How Hearing Works

You might want to review the discussion of the hearing mechanism in chapter two before starting this chapter. An understanding of how hearing works is vital to understanding what can go wrong.

What Can Go Wrong

There are several ways in which we can describe a hearing impairment. The most basic description of hearing loss is by degree. Classification by degree may be done according to functioning level, deaf and hard of hearing, or it may be described in terms of measured hearing loss, such as mild, moderate, severe, or profound.

It is important to understand the type of loss an individual is experiencing. Type of loss refers to the physical structure that is damaged. The two types are conductive and sensori- neural.

And, as was true of the other disorders in this book, hearing loss can be described by general etiology. There are several sub-classification categories that will be discussed later in this chapter.

Degrees of Hearing Loss

Degrees of hearing loss can be described by using different classification systems. The two I will discuss are ones that do not require a professional background to understand.

Classification by Degree of Communication Function

The general term that is most appropriate for all hearing loss is the term "hearing impairment". This description includes all hearing loss regardless of degree. The most common appropriate terms to subdivide hearing impairment are "deaf" and "hard of hearing". There are different ways to define "deaf" and "hard of hearing," but for purposes of this discussion I will use functional definitions.


A deaf person is one who has a hearing impairment that is so severe that the person's main means of receptive communication is something other than hearing. Normally this would be some visual means, such as lip reading or sign language.

"A deaf person is one whose hearing is disabled to an extent that precludes the understanding of speech through the ear alone, with or without use of a hearing aid (Moores, 1987, p.9).

While residual hearing may be a significant aid to learning in some, deaf children must rely primarily on vision in the school setting (Berg, et al., 1986, p.3-4).

Hard of Hearing

"A hard of hearing person is one whose hearing is disabled to an extent that makes difficult, but does not preclude, the understanding of speech alone, without or with hearing aid "(Moores, 1987, p.9).

Hard of hearing in its mildest form would be an individual with a minimal hearing loss, with little consequence other than it requires the person to ask others to repeat occasionally. At the other end of the hard of hearing continuum would be a person with loss that requires powerful amplification, but who can understand speech with that amplification. Because hard of hearing children rely primarily on audition, learning processes are essentially the same as those of children with normal hearing (Berg, et al., 1986, p.3-4).

Classification of Loss by Measured Hearing Level

Another descriptive protocol for hearing impairment is on a continuum that includes terms "mild," "moderate," "severe," and "profound". Maybe the best way to explain these losses is to have you pretend you are on a football field with a friend. You stand on the goal line and your friend goes to the 15 yard-line and talks to you in a normal loudness level. The decrease in hearing that you would experience would be comparable to a mild loss. You can hear what your friend says, but you have to listen more carefully than you usually do. Now have your friend go to the 30 yard-line and talk to you in a normal loudness level. This is comparable to a moderate hearing loss. You will miss some words, and will have to be very attentive to pick up the rest. You can still function well, particularly if you can have the sound amplified (by having your friend talk louder).

Having your friend go on out to the 50 yard-line will decrease the hearing level to about that of a severe loss. When talking at a normal level you will be able to hear almost nothing. You will be able to hear fairly well with strong amplification (your friend shouting), but you will still miss a lot of words and you will have to strain to hear the others.

To simulate a profound loss, stand on the goal line and have your friend leave the stadium. If they speak from the parking lot in a normal loudness level, obviously you will not hear them. That is the silent world of the profoundly deaf. However, almost all deaf people have some residual hearing.

People who have mild and moderate hearing losses normally function as hard of hearing individuals and can participate in normal communication activities with amplification, usually in the form of a hearing aid. Persons with severe loss may still be able to use hearing to understand speech well enough to use hearing as the primary avenue of understanding speech or they may choose to use alternative communication means. Persons with profound hearing loss must learn a visual communication mode, normally either lip reading or sign language. Table 4 is a |description of the characteristics of various levels of hearing loss (.

Table 4. Levels of Hearing Loss

Profound hearing loss: Profound hearing loss is the most extreme hearing loss. A profound hearing loss means that you may not hear loud speech or any speech at all. You are forced to rely on visual cues instead of hearing as your main method of communication. This may include sign-language and/or speechreading (also commonly referred to as "lipreading").

Severe hearing loss: People with severe hearing loss have difficulty hearing in all situations. Speech may be heard only if the speaker is talking loudly or at close range. A severe hearing loss may sometimes cause you to miss up to 100% of the speech signal. Symptoms of severe hearing loss include inability to have conversations except under the most ideal circumstances (i.e., face-to-face, in quiet, and accompanied with speechreading).

Moderate hearing loss: A moderate hearing loss may cause you to miss 50-75% of the speech signal. This means you would not have problems hearing at short distances and understanding people face-to-face, but you would have problems if distance or visual cues changed. Symptoms of moderate hearing loss include problems hearing normal conversations and problems hearing consonants in words.

Mild hearing loss: A mild hearing loss may cause you to miss 25-40% of the speech signal. Usually this results in problems with clarity since the brain is receiving some sounds but not all of the information. Symptoms of mild hearing loss include problems understanding someone farther away than a normal distance for conversation, or even up close if the background environment is noisy. Weak voices are also difficult to understand for people with mild hearing losses.

(, 2012)

Types of Hearing Loss

Conductive Loss

The two basic divisions of hearing loss by type are conductive and sensori-neural. Conductive hearing losses are ones that are the result of the outer or middle ear not functioning properly. They are called 'conductive' losses because the damage is to the part of the hearing mechanism that conducts the sound signal from the air to the inner ear, which is the point where sound becomes a sensation in the nervous system.

The most likely culprit in conductive loss is the middle ear. There is less to go wrong with the outer ear. The outer ear, you will remember, is the part that is visible and attached to the side of the head. It includes the opening through which sound can pass to the eardrum. The eardrum is the outer boundary of the middle ear. About the only problem that occurs in the outer ear is an obstruction. Foreign objects, or growths such as a cyst, can occlude the opening and block sound from reaching the eardrum. The obstruction has to be complete to cause significant loss. If there is even a small opening through which sound can pass, there is little loss. Conductive losses can result from curious children trying to determine how many beans, or what amount of mashed potatoes, they can stuff in their ears. Many strange substances have been removed from the ears of children.

The middle ear is more complex. It contains the three bones that conduct sound from the outer ear to the inner ear. Lots of things can happen in the middle ear. The most common problem is fluid in the middle ear. The lining of the middle ear produces a fluid that lubricates the bones. Normally this fluid builds up slightly, then drains through the Eustachian tube, which is a connection between the pharynx (throat) and the middle ear. When the Eustachian tube is closed (its normal position) the middle ear is sealed from the outside. No air or fluid gets in or out.

When we yawn, chew, or swallow, the muscles of the soft palate contract, causing the soft palate to elevate and retract. This action draws the mass of the soft palate into the naso- pharynx, blocking anything from entering the nasal cavity from the throat. Most people have had an episode of coughing that resulted from a beverage getting into the nose from the throat. It happens when people laugh or talk when drinking. This occurred because the contraction of the muscles of the soft palate was incomplete. Fibers associated with the muscles of the soft palate also open the Eustachian tube.

We notice changes in middle ear function when we experience a relatively sudden change in altitude, such as going up or down in an airplane or driving on a mountain road. The air pressure is less at the higher altitudes. If the Eustachian tube does not open during the change in altitude, the middle ear maintains the same air pressure. The higher pressure inside the middle ear will cause the eardrum to be pushed outward, which can be uncomfortable.

Descending in altitude results in higher atmospheric pressure. If the Eustachian tube is not opened, the higher pressure outside will push the eardrum in. The result of that is also uncomfortable. As indicated earlier, yawning, sighing, or chewing gum, initiates muscle action that normally will result in opening the Eustachian tube. We may hear a clicking or popping sound when it opens, indicating that the eardrum is returning to its normal position. See if you can hear the sound when you yawn or sigh. Sometimes it can be elicited by opening the mouth as much as possible.

Fluid in the middle ear builds up when the Eustachian tube is blocked. Blockage may be due to an differences in the physical make-up of the ear or an inflammation. Often the adenoids are the site of Eustachian tube problems. The adenoids are tissues that surround the opening to the Eustachian tube in the throat. A sore throat may mean an inflammation of the adenoids. Swollen adenoid tissue can block the opening.

You might suppose that if the Eustachian tube doesn’t open and the fluid builds up in the middle ear, it would push outward against the eardrum. Such is not the case. As the fluid increases, it dissolves the air in the middle ear. This creates a negative air pressure that causes the eardrum to be pulled inward. The mismatch in pressure from outside to inside can result in depressed hearing.

The damage can be severe if middle ear fluid build up is not treated. There are exercises that can increase the likelihood that the Eustachian tube will open. There are also devices that can create pressure to try to open it. Restoring the function of the Eustachian tube is the best way to treat the problem, because this is nature's way of dealing with it.

If for some reason the Eustachian tube function cannot be restored, simple surgery can be performed to provide an outlet for pressure and fluid by making an opening through the eardrum. This is a quick solution in that pressure will be equalized immediately and fluid can drain. However, it is a temporary one because the eardrum heals quickly. The opening through the eardrum can be maintained by placing a tube through it to hold it open. The tube will usually stay in place for a length of time from a few days to a few months. As soon as the opening closes, the problem will re-occur unless Eustachian tube function is restored.

If an infection develops in the fluid, the infection can build up in the middle ear to the point it pushes outward against the eardrum. It is painful, and if left untreated, can rupture the eardrum. The infection, which is a thick, white substance at this point, drains through the ear canal. The condition is sometimes called “glue ear” because the drainage looks like common school glue.

Conductive hearing losses can also occur as a result of malfunction of the bones of the middle ear. The bones form a chain that is essential for normal hearing. The chain can be broken by trauma or disease. Also, growths in the middle ear can affect the functioning of the chain.

Conductive hearing losses can usually be resolved, at least to some degree, by medical treatment. While the degree of hearing loss created by a conductive loss can be serious, the individual with a pure conductive loss would still have usable hearing.

Sensori-Neural Loss

Sensori-neural losses are ones that are caused by damage to the sensory organ (the inner ear) or the nerve that conducts the signal from the inner ear to the brain. These sites are located deep within the skull and are much more difficult to treat. Sensori-neural damage is more likely to be permanent, and sensori-neural damage is more likely to result in hearing that is not only impaired, but also distorted. People with sensori-neural loss are more likely to have trouble understanding speech, even if the speech is produced at a loudness level that is comfortable for them.

Sensori-neural losses have a variety of causes. One of the most common causes is noise. Intense sounds, such as gunfire and percussion sounds made by heavy industrial equipment, can damage the sensitive hair cells that change sound into neural impulses in the inner ear. There are strict limits on noise exposure in industrial settings. Earplugs and earmuffs can significantly reduce noise exposure.

Sensori-neural loss can also be the result of disease that reaches the inner ear. Also, certain drugs, known as “ototoxic” drugs can damage the inner ear. Because of the damage they can do, ototoxic drugs are only used in treating the most serious illnesses.

The auditory neural pathways from the ear to the brain can be damaged by the growth of tumors. The tumor presses against the nerve and if not removed will result in severe nerve damage.

Classification by Etiology of Hearing Loss

Age of Onset

Congenital Hearing Impairment

One classification scheme for the age of onset of hearing loss divides age of onset into two categories; congenital and acquired. Congenital hearing loss is one that is present at birth, or occurs at the time of birth. Hearing loss at birth could be due to a genetic trait, as hearing loss is common in many syndromes, of which Crouzon's Syndrome, Waardenberg's Syndrome, Treacher Collins Syndrome, and Apert's Syndrome are a few.

Congenital hearing loss can also be due to a problem during embryonic development, or during fetal growth. Significant illness or trauma to the mother during pregnancy may affect the child. Children born to mothers who are exposed to such infections as chicken pox, rubella, and cytomegalovirus (CMV) are particularly at risk for having hearing loss.

Acquired Hearing Impairment

Acquired hearing impairment is hearing impairment that occurs after birth. Acquired hearing loss can have many causes. Infection can result in hearing impairment. Measles, mumps, and meningitis are particularly dangerous to hearing. Also, as discussed earlier, ototoxic drugs can cause hearing loss.

Hearing loss can be caused by head injuries. Automobile accidents, war, and violent crime, are sources of head injuries. Hearing should be checked in the evaluation of any patient who has had a head injury. Hearing impairment that may not be readily apparent during a routine examination may be detected by a thorough hearing test.

Hearing Impairment and Aging

The largest group of hearing aid wearers is the older population. Hearing impairment that is a result of the aging process is known as "presbycusis". Hearing actually starts to decline in the 20s, but losses significant enough to disrupt communication usually don't occur until the 60s. Virtually all persons over the age of 70 have some degree of hearing loss.

Hearing impairment due to aging occurs because of damage to the sensori-neural components of hearing, or deterioration of the inner ear (sensory organ) and/or central nervous system. Hearing aids are helpful, but remember, the ear is a dynamic processor of incoming sound. Damage to the sensory organ includes damage to the parts of the nervous system that actively process the signal. Hearing aids amplify the signal, but can do nothing for the processing of the sound.

Older persons with hearing loss often have recruitment, or the abnormal growth of loudness, which was discussed earlier. They may also have deficits in other areas of cognitive and language processing. The result is that older persons need special handling by those around them. An older person once told me "If I could get a hearing aid that would slow speech down, I'd be okay." This is an acknowledgement that it takes longer for the older person with a hearing impairment to process incoming information.

When speaking to an older person the rule should be to speak more slowly and distinctly, but only slightly louder than normal. Also, the older person should be given more time to respond. We tend to communicate at speeds that are comfortable to us, but we should realize that often the key to communicating effective with an older individual who has a hearing loss is to adjust the rate to that which is comfortable for the listener.

Noise Induced Hearing Impairment

Perhaps the most insidious type of loss is NIHL (noise induced hearing loss). Exposure to loud sounds can result in hearing loss. Even short-term exposure to extremely loud sounds can cause permanent hearing loss. The Occupational Safety and Health Act (OSHA) of 1970 was enacted to protect workers from loud noise, as many hearing losses are the result of persons working near machines that create loud noise. This law mandated hearing conservation measures for industries in which workers were exposed to over 85 dBA of noise in an eight-hour period (Sataloff & Sataloff, 1993, p.371).

The OSHA sets standards for employers to provide employees with an environment that is safe for hearing. Below is a list of the current dB levels and amount of time that a worker can safely work in an environment with that noise level.

Any one who works in an area where there is a lot of noise, or in which there is the potential for loud noise (above 90 dB), should wear ear protection. This includes activities that are a part of a normal yard work routine; mowing the lawn, operating leaf blowers, power trimmers, and other power devices.

Hobbies may include a significant noise environment. Power tools such as saws, sanders, routers, and air-powered hammers generate noise levels that could be harmful to hearing. Flying model airplanes is also a hobby that puts the enthusiast in significant noise. Persons who are involved in shooting, or any activity involving firearms, should always wear ear protection. Playing loud music, or attending rock concerts, can be hazardous to hearing.

If you find your ears ringing after participating in an activity, then probably the noise level was sufficient to cause some damage to your ears. Usually such damage is easily repaired by the body itself by simply staying out of noisy environments for a period of time. The hearing loss that occurs immediately after exposure to loud noise is called a temporary threshold shift (TTS). The ear recovers from the TTS in a short period of time. However, the more times the ear is exposed to sound, the more frequent the exposure, and the longer the time of exposure, the more likely the damage will become a permanent threshold shift (PTS), or permanent hearing loss.

For a period of time I was involved in testing the hearing of persons who had been exposed to loud sounds over many years. These were workers in industries that were noted for having high noise levels. Some of the situations I observed during that period were among the saddest I have experienced in professional life. The typical client was a man in his 50s who had worked 20- 30 years for a company. For many of those years the company had not required hearing protection. Noise induced hearing loss occurs very slowly, so slowly that the person suffering the loss does not realize what is happening. Almost without exception the family members are the ones who complain first. Below are typical comments:

"He turns the radio and television up so loud we can't stand it."

"We have to repeat everything to him."

"He claims that none of us talk clearly."

"He won't admit that he has a hearing loss, so we have to cover for him."

Often the family complains that the person becomes withdrawn and isolated. He doesn't want to go to social gatherings because it is difficult to communicate. He feels he is too young for a hearing aid, or he tried a hearing aid and it didn't work for him. Often a family member comes with him to the hearing test, just as they go everywhere else with him, to communicate for him.

The saddest part is that here is a man who has earned a living for his family for his whole life. He deserves respect. He has normal intelligence and can do everything that everyone else can do-except he can't hear. Because he can no longer cope with everyday communication situations, the people around him tend to think of him as less than competent and his esteem is lowered in the eyes of others. Eventually this affects his own self-esteem. So many times people associate reduced mental capacities with persons who have hearing loss. This is true for persons of all ages who have hearing loss, but particularly true for persons who are also aging. The person with a noise induced hearing loss is often treated as a child, or an older person of limited capacity, when there is nothing wrong except hearing.

We can reverse the circumstance if we can get a good hearing aid fitted and teach the client some coping skills. However, a great number of these men accept the hearing impairment as part of the price they had to pay to earn a living. Their feeling of the inevitability of the hearing loss, and acceptance of it as a part of their life, is truly the saddest aspect of noise induced hearing loss.

Rehabilitation of Hearing Impairment

Hearing Aids

It would seem, on the surface, that hearing impairment can be equalized by amplifying the sound. This is true in some circumstances, however, there are some major problems with fitting hearing impaired persons with hearing aids.

To understand the first problem, we have to look more closely at how the ear processes sound. We now know that the ear is not a passive receiver of sound. The nervous system generates neural potentials that make it possible for us to hear some sounds more clearly. Also, there are neural activities that tune incoming sounds to make them more distinct.

These mechanisms are intact in the individual with a conductive loss, so amplification works well with that individual. However, when there is damage in the sensory organ or the neural pathways, the ear may lose the tuning mechanism. The result is sound that is distorted in relation to what the normal ear hears. Certain frequencies aren't heard as well and the damaged tuning mechanism doesn't give sounds the normal clarity. The signal is distorted for the listener, and even if it is made louder, it may be difficult to process.

Damage to the sensori-neural system can also result in recruitment. Recruitment, as indicated before, is the abnormal growth of loudness. At some time you have probably spoken to an older person who asked you to repeat. When you repeated, you raised the level of your voice only to get the response 'don't shout, I can hear you!' Once the sound reaches the threshold for the person with recruitment, or point at which it can be heard, it becomes loud quickly. This is a result of damage to the tuning mechanism in the inner ear.

Another major problem in fitting an individual with a hearing loss with amplification lies in the amplification process itself. Amplification is normally provided through a hearing aid, fitted either entirely in the ear canal or behind the ear with a tube and ear mold fitted in the ear canal. Electronic amplification of sound in an instrument this small does not have the same quality of the amplified sound as from your stereo system. If you have the opportunity to experience listening to sound through a hearing aid, you will immediately be aware that there is a much different quality to it.

Hearing technology has made great strides in recent decades. Hearing aids can selectively amplify frequencies, suppress certain unwanted sounds, and control the signal to make it more comfortable to the listener. However, the hearing aid still cannot remedy a hearing loss in the way that most eye glasses remedy a vision problem. Things do not sound the same as they normally do through a hearing aid, and much of the success of a hearing aid fitting is the result of the user learning to hear with it.

Lip Reading

Another area of rehabilitation for persons with hearing impairment is lip reading. We have all seen the spy movie in which an agent lip-reads perfectly through binoculars at 500 yards. Unfortunately, lip reading in real life doesn't hold the potential for comprehending the whole signal.

There are 40+ sounds in the English language, only about half of which are even partially visible. Vowels are partially visible by the position of the lips. However, the position of the tongue is also important for vowels and it cannot be seen at all. The only consonants that have significant visible components are the ones made with the lips and teeth, which are 'm,' 'p,' 'b,' 'f,' and 'v'. Study the production of the 'p,' 'b,' and 'm' and you will find that they are all look the same way on the lips. Look into a mirror and say "my," "pie," and "bye". Try the same with 'f' and 'v' by saying "fan" and "van". You can imagine the confusions that might occur.

The rest of the consonants are made with the tongue and other parts of the speech mechanism that cannot be seen. Lip reading can help fill in some of the gaps a person might experience with a hearing impairment, but it cannot begin to replace hearing by itself. To see what kind of confusion can occur, try the following. Have a group of friends try to lip read phrases such as “peanut butter,” “safety pin,” or “after work".

Importance of Hearing to the Individual

Experiencing a Hearing Loss

The best way to experience a hearing loss is to try to watch television with the sound turned down. You'll notice I said 'try'. Time yourself and see how long you can sit and watch a program before you give up trying.

Probably the best program to watch is the news. You will get some visual cues from the screen, but you find yourself 'making up' the speech from the context. Turn it up in the middle of some running speech to see how much of the signal you have understood. Most people will be able to get a few of the words, but few will follow the overall communication. Consider having a hearing loss and facing that situation every day. This will help you understand why captioned television was a significant development for the deaf population.

Another good way to experience a hearing loss is to take a lip reading test. This is a test administered on video or film in which the speaker reads a list of words, sentences, and/or a paragraph with the sound turned down. I've found that almost everyone can lip read to some extent, but only a few are really good at it. At one time I taught a university class which included deaf individuals for whom lip reading was a primary communication mode. As a part of the class I gave a lip reading test. While most of the normal hearing students did poorly, one or two of a class of thirty with normal hearing would score as high as the experienced lip readers. Almost everyone looks at a speaker during conversation, and it appears that some people with normal hearing learn lip reading incidentally over the years.

Lip reading doesn't correlate well with any other single trait, such as intelligence or visual acuity. It doesn't improve significantly with training. It appears to be an ability to which individuals are predisposed.

The Telephone

We don't always appreciate the importance of the telephone in our daily lives until the lines aren't working and we need to make a call. Consider the communication that takes place in your life over the telephone. I began working with the deaf before the advent of the TDD (Telecommunication Device for the Deaf, Erber, 1985, p.12-13). Deaf persons had to drive to places, or have hearing friends or relatives call, anytime they wanted to communicate for business or social purposes. The TDD was a major step forward in that it allowed the user to place a conventional telephone receiver on a device on which they could type a message. This message would be printed on the screen of a TDD connected at the other end of the line. The problem, of course, was that the deaf often wanted to call places that did not have a TDD. Now many agencies to which the public needs access have special TDD lines for the hearing impaired. There are now portable TDDs deaf persons can carry with them that can be used with standard telephones.

Cell phones, with the capability of texting, are a major step forward in communication for the deaf. And the advent of Skype, with the ability to transmit a visual image from one to another, enriches the communication environment of the hearing impaired.

Communicating with the Public

Careers are an important aspect in the fulfillment of life potential. The role of hearing impairment becomes more significant when you consider the importance of spoken communication in occupational/professional options. Both receptive and expressive communication is affected, so the result is an overall deficit. The degree of speaking impairment correlates well with the degree of hearing impairment.

Social Implications

The social implications of a hearing loss are perhaps the most significant. We've talked earlier about the impact of communication skills in general on social involvement. Hearing loss adds dimensions that are difficult to overcome. One is the fact that hearing loss, particularly the hearing loss of a greater degree, may interfere with the individual using the telephone. Much of our social affairs are conducted over the telephone. Fortunately, texting and Skype resolve much of this problem.

The deficit to speech caused by a hearing loss is another dimension. Speech is part of our appearance and any deficit in that area is a social deficit for the individual.

Listening is as important as speaking. A critical part of listening is being able to hear the communication. Misunderstanding spoken communication and asking people to repeat, are obstacles to social interaction. Try this experiment to see how a hearing loss affects attitude. At a restaurant or in a store, ask the waiter/clerk to repeat at least two times every time something is said. Watch the reaction.

Monitoring Surroundings

One capability that hearing gives us that most of us take for granted is the ability to monitor what is happening in our surroundings. As I sit in my office working on this I can hear people coming and going in the hall outside. An increase in activity indicates to me that classes are changing. On days of special activities, I can hear the increase in activity by the noise coming from our clinic's waiting room, which is at the other end of the hall.

I am not consciously aware of many of the sounds, but they are still ones important for keeping me in touch my environment. I can identify the off and on cycle of the ventilation system. When in my car, I can hear the engine and am quickly alert to any new noises that might occur. Just being able to tell whether or not the engine of your automobile is running is important. Have you ever left your car running while parked and it ran out of gas? A lot of deaf people have had this happen many times over. Likewise being able to hear running water (did I leave the faucet on?), water boiling on the store, the alarm clock, the door bell, how loud the television set is turned up....the list goes on and on. People with hearing impairment have to find other ways to monitor their environment. Monitoring their environment is an area of daily living for which persons with hearing impairment have to develop compensatory strategies.

Hearing Important for Learning Speech

When I started working in the field of communication disorder during the 1960s, it was not unusual for a child's hearing loss to be found at five years of age or older. Parents were told the child "will grow out of it" or "will talk when he's ready to talk." Now we know that hearing from birth is critical to the development of speech. Our testing procedures today can identify serious hearing loss at a few days of age and less serious losses can be found with good reliability within a few months of birth.

You will remember that earlier we discussed how much speech and language the child learns in the first few years of life. Because of this facility, those first five years are considered the optimum years for learning speech and language. Anything that interferes with communication during those years can cause a significant delay to the development of speech and language. Helen Keller is revered for her accomplishments in life, and in particular her communication skills. However, Helen Keller had normal hearing until eighteen months when it was lost due to illness (Brooks, 1956, p.7). It is unlikely she would have achieved the level of communication skills she eventually developed if she had been deaf from birth.

Hearing impairment in an infant is a major obstacle to the development of communication skills. Even a minimal hearing loss can have an impact on the long-term development of communication skills (Stewart & Downs, 1984, p.267-268). Language is a tool of learning, so the delays in the development of language may be mirrored in learning deficits.

We now realize the importance of early detection of hearing impairment. Early detection leads to early treatment. If the treatment can restore the hearing, the child will be able to take full advantage of the optimum time for learning language. Any improvement in hearing that treatment can achieve for the child during those years can have a significant influence on the development of communication and learning skills.

Case Histories


Curtis was an 8 1/2 year-old child who was referred to the Speech and Hearing Clinic for delayed language. He was a great kid: easy to work with and eager to please. His parents reported that Curtis had always been a little behind the other children, but now he was repeating the second grade and still having difficulty. He was labeled as having a learning disorder. The parents thought that maybe his poor school performance might be the result of the language problem.

Curtis' speech was within normal limits, but there were some differences. Some of the consonant sounds weren't as distinct as expected, and he made errors that were suggestive of a hearing loss. His hearing appeared to be normal as he responded to sound at normal intensity, could hear a whisper across the room with his back turned, and could identify background environmental noises such as cars passing, air conditioner's running, etc. accurately and with ease. An audiologist at our clinic tested Curtis and confirmed that he had normal hearing.

Curtis had difficulty following directions. He seemed to pay careful attention, but had a difficult time processing speech. He would sometimes grimace when he encountered difficulty trying to comprehend what had been spoken to him. We focused our efforts on teaching language through his schoolwork and the treatment sessions became a combination of language treatment and tutoring. After several months at the clinic, his schoolwork improved, but he still was not achieving at the level of the rest of the class. I referred him to a comprehensive evaluation clinic for further testing, as we did not seem to be getting the gains of which I felt he was capable.

The clinic to which I referred him was in a city two and one-half hours away. The parents were curious as to why I made such a strong recommendation on referring him, as he had shown some improvement during treatment. It was a major transportation and financial challenge for them to get there and pay for the evaluation, as they were a family with limited means. I explained to them that the clinic to which I was referring them saw many different types of cases and might be able to give us some ideas of what we could do with Curtis. I assured them that we would continue the treatment recommended at our clinic. The parents were very interested in the child’s welfare and cooperated completely.

I received the report from the clinic to which we referred Curtis the day before the parents came in for the first treatment session following the evaluation. The clinic had been thorough in the evaluation and identified the problem. Their diagnosis matched his symptoms and was straightforward. Curtis had a hearing loss. His hearing was normal in the lower frequency range, which explained how he was able to hear most sounds, but he had a moderate to severe loss in the higher frequencies.

The person completing the evaluation from the other clinic had many years of experience and was patient (and kind to us) in explaining the hearing loss in the report and to the parents. He, too, had missed it the first time around. But when giving other tests to the child, he was so sure there was a hearing loss he went back and tested again. What he found was that the child sat in the audiometric testing room at an angle so he could watch the persons testing him in his peripheral vision. As I said before, Curtis was eager to please and he wanted the examiner to think that he heard the sounds as they were presented. He had enough experience being tested to watch the subtle movement of the examiner and determine when the tones were being presented. In other words, he was using his vision to take the hearing test. He did it in such an unobtrusive manner that it was anything but obvious.

I took Curtis immediately back to our own audiometric suite and confirmed the findings. The hearing test matched perfectly with the one from the other clinic.

Audiologists are trained to watch for suspicious behavior during testing. However, most people who try to manipulate a hearing test are trying to fake a hearing loss for purposes of compensation or some other benefit. It is unusual when someone tries to "pass" the test. This child was so persuaded that he was supposed to "pass" the test that he was embarrassed when we got the true hearing test. He was not embarrassed about the loss, only that he knew he hadn't signaled at the right times.

Curtis' father brought him to the clinic this particular day. I'll admit that had Curtis been my own child, and if I had been taking him to a clinic that had been treating him for something other than a hearing loss, I would not have been as understanding. As it was, the audiologist at the other clinic had praised our efforts and discussed with the parents how difficult it was to test Curtis. The parents remained remarkably cooperative, I believe because they now had something tangible to associate with the deficit.

We discussed the situation and decided to continue the treatment to improve language. The main change would be in fitting Curtis with amplification. Fitting an adult who has normal hearing in some frequencies is a "challenge" to say the least. Fitting a child would be an even greater challenge.

Curtis proved to be as conscientious learning to use the hearing aid as he was in the rest of treatment. Learning to use a hearing aid for him was not as simple as it might seem. The sounds that were now amplified for him were sounds he had never heard before. While he could now hear them, he had nothing to associate with them. Basically he had to learn to associate sounds with symbols. The sounds on which he needed instruction were the higher frequency sounds, 's', 'th', 'sh', 'f', 't', and 'k' sounds in particular.

It took Curtis about three months to accommodate to the hearing aids and learn to discriminate the new sounds he was hearing. He was still close enough to that optimum time for learning language that he was a quick study. We worked with him until the end of the school year, which was about six months beyond the time it took him to learn to use the hearing aids. At that time he had caught up to grade level and showed evidence of progressing even faster in school. Curtis was obviously a brighter than average child. This was confirmed by the way in which he managed to "pass" the hearing tests.

I had about ten years experience when Curtis appeared at the clinic and was pretty confident of my clinical skills. It was a humbling learning experience for me. I was fortunate that Curtis' family accepted the mistake I had made and went on from there. This story had a happy ending, but if somewhere earlier in Curtis' life the problem had been identified and dealt with appropriately, there would never have been a story.

Carrie and Annie

Carrie and Annie were two children I encountered in my very first teaching experience with deaf children. I had completed most of my course work and needed hours of practice teaching in the classroom. It was the beginning of the school year and this was a class of five four-year-old children who had not been in a classroom before. Carrie and Annie were the most lively, with bright smiles and shining eyes that showed nothing but excitement at the prospect of a new adventure. Testing had indicated that they were both intelligent children whose only deficit was hearing loss.

Annie's hearing loss was severe. She could hear some sound through her hearing aids, but not enough to learn to speak, and understand speech, without a special program. Carrie was profoundly deaf. She wore hearing aids and could respond to sound, but only when the sound was loud enough to cause skin vibrations. She was feeling the vibration through the tactile sense, rather than actually hearing sounds.

Both Annie and Carrie came from very caring families, neither of which had experience with deafness. They brought the girls to the program at the university because they wanted their children to be "oral". At this point I have to divert from the story to explain what "oral" means in deaf education, and the controversy in which it was, and still is, enmeshed.

There is a school of thought in education of the deaf that believes deaf children should be taught spoken language. The rationale is that deaf children will live in a world that is primarily hearing. They can only function normally in that world if they use the language of those with normal hearing.

The followers of this belief recommend that children be taught to use what hearing they have, and visual, tactile and kinesthetic cues, to learn speech. To be successful, speech must be taught through an early and intensive treatment program. Some members of the family must commit themselves to daily exercises and the whole family must be involved in teaching the child to speak, and to understand speech.

There is a diametrically opposed school of thought that suggests deaf children be taught language in a mode that is "natural" for them, which is "manual" communication. Manual communication includes sign language and finger spelling. This is a visually based language so the children can "see" the communication system in its totality. Deaf children can learn manual communication without the special effort needed for learning speech. The followers of this belief suggest that teaching deaf children manual communication provides them with a complete communication system that is natural for them. This will promote learning language early and facilitate the educational process.

Both "oral" communication and "manual" communication have advantages and disadvantages. The primary advantage of the oral method is that through it children learn the language of the hearing world. This has some obvious, and strongly positive, benefits. However, there are disadvantages. From my perspective there are two primary ones. First, not all children can learn the oral method, although some children learn it remarkably well. There are marvelous video taped examples exhibited by oral schools demonstrating how well some children have learned to speak.

However, there are many children who will fail in the process. The family, as well as the children, will have to accept that failure. The time and effort required for teaching the spoken language is expended during the children's prime learning years. That means those years would be lost to teaching using another mode of communication.

The advantages and disadvantages of manual communication are obviously the opposite of those of oral communication. Children who learn manual communication will have to use an alternate form of communication as adults in the hearing world. This will set them apart as "different". The followers of manual communication would argue that the speech of oral deaf adults lacks many of the characteristics of the speech of the normal hearing and that sets them apart as "different" anyway.

Adults who practice manual communication have to use alternative communication methods to communicate with hearing people. Normally this is reading and writing messages. Choosing manual communication as the primary communication mode for children also means that their own family will have to learn manual communication to communicate with them. Here again, the family must be involved in the process.

There is a so-called middle ground, an approach sometimes called the "simultaneous method" whereby children are taught manual communication and speech at the same time. Proponents of the simultaneous method suggest that children can be exposed to both methods at the same time and learn the communication mode which is most natural for them. Oral school advocates suggest that the attention taken away from the development of speech lessens the chances children will learn the spoken language. They believe that learning speech should be an all-out effort.

The decisions for choosing a communication method must be made early to take advantage of the prime language learning time. Therefore, it falls to the parents to make the decision within a limited time frame. This is a major stress situation for the family. First they have learned that their child has a severe hearing loss. This often generates feelings of persecution ("why me?") or guilt ("what did I do wrong?"), and always the grieving process. The family has to accept the “loss” of a “normal” child, and accept the limitations the child has. Then, they have to make a decision about the child's training, a decision that will require increased family effort, regardless of the choice, and have life-long implications for the child. The decision may create the necessity of the family moving to an area where the type of training they want is available. It must be one of the greatest strains a family can face.

I believe most professionals, and most families, approach the decision by considering what will be best for the child when the child reaches adult age. One of the best ways to make this decision is for families to meet with individuals, and groups of individuals (such as clubs for the deaf), where many deaf adults are present. Parents can hear the type of speech deaf adults can achieve, and they can experience what it is like to be around deaf adults who communicate manually.

It has been my experience that families having to make this decision do not have significant exposure to deaf adults who are products of both schools of communication. That, to me, is unfortunate, because I believe it would relieve a lot of the concern. The gatherings of deaf adults I have attended would convince almost anyone that regardless of the communication system they use, deaf adults are just like everyone else, except for the communication mode. They hold jobs, raise families, have hobbies, and enjoy the company of both friends who are hearing and hearing impaired. If one measures success in terms of career achievement, the common denominator is not communication system, but education. Those with the best education have the best jobs.

Many hearing people who have not been exposed to deaf persons experience anxiety, some even fear, at the prospect of having to deal with a deaf adult. This, too, is unfortunate because it inhibits social interaction between hearing and deaf persons. Deaf people have the same range of personalities as any other population. Most are very nice people who work hard at maintaining relationships and make excellent friends. Some are con artists who use the hearing loss to exploit those not familiar with hearing loss. And then there are all of those in between, just as in any group of persons.

Probably the most important thing to remember is that most deaf persons do not think of themselves as being "handicapped" and do not want others to think in those terms. They may be "different" in the mode in which they communication, but they do not want people to pity them or feel they are not capable of achievement. The main thing they wish is to be treated like everyone else and have their differences accepted. In this they have a wish that all of us share.

Back to the story of Carrie and Annie. They were instant 'stars' in the classroom because they were smart and eager to please. The initial weeks of the class were focused on establishing a routine, becoming familiar with the setting, and developing a working relationship with the teachers and student teachers. During this time the children were being informally evaluated for concept development that would be important for formal learning, such as ability to discriminate between things, ability to sequence events, time and spatial concepts, etc. Both Annie and Carrie excelled in all of these areas.

At the end of the second month the focus turned to teaching the children to speak and to understand speech. Both Carrie and Annie made sounds and watched speakers carefully, so both were considered good candidates for the oral method.

Whatever the reason, Annie continued to shine while Carrie struggled. Being a bright child, Carrie was overtly aware of the difference in performance level. She was also aware of the positive reactions of the teachers to Annie's successes. Annie would run to get her mother at the end of the day and pull her to the teacher, because she knew the teacher would relate some achievement. Carrie came to walk straight to the door without looking back. Other children in the class, who at the beginning of the year seemed less capable, developed oral communication skills much more quickly than Carrie.

The teachers knew Carrie was capable and pressed as hard as possible for success. Their motivation was admirable, but Carrie was paying a high price in terms of self-esteem. The nature of school was such that a child was kept in a class until the end of the year. There was no reprieve for Carrie that year. Because of lack of progress, the parents withdrew her at the end of the year. I remember watching her leave the last day of school. She was not the same bright eyed, enthusiastic child who started the year.

Annie continued through the rest of the three-year program and continued to be the star. She developed intelligible speech and was eventually mainstreamed into a regular classroom. The training she had at the early years was perfect for her.

I saw Carrie only briefly a few years later. She went to the state school for the deaf that was primarily manual in orientation. Her parents reported that she learned sign language quickly and did well in class. It seemed to be a good placement for her. I still wonder, however, how the early exposure to failure affected her long term well being.


I met Joan while working on my doctorate. I was working with a university department as part time faculty and was called upon to teach sign language classes for vocational rehabilitation counselors. The purpose of the program was to give every vocational counselor in the state basic manual communication skills that they could use with their deaf clients. I was the only one on campus who had any background in manual communication at that time, so I was elected.

My signing skills were limited so I had to concentrate when using them. I should point out that "manual communication" refers to "sign language" and "finger spelling". Sign language is a set of hand positions and movements that stand for a word or concept. Finger spelling is hand positions or movements that stand for a letter of the alphabet.

The sign language that most deaf individuals use does not match word-for-word with the spoken language. Sign language relies more heavily on concept and context. There is not a straight translation of signs to spoken language, or vice versa. There are, however, some forms of sign language taught that dictate signing or finger spelling all of the words that would be spoken by a hearing speaker. These forms require that many words be finger spelled because of necessity, as there are over 100,000 words in the English language and only a few thousand signs. The efforts of interpreters, people who translate spoken messages into signs, and who translate signs into spoken messages, are appreciated more if you realize that they are not just "translating," or changing the message from one form to another, but "interpreting," which involves choosing the most appropriate forms of expressing a concept or idea.

It became apparent as I developed the class outline that I was going to have to get some help if I was going to do justice to the class. So, to prepare for the class, I took the three most popular sign language books at the time and met with a group of deaf people to discuss the signs in each.

The university was in a state capital with a sizeable population, so a deaf group was not hard to find. Most worked for the state government, and all belonged to a loose knit social group that met regularly.

Most of the deaf people I have known are most at ease in social situations in which the majority of persons are deaf. I believe it is because there is camaraderie in sharing a common trait, in this case, hearing impairment. Most of the deaf social gatherings I have attended are lively affairs. Perhaps it is because sign language is a more animated form of communication. Their stories and jokes always seemed to have an extra edge. The groups of deaf persons with which I have been associated have always been warm and friendly, particularly to the hearing person who struggles with their communication system.

Meeting in social situations taught me a great deal more about deafness than any classes I had. I became aware that they are just people, like all the rest of us. Perhaps they were more patient and understanding because of the life they have lived as a population whose communication system was that of a minority. Being a hearing person without signing skills in a group of deaf people with signing skills is one of the best ways to understand how it feels to have a communication difference.

Back to preparing for the class. The deaf education program in which I had trained did not teach, or allow, signing. I learned signs at a state school for the deaf where I was assigned to finish my practice teaching. I taught the extremes of the high school English spectrum; remedial English and college preparatory English. Signing was used in all classes. Most teachers had normal hearing and spoke and signed as they taught. However, there was no doubt that the main means of communication was signs.

My crash course for signs while practice teaching was finger spelling words in class and asking the students to show me the sign. I could fingerspell well enough to get ideas across, but finger spelling is very slow compared to communicating with signs. I was communicating adequately by the end of the six-week period. "Adequate" was the operative word. This was the background with which I was planning my sign language course at the university.

The deaf community was eager to help me decide which book and which signs I should use. They gave their advice freely, and after several hours of consultation I was only slightly further along than I started. It seems that sign language, like spoken language, has regional differences. Just as people speak with different accents, people with signs have differences. Not only that, I found signs were a very personal matter. If I asked three deaf people to critique a sign, I would get three different versions of how it should be done. While there were common characteristics to any given sign, there were enough variations to make me skeptical of any one particular interpretation. I decided to teach the most common characteristics in my class for vocational rehabilitation counselors.

I also asked the deaf people to come to class to help me teach it. Joan was among the small group who volunteered to come to class and help. The ones who came were helpful, but after a while it became evident that Joan was the most effective teacher. The first night she stood near a corner of the room and watched, obviously not comfortable. Finally I coaxed her near the front of the room where the students could see her as well as me. I would stop and ask her for a sign as I was teaching and the students came to accept her as the authority.

The class was a three-hour evening block, so there were two breaks. The students would cluster around her at break, trying out their newly found communication system. The fact that Joan was very attractive probably stimulated interaction. At this time most of the counselors were male.

We had a routine by the third term I taught the class. I would present a sign, Joan would show her version of it and any alternatives of which she was aware, and then she would circulate around the room making individual suggestions while I talked about some aspect of using the sign. She was an exceptional teacher, given particular encouragement to the ones having the most difficulty, and making corrections without being critical. This was a class largely of adult males, 30-45 years old; a challenging group in the classroom. Most were attending not because of a burning desire to learn manual communication, but because it was required for their jobs.

Joan was in her early thirties, and the guys were not the most subtle of individuals. It could have become an uncomfortable scene if Joan had reacted differently. But, she handled the teasing and advances of the group with aplomb and good spirits. She had an exceptional sense of humor and could turn teasing around quickly. She had the ideal balance of a teacher in regard to reacting to students; she put no one down and had no pet students. There is no doubt that the success and popularity the course came to enjoy was due to her participation.

Joan was an exceptional person in her own right. She worked as a file clerk for a large department in state government. It was a position that required little communication skills. Folders were brought to her and she filed them. She rarely missed a day of work and had consistently high work ratings. She was selected state employee of the year on two occasions because of her ratings. This was in a state government of several thousand employees.

She was married and had two children. Her husband was visually impaired as well as deaf, so he could not drive. He contributed to the household by contracting with a local furniture maker to make cane chairs, which were beautiful. His workshop was in his garage and so he was available to care for the children when they weren't in school.

Both children had normal hearing and were advanced for their years. By advanced, I mean they played a more active role in family affairs than might be expected. Deaf parents are very good about making sure their hearing children are exposed to spoken language and learn to speak normally. When the children learn to talk, they become interpreters for the parents. They are often placed in situations that can be delicate, so many learn more about the subtleties of household affairs and social interactions than would normally be expected of children. This obviously has its advantages and disadvantages in their development. Both of Joan's children were friendly, but cautious in dealing with adults.

It was obvious that Joan had accepted deafness and found a life in which she felt comfortable. I wondered, and knew she must have wondered, how much more she could have achieved if she had had normal hearing. She was obviously bright and socially aware. There would have been few limitations.

The sad note to this tale is that Joan was born with normal hearing. She lost her hearing as a preschooler, the result of an infection from a tonsillectomy. Tonsillectomies were performed at the time of hers in the physician's office as an outpatient procedure. A little more care in that surgical procedure would have made her life quite different.

Identifying Persons with Hearing Loss

It is more difficult to recognize hearing loss that you might imagine. One of the most common mistakes is assuming reduced mental capacities. The hearing impaired person may ask the speaker to repeat and, even when the message is repeated, may not understand it completely. One of the first things we suspect when people have trouble understanding what we say is that they are mentally deficient. Many children who have hearing loss have been placed in rooms for slower learners or mentally retarded because of this confusion. The lesson to be learned is: when encountering a person who seems to be slow in understanding, suspect hearing loss.

There are several other cues to hearing loss. Hearing impaired people will ask you to repeat, sometime several times. Many people become aggravated when they are asked to repeat more than one time, especially if they don't realize the person asking them to repeat has a hearing impairment. Many persons with hearing impairment do not announce that they have a hearing impairment. Telling others they have a hearing impairment draws attention to themselves. Also, they know that some people will treat them differently when they find they have a hearing impairment. So, they try to hide it.

I once watched a conversation between a hearing-impaired person and a person with normal hearing who did not realize the other had a hearing loss. The person with the hearing impairment was sensitive about the hearing loss and didn't identify herself as being hearing impaired. After being asked to repeat several times, the person with normal hearing become upset and said in a loud voice, "what's the matter? Can't you hear?" The person with the hearing impairment finally admitted quietly, "no, I can't." Both were embarrassed.

Exercise patience when asked to repeat, and study the listener to determine if there is possibly a hearing impairment. Look for hearing aids. Some persons with hearing impairment style their hair to hide hearing aids, so the aids may not be obvious. Note if the person is watching your face closely. Most hearing impaired people rely to some extent on lip reading. This obviously requires attending to the speaker's face. Don't rule out the possibility of a hearing loss just because the person turns to sounds like doors closing and telephones ringing. Remember, they may be able to hear part of the signal normally, but miss the part of the signal that is important for understanding speech.

Suspect hearing loss if the person seems distracted, or if the person’s attention seems to wander. There are two reasons why this happens. First of all, if a person with hearing impairment is having a difficult time understanding you, the person may become frustrated and need time to re-focus. Secondly, it requires more effort for a person with a hearing impairment to watch and process communication. Looking away may be their way of "taking a break" from the communication process.

Suspect hearing loss if a person confuses words. If you say "Are your ear rings lost?" and the person says "No, I don't have a hearing loss" you can suspect they do. The hearing impaired person is constantly having to guess among meanings because so many words sound alike and so many more look alike.

Suspect hearing loss if the speech pattern is different. The quality of speech is generally proportional to the degree of hearing loss. The greater the hearing loss, the poorer the quality of the speech expected. This is only a general rule, however. Some persons with severe hearing impairment have excellent speech. Overall, though, speech is usually an index of hearing.

How to Interact with Persons with Hearing Impairment

The same general rules that apply when interacting with persons with other types of communication disorders obviously apply with the hearing impaired.

  1. The primary rule is that persons with hearing impairment do not want to be treated differently from others. They want people to accept them and accommodate to their communication needs. As I have said before, all of us are different in some way, and the hearing impaired simply want people to recognize how they are different and accept that difference.

  2. Be patient in the communication process. If you are talking with a hearing impaired person who is having difficulty understanding you, slow down your own speech pattern. Some persons with hearing impairment who have difficulty processing speech at a normal rate understand it more easily at a slower rate. And allow them more time to respond.

  3. Avoid talking loudly. There are instances in which raising the intensity of your voice will be helpful to the person with a hearing impairment, particularly if they are not wearing hearing aids. Usually, however, it is better to slow down and pronounce each word very distinctly.

  4. Face the listener and try to stay within ten feet to give them the opportunity to lip read.

  5. When asked to repeat, revise the sentence rather than simply say it over again the same way. Think of the key words which may be confusing them and try to find substitutes that may be easier to understand. I remember one student asking an older patient "what is your age?" only to draw a blank look. Next the student said, "in what year were you born?" Still a blank look. The answer was finally elicited when the student asked, "How old are you?" Use wording you feel will be familiar to the listener. Give additional cues with facial expression and gestures. Expressive visual signals can fill in many gaps in communication.

  6. If the communication situation becomes strained, don't hesitate to go to pencil and paper. It is often easier on everyone to work with a written message than to struggle with a spoken one.

  7. If you interact with deaf persons on a regular basis, sign language for the deaf is an alternative that can be valuable. Most people can learn enough sign language in 15-20 hours of instruction to have basic interaction skills with the deaf. Many communities have sign language classes through universities, colleges, or adult education programs. If you find yourself working in an area in which deaf persons are frequent visitors, it might be worth learning basic sign language.


Working with hearing impaired individuals is one of life's more rewarding experiences. Part of this is because most of them have no limitations other than the hearing loss and the communication difference that results from it. They have the same range of talents, skills, and emotions as people with no hearing impairment. Those who help persons with hearing impairment cope with their challenges are amply rewarded, as they can see the positive benefits to the hearing impaired person in terms of participation in society and achievement in life.

Persons with hearing impairment make good friends. There is the same range of desirable-to-less-than-desirable personalities, but overall they are appreciative of those who meet them half way in the communication process. They respond in kind to thoughtfulness.

It has been encouraging to see improvements in the resources society provides to the deaf population. Captioned films/television opened a new world to them and has contributed significantly to helping them to be more aware of the world around them. Cell phones and Skype have enhanced the communication process. Interpreters are more common in legal, business, government, and social agencies.

There is still more to be done. Laws now require new public buildings to provide accessibility to the handicapped in terms of curb cuts, ramps, and elevators that make the facility accessible to the person in a wheelchair. However, for the buildings to be fully accessible, the agencies housed in the buildings must be aware of the needs of those with hearing impairment. Accessibility of information is as important as physical accessibility. This can only be accomplished through providing communication resources that give the hearing impaired person accessibility to information.