Common areas of expertise once characterized the scope of practice for audiologists and speech-language pathologists. Rapid and significant advances in knowledge and technology in each area have allowed for—and in fact necessitated—specialization for each profession, as evidenced by the requirement of an AuD as the entry-level degree for audiologists.
Certain topic areas, however, remain essential for both professions. For example, audiologists must maintain a working knowledge of speech and language development to best understand the implication of hearing loss in children. Similarly, the diagnosis and treatment of some communicative disorders, such as auditory processing disorders, are best served when both SLPs and audiologists are involved. This healthy sharing of knowledge and skills allows for greater access to professionals by individuals seeking care.
Unfortunately, patient access to other services once commonly offered by both SLPs and audiologists has decreased. Provision of comprehensive aural rehabilitation (AR) by audiologists, once the core of the audiology profession, has declined in the past 20 years, partly due to the definition of audiology as a diagnostic profession rather than as both diagnostic and therapeutic. The resulting lack of adequate reimbursement has led to many audiologists being unwilling or unable to provide comprehensive AR.
Many Skills and Processes
Some audiologists assume that patients need only technologically advanced hearing aids to gain better audibility, comfort, and enhanced communication skills. This logic is flawed, as shown by the wide disparity in outcomes for individuals presenting similar audiometric profiles and receiving similarly advanced hearing aids. Various factors account for this disparity, including the individual's assimilation of acoustic, linguistic, and environmental cues. To optimize this integration, a person must call upon many skills and processes, including cognition, auditory memory, auditory closure, auditory learning, metalinguistics, pragmatics, semantics, grammatical shape, localization, visual cues, repair tactics, and effective interactive communication strategies.
Working against many individuals with hearing impairment is the fact that certain cognitive skills important for comprehending speech in adverse acoustic environments— such as processing speed and auditory working memory—diminish with age. The skills and processes vital for the individual with a hearing impairment are within the expertise of both SLPs and audiologists. Both professions now recognize that peripheral hearing disorders lead to central auditory pathway changes, rendering it unlikely that amplification alone will produce optimal re-adaptation of the auditory system and auditory skills. It is important that members of both professions provide these needed rehabilitative services.
Communication, Not Audibility
AR has come to be viewed by some as an "add-on" procedure to the fitting of hearing aids. This view is backward-thinking. In fact, the use of hearing aids should be considered as part of the overall AR process, not the other way around. Hearing aids address only audibility. They don't address communication strategies. Hearing aids help hearing but don't address listening. A person may have normal hearing, but still be a poor listener. Conversely, a person with hearing impairment may be an excellent listener. Hearing requires audibility. But to be a good listener, an individual must integrate the skills described above, and many—particularly the elderly—find themselves in a compromised position characterized by progressively declining cognitive function (Pichora-Fuller, Schneider & Daneman, 1995).
Comprehensive AR includes counseling, communication strategies, individualized auditory training, hearing aids, assistive listening devices, and group therapy. An abundance of evidence demonstrates the benefit of each of these services. Among these options, it is certainly cost-effective to provide group therapies, although such sessions are not commonly offered. Sweetow and Palmer's (2005) evidenced-based analysis of research related to individual adult auditory training found mixed results for analytic training.
We found that with synthetic or combined training, improvements in communication strategies—and often in sentence recognition—can be expected. Such individual training can be both time- and cost-intensive. Alternatives are available through computerized auditory training. These programs can enhance formal perceptual training, provide user feedback, and identify and modify perceptual and communication repair strategies.
Examples of software using established rules of perceptual learning are LACE (Listening and Auditory Communication Enhancement), CASPER (Computer-Assisted Speech Perception Evaluation and Training), CAST (Computer Aided Speech-Reading Training), and CATS (Computer-Assisted Tracking Simulation).
LACE is a home- or clinic-based interactive adaptive computer program designed to engage the adult with hearing impairment in the hearing aid fitting process, provide listening strategies, build confidence, and address cognitive changes characteristic of the aging process. In a multi-site study (Sweetow & Sabes, 2006) of the effectiveness of a pilot version of LACE, significant improvements were shown not only on the training tasks, but also on a variety of standardized outcome measures including the QuickSIN, Hearing Handicap Scale for the Elderly, and Communication Scale for Older Adults. Performance data are transmitted to a HIPAA-compliant server easily accessible online by the professional.
The most difficult hurdle is to convince both patients and professionals of the importance of training and to provide them with a means of achieving this goal. Many patients believe that they have spent enough money on products and professional programming, and have the unrealistic expectation that success should rest solely with the hearing aids and the audiologist's expertise. Moreover, the financial investment also may translate into the belief that a personal time commitment should not be necessary. This belief is certainly not the mindset of patients regarding physical therapy following surgery, however. Our professions must evolve to the point that we can inform patients confidently and compellingly that they must actively engage in rehabilitation training in order to achieve maximum potential.