Conversation Guidelines

Conversation Checklist

1. Support effective conversation

• • Strive to consider the family’s perspective and consider your own perspective
  • Setting and arrangement facilitates communication with all family members (and interpreter)
  • Use appropriate body position/eye contact/tone of voice with limited use of note-taking
  • Clearly state purpose of the visit and summarize past history
  • Welcome family input on goals for the consultation
  • Recognize participation of child and family in assessment measures
  • Use signpost transitions
  • Explain procedures

2. Ask
   • Ask history questions individualized to the child and family
   • Encourage family to expand with open-ended questions

2. Explain
   • Provide an overview of findings in family-friendly terminology
   • Illuminate the impact of hearing with clear and concise details
   • Check in with family re: understanding and need for more information
   • Allow family to determine details they need
3. Listen

• • Use silence/pause effectively
  • Acknowledge their perspective
  • Acknowledge feelings and empathize
  • Summarize what they have shared

5. Discuss
   • Explain options clearly and concisely as appropriate given the diagnosis: hearing monitoring, medical treatment, hearing technology, communication modes,
   • Examine benefits, challenges and uncertainties of options

• 6. Explore
  • Explore what is working now for the family
  • Explore the family goals
  • Explore family’s interest in addressing the hearing issue
  • Explore barriers
  • Illuminate the differences between goals and family practice, if necessary

7. Plan
   • Make a specific action plan
   • Provide resources for parents in line with their needs

Support effective conversation

• Develop a family-centered approach to your conversations with families

Family-centered care is at the core of how we communicate with families; we strive for a collaboration with families where input from both professionals and families are valued in the process and conversations reflect this collaboration. Professionals empower families with information and choices. Every family has strengths: in our conversations with families, we can help them identify and build on their unique strengths. Meeting them where they’re at on their journey means we individualize the conversation for each family. Families gain emotional strength when they receive emotional support from the professionals they work with.

• Understand the family perspective

Prior to meeting with a family, we can set an intention for understanding the family’s current perspective and individualize the conversation for the family. If we attempt to understand the family perspective, we set the stage for a conversation that is unique for their needs. If we’re meeting them for the first time, there are more unknowns. But, based on what limited information we have we can start to form some hypotheses about the perspective they might bring to the appointment. If we have worked with the family before, we can remind ourselves of their perspective at our last meeting, and remain open to the idea that their perspective could have changed in the interim since we last met.

It may be helpful to think about what stage the family is at on their journey of acknowledging, addressing, and advocating for their child’s communication. Considering what stage they are at helps remind us what likely will come up in the conversation and how we can meet them where they’re at.

• • Where is the family at in developing resiliency for addressing their child’s needs?
  • Are the family resources a factor in their journey?
  • Is the family approaching the hearing loss with resistance?
  • Is the family addressing communication and access?
  • Is the family advocating for their child?

• Consider your perspective for the consultation

When we pause to consider our own perspective for the consultation, we can work on facilitating a neutral but supportive perspective for the conversation. What are my objectives for the consultation? Do I have a hidden agenda for this family? A hidden agenda might sound something like: ”I really want them to get their hearing aid use increased” or “They really need to get started with the cochlear implant process”. If we can maintain a more neutral objective for the consultation, we remain open and avoid bias.

• • • I’m wondering where they’re at with considering how to address their child’s hearing.
    • What are the family’s barriers to using hearing technology right now?

• Create a setting for conversation

We facilitate effective conversations when we set aside time and space for conversation. Position yourself in a chair so that you can communicate with all family members; avoid standing. Use good attending behaviors with eye contact and leaning forward. Avoid focusing on your notes on your clipboard or spending too much time documenting.

• Establish rapport and maintain a supportive calm tone

Introduce yourself, your classmate and your preceptor. Clarify who are the family members present. Make sure to check on the correct pronunciation of the child’s first name. Engage in small talk with the family during transitions, particularly during the initial welcome in the waiting room and walk to audiology; focus topics on family, drive to clinic, weather, etc. The tone of our interactions with families should remain calm and supportive throughout our time together. Our conversations show our investment in the family. When we err on the side of being casual or too upbeat, there is a mismatch with a family who is concerned about their child. Your interest and investment in the child shows your commitment to the family. Keep conversations focused on the family not on yourself with oversharing your own experiences.

• State the purpose of today’s consultation
  • • “You’re interested in learning more about Mary’s hearing.”
    • “Kelly is being seen for a hearing evaluation today because she did not pass her newborn hearing screenings.”
    • “John is being seen today for his regular follow-up hearing evaluation and hearing aid check. He was last seen in clinic 6 months ago”.

• Welcome the family to the conversation
  • We set the tone for the appointment, by welcoming the family to the collaborative conversation.
    • “I want to make sure we use our time together today to address your questions and concerns.”
    • “What do you want to make sure we cover during this consultation today?
  • In situations where we’re meeting the family for the first time particularly when seeing the family for a new consultation, it is helpful to get their input on what information they already have.
    • “You’re here to learn about your child’s hearing today. Tell me what you know already.”

• Prepare families for the conversation
  • Families benefit from knowing what to expect. Preparing them for what we might learn during the consultation can be helpful.
    • “How can I prepare you for what we might learn today?”
    • “At the end of today’s appointment, we’ll discuss what we’ve learned about your child’s hearing. There are 3 possible outcomes of today’s assessment; we will learn that he has normal hearing, temporary hearing loss, or permanent hearing loss.”
  • Include all family members in the conversation by giving eye contact to each individual and inviting each to the conversation. For communicating with families with school-age children and teens, address both your questions and explanations directly to the youth.
  • If an interpreter is being used, the interpreter should be seated near you, facing the family. “Chunk” what you say into several sentences and then pause, allowing the interpreter to translate. When the interpreter is speaking, look at the parents. Always speak to the family, not to the interpreter.
  • Both you and your preceptor will communicate with the family during the session. The goal is for the student to conduct most of the communication and the preceptor will add or ask for information as needed or will cover topics that are outside of the expertise of the student.

• Guide the family through the consultation appointment using signposting
  • To let the family/child know what is coming next
    • “We’ll start with some questions and discussion about your child’s hearing and communication, then we’ll complete some hearing measures and then finally, we’ll discuss what we’ve learned from those measures.”
    • “We’re done with the measures in this booth, we have some additional quick measures in the other room and then we’ll be done with the assessments”.
  • To transition in a conversation
    • “We’ve completed all the measures of Brenna’s hearing and now we’ll sit down and talk about what we’ve learned about her hearing.”
    • “We’ve been talking about options for addressing Brenna’s hearing loss; we should probably continue our discussion at our next meeting together and give you some time to read the resources….let’s go ahead and make that next appointment..”

• Explain procedures before you start:
  • Give a brief overview of the purpose and method of the test and instruct parents as to what they can do to help the testing go well
    • “We measure hearing by teaching the child to respond to sounds by turning his/her head in response to the sound. His/her reward is the activation of a mechanical toy or video. You can help the session go well by having your child on your lap facing the mirror. Please don’t talk during the assessment and do not cue your child by turning your head/body when you hear sounds. When we use an earphone, please hold your child’s hand/arm to prevent him/her from removing the earphone.”
    • “This measure determines if there is any blockage in the ear. You can help us get a good measure by hugging your child while I place the probe in her ear.”
    • “We measure the function of the child’s hearing system by recording a response from the ear to soft sounds. You can help us get a good measure by helping the child to stay quiet and still during the measure.”
  • Instruct older children/teens about the procedure and what the child/teen’s role is in the procedure. Modify the instructions to be appropriate for the age/developmental level of the child.
    • “Let’s go into my special room to play the listening game. Your parent can sit behind you and watch you play the game. You’re going to listen to beep sounds from these earphones. Whenever you hear beeps you get to put a peg in this board”.
    • “We’re going into this soundproof room to measure your hearing. You’ll be hearing beeps through these earphones. Let me know you hear the beeps by pushing this small button.”

• Recognize participation
  • • “Sally was very patient with participating in all of the hearing measures today.”
    • “You really helped Kevin to participate in today’s testing.”
    • “Casey worked hard to participate in the hearing measures today.”
    • “You all have been very patient and helpful with getting through all of the hearing and ear measures.

 Ask

• Individualize the questions
  • Given the variety of patient ages and reasons for the visit, the questions we ask should be individualized for each family. Ask case history questions in a logical order so that there is a flow to the communication; the most important questions should come first. Respond to parent answers with follow-up questions for more details, as needed. Be flexible with the flow of questions and follow the parents’ lead into topics. Your goal for the case history is to have it feel like a conversation, not an interview. It is crucial that you record parent answers on your case history/worksheet form as you will need these details for writing your report, but do so in an manner that does not impact the conversation.
• Tell the parents what you know about from the records and ask for an update.
  • • “Mary passed her newborn hearing screening. Has she had any further hearing evaluations?”
• Use open-ended questions to allow room for families to respond with what is important to them.
  • • “How is he hearing at home?”
    • “Tell me about his communication skills.”
    • “Tell me about how it’s going with incorporating hearing aids into your daily lives.”
    • “What works for you when he removes his hearing aids?”
    • “What works for you in that situation?
    • “How do you feel like this information fits with your perspective on his hearing?”
• Use close-ended questions for specific health information
  • • “Has he had any ear infections?”
    • “Is there any history of childhood hearing issues on either side of your child’s family?
• Ask about feelings: Families benefit from being able to talk about their worries and frustrations, their sadness and their joys, in raising their child. Simply inquiring about how a parent is feeling gives them the option of talking about it.
  • • “How are you feeling about this new information?”

Explain

• Explaining can be a very helpful communication component in supporting families; as they gain knowledge they understand their child’s hearing and the impact of hearing loss and are empowered to make decisions that work for them. Families benefit from a summary in family-friendly terminology. Every family needs a different level of detail; we will be the most effective when we individualize the information we provide based on family’s needs. Families vary significantly in their health literacy. The goal is to provide the “just in time” information that they need at this moment, recognizing that a family’s needs will change over time. Slow down the pace of the delivery of information to allow families time to digest new information before moving on to learn more.
• Families benefit from information given in verbal form as well as other formats. We can offer families information in handouts or a notebook, or suggestions of websites. We recognize that every family learns differently; and conversations are only one of the ways for families to get information.
• Overview: Provide an overview of the findings expressed in parent-friendly terminology.
• Interpret: Provide a brief explanation of what we know about the child’s hearing and auditory system. Focus on explaining what the child is able to hear and what the child is not able to hear and whether the hearing loss is permanent or temporary. Avoid describing the outcomes of the tests, unless that detail is requested. Use neutral terminology such as “evaluation” or “measure” instead of “tests”. Address the consistency and reliability of the child’s responses, as well as the consistency across measures that support the diagnosis. Address how today’s findings compare to previous test results.
• Check-in:
  • Check in in with the family on their understanding and desire for more detail.
    • “Does that make sense?”
    • “Do you have any questions about what we’ve discussed so far?”
  • Check-in with a teach back question
    • “We’ve gone over a lot of information about…. tell me what your takeaways are…
    • “I want to make sure I am being clear and to answer any questions you may have. In your own words, can you tell me what you need to do to…”
• Illuminate the impact of HL:
  • Help the family to understand the impact of hearing loss on the child; important concepts include the impact on auditory access, communication, learning, and brain development.
  • Help the family to understand the use and benefit of hearing technology and sign language as access tools for communication, language and learning.
  • Address unique aspects of the impact of HL in special populations such as UHL and ANSD.
  • If you have completed functional measures (speech audiometry and outcome questionnaires) interpret and integrate these findings to provide insight into the impact of the hearing loss in this child either with or without hearing technology, or both.
  • Anticipate that when families are learning about the impact of hearing loss, they often want answers to:
    • What can my child hear?
    • Why does my child have hearing loss?
    • Will hearing change?
    • What are the treatment options?
    • Why is it important to start treatment soon?
    • Will my child be “different”?
    • What will my child’s future be like?

Listen

• Listen to understand: Be present in the moment and seek to understand the family perspective. Listen to families and acknowledging their challenges. Don’t rush to offer a solution; sometimes families just need to be heard.
• Use silence: We all benefit from moments of silence during the conversation, to pause and think. Sometimes when we’re uncomfortable, we feel inclined to fill the silence.
• Avoid ineffective listening:
  • Parrot: When we simply repeat what the individual said, the reflective statement is not effective.
  • Reassurance: Avoid statements that provide too much reassurance when what the family needs is a simple acknowledgment.
  • Sympathy: Responses that convey sympathy are less effective at supporting families; sympathy conveys that we’re feeling sorry for them.
  • Listen to reply: If we’re just waiting for the family to stop talking, so we can talk, we’re not listening.
  • Listen to judge: As we listen to the family we’re making a judgment about their perspective.
  • Autobiographical: Sometimes we think we’re offering empathy by relating a similar situation in our own life or with another family we work with. From the family perspective is “it’s not about them, it’s about us”. There are probably situations where families might find those shared experiences helpful, but it’s probably a safer call not to include them.
• Use active reflective listening: Reflections let the family know we’re listening and that we understand them. The reflective nature of our response helps the family sort out their own thoughts; when their comments are reflected back to them, they see them more clearly. A reflection may also take the form of continuing on what the parent said, but is yet unsaid. A reflection also allows the parent to correct our misinterpretation. Reflections serve to acknowledge, provide empathy, and summarize.
• Acknowledge: Acknowledgements are powerful ways to acknowledge the parent perspective.
  • • “It’s hard to see the impact of hearing loss in young children.”
    • “It’s understandable that from your perspective he seems to be hearing well.”
    • “You’ve worked really hard to…”
    • “It’s frustrating for you to not have all the answers now.”
• Empathize: Reflections that express empathy demonstrate our understanding and concern about the family’s feelings and what they’re going through. We show empathy by communicating understanding of the family’s perspective with accuracy and unconditional positive regard.
  • • “This is a lot to take in.”
    • “This is unexpected information.”
    • “That must have been difficult for you.”
• Summarize: Summarize the discussion by pulling together the pieces of what the parent has shared. Provide a summary/signpost to transition to the next stage of the conversation. A summary statement can acknowledge the importance of the discussion but also signal that it might be a good time to move on to other tasks to accomplish during the visit.
  • • “Let me summarize what I’m hearing from you….you’re interested in learning sign language, but you’re not sure if it’s reasonable for your family to try to put aside time to learn signs.”
    • “From your perspective, he’s taking his hearing aids off more frequently and you’re wondering if it’s because he doesn’t like them or they’re not set correctly”.
    • “We’ve been talking about the challenges of him not wearing hearing aids; I’m wondering if you’re ready to move on to talking about some possible options…”

Discuss Options

• The audiologist discusses options appropriate based on the individual:
  • Monitoring hearing
  • Medical management
  • Communication continuum options
  • Hearing technology
  • Specialized support/intervention
• When explaining and evaluating options, we can help families evaluate each option based on:
  • Benefits
  • Limitations
  • Uncertainties

Explore how family is addressing hearing and communication

• Explore the family’s perspective on the child’s hearing and what is working now for the family:
  • Families benefit from looking at how they’re currently addressing the child’s hearing and how it is working for them. Reflective acknowledgement statements help to bring their current actions into focus. Acknowledge family strengths
    • “How does communication go when he isn’t wearing his hearing aids?
    • “It sounds like you’re comfortable with ….”
    • “It’s working for you to…”

• Acknowledge the family perspective and empathize with their perspective.
  • • “It sounds like you’re worried that people will view her differently.”
    • “You want …but you’re finding it challenging to……”
    • “Early learning is important to you…and you’re
    • “On one hand you realize the hearing aids help her and on the other hand you see that she hears pretty well without them.”
    • “It sounds like your concerns about people’s comments and questions about his hearing aids are limiting you having him wear them outside of your home.”
    • “It sounds like you’re worried that people will view her differently.”
    • “Early learning is important to your family….you’re not sure if hearing loss is really impacting her learning.”
• Explore family goals regarding communication and learning
  • • “Tell me about what is important in your family in raising your child.”
    • “How you would like to see him communicating in this next year?”
    • “How did you see your child in the future”
    • “I remember what you said earlier about…..that seems important to you.”
• Explore family advocacy and self-advocacy
  • • Explore family’s willingness to share about hearing loss with others
    • Explore family’s interest in making connections with others who are DHH
    • Explore family’s interest in supporting the child/teens’ self-advocacy skills
• Explore challenges vs barriers:
  • Families face challenges in addressing hearing loss and these challenges may seem like barriers that are preventing them from moving forward and barriers to implementing actions that they value. Explore the family goals as they relate to the treatment options and illuminate the differences between goals and family practice, if necessary.
• Explore family’s interest in changing their actions
  • When the family can explore their values and motivations with help from the professional, the family can determine their goals and evaluate for themselves if their actions are in line with their goals and values. Motivation to change their actions occurs when families themselves recognize a discrepancy between where they and where they want to be.
  • Instead of telling a family to change how they are addressing their child’s hearing loss, explore their desire to change what they’re doing. Ask directly about their priorities for their child and where the priority fits with other issues to address. You may find it helpful to have them use a scale to determine the importance of addressing the hearing loss.

Plan next steps

• Ask permission to transition: Ask the family if they’re ready to talk about next steps.
• Determine next steps
  • In collaboration with the family, determine what next steps work for the family and are in line with their goals
    • “What is reasonable for you to do between now and when I see you next?”
    • “What next steps work for your family?”
    • “Based on our discussion, it sounds like you would like to first…and then…”
• Ask about family need resources: When we directly ask what information the family needs, then we can individualize the resources we provide. Use the family list of questions (the Sound Beginnings/Sound for Life questionnaires) to give families ideas of information that might be helpful to them on their journey.
  • • “Do you need some more detail about…?”
    • “What additional information would be helpful for you?”
    • “What would be helpful for you in exploring X to have more resources about it?”
    • “Is this a good time for us to talk about…?”

Case History for Screenings

• Hearing history: Tell the parents what you know about the child’s previous audiological testing and then ask if the child has had any other interim evaluations
• Middle ear history: Inquire about history of middle ear infections, ear tubes.
• Family history of childhood hearing loss: determine if there is a relative within 2 generations that has had hearing loss since childhood

Case History for diagnostic patients

• Hearing history: Tell the parents what you know about the child’s previous audiological testing and then ask if the child has had any other interim evaluations.
  • “Mary passed her newborn hearing screening at UW Medical Center. Has she had any further hearing screenings or evaluations since that time?”
  • “ As you know, we’re following John for his loss and hearing aids and he is here for his yearly follow-up; we last saw him 12 months ago…I have a few questions about how things have been going for the past year, particularly in regards to his hearing and hearing aids.”
• Middle ear history
  • “Has he had any ear infections? How many? When was the last one?”
  • “Has he ever received ear tubes?”
  • “Have you had any recent ear pain, pressure or fullness? Any dizziness?”
• Medical history
  • “Does James have a cold currently or has he had any recent congestion?”
  • “Has he had any significant injuries or hospitalizations that could have impacted his ears?”
• Family history of childhood hearing loss
  • “Is there a history of childhood hearing loss on either side of Mary’s family?”
• Auditory and Speech and language development
  • “How does Mary respond to sound at home?”
  • “How does James seem to respond and understand you?
  • “Does Mary have any words that she uses?” “Does she seem to understand a few words?”
  • “Is the clarity of his words such that most people can understand him?”

Case history questions for children/teens with hearing technology

• Interim middle ear, health issues
  • “Has John had any ear infections or ear issues since we saw him 6 months ago?
• Communication
  • “How is communication at home going?”
  • “How about at school…how is it going in the classroom in terms of communication?”
• Hearing Aids and earmolds
  • Overview:  “John is wearing Phonak Sky hearing aids that he has had for 18 months. His earmolds were last made 6 months ago.”
  • Device issues: “Are there any current issues with the hearing aids or earmolds? “
  • Wear time: “How often does John wear the hearing aids?
  • Retention and removal issues: “Are you having any issues with Mary removing the hearing aids or the hearing aids falling off? “
  • Maintenance/care: “Tell me about your routine for taking care of John’s hearing aids and earmolds. How are the hearing aids stored at night?”
• Hearing assistance technology
  • “Does Mary have access to a remote mic system at school?”
  • “How do you listen to music and video?”
  • “How do you communicate on the phone?”
• Intervention/School
  • “Are you still receiving services from Listen and Talk with Mary Smith as your provider?”…Weekly visits?…how are those services working for your family?
  • “What grade are you in now?….do you still go to Stanwood Elementary?”

Conversation example: When hearing differences have been ruled out

Explain

• Overview
  • “Today’s measures show that Mary has hearing levels in the typical range of hearing; she is able to hear a full range of sounds”
  • “Steven is passing the hearing screening today.”
  • “We do not have any concerns about Sally’s hearing.”
• Interpret
  • “Children who pass this screening show responses to sounds presented to the ear, whereas children with hearing differences show no responses. Tommy shows responses across the pitch range in both ears.”
  • “Kathy is able to hear a full range of sounds across the pitch range in both ears, including very soft sounds within the expected “typical” range of hearing. “
• Consistency
  • “Mary’s responses to sound were consistent and her pattern of results were consistent across the different measures we completed.”
• Illuminate
  • “When children have delays in developing their speech and language skills, it can be due to hearing differences, but in other children hearing is not the issue.”
• Compare
  • “Steven likely did not pass previous hearing screenings due to a temporary blockage in his ears; today’s screening shows an improvement and the blockage has resolved.”
  • “Ben has shown typical hearing at past screenings and evaluations and we’re seeing those same findings today.”

Listen

• Check-in
  • “Do you have enough information about Mary’s hearing, or do you need more detail with some graphs?”
• Family perspective
  • “How do today’s findings fit with your perspective on Mary’s hearing?”
• Acknowledge and empathize
  • “A hearing loss made sense to you given he doesn’t always respond to sound.”

Discuss options

• Discuss options for monitoring hearing, referrals, etc.
  • “Hearing can change throughout childhood, so it is important that all children receive regular hearing screenings. National health guidelines support yearly hearing screenings over the age of 4 at well-child visits and in the public schools.”
  • “Given that you have concerns about Mary’s communication development, it may be helpful to pursue evaluations that look specifically at her communication skills. An evaluation can give you a baseline of measures of her strengths and challenges and identify strategies to help her develop her communication skills”.

Plan next steps

• • Based on the discussion of options, make a plan for next steps.

Conversation example: When hearing levels are undetermined

Explain

• Overview
  • “Kevin is not passing the hearing screening today”.
  • “We have limited information about Casey’s hearing today.”
• Interpret
  • “Kevin is not showing a response to the sounds presented into his ears; it is either a temporary issue due to blockage or a permanent hearing issue”.
  • “We are not able to determine Casey’s current hearing function based on today’s limited testing”.
• Consistency
  • “Casey responded to sounds during the testing today, but his responses were inconsistent and we could not establish his hearing threshold levels. We attempted other testing that measures a response from his auditory system, but he did not tolerate the ear procedures.”
• Illuminate
  • “Obtaining accurate and complete hearing evaluations can be a challenge. Sometimes it takes several visits to get adequate information. ”

Listen

• Check-in
  • “Do you need more details about what we learned about Kevin’s hearing today?”

Discuss Options

• • “Further detailed testing is needed to measure his hearing levels and determine the function of his entire hearing system. We would like him to return for a full hearing evaluation within the next month.”
  • “Determining Casey’s hearing in the near future will be helpful in understanding if hearing loss is impacting his communication and learning or if hearing loss is not an issue for him.”

Explore family’s interest in addressing hearing

• • “You have a lot going on with all of Casey’s appointments right now. Where does learning more about Casey’s hearing fit in your priorities?”
  • “How important is learning more about Kevin’s hearing in the future for you?”

Plan Next steps

• • “Would you like to go ahead and make an appointment for Kevin’s next hearing evaluation?”
  • “It sounds like you’re comfortable with contacting our clinic to make an appointment to evaluate Casey’s hearing when your family has some time to get back to this area.”

Conversation example: When a temporary conductive hearing difference has been identified

 Explain

• Overview
  • ” Steven has a temporary, partial hearing difference associated with blockage in his ears.”
• Interpret
  • “Steven responds to louder sounds, but not softer sounds. The reason he isn’t hearing the full range of sounds is due to a blockage in his ears today”.
  • “We know that he has a blockage in his ears because he shows a flat response on this measure, when it should have a peak. We know that the issue is temporary;   when we by-passed the blockage; his inner ear/organ of hearing is functioning well.”
• Consistency
  • “Mary’s responses were very consistent so we have confidence in the hearing threshold levels and she shows a consistent pattern across all of the measures today.”
• Compare
  • “Today’s results are similar to the results from his evaluation 3 months ago, showing that the blockage and temporary hearing issues have persisted over time.”
• Illuminate
  • “Hearing differences associated with middle ear fluid typically resolves on its own in most children within about a month. However, if the blockage persists for a significant period of time, more than 3 months, there are concerns that the hearing differences will impact the child’s development.”
  • “Middle ear fluid can become infected and then the infection will likely need to be treated with antibiotics. It is important to monitor your child’s health, watching for signs of fever and discomfort and, if there are concerns, have the child be seen by the primary care physician.”

Listen

• Acknowledge and empathize
  • “It’s hard to see the impact of a partial hearing difference in young children.”
  • “This is unexpected information for your family.”

Ask

• Check-in
  • “Do you need any more details about what we’ve learned about Steven’s hearing?”
• Family perspective
  • “How do today’s findings fit with your perspective on Mary’s hearing?”

Discuss Options

• • “Steven may benefit from getting ear tubes. The procedure is done by an ear physician (otolaryngologist): the middle ear fluid is removed and tubes are placed to prevent the fluid from returning in the future. Ear tubes last about a year. I can refer Steven to an ear physician for a consultation for ear tubes.”
  • “It’s important to monitor Mary’s hearing in the near future. This is a temporary hearing issue and should resolve quickly; a follow-up hearing evaluationand ear check will give us more information about her hearing over time.”

Explore family’s interest in addressing hearing issue

• • “How important is it for you to address his temporary hearing issue?”

Plan next steps

• • “Would you like to me to make a referral so that Steven can be evaluated by an ear physician?”
  • “We can go ahead and schedule Mary’s next hearing evaluation; we should allow about 6 weeks to allow time for the fluid to clear .”

Conversation example: When permanent hearing differences have been identified

Explain

• Overview
  • “We’re ready to share with you what we’ve learned about Mary’s hearing. Mary has a permanent partial hearing difference, or hearing loss. She is able to hear louder sounds, but not the full range of sounds”.
• Check in
  • “I can give you some more information about what this means for Mary; do you have some questions at this point?”
• Interpret
  • “We played a range of sounds for Mary today at different pitches and loudness levels. Most children hear the whole range of sounds, including very soft sounds. Mary hears louder sounds and not softer sounds.”
  • “Mary’s hearing loss is a permanent type, called “sensorineural”. Temporary hearing issues are caused by blockage in the ear; her ears are clear today, with no blockage. We also measured her hearing directly at the inner ear and determined that the hearing loss is located within the organ of hearing.
• Consistency
  • “Mary’s responses on the measures were very consistent and we see a clear pattern across all the measures today.”
• Compare
  • “Mary did not pass several hearing screenings, so today’s results are consistent with her past hearing screenings.”
• Illuminate
  • “Hearing affects communication and learning.”
  • “Brain development is impacted by limited access to communication and learning.”
  • “Children with hearing differences can communicate and learn using listening and speaking or sign language or a combination of both”.
  • “The measures of how Kyle’s hearing difference impacts his ability to recognize words and sentences in the booth in quiet and in noise shows that…. You and Kyle to filled out the questionnaires to give us a measure of his “real world” communication challenges. Together, these measures tell us that in quiet settings, he is having small, but significant challenges understanding and more significant challenges understanding in noise.”
  • “With hearing difference in one ear, she has good access to sound in close and quiet situations. She has difficulty hearing in more challenging situations where she needs hearing in 2 ears, when listening in noise and when trying to find the source of sound.”
  • “This type of hearing issue (ANSD) impacts her ability to hear; children with ANSD have a range of hearing abilities. We’ll find out more about how she is impacted in the next few months when we can measure how she responds to sound with her behavior and listening.”
  • “At this point, we do not know the cause of the hearing difference. Some of the common causes for permanent hearing loss in children include hereditary/genetic conditions, infections during pregnancy, and complications from prematurity/neonatal illness. There are additional tests that could be done in the future including genetics, imaging, and tests for congenital infections.”
  •  Permanent hearing differences can be stable or can progress over time; if the hearing difference is permanent , it will not resolve over time. We will be monitoring her hearing levels closely over time.”

Ask

• • “How do today’s findings fit with your perspective on Mary’s hearing?”
  • “How are you feeling about this new information?”

Listen

• Acknowledge and empathize
  • “This is unexpected information.”
  • “This is a lot to take in.”
  • “It’s understandable that from your perspective she is hearing well; it’s hard to see the impact of partial hearing loss.”

Discuss options

• • Ask permission for transition
    • “Would you like to…”
    • “Would it be okay for us to talk about…”
  • Discuss options appropriate based on the individual:
    • Monitoring hearing
    • Medical management
    • Communication continuum options
    • Hearing technology
    • Specialized support/intervention
  • Evaluate each option based on:
    • Benefits
    • Limitations
    • Uncertainties

Explore family values

• • • “Tell me about what is important for you and your family in thinking about goals for Mary’s communication.”
    • “Tell me about why you don’t want other people to know about his hearing loss.”

Next steps

• “We can make an appointment in the next week or so for us to talk more about Mary’s hearing and discuss the details of some of the options we touched on today.”
• “It sounds like you are interested in having her use hearing aids to improve her access to sound. The steps needed to start with hearing aids are: 1) to make custom earmold impressions, 2) get a medical evaluation by an ear doctor, 3) return for fitting of hearing aids.”
• “I can make a referral for a home educator to come talk to you at your home.”
• “It sounds like you would prefer that we do another evaluation of John’s hearing before making any decisions.”

Conversation example: When permanent hearing difference is confirmed

Explain, Interpret and Compare

• • “She shows hearing levels of 70 to 80 decibels in both ears . “Her hearing levels are stable; we see no significant change in her hearing since her last evaluation.”
  • “Your hearing levels are at 70 to 80 decibels today;. “His hearing levels have changed by about 10 decibels since his last evaluation. This is a slight progression. We have adjusted his hearing aids to accommodate the change.”
  • “Mary is able to detect a range of speech sounds at both soft and average speech levels, showing that she has good access to spoken language when wearing her hearing aids.”
  • “Kelly’s hearing aids are functioning properly and achieving the target level of amplification. Her earmolds are fitting well, so we do not need to make new impressions.”
  • “With your hearing aids, you have very good access to speech in a quiet setting. When you’re listening to speech with background noise, you have more challenges.”
  • “You filled out the questionnaire and the scoring shows that Kelly is making progress in her auditory development since her last visit and she continues to show auditory skills that fall within the expected range for her age.”
  • “You and Ben filled out the questionnaire to give us some more details about listening challenges at home. You both report that Ben has some small challenges with daily communication, but you both report that he has significantly more significant challenges in settings where there is noise and echoing noise. “

• Consistency
  • “She was very consistent in her responses; we have accurate measures of her hearing today.”

Ask

• • “Do you have any questions about what we measured today?”
  • “Would it be helpful to look at the graphs or do you have enough information?”

Listen

• Explore what is working now for the family
  • “Tell me about how you feel about communication is going at home?”
• “Tell me about a typical day at your house and how hearing aids fit in.”
  • “What do you like about going to school without hearing aids?”
  • “How does communication go at home during family time when he isn’t wearing hearing aids?”

Explore family goals and values

• • “Tell me about what is important in your family in raising your child.”
  • “How you would like to see him communicating in this next year?”
  • “How did you see your child in the future?”
  • “Tell me about where hearing aid use fits in with your family priorities for your child.”
  • “How is communication going for you at home and in your community?”

Acknowledge and empathize

• • “On one hand you realize the hearing aids help her and on the other hand you see that she hears pretty well without them.”
  • “You want her to be who she is and at the same time you don’t want her to be viewed as different.”
  • “You realize you miss some things, but you have strategies to get the information”.

Ask permission

• • “Would it be okay for us to talk about options for giving her better access to communication?”
  • “Would you be interested in discussing how Ben could benefit from using hearing aids at home and in the community?”

Illuminate

• Use
  • “Mary will benefit from having access to sound by wearing her hearing aids all of the time.”
  • “It sounds like she is wearing her hearing aids full time at school and part time at home. Keep in mind that children benefit from full access to family conversations and children learn a lot by overhearing; hearing aids support better access.”
  • “Toddlers remove hearing aids due to curiosity, not because they don’t like the hearing aids or don’t benefit from them. A hat can be the most helpful tool in preventing removal of hearing aids.”
• Care
  • “It sounds like you have a good routine for cleaning the earmolds. Your hearing aids could benefit from using the dry kit at night to remove moisture.”
• Future technology
  • “I can tell you about some advanced hearing technology that you could benefit from….”
  • “She could benefit from using some technology to help her hear in challenging noisy situations…are you interested in more specifics about technology?”.

Explore barriers

• • “It sounds like Jane is giving you a lot of challenges with removing her hearing aids.”
  • “It sounds like you’re worried about people noticing your hearing aids at school.”

Explore family’s interest in addressing the hearing issue

• • “What would you like to see different about Kevin’s hearing aid use?”
  • “How important is it for you to address your access to sound with hearing aids using a scale of 1 to 10?…Why did you choose that number?”

Next steps

• • “What next steps work for your family?”
  • “What is reasonable for you to do over the next few months?”
  • “We can stay on the same schedule of seeing Jane every 6 months…does that work for you?”