some time to acquire improved hearing skills and to accept that their CI cannot provide normal hearing. Someone who lost their hearing later in life may be disappointed when their auditory progress does not occur as quickly as they had anticipated.
It may appear that people who had progressive hearing loss have the least need for auditory rehabilitation given their prior auditory perception. On the other hand, such recipients may experience high levels of stress. They may derive special benefits from an auditory therapist who can help them to recognize their achievements rather than dwelling on their difficulties. A therapist can also help the new recipient understand the gradual nature of the rehabilitation process, provide answers to questions and help them remain positive about the process.

Recipients with Usable Residual Hearing in One Ear

People who have usable residual hearing in their non-implanted ear may feel that the hearing aid continues to provide the dominant hearing information during the initial timeframe after activation while the implanted ear provides less usable information, even to the extent that information from the implanted ear interferes with speech understanding. Auditory training improves the implanted ear auditory abilities as well as contributes to the CI users' faith in the potential auditory benefits of the implanted ear. The concern is that people with functional hearing in their non-implanted ear do not continuously use their implant and may not give their implanted ear sufficient opportunity. An auditory therapist can help such recipients to maximize the benefit from the sound from cochlear implant and merge the two sources of sound.

Prelingually Deaf Recipients

This group includes people who never experienced normal hearing and must learn to adjust to entirely new auditory stimulation. During the first period after implantation, the auditory information they receive may be incomprehensible and may be perceived as disturbing noise. The silence that engulfed them before cochlear implantation is gone and they are exposed to many sounds without the ability to distinguish or choose which sounds are worthwhile to focus on. These recipients may struggle to acquire basic auditory skills such as identifying environmental sounds, speech sounds, and words and phrases. They may also need to learn about the impact of various acoustic environments on speech perception.
Prelingually deaf recipients who come to CI may also need to learn a good bit more about spoken language communication. During the rehabilitation process, CI recipients are gradually exposed to new sounds and they expand use auditory information in their daily life. This is a fascinating journey in which CI users' experience auditory learning and growth, however they also become more aware of their past and present limitations. This rehabilitation process requires emotional strength and support.

Concluding Thoughts

It is important to remember that the course of adjustment and rehabilitation is very personal and there are various possible scenarios relative to one’s emotional adjustment. Every scenario is legitimate and should be accepted sensitively and patiently by the CI recipient’s family, their CI team, and by the CI user himself. One’s emotional reaction is not predictable. It is affected by a variety of personality factors and by the course of the auditory learning as well as the support from the recipient’s family, social environment, and his or her CI team.

Recommendations

If you are experiencing emotional difficulties arising from cochlear implantation, know that you're not alone. Like many other starts in life, the beginning of the path can be difficult but it does not necessarily imply the future and there is no reason for despair. Remember how brave you were choosing to go through the surgery. Continue to have faith that your dreams for a better quality of life will eventually come true. As explained in this and earlier posts, CI rehabilitation is hard work.
In addition, CI rehabilitation is a very dynamic process that requires emotional adjustment skills, flexibility, positive thinking and faith in yourself and your CI team. If you feel that the process of adaptation to the cochlear implant is an overwhelming emotional burden, please seek professional support. You can contact your CI team and seek the appropriate assistance.

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Adult CI Support Groups: Linda Daniel Guest Blog/Part 2 

The Adult CI Support Group at HEAR In Dallas has a few other goals and purposes. We do not have captioning at this time for several reasons. First, captioning services are costly and there are no dues for the group. Second, everyone who attends is working on listening and communication skills along with learning to advocate for themselves. During the sharing, participants are encouraged to raise their hand and request clarification when needed or state what would help them such as “Could you please speak a little slower?” or “Could you please take your hand away from your face?” The group is a safe and understanding environment for practicing these strategies and allows participants to build skills and courage to do so “out there.” We have had hearing health professionals attend as well; they share their questions and concerns about interacting with individuals with hearing loss and the participants are gracious in coaching them in how they can be more sensitive to those they serve. The two-way sharing is such a beautiful and touching experience for all.

Excerpts from One Group Discussion
At one meeting, I posed these questions to the group: “Why do you come to the support group meetings? What do you get from it?” As they took turns sharing, I recorded their comments. This is a summary of what some of the participants shared.

FT—42 year-old man, post-linguistic progressive hearing loss, years of hearing aid use, and then CI 5 months ago

I was rather by myself just by being male then I became isolated even more as my hearing deteriorated. I didn’t admit I had a hearing deficit, which just made me more isolated. With hearing loss, there is so much unknown to experience – everything is all new ---and it’s good to be with people who are struggling like me. I now know I’m not alone in the struggle—we are struggling together. I come here to feel community and meet people who can sympathize and empathize with what I’m going through. This group is unique because we come together to support each other; the other group I’ve been to is a lecture-based group but does not provide the personal closeness and sharing of this group. I am grateful to hear from people who have had a CI for over 20 years share their experiences; I’ve had mine just five months. I learn so much from people at all stages of the journey.

RB--congenitally deaf, lifelong hearing aid user, CI and AR in her 30’s

So many CI users don’t feel Deaf and don’t feel Hearing. We’re in between the two groups. With the support group of people in the same situation, I now see that we can have a sense of belonging. We are a group—we do have a community: we are the group in between Deaf and Hearing! I also benefit from this group because we strive to strengthen our self-advocacy skills. I hear what others have done to advocate for themselves and it gives me the courage to try it myself. I feel so empowered when I break through one of my barriers. We’re learning to speak up for ourselves in the group…we tell each other is we can’t hear them, if they talk too fast or too soft. This helps me do this too in other situations that come up in life!

PS—55 year-old woman, post-linguistic progressive loss, years of hearing aid use, will get CI soon

I don’t have a CI yet and I’m amazed at the bravery I’ve heard from everyone’s sharing tonight. I’ve read tons of things about CIs but at the group, these are REAL people who have them and I feel honored to meet people who have the strength to go through this. My supervisor at work told me the most unbelievable thing that showed me how completely she does not know what my hearing loss is about and why I need a CI. She actually told me if I didn’t stress out, my hearing would come back. In the group, people showed me their reality with hearing loss and validated my experiences and my needs. These people have experienced what I am going through. With a hearing disability, we need so many people to assist us with so many things. It gets so awkward going through life misunderstood or being looked at like there’s something wrong with me.

BV—50 year-old woman, post-linguistic progressive loss, years of hearing aid use and recent CI

I came to the group originally because I wanted to meet a new community that has the same issues that I face as a CI recipient. I keep coming back because of the wonderful people I have met. Seeing all the bravery and courage makes me glad to come back. We talk about snags in our daily lives such as how to order food at a drive-through. It’s a frustration hearing people just don’t understand but the people in the group know what it’s like! Though we are all different in many ways, we all have a core of similar experiences. We give each other tips to handle life experiences. I also like this group’s FB page. We can throw out any question we want and others will respond and I get so many answers to read and see which one will work for me. When you’ve felt “different” for so long as a person with hearing loss, it’s great to feel the “same” as everyone in the group. It’s a great feeling and I take that feeling with me when I go home.

FE—30 year old woman, deaf since four years of age; years of hearing aid use, CI two years ago

I don’t always want to explain my CI to everyone over and over and deal with all the misconceptions about getting a CI. I’m lucky that I work in the field of deaf education because I’m around people who understand hearing loss. In the support group, I feel “power in numbers!” I get strength being with people who have CIs. I learn something new every time I am with people who have CIs. Deafness is The Invisible Handicap; hearing loss is very misunderstood. In the group, everyone understands how I feel. It reinforces that there are not CI “successes” and “failures.” Rather, there are a range of experiences and differences. Hearing what everyone goes through helps me count my blessings. The grief still comes back with the denial and the sadness and the group is where I know people understand how I feel.

GT—20 years old, congenitally deaf, CI since 2 years of age with Auditory-Verbal Therapy

I wanted to meet people like me so I could make friends with people who know how I feel. My mom is in the field of deaf education and even she can’t fully understand what I’m going through. But meeting others who have CIs, I feel they really understand what I’m going through. It’s nice to hear that I’m not the only one who struggles in a drive-through and who pretends to understand what someone says when I really don’t. Sometimes we laugh when we share the crazy things we ‘mishear’ during our day and what happens because of that! One lady shared that she nearly got fired when she told a co-worker something about a person in the office that she thought she heard but it wasn’t even close to right! We gasped, then laughed and nodded our heads, knowing how easily that can happen.

FS--deaf since age four; years of hearing aid use, CI in her mid-30’s

Before coming to the group, I though I was the only person with a hearing loss. I am the only person in my family who is deaf. The first time I came, I saw so many people like me and I was so excited. I love sharing experiences with each other, learning from each other and teaching each other about different devices. As much as my family loves me, they just don’t know how to support me. With the support of the group, I don’t expect as much from my family. I love this group—I come every time. I want to be independent. I don’t want my husband to have to be my ‘hearing’ for me all the time. One professor I had in college told me about the Disability Office and I found out about CART (Computer Assisted Real-Time Captioning). That was such a big step for me to be independent. This group helps me feel so much better and helps me know how to navigate life situations on my own.

Adult CI Support Groups: Linda Daniel Guest Blog /Part 1

After decades of working with children with hearing loss, HEAR In Dallas, my aural rehab private practice, now serves many pre- or post-linguistically deafened adults who have elected to pursue a cochlear implant. As I worked with them and listened to their experiences and struggles, I thought they would greatly benefit from meeting others in
Similar situations. One by one, as they came to therapy, I asked if they were interested in my starting a support group; each person answered “Yes” without hesitation.

I am a rehabilitative audiologist and host the group once a month in the evening in my office. We just finished our 7th month of meetings. Typically about a dozen CI users attend, ranging from college age through older adults. Though their ages and life stages are different, they feel great comraderie with one another as they share their joys and
struggles as people with hearing loss living in the mainstream of society. I function as the professional advisor of the group and attend every meeting.

In addition, I am the “ears” of the group. During our time together, if someone makes a comment or asks a question and it appears that they misheard the previous person’s comments, I clear up the miscommunication. We usually meet for 1 1/2 hours. If there are newcomers, we go around the circle and provide brief introductions—name, duration of hearing loss, when implanted. Then I state the topic of the evening such as “What I like most about my CI” or “My greatest struggle with my CI” or “What this group means to me." Meeting topics are solicited from the group for future meetings. We sit in a circle and everyone takes turns sharing. We pass a timer and each person sets it for three minutes before starting to share; the format is relaxed and interactive. The timer is a guide for an approximate time to share; after a person shares, others freely comment or ask a question of that person. They love their individual time to share and the free-flowing interaction and comfortable nature of the format. There is no advice giving, no discussion of the hearing health professionals, no promotion of device manufacturers. The primary goals are meeting others with a CI, sharing one’s experiences, dialoguing with others on topics of interest, gaining strength and learning tips from one another, and feeling a sense of belonging and community.

Excerpts from One Group Discussion
At one meeting, I posed these questions to the group: “Why do you come to the support group meetings? What do you get from it?” As they took turns sharing, I recorded their comments. This is a summary of what some of the participants shared. I will include additional participant comments in my next blog post.

RV—26 year-old woman, hearing aids fitted at 15 months and started Auditory-Verbal Therapy, then received a CI at age 4

Even though I’ve had a CI since I was 4, I have never been to a CI support group. I go whenever I can because I meet other people with cochlear implants and communicate with them without worrying what others think of me. In one meeting we talked about how others treat us differently and the misconceptions they have about us. It’s funny and sad at the same time what people say to us; it’s as if they don’t give a thought to how we feel before they start talking. One woman was at a party and the hostess told her, “You can go sit over there with my grandpa: he’s deaf too.” Come on! Really? We laughed and shook our heads; we all could feel what she felt. I take our group strength and solutions with me into my daily life in the hearing world. If you are struggling with your hearing in the hearing world, “This is definitely where you should go!”

SJ—39 year-old woman with congenital hearing loss, no intervention until CI and AR a year ago

The meetings have been a wonderful opportunity for camaraderie with people in similar situations. It has helped me feel not so alone in my experience with hearing loss. Nobody in my daily life has any understanding of my life before and after the CI. Being able to share my story with like-minded people.

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Thoughts about Unilateral Hearing, Unilateral Cochlear Implantation, 
and Bilateral Cochlear Implantation

During the early days of cochlear implantation, the procedure was performed in one ear only. Some users continued using their hearing aid in the non-implanted ear, sometimes with little benefit. Some CI users even noted that that their hearing aid might be interfering to some degree with their speech understanding but continued to use amplification to keep their residual hearing active in the event that they were able to benefit from future technology.

Growing awareness of the disadvantages of unilateral hearing loss and the benefits of bilateral hearing led, to two important changes relative to cochlear implantation:

1. Bilateral implantation became a rehabilitative path chosen more for both adults and children;
2. Criteria for implantation expanded to include people with some functional hearing in the non-implanted ear (e.g., moderate to severe hearing loss with some open set speech recognition). 

Appropriate candidates benefit from the advantages of bilateral hearing when using a conventional hearing aid in one ear and CI in the other. We'll talk about this topic in another upcoming blog post.

This blog post is directed mainly to those who have one CI—either those who do not use a hearing aid in the contralateral ear or those who use a hearing aid in the other ear but derive minimal benefit. Unilateral hearing should be considered in the context of the following questions:

• What are the disadvantages of unilateral hearing?
• What are the benefits of bilateral cochlear implantation?
• When should someone choose to "go" bilateral?

The answer to the last question should be made on a case-by-case basis considering factors such as functional hearing in the non-implanted ear, years of hearing deprivation, and the person’s age. There is no conclusive answer that applies for all individuals. However, we can discuss the different effects of unilateral hearing on communication function as well as the advantages of bilateral cochlear implantation.

There is no doubt that unilateral CI can significantly contribute to one's auditory skills and quality of life. Many environmental sounds and speech sounds become accessible for unilateral CI users and a significant improvement is usually experienced in speech perception, especially in quiet conditions.

We have learned from those with normal hearing in one ear and hearing loss in the other ear, as well as the experience of people using one cochlear implant, that unilateral hearing imposes limitations for various situations in everyday life. Children with single-sided deafness, who have normal hearing in one ear, are at risk for lower language performance as well as social and academic difficulties. Many of these children report fatigue during class and difficulties in coping with school requirements. Adults with single-sided deafness may also experience difficulty in social settings, inattentiveness, stress, and headaches. Evaluations of people with normal bilateral hearing point that hearing with two ears contributes significantly to speech understanding, especially when listening to speech in noisy environments.

The challenges of unilateral hearing are due to reduced auditory ability in the following types of situations:

1. Speech is directed to the side of the "poor" ear;
2. Individual has difficulty knowing the speaker’s location to aide speechreading;
3. Detection and understanding of soft sounds as two ears provide “redundancy”;
4. Understanding speech in noisy situations.

Unilateral CI users often report on similar difficulties. Yet we cannot consider single-sided deaf individuals and those with bilateral hearing loss with one CI as one and the same because a cochlear implant does not provide normal hearing. Therefore, the difficulties of unilateral CI users are typically greater compared to those of people with normal hearing in one ear. 

These considerations are at the heart of why we should closely examine the potential benefits bilateral cochlear implantation for everyone. So, what can we learn from the literature? We find research focusing on adults' auditory function with one CI versus two CI's (i.e., how their function changed with a second CI). We can also find research comparing the function of adults who have unilateral CI with adults who have bilateral CI. A review of 20 studies* highlights the following key findings: 

1. Speech perception in quiet. There are no consistent findings of bilateral advantage over unilateral CI use.
2. Speech perception in noise. Studies consistently demonstrate the benefit of two cochlear implants over one and these advantages increase as the acoustic conditions worsen.
3. Localization. Studies demonstrate the benefits of bilateral hearing to identify the location of a speaker or environmental sounds.
4. Daily activities and quality of life. Self-reported questionnaires found bilateral CI benefits for spatial hearing, ease of listening, quality and clarity of sounds, and social interactions. These findings suggest that bilateral cochlear implantation has real potential to enhance communication and orientation, reflected in various daily situations, and thereby improving quality of life.

As is the case for an initial cochlear implant, the decision on a second CI is affected by various parameters beyond the patient's motivation to take another step towards better hearing. There are pros and cons that are unique to each person. If you wish to consider a second cochlear implant, the recommended first step is to consult with your CI team. Realistic expectations are important. While there is the potential for quality of life improvements, it is important to recognize that bilateral CI will still not provide normal hearing. Further, one must consider that there are rehabilitation requirements in order to maximize outcomes with the second CI and that this is essential to your success!

*Van Schoonhoven J, Sparreboom M, van Zanten BG, Scholten RJ, Mylanus EA, Dreschler WA, Grolman W, Maat B (2013). The Effectiveness of Bilateral Cochlear Implants for Severe-to-Profound Deafness in Adults: A Systematic Review. Otology & Neurotology, 34 (2), 190-198.

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Using Recorded or Other Materials in Self-Learning Rehabilitation

• Using written materials will be more effective if you are able to be creative and adaptive in their use. In addition to repetition, be aware of the appropriate speech rate of the stimuli presentation. You can use the same stimuli in a more normal (higher) speech rate with time, as your speech perception skills improve. Similarly, you can use more speech-reading (lip-reading) cues during the first period of training, moving towards auditory-only perception with time. Another way to adjust the existing materials to your needs is to add stimuli that have specific relevance to your life. For example, you may include the names of your relatives and friends, common sentences from your everyday life and so on.

• Recorded materials are typically more difficult to understand than live voice and may pose greater auditory challenges. You may find recorded materials to be overly challenging during the early rehabilitation timeframe. If this is the case, try using them later when you are a more experienced CI user. Not every CI user has a positive experience with recorded materials so don’t feel that using them is a requirement. Adjust auditory training materials to your own auditory abilities.

• There are a number of interactive rehabilitation programs that run on one’s personal computer and are designed to help cochlear implant recipients practice and improve their listening skills. Some of these products are free including Angel Sound™ Tiger Speech available at http://angelsound.tigerspeech.com/.

• If you wish to develop your appreciation of music, practice listening while reading the lyrics for songs. These can typically be downloaded from music websites. You may wish to begin with children’s songs—which often have simple words, a strong beat and a limited number of instruments. When you feel you can move forward, build a hierarchical list of songs considering certain parameters. These parameters might include tempo, quantity and type of instruments, single vocalist songs versus multi-vocalist bands, etc. Even people with normal hearing are unable to understand every word in every song. Be selective about the songs you are choose and don't be surprised if you miss some words. It’s not a competition! You might also check out the websites of the CI companies for more tips and music listening products.

• When watching TV, try following some speakers without using captions.

• Talking on the phone presents special challenges and will be discussed separately in a future blog posting.

• Establishing and expanding auditory memory skills can have important implications for your ability to understand speech. The longer you had poor discrimination with your hearing aids, the longer and harder you must work on your auditory memory skills. This kind of work can be done using repetition tasks utilizing lists of words (e.g., repeating 2-5 words out of 10 word list). As your speech perception skills improve, you can use words from a given category (e.g., names of cars, football players) or a given topic (e.g., work, summer, vacation). For advanced CI users, you might repeat 2-3 sentences from a list of short sentences or work on perception of two-phase instructions (e.g., "Take your shirt and put it under the table") or listen to a short story and try to recall as many details as possible.

• Report specific difficulties in speech perception to your audiologist (e.g., the consonant /z/ perceived as /s/ and vice versa). Some difficulties may be resolved with mapping adjustments. Most will be resolved with CI usage and auditory practice. It is possible that you will not be able to identify all the consonants and vowels. However, it may not impede your communication interactions since people always use context combined with verbal information to understand speech.

In summary, there are many ways for you to improve your auditory skills outside of a formal rehabilitation program with a trained professional. The above is intended to give you ideas; your CI team may offer additional guidance. The world of sound surrounding us provides countless opportunities for auditory learning. It requires your attentiveness and dedication as well as constructive support from your family and friends. However, if there are emotional or other difficulties associated with adapting to your cochlear implant and the rehabilitation process, don’t try to do everything alone. Reach out to the appropriate professional for support in getting back on a positive track.

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Practical tips for self- learning auditory rehabilitation

• In the absence of speech language therapist to help manage the rehabilitation process, you are the case manager of your own rehabilitation. This is an important responsibility with many implications.

• First, you will need to pursue available professional resources yourself. Ask questions of your mapping audiologist and don't wait until your next meeting if you need answers. Immediate answers can be crucial. Report any changes in your hearing or other issues to your CI team.

• Ensure that you understand how to maintain and use your processor. The recipient kit comes with different accessories. You might not need them during the initial period of using your CI, but later on they can be very useful. Ask for professional guidance to enjoy the full benefits of your technology.

• Use your CI regularly throughout the day. If there are any restrictions or difficulties in your CI daily use, inform your audiologist and look for suitable solutions.

• Knowledge can be a great source of strength. In order to acquire this knowledge, participate in lectures and conferences, read professional papers and books, visit the online website for the company that manufactured your device, and stay abreast of technological improvements.

• Online CI users groups can provide you with many practical answers as well as emotional support.

• Document your hearing follow-up outcomes and ask your audiologist to explain any changes.

• Offer to participate in research at your CI center. This could provide you with additional knowledge as well as additional opportunities to meet and talk with the CI team.

• Be optimistic but realistic about your rehabilitation goals. Discuss your goals with your audiologist. Setting realistic rehabilitation goals is often the key to a sense of accomplishment and success.

• Be aware of the fact that spontaneous auditory learning during natural situations is not always possible. Typical everyday (noisy) acoustic conditions mask parts of the speech signal. In addition, natural communication interactions include a lot of inaccessible speech information (e.g. multiparty conversations, classroom situations, group meetings, and so on). Therefore, especially in the first period of your CI experience, you need to set aside time in a favorable setting to practice your hearing skills.

• Ask family members and friends to help clarify sounds. Choose one person to be your auditory trainer. If possible, this person should accompany you to as many meetings with your CI team as they can to help motivate you to acquire auditory skills. It may require lots of patience on their part for the repetitive practice required for success. They will also want to be there when you wish to share your concerns and frustrations. From my experience, these partners experience high levels of satisfaction and gratification for your trust and for the chance to be a part of such an important phase of your life.

• Know that auditory learning after cochlear implantation is a long-term process, characterized by changes in objectives and in the pace of progress along the way. We will discuss this issue in the future. However, for now, it is important to note that efficient auditory learning should become part of your daily life. This is not a short-term effort, but a long-term commitment.

In my next post, I will share information on specific recorded and other materials that you may find useful in your auditory self-learning rehabilitation program.

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People sometimes ask about the need for adult auditory rehabilitation after cochlear implantation. How can one teach hearing? Are there special speech and language therapists who work with adult CI users? Is adult rehab really necessary?

Such questions, together with a belief that modern cochlear implant technology is sufficiently robust to allow the auditory learning process to happen on its own, sometimes discourages adult CI recipients from seeking appropriate auditory rehabilitation after implantation.

There are people who acclimate to the sound provided by a cochlear implant relatively easily and some even note that their auditory learning proceeds rapidly and smoothly.  Often they are individuals who had normal hearing for most of their lives and experienced relatively short periods of bilateral deafness. Such individuals may be well served with periodic mapping sessions and being able to direct questions to their audiologist with no additional rehab support.

Other people find that they need guidance in learning to understand the auditory signal provided by their newly activated cochlear implant. Some feel that their speech understanding is restricted to certain situations (e.g., people who speak clearly and at a slower pace, quiet one-on-one environments). Some people may understand speech, with time, in specific communication situations and using strategies, such as prior knowledge of a topic, content cues or context. However, when they are exposed to new words (for example, names of people) or to terms not used frequently, these strategies may not work for them and they may have difficulty perceiving speech sounds. Another group of CI recipients who may derive benefit from auditory rehabilitation are those who experience the new auditory signal as an almost meaningless blend of sounds. Some people even find that the new sounds disrupt their prior speechreading ability.

The support of an expert in the adult hearing rehabilitation process can help address all of these issues. We can also describe this process as guidance in finding meaningful footholds in the presence of an abundance of auditory data.

It is well accepted that people can improve their physical fitness with the help of an expert who takes into account one’s physical abilities and lifestyle and then customizes an exercise program appropriate for one’s age, fitness and agility. Similarly, an auditory therapist can suggest training activities appropriate for your hearing history, communication skills, and lifestyle. A therapist can help you with a hierarchical auditory training program that includes exercises that consider: (1) type of auditory task (e.g. detection, discrimination, understanding and auditory memory); (2)linguistic content (e.g., monosyllables, short/long words, sentences, every day spoken language versus more formal written language); and (3) presentation method of the auditory stimuli (with or without speech reading, rate of speech, recorded or live speech, telephone).

Adaptation to a cochlear implant is a dynamic process. While adapting to new hearing aids can take a few weeks or even months, hearing access after cochlear implantation changes dramatically immediately and during the first few months and continues to improve during the first few years after cochlear implantation. Therefore, the rehabilitation goals vary according to the individual’s hearing history and where (s)he is in the process. The rate of progress and rehabilitation goals differ between CI users due to various parameters including previous use of hearing aids, amount of residual hearing, non-implanted ear functional hearing, spoken language skills, daily use of spoken language, age, physical condition, additional disabilities, cognitive state, family support, and motivation.

Short term rehabilitation goals:

One of the first short term rehabilitation goals for CI user "A" might be establishing the ability to detect speech sounds while for CI user "B" a first rehabilitation goal might  be discrimination between speech sounds. At a later stage of rehabilitation, one of the rehabilitation goals for CI user "A" might be recognition of two-syllable words (presented in a closed set of 3 to 4 words) and for CI user "B" the goal might be to understand short everyday sentences on a given topic (presented in a relatively slow speaking rate with repetition as needed).

At a more advanced stage, the goals for user "A" might include enlarging the sets of two-syllable words presented in recognition tasks, moving towards the ability to identify and understand words from a given category and recognition of short everyday sentences (presented in a closed set of 3-4 sentences). For user "B" the goals at a more advanced stage can include understanding short everyday sentences and expanding auditory memory skills (3-5 words presented in a closed set of 10 words). As you can see from these examples of two adult CI users, a customized rehabilitation based on an assessment of individual needs is essential.|

CI recipients can benefit significantly from an expert's help in adapting short-term rehabilitation goals to their current auditory abilities as well as in determining long-term rehabilitation goals. Working constructively towards appropriate goals will enable an adult recipient to identify and celebrate the steps of his or her progress. It will help the recipient to focus on their achievements rather than being frustrated by the hearing skills that they have not yet acquired.

There is also much to say about the emotional experience that is an integral part of almost every adult CI recipient's rehabilitation process and we will discuss this element in a separate posting. Your rehabilitation therapist can be a significant source of support for you and for your family. Ongoing communication with the speech and language therapist provides CI users with a reliable source of information about a range of topics.

From personal experience, I can say that I encountered many CI candidates who were not certain they would be able to attend weekly or bi-weekly rehabilitation sessions, mainly due to workplace commitments. After implantation they all made time in their busy schedules to attend the rehabilitation sessions, depending on their progress and needs. Weekly or bi-weekly sessions provide the speech language therapist with the ability to track process and offer a reliable basis for collaborative work with the audiologist. CI users who are more aware of their CI usage patterns and rehabilitation programs can promote their own needs in effective ways. Involving a professional in the long-term rehabilitation support following cochlear implantation will positively contribute to the process by making it easier and more enjoyable for the recipient and his or her family and by potentially resulting in better long term outcomes.

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The cochlear implant candidacy process includes a medical examination, auditory assessment, and sometimes a psychological evaluation. The goal is to obtain information to provide reliable answers to two key questions:

(1) Is a cochlear implant the most appropriate hearing assistive device?

(2) Are there any medical restrictions for the surgery?

This step in the process requires the cochlear implant team to have broad theoretical knowledge and clinical experience.  First the team must collect the relevant information concerning the hearing abilities of the candidate. The role of the audiologist and speech pathologist is to gather information regarding your current amplification and communication status in order to be able to compare it to your expected future outcomes using a cochlear implant.

Audiological Evaluation

The first step in the hearing evaluation is to have your pure-tone audiograms taken with and without your hearing aids. The audiogram determines the type and degree of the hearing loss. The audiogram can indicate the origin of your hearing loss and whether it originates in the inner ear or elsewhere. The severity of the hearing loss is reflected by the pure tone average hearing thresholds. This information serves as a key parameter in the decision regarding whether the candidate meets the audiological criteria for cochlear implantation. Information regarding which sounds are perceived best by the CI candidate is reflected by the shape of the audiogram. The audiogram also enables the audiologist to compare ears as well as aided and unaided outcomes. It is also helpful to have your past audiological records. Comparison of your audiograms over time can indicate whether the hearing loss is stable, fluctuating, or progressive.

Since the decision for implantation is based upon a comparison between the benefit you receive from hearing aids and the expected benefit from cochlear implantation, the hearing evaluation is performed with appropriately fit hearing aids.

The aided audiogram provides information regarding your current amplification. Other relevant information regarding your hearing aids includes the purchase date, recent tuning, and maintenance. Sometimes there is a need to return to the hearing aid audiologist for adjustments or overall maintenance. Occasionally, a trial period with different (better fit) hearing aids is recommended.

In order to minimize the steps to determine candidacy, my recommendation is to visit your hearing aid dispenser a month before your first visit to the CI center for any necessary refitting and maintenance. If the dispenser's recommendation is to purchase new hearing aids, you should wait until after you begin your evaluation process at the implant center to avoid wasting money if you are a good CI candidate. Sometimes, in borderline cases, candidates will be encouraged to try newer or stronger hearing aids and then be re-evaluated.

Speech Perception Evaluation

The next step of the hearing evaluation is speech perception testing. Understanding speech is a complex task; difficulty level depends on many variables. For example, when the speech stimuli provides context and verbal information (such as in tests using simple everyday sentences), a CI candidate can use this type of information to repeat sentences—even if (s)he had not understood every word.  Tests that use single words are harder because they don’t provide context. 

Single words perception tests can vary in their level of difficulty. The more familiar and longer the words, the easier they are to be understand. Short "nonsense” words are hardest to perceive.

Most cochlear implant teams base their evaluation on tests of both words in sentences and single words. Single word tests provide more information on the ability of the candidate to perceive the various components of speech. However, sentence tests are more reflective of the candidate's ability to manage a conversation.  Since many conversations occur in noisy environments, speech perception testing is often completed in background noise to better replicate real life communication challenges.

Some candidates are unable to understand speech presented in an "open set" stimuli, as described above. For these individuals, it is common to use "closed set" tests. In "closed set" tests, the answers are presented as in a multiple-choice test.

Another communication aspect that may be evaluated is speech-reading ability (often referred as "lip reading"). This evaluates the benefit people derive from visual information such as the speaker’s lips and facial expressions combined with auditory information in order to understand speech. Gathering such data can show the positive contribution of cochlear implantation to speech reading performance. Enhancement in speech reading may also be reflected in the ease of communication reported by CI users.

Speech perception evaluation is performed for each ear separately and both ears together. The decision on whether to recommend cochlear implantation, as well as which ear should be implanted, are based upon these results.

Informal Assessment of Communication Status

Besides formal testing, there are other relevant data, usually collected through conversation or by using various self-reported questionnaires. Such data includes information on the history of the person’s hearing loss, auditory rehabilitation, lifestyle and communication challenges, and the communication modes used by the candidate.

Last but not least, a few words about expectations…

In one of the upcoming posts, I will discuss expectations about cochlear implantation.  This issue continues to be relevant beyond the candidacy phase. You should feel free to discuss your expectations with your CI team.  It is important that you have realistic expectations about your outcomes as well as the rehabilitation process (e.g., mapping, auditory training, and medical follow ups).

Do not hesitate to share rationale for pursuing CI as well as your dreams and future goals.  Feel free to ask your team about any question you have on the process.  After they have gathered all the above information, they will be able to give you reliable answers to many of your questions including examples of how the cochlear implant may affect your life.  This discussion will provide you with important perspectives regarding the ongoing nature of the rehabilitation process. It will also clarify your future responsibilities to maximize your success with your new implant.  

For 20 years I have dedicated my professional life to the rehabilitation of deaf and hard of hearing children and adults and research in deaf education. I have worked as an educational audiologist in special education and mainstream education settings, taught in college, and supervised SLT students, educators and rehabilitation teams. As a SLT, I worked in rehabilitation of adolescents and adult cochlear implant (CI) recipients in the Cochlear Implant Program at the Bnai-Zion Medical Center, Haifa, Israel.

My experience with adult CI users supports the importance of auditory rehabilitation following cochlear implantation. I was there to challenge the auditory ability of new CI recipients, to direct and support their building of new auditory skills, and to continually find ways to move forward.

I encouraged my patients to view their progress in a positive way, as a "glass half full" and to take advantage of every auditory skill they have acquired to improve their lives.  CI users' awareness and understanding of auditory rehabilitation have great potential for improving their CI outcomes. Their attitudes, needs, hopes and goals serve as key variables in every step of the rehabilitation process. I truly believe in consistent, structured, professional support after cochlear implantation. This kind of individual long-term support increases the chances for CI recipients to use their device regularly and maximize their outcomes.

Much has been written for parents of implanted children but there is less available for adults with cochlear implants. This blog is for you: CI candidates and recipients who have gone through cochlear implantation as adults.

In this blog I will share with you my longstanding experience in working with dozens of teenagers and adults. Together we will use this unique platform to discuss various issues at the heart of the rehabilitation process that are reflected in everyday life.

Before we start, I want to thank my patients, courageous people who have chosen to change the course of their lives by giving themselves the chance to enjoy the world of sound to improve their communication. Their trust and willingness to include me in their private world and devote themselves to a long-term auditory rehabilitation process was not taken for granted.

I have joined these people on their fascinating personal journeys and I was exposed to the complex nature of the adaptation and rehabilitation process following cochlear implantation. I shared moments of disappointment and difficulty, as well as moments of happiness and satisfaction, and of course I have witnessed a process of significant improvement in many aspects of their lives. I learned how cochlear implantation can be a life-changing step. My patients were the best partners for my own professional journey. Thanks to them I was exposed to the wonders of technology and broadened my understanding about communication and hearing impairment. Above all, they taught me about the power of the human spirit.

Each person is unique in his own way, and has a different experience with the implant. Yet, there are many common topics and experiences that are important to share. One can definitely learn from someone else's experience and use it as a source of knowledge and encouragement to improve their adaptation and rehabilitation following cochlear implantation.

I wish you all the best and look forward to the future. 

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