Can I be Compensated for Work-Related Hearing Loss?

What should I do if I notice hearing loss?

  1. Speak to your employer: Inform them of hearing loss symptoms. If you work in a noisy work environment, you should ask your employer to provide you with the appropriate hearing protection.
  2. Consult your GP: Your doctor can advise you about the appropriate treatment requirements and whether a referral to an Audiologist is necessary.
  3. Lodge a WorkCover claim: A Workcover claim should be lodged with your last employer that has contributed to your hearing loss. There is no requirement for you to be working to lodge your claim.

What are my entitlements?

Once your claim is accepted, you are entitled to the following:

  1. Weekly payments:
    • For the first 13 weeks from the date of your incapacity, you are entitled to 95% of your pre-injury average weekly earnings if you cannot perform your pre-injury duties.
    • From 14 weeks to 130 weeks from the date of your incapacity, you are entitled to 80% of your pre-injury average weekly earnings if you cannot perform your pre-injury duties.
    • After 130 weeks from the date of your incapacity, you are entitled to 80% of your pre-injury average weekly earnings if you cannot perform any suitable employment on an indefinite basis.
  2. Medical and like services: The Workcover insurer will pay the reasonable cost of any medical and like expenses that are referable to your work-related hearing loss. These expenses can include hearing aids or devices.
  3. A lump sum impairment benefit: You are entitled to a modest lump sum benefit, provided that your hearing loss impairment is permanent and assessed at a whole-person impairment rating of 10% or more. Currently, the maximum amount that can be awarded for a total loss of hearing is $206,500.[3]
  4. Common law damages: If the consequences of your hearing loss are considered ‘serious’ and negligence can be established against your employer, you may be entitled to damages for pain and suffering and economic loss.

How much compensation do you get for hearing loss impairment benefit claim?

An individual with minor hearing loss can obtain workers compensation and benefits through WorkCover. If they have industrial deafness, they may receive an impairment benefit lump sum award of up to $117,590.00 (2022/23 maximum figure). Should it be established that you have a total loss of hearing, you would be entitled to $211,730 (2022/23 figure). 

Ultimately, how much compensation you are awarded for hearing loss varies depending on the level of impairment. 

How is my hearing loss impairment assessed?

Hearing loss impairment is assessed by an approved specialist who has training in assessing injuries against the NAL Hearing Loss Guidelines. The specialist will use an audiogram to inform their assessment of the hearing loss suffered. This hearing test is used to determine the severity and the probable connection with your employment.

Who pays for hearing loss compensation?

Hearing loss compensation benefits are paid by the Victorian WorkCover scheme through the insurer of the employer who has accepted your hearing loss claim. The injury employer in most cases is the last noisy workplace you worked at the time of lodging your claim. 

Is there a time limit on lodging a hearing loss claim?

No, there is no time limit on lodging a hearing loss claim. However, you must lodge a WorkCover claim as soon as possible after being diagnosed with hearing loss or industrial deafness.

WorkCover claims are typically made within 30 days of you finding out about your injury and must be lodged against your last “noisy employer”, that is, the last place where you were exposed to unreasonable noise. That employer will pass your claim onto their Insurer within 10 days and the insurer then has 28 days to determine the claim in most cases. Our team of Workcover lawyers can assist you with completing your claim form.

General federal law: Hearing types

It is important to note that at each hearing, orders will be made. Court orders can be made:

  • by consent of the parties, or
  • by decision of a judge or judicial registrar.

If you and the other party or parties reach an agreement on the day, or in the lead up to the hearing, you can present the signed agreement to the judge or judicial registrar and ask that the orders be made by consent. Consent orders can be interim (temporary) or final. If you cannot reach an agreement, the judge will make any orders necessary for your case to proceed to the next court event.

When an order is made, each person bound by the order must comply with it.

The Court will notify you on how your matter will be heard, for example in person or a remote hearing.

Hearing types 

First court date (directions hearing)

When you initiate your case in the Court, the documents you file will be stamped with a date for the first ‘directions hearing’. This is usually the first time that people involved in a case appear in court. 

Your directions hearing may only take a short while – 15 minutes or less. The purpose of the hearing is to work out the timing of your matter, not to hear the substantial facts of the case. You may be asked how long you think the final hearing will take. This allows the Court to schedule your final hearing.

In addition to possibly setting the date for a final hearing, the Court may, on this date:

  • give directions (instructions on the next step/s that are required in a case), including directions to attend mediation or other dispute resolution
  • approve proposed consent orders (either provided to the Court before the hearing or at the hearing)
  • if time permits, conduct an interim hearing (a short hearing about an urgent or defined issue) and make interim orders
  • make final orders for certain types of applications, and
  • give directions of steps to be taken in preparation for the final hearing, including setting deadlines for filing and serving documents.

The first court date also provides the parties with an opportunity to define the issues that are in dispute and, if possible, reach an agreement.

It is likely that your case will be just one of many listed at the same time. This is sometimes known as a ‘duty list’. The way in which judges or judicial registrars conduct a duty list will vary. Some judges and judicial registrars may call through the list alphabetically or in numerical order. Others may ask for matters to be ‘stood down’ and deal with consent matters or applications for adjournment first. In any event, the judge or judicial registrar will call through all the cases in the list. If you are unsure, ask the associate before the duty list starts.

If your case is ‘stood down’, it means that it is put on hold for a short time and the Court will deal with your case later that day. This gives you an opportunity to negotiate, define the issues in dispute and, possibly reach an agreement with the other party. This is different from an adjournment. If your case is adjourned, it will be postponed to another day.

In some matters, such as Fair Work small claims and consumer credit small claims, the first court date is likely to be the only court date, and the matter will be heard (and probably decided) on this date.

Further directions hearing

In addition to the hearing on the first court date, you will sometimes have to attend court for a further directions hearing, especially if a considerable time has passed since you were first in court and things have evolved in your case. The Court will make the same kinds of orders as it made on the first court date, such as directions on the next steps to be taken, including a possible direction to attend mediation.

Interlocutory hearing

Interlocutory hearings deal with specific issues that need to be determined before the final hearing. For example, an interlocutory hearing may be scheduled if a party applies for:

  • interim relief (such as an injunction – an urgent order to stop someone doing something)
  • procedural matters (such as ordering a party to give the other party documents), and
  • security for costs (if the Court thinks that you may not be able to pay the other party’s costs if you lose the case, the Court may order that you deposit money with the Court or provide security, such as a bank guarantee).

Final hearing

At the final hearing or trial, each party presents their case. In most matters, witnesses will be called to give their evidence and may be cross-examined. If a witness has given evidence by affidavit, they will not have to give the evidence again, but they may be cross-examined on their evidence.

The judge or judicial registrar usually asks the applicant to outline their case first. Following this and any cross-examination of witnesses by the respondent, the respondent outlines their case, and their witnesses may be cross-examined by the applicant. The parties then make any final comments or legal arguments in support of their case.

The judge may ask questions or interrupt you. Listen carefully and answer as clearly as you can. If the judge says something is not relevant, move on to your next point.

You cannot interrupt the other party with an objection unless it is about a matter of law. If you do have a legal objection, stand and tell the judge of your objection.

The length of the final hearing will depend on the facts of the case.

After hearing the case, the judge may make orders and give reasons for their decision. Ask for the orders to be repeated if you missed any. If you do not understand any of the orders, ask the judge to explain them once they have finished speaking. Once finalised, your orders will be signed and sealed electronically, and you can download them from the Commonwealth Courts Portal. For a step-by-step guide to accessing orders, see How do I access orders?

Sometimes, a judge may reserve or hold over their decision for another time or date. In such a case, the Court will let you know when the decision has been made, and you must attend court when the decision is handed down. The decision will include the orders made and the reasons for the decision.

Know Your Rights with Hearing Loss

It can be difficult to live with hearing loss in a world that seems to cater almost solely to the hearing population. Much of the communication between people, in your town city hall or at the bank and other commercial establishments tend to be very verbal. Perhaps you have even spent much of your life communicating verbally, but now have to shift to other venues now that hearing loss has appeared in your life. What exactly are the rights you have, as a person with hearing loss, to demand accommodation for easier communication?

Luckily, due in large part to the labor of activists over many years, the rights of people with hearing loss and other disabilities are protected by laws, both large and sweeping, like the Americans with Disabilities Act (ADA), to lesser known state and local provisions. 

The Americans with Disabilities Act was first drafted in 1986 and introduced into the US House of Representatives in 1988. Two long years later, in 1990, President George H.W. Bush signed the bill into law. It was revolutionary in its increased access for people with disabilities. Under this law, people with disabilities — like hearing loss — cannot be discriminated against and it further requires employers and workplaces to provide “reasonable accommodations” and makes accessibility requirements mandatory on public accommodations. 

But what does the ADA mean for you, a person with hearing loss? 

In the Workplace: Persons with hearing loss cannot be discriminated against in the workplace. Your employer must provide the necessary information so that you can participate in meetings, negotiations and decision-making. For example, if this information is shared with employees verbally, a written copy should be provided for you. If you were to file an ADA-related complaint against your employer, the ADA makes it illegal for them to fire you. 

Government Services: You probably use the local library, schools, hospital or courts at least infrequently if not much more often. Under the ADA, government services are required to communicate effectively with you in ways that are reasonable for a person with hearing loss. This ensures that the information the local school, for instance, is providing to the public will be tailored to be delivered to you in an effective manner. A public school board meeting would need to provide an assistive listening device or other means of hearing loss-friendly communication in order for you to attend as a member of the community. 

Business/Commercial Establishments: Even commercial establishments in which you are a customer with hearing loss are mandated to provide access under the ADA. You must be able to participate in the business’s offerings in a way that works for you. This means that in visiting a movie theater, you can request closed captioning hearing devices. Or, when visiting a hotel, you will be provided with a non-sound-based alarm system in case of an emergency. 

Telecommunications access: Not everyone has a hearing aid with bluetooth connectivity for easy phone calls with loved ones. Without the ADA, the cost of simple telecommunications for people with hearing loss could be astronomical. Instead, the ADA means that if requested, you must be provided with a TTY phone or video relay service so that you can plug into the already existing extensive telephone networks. 

Interacting with law enforcement

In addition to these now standard accommodations for people across the disability spectrum, including hearing loss, you might wonder how public services accommodate those hard of hearing. It is a sad fact that a number of people with deafness or hearing loss are harmed, and even killed, by police officers every year. What appears to officers as non-compliance is simply a matter of obstacles in officer’s communication. 

Though the burden of effective communication and fair access is squarely on the shoulders of the police, per the ADA, there are steps you can take in your own community. Your local police department may already have a relationship with the deaf and hard-of-hearing community. Be in touch to see if there is a card or pamphlet you can provide officers in the case of personal interaction. These cards let law enforcement know that you have hearing loss and that you will need additional accommodation.

Hearing Loss

What Is Hearing Loss?

Hearing loss is the condition that results when any part of your ear isn’t working the way it should. It’s the third most common health problem in the U.S, and it can affect the quality of your life and relationships. About 48 million Americans have lost some hearing.

You can have three different types of hearing loss, depending on where your hearing is damaged. Your hearing loss can be:

  • Conductive if it involves your outer or middle ear
  • Sensorineural if it involves your inner ear
  • Mixed if it involves a combination of the two

Certain conditions, including age, illness, and genetics, may play a role in hearing loss. Modern life has added a host of ear-damaging elements to the list, including some medications and many sources of loud, ongoing noise. Learn more about the common causes of hearing loss.

With so many untreatable cases of hearing loss, prevention is the best way to keep hearing long-term. If you’ve already lost some hearing, there are ways to stay connected and communicate with friends and family. 

Hearing Loss Symptoms

In many cases, hearing fades so slowly you don’t notice it. You may think people are mumbling more, your spouse needs to speak up, or you need a better phone. As long as some sound still comes in, you could assume your hearing is fine. But you may become more and more cut off from the world of speech and sounds. So how do you know if you are losing your hearing?

Doctors classify hearing loss by degrees.

  • Mild hearing loss: One-on-one conversations are fine, but it’s hard to catch every word when there’s background noise.
  • Moderate hearing loss: You often need to ask people to repeat themselves during conversations in person and on the phone.
  • Severe hearing loss: Following a conversation is almost impossible unless you have a hearing aid.
  • Profound hearing loss: You can’t hear other people speaking unless they’re extremely loud. You can’t understand what they’re saying without a hearing aid or cochlear implant. Learn more about how much hearing loss is considered deaf.

Early on, high-pitched sounds, such as children’s and female voices, and the sounds “S” and “F” become harder to make out. You may also:

  • Have trouble following a conversation when more than one person speaks at once
  • Think other people are mumbling or not speaking clearly
  • Often misunderstand what others say and respond inappropriately
  • Get complaints that the TV is too loud
  • Hear ringing, roaring, or hissing sounds in your ears, known as tinnitus

Hearing Loss Causes

Your ear has three main areas that play a part in hearing. Sound waves go through your:

  • Outer ear where they cause vibrations in your eardrum.
  • Middle ear, which gets the vibrations next. They’re boosted by three small bones.
  • Inner ear, which houses the cochlea, a snail-shaped fluid-filled structure. It has tiny hairs that change the amplified vibrations into electrical signals and send them to your brain, where you hear them as sound.

Advanced age is the most common cause of hearing loss. One out of three people between 65 and 74 has some level of hearing loss. After age 75, that goes up to one out of every two people.

Researchers don’t fully understand why hearing declines with age. It could be that lifetime exposure to noise and other damaging factors slowly wears down the ears’ delicate mechanics. Your genes are also part of the mix.

Noise wears down hearing if it’s loud or continuous. The CDC reports that about 22 million American workers are exposed to dangerous noise levels on the job. This includes many carpenters, construction workers, soldiers, miners, factory workers, and farmers.

Musicians are also at risk for noise-induced hearing loss. Some now wear special earplugs to protect their ears when they perform. The earplugs allow them to hear music without harming their ears’ inner workings.

Certain medications can impair hearing or balance. More than 200 drugs and chemicals have a track record of triggering hearing and balance side effects in addition to their disease-fighting abilities.

Sudden hearing loss, the rapid loss of 30 decibels or more of hearing ability, can happen over several hours or up to 3 days. (A normal conversation is 60 decibels.) Sudden hearing loss usually affects only one ear. Although there are up to three new cases per every 10,000 people each year, doctors are not able to discover the cause in most cases.

Illnesses such as heart diseasehigh blood pressure, and diabetes put ears at risk by interfering with the ears’ blood supply. Otosclerosis is a bone disease of the middle ear, and Ménière’s disease affects the inner ear. Both can cause hearing loss.

Trauma, especially a skull fracture or punctured eardrum, puts ears at serious risk for hearing loss.

Infection or earwax can block ear canals and lessen hearing.

Types of Hearing Loss

Hearing Health text on green background

Hearing loss affects people of all ages and can be caused by many different factors. The three basic categories of hearing loss are sensorineural hearing loss, conductive hearing loss and mixed hearing loss. Here is what patients should know about each type.

Sensorineural Hearing Loss

This type of hearing loss occurs when the inner ear or the actual hearing nerve itself becomes damaged. This loss generally occurs when some of the hair cells within the cochlea are damaged.

Sensorineural loss is the most common type of hearing loss. It can be a result of aging, exposure to loud noise, injury, disease, certain drugs or an inherited condition. This type of hearing loss is typically not medically or surgically treatable; however, many people with this type of loss find that hearing aids can be beneficial.

Sudden Sensorineural Hearing Loss

Sudden sensorineural hearing loss may occur very suddenly or over the course of a few days. It is imperative to see an otologist (a doctor specializing in diseases of the ear) immediately. A delay in treating this condition (two or more weeks after the symptoms first begin) will decrease the chance that medications might help improve the problem.

Hearing Loss: Why Choose Johns Hopkins?

Conductive Hearing Loss

This type of hearing loss occurs in the outer or middle ear where sound waves are not able to carry all the way through to the inner ear. Sound may be blocked by earwax or a foreign object located in the ear canal; the middle ear space may be impacted with fluid, infection or a bone abnormality; or the eardrum may have been injured.

In some people, conductive hearing loss may be reversed through medical or surgical intervention. Conductive hearing loss is most common in children who may have recurrent ear infections or who insert foreign objects into their ear canal.

Mixed Hearing Loss

Sometimes people can have a combination of both sensorineural and conductive hearing loss. They may have a sensorineural hearing loss and then develop a conductive component in addition.

Hearing testing is critical for discovering exactly what type of hearing loss you have, and will help determine the hearing care solution that is right for you. Hearing aids are available in many sizes, styles and technologies; there are also many alternatives to hearing aids.

Hearing Loss in Adults

People over age 50 may experience gradual hearing loss over the years due to age-related changes in the ear or auditory nerve. The medical term for age-related hearing loss is presbycusis. Having presbycusis may make it hard for a person to tolerate loud sounds or to hear what others are saying.

Other causes of hearing loss in adults include:

Baseline Hearing Test

Most adults received their last hearing test when they were in grade school. It is a good idea to have your hearing checked when you are an adult at least once during your annual physical. This test becomes your baseline test, so that later, if you do suffer hearing loss, your audiologist can compare your current hearing to your baseline to assess the severity of your hearing loss so you can be treated appropriately.

What Percentage of Hearing Loss Is Legally Deaf?

If you believe you are experiencing hearing loss, you are not alone.

Our ability to hear allows us to communicate, interact with others, and complete important tasks – particularly at work. Our hearing is an important sense that helps us connect to the outside world and stay safe. Despite these factors, we often take our hearing for granted. Hearing loss can happen so gradually that you won’t notice it until your friends or family members mention it.

What’s the definition of hearing impairment?

Hearing loss, or hearing impairment, is typically defined as having a limited or total inability to hear sounds. If you are unable to hear sounds under 25 decibels in volume, you are considered to be experiencing mild hearing loss. On the other end of the spectrum, an individual is considered deaf when he or she has absolutely no – or very little – hearing.

Legally, hearing impairment is usually defined at the state level. For example, many states will define hearing impairment as loss of 70 decibels (or more) or the ability to discern speech at 50 percent or less with aids. Special education laws define it as any hearing loss that affects the ability to learn that is not covered under the definition of deafness.

A hearing test will help you determine if you are experiencing hearing loss, as well as the severity of your hearing loss.

  • If you are having difficulty understanding quiet conversations or hearing spoken words across the room, you are most likely experiencing mild hearing loss.
  • If you have difficulty hearing conversations unless the other person speaks loudly, and listening in noisy environments is extremely difficult, you probably have moderate hearing loss.
  • If you have difficulty hearing quiet conversations or the ring of a cell phone, you are most likely experiencing moderately severe hearing loss.
  • Individuals experiencing severe hearing loss can only hear people when they stand next to them and speak very loudly.
  • Individuals with profound hearing loss are unable to hear loud speech or the everyday sounds around them.

What percentage of hearing loss means you’re legally deaf or medically deaf? Is there some kind of universal point at which the line is drawn between hearing loss and deafness? Those might sound like philosophical, esoteric questions, but they’re not. Hearing loss labels affect whether you qualify for protection and can help you determine what treatment options are best for you.

How do we categorize hearing loss?

There are a number of terms and labels you can use to describe your hearing loss. This gives the individual a healthy amount of leeway when it comes to defining his or her own experience and identity.

There are several widely recognized frameworks you can use to help categorize your own hearing loss:

  • Medical categories focus on the biological function of your ears and the physical thresholds of your hearing. Medical categories exist primarily for diagnostic purposes to provide individuals with better treatment options.
  • Legal categories tend to focus on how the law intersects with those who have hearing loss. Legal categories can be attached to certain protections and rights under the law.

In addition to these categories, words also often have connotations that change how people feel. Some people still worry about a perceived stigma associated with hearing loss and try to avoid terms like “deafness”. For these people, phrases like “hard of hearing” or “that’s my bad ear” are more comfortable. It’s a way of exerting some agency over your hearing condition and how others perceive it.

So why do we call it “legally” deaf?

We often hear people talk about whether someone is “legally deaf” or not, even though that phrase in and of itself can be fantastically nebulous. What qualifies as a legal hearing disability can change depending on the specific law it’s referencing.

For example:

  • The Americans with Disabilities Act (ADA) qualifies any kind of hearing loss as a disability if it limits your participation in life events (either currently or in the past) or if an employer perceives it as possibly limiting your participation. Meeting this requirement under the ADA entitles you to certain rights and protections under the law.
  • The Social Security Administration (SSA) office of disabilities requires that certain medical thresholds are met before they allow individuals access to disability benefits. If your hearing sensitivity is less than 90 dB (through the air) or you fail to repeat 40% of words in a word recognition test, you may be able to qualify for disability benefits under the SSA. Why do we say “may”?

Whether you are legally entitled to disability benefits or protections will change depending on what law you’re measuring your hearing loss against (and those laws vary from nation to nation and state to state).

So what definition should we use?

Colloquially, we tend to consider individuals “hard of hearing” if they still retain a partial sense of hearing and “deaf” if they are mostly unable to hear. That mirrors, more or less, the way that the medical community categorizes hearing loss.

Medically, hearing loss is split up into four categories: mild, moderate, severe, and profound. Hearing loss reported in the severe and profound stages tends to be considered “deaf” by hearing professionals.

So if you really wanted to get into categories, you could easily consider the definition of “legally” deaf to begin when the hearing loss in your good ear reaches a range of 70-89 dB. This is the “severe” category of hearing loss. Anything over 90 dB of hearing loss is categorized as profound.

Hearing loss & hearing impairment on the job

Legally, all employers must make reasonable accommodations for employees with hearing loss, as stipulated in the Americans with Disabilities Act (ADA). Proactive employers will provide assistive technology to help employees with hearing loss perform their daily responsibilities. For example, employees who answer phones may be provided with a handset amplification system, videophone, or captioned phone that provides a text display of the caller’s dialogue.

Employees who work with intercoms or paging systems may benefit from software that can turn intercom messages into texts or other video messages. Furthermore, an FM loop system can be utilized to broadcast audio messages directly to an individual’s hearing aid without background noise.

Employers searching for ways to accommodate employees with hearing loss can consult the Job Accommodation Network (JAN), as well as the Employer Assistance and Resource Network on Disability Inclusion (EARN). Workplace accommodations are often inexpensive, with most costing less than $500. However, your employer is not responsible for providing assistive devices or equipment for personal use, which includes hearing aids.

Why does it all matter?

The level of hearing loss that counts as a disability will change with every law you measure it against, so you’re really conjuring a matrix of legal definitions when you use the phrase “legally deaf.” The more you know about all the different legal and medical definitions, the better you’ll be able to select where you fit in–and which definition of “legally deaf” best applies to you.

Knowing how profound your hearing loss helps you determine when medical treatment is necessary and which treatments are right for you. Hearing loss has been associated with cognitive decline, depression and an increased risk in falls, so it’s important to treat it early. Treatment for hearing loss often includes hearing aids or some kind of assistive device. But which device will work for you will depend on your level of hearing loss, so the first step is to get a hearing test.

What is the Equality Act for hearing loss?

Rights to equality in England Scotland and Wales

Young girl with cochlear implants in a big hug with mum and dad outside.

Photo: Public services have to make simple changes to what they do if this would help disabled children

The Equality Act 2010 applies in England, Scotland and Wales. It sets out a wide range of important legal rights for disabled children and their families.

The Act only applies to those who have a permanent disability. If your child has a temporary hearing loss, such as glue ear, the Act will only apply if the condition has lasted (or is likely to last) for 12 months or more.

Under the Equality Act, your child has the right to:

  • not be discriminated against because of their deafness
  • expect that public services (such as school, nurseries and the NHS) will make ‘reasonable adjustments’ to how they do things to make sure deaf children can get involved
  • expect that public services will think about how they can promote equality of opportunity for deaf children, and to think about the impact that their policies, procedures and decisions have on deaf children and their families.

In Northern Ireland, different laws – the Disability Discrimination (Northern Ireland) Order 2006 and the Special Educational Needs and Disability (Northern Ireland) Order 2005 apply. In practice, most of the laws around disabled children are similar across the UK.

On this page

Who has to follow the Equality Act?

All public services, including the Government and local authorities, and anyone who delivers a service to the public must follow the Equality Act. This includes schools, nurseries, colleges, the NHS and shops. It also applies to employers.

What are reasonable adjustments?

Public services have to make simple changes to what they do if this would help disabled children. For example, asking your child’s nursery to make sure they communicate with your child in the quietest room in the nursery is a relatively simple and ‘reasonable’ adjustment for them to make.

If it would be difficult or expensive for the public service to do something to support your child, this may not be seen as a reasonable adjustment.

The law doesn’t say exactly what is or isn’t a reasonable adjustment. This is because what’s reasonable in one area might be unreasonable in another. For example, a very small childcare provider may find it expensive and difficult to improve the acoustics in their building. However, a secondary school with a large budget may find this easier.

What if a service won’t make reasonable adjustments?

If a service says that something wouldn’t be a reasonable adjustment, ask them to explain their reasons in writing.

You could also offer to meet with the service to discuss your ideas for reasonable adjustments and how they could be achieved. It might help to ask other professionals who are working with your child for advice on what reasonable adjustments to suggest and how they could be put into practice. For example, a Teacher of the Deaf may be able to provide advice on simple measures to improve acoustics.

If the service is arguing that something would be too expensive to provide, you could ask if they’ve explored alternative sources of funding from other public services. For example, if a small nursery doesn’t have enough funding to purchase special equipment (such as a radio aid), you and/or the nursery could ask the local authority to meet the cost and take responsibility for this reasonable adjustment instead.

All public services should work together to make sure that the needs of your child are met and that any reasonable adjustments are made by the most appropriate service.

A failure to make reasonable adjustments is discrimination. See below for what to do if you think your child has been discriminated against.

Go to the Equality Act and your child’s education for more information specifically about how you can take action in response to a failure to make reasonable adjustments in education.

What is discrimination?

Discrimination happens when your child is treated less favourably compared to a hearing child because of their deafness. For example, if a shop assistant was rude or provided poor service to your child because of their deafness, this would be discrimination.

Another example would be a refusal to give a deaf young person a job or allow them to join a particular school activity simply because they were deaf.

Discrimination can sometimes be indirect – and this is against the law too. Indirect discrimination is when a public service does something in a certain way which has the unintended effect of treating deaf people unfairly.

For example, if a GP practice insists that appointments can only be made by phone because it saves them time, this might be considered to be indirect discrimination because it makes it harder for deaf people to see their GP.

Parents and carers of disabled children are also protected by the Equality Act against any discrimination by association. This means that public services can’t treat you unfairly for something that happens because you’re looking after a disabled child.

An example of discrimination by association would be if your employer disciplined you for taking time off to attend audiology appointments with your deaf child when your colleagues also took time off for other reasons and weren’t disciplined.

If you think you or your child have been discriminated against you can contact our Freephone Helpline or the Equality Advisory and Support Service for advice and support on what to do next.

6 Impact of Hearing Loss on Daily Life and the Workplace

As people move through the activities of daily living at home, at work, and in social or business situations, basic auditory abilities take on functional significance. Audition makes it possible to detect and recognize meaningful environmental sounds, to identify the source and location of a sound, and, most importantly, to perceive and understand spoken language.

The ability of an individual to carry out auditory tasks in the real world is influenced not only by his or her hearing abilities, but also by a multitude of situational factors, such as background noise, competing signals, room acoustics, and familiarity with the situation. Such factors are important regardless of whether one has a hearing loss, but the effects are magnified when hearing is impaired. For example, when an individual with normal hearing engages in conversation in a quiet, well-lit setting, visual information from the speaker’s face, along with situational cues and linguistic context, can make communication quite effortless. In contrast, in a noisy environment, with poor lighting and limited visual cues, it may be much more difficult to carry on a conversation or to give and receive information. A person with hearing loss may be able to function very well in the former situation but may not be able to communicate at all in the latter.

In this chapter we examine what is known about the impact of hearing loss on adults as they function in daily life; the impact of hearing loss in the workplace; the effectiveness of sensory aids, prosthetic devices, and assistive devices; and the implications and challenges for disability determination.

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HEARING IN DAILY LIFE

Impact of Hearing Loss for Adults

Early Versus Late Onset

It is important at the outset to distinguish between adults who have experienced an early onset of severe or profound hearing loss and adults whose hearing loss was acquired later in life. When hearing loss occurs at an early age (i.e., prelingually, defined in this report as before age 2 years), there is an impact on the development of spoken language, on reading ability and educational attainment, and, ultimately, on employability (discussed further in Chapter 7). These persons are usually considered deaf, and a good number may use American Sign Language or a similar sign system as their preferred mode of communication. When hearing loss occurs after the development of spoken language, and particularly when it occurs slowly, as it does in aging or as the result of prolonged noise exposure, there is a loss of functional hearing ability, but other cognitive skills and competencies are not greatly affected. The terms “hard-of-hearing” and “late deafened” are often used to describe these individuals. In the sections that follow, we examine the impact of hearing loss in adults, with only occasional reference to etiology or time of onset. Nevertheless, each issue or research finding has greater relevance for one of these groups than for the other.

Education and Employment

Communication Access. Communication access for people with hearing loss can be described as “the right of deaf and hard of hearing people to receive and understand information and signals presented directly … and … the lack of barriers to, and the concomitant presence of access to, visual or auditory communication” (Barnartt, Seelman, and Gracer, 1990, p. 50). Individuals with hearing loss can perform as well as their counterparts without hearing loss when equitable educational and employment opportunities are provided (Schroedel and Geyer, 2000). These equitable opportunities are dependent on the individual student or worker having access to the information necessary for learning or for getting the job done. The nature of this communication access depends on individual needs and the auxiliary aids available to address these needs. For example, a deaf person who is unable to use the telephone can use a TTY or computer system and can communicate with hearing peers through telephone or Internet relay systems. These systems provide operators who type or, via video, sign the hearing person’s spoken words for the deaf caller and voice the deaf person’s typed words or signed phrases for the hearing caller.

In the educational setting, an individual with a hearing loss is most likely to have trouble hearing what is said. In these situations, communication access is enhanced with the use of FM systems and other assistive listening devices (see Chapter 5), computer-assisted note-taking systems, and other accommodations. However, for various reasons, including background noise in the classroom, communication is often less than clear, thereby affecting access to the English language and educational achievement. Chapter 7 discusses hearing loss in an educational setting in greater detail.

Those with education are less likely to be in need of Social Security Disability Insurance and Supplemental Security Income (SSI) than those without education (Clarcq and Walter, 1997-1998). Most worrisome, however, is the 44 percent high school dropout rate among deaf students (Blanchfield, Feldman, Dunbar, and Gardner, 2001), compared with a general population rate of 19 percent. With high-stakes testing now being instituted by the states, the potential for this dropout rate to increase is high.

Buchanan (1999) notes that in addition to employer resistance to hiring deaf individuals, the automation of many work functions has disadvantaged the unskilled deaf worker. The implication here is that education is a critical factor that facilitates occupational entry and mobility for the deaf worker. The generally lower educational achievement of deaf persons continues to contribute to vocational difficulties. Those who lose their hearing later in life, and whose jobs depend on effective communication, run the risk of eventually losing their jobs if satisfactory accommodations, including the provision of auxiliary aids that meet their communication needs, are not instituted.

Americans with Disabilities Act. Title V of the Rehabilitation Act of 1973 was landmark legislation enacted to address job discrimination in federally supported programs that affected qualified people with disabilities (National Association of the Deaf, 2000). Under the Americans with Disabilities Act of 1990 (ADA), which was enacted in part because of pervasive ongoing discrimination in the mainstream of American public life, the removal of communication barriers (which deny information access for individuals with hearing loss equivalent to what hearing persons might have) became a legal right for deaf and hard-of-hearing people (National Association of the Deaf, 2000). The legal protection of both acts covers individuals who can demonstrate that, even with corrective devices such as hearing aids or cochlear implants, they have a substantial impairment to a major life activity—for example, the inability to distinguish words due to background noise on the job. Public venues must provide auxiliary aids or services when necessary. A comprehensive list of auxiliary aids and services required by the ADA is included in the corresponding regulations, with the understanding that evolving technology will create new devices.

Psychosocial Impact of Hearing Loss

Perspectives of the Deaf Community

The deaf community is defined as an entity that shares the common goals of its members and works toward these goals (Padden, 1980). These goals include, for example, telecommunications and entertainment access, captioning, sign language and oral interpreting, and accommodations in the work setting. For the most part, the deaf community comprises individuals who have been deaf from birth or early in life (Lane, Hoffmeister, and Bahan, 1996). Some of these individuals prefer oral communication but see themselves as part of the deaf community. Most are deaf individuals who rely on some form of signed communication or American Sign Language and identify with Deaf Culture. These individuals value American Sign Language as their language, and they tend to devalue speech when they interact with each other. Socialization with other deaf persons is strongly emphasized, particularly through local, state, and national associations, sports leagues, deaf clubs, religious settings, and Deaf festivals (Lane et al., 1996; Padden and Humphries, 1988).

Within the deaf community, hearing loss is not a detriment to socialization; rather, it brings people with common issues together into a vibrant entity (Andrews, Leigh, and Weiner, 2004). As Lane, Hoffmeister, and Bahan (1996) indicate, hearing loss as measured in decibels is not a significant issue for those who identify with Deaf Culture as defined above. Rather, what is significant is how deaf community members relate to each other and how they communicate with each other. The use of vision rather than audition to communicate, most often using sign language, is integral to their daily living (Andrews et al., 2004). Many wear hearing aids to alert them to environmental noises at the very least, but audition is still not primary in their lives. While some value their previous speech and auditory therapy to maximize spoken English abilities, others may experience such exposure as stressful and potentially inadequate in providing them with functional expressive and receptive spoken English skills (Bain, Scott, and Steinberg, 2004). It must be kept in mind that most individuals whose hearing loss goes back to the early years of life do have the ability to speak with varying degrees of clarity ranging from speech indistinguishable from hearing peers to speech that is incomprehensible, depending not necessarily on level of hearing loss, but rather on background training, ability to benefit from hearing devices, and the use of speech (Blamey, 2003).

Generally, those identifying with Deaf Culture see sign language as providing them with critical access to language, communication, and positive social experiences. Because they have a language acquired through vision and a means to education, they do not see themselves as disabled per se, although many will acknowledge having a disability regarding the lack of hearing that entitles them to coverage under the ADA and its provisions for more equal opportunities. Hearing disability per se is not as much an issue for them as is the disability engendered by society’s reluctance to accommodate to their needs by providing interpreter services, captioning, and other means of access to communication (Lane et al., 1996). This reluctance of society is what they see as profoundly disabling.

Psychosocial Adjustment and Hearing Loss

The majority of those with hearing loss acquire it later in life at a time following the acquisition of spoken language. The prevalence is particularly high among those who are over 65 years of age and among those who have been exposed to noise. Because hearing loss tends to disrupt interpersonal communication and to interfere with perception of meaningful environmental sounds, some individuals experience significant levels of distress as a result of their hearing problems. For example, some express embarrassment and self-criticism when they have difficulty understanding others or when they make perceptual errors. Others have difficulty accepting their hearing loss and are unwilling to admit their hearing problems to others. Anger and frustration can occur when communication problems arise, and many individuals experience discouragement, guilt, and stress related to their hearing loss. These negative reactions are also associated with reports of negative attitudes and uncooperative behaviors of others (Demorest and Erdman, 1989).

Interestingly, the association between degree of hearing loss and psychosocial adjustment to hearing loss per se is not strong (Erdman and Demorest, 1998). Individuals with virtually identical audiograms and clinical test results may differ greatly in their self-reported adjustment problems. This finding is not unique to the impact of hearing loss on psychosocial adjustment; low (negative) correlations between severity of impairment and degree of psychosocial adjustment have been found repeatedly in the disability literature for a wide variety of health-related problems (Shontz, 1971).

Given the high variability in how individuals adjust to their hearing problems, it is not surprising that hearing loss does not seem to affect basic personality structure (Thomas, 1984). Although many adults are resilient, acquired hearing difficulties are nevertheless responsible for a high level of general psychological distress for a significant number of people due in part to isolation, loneliness, and withdrawal (Meadow-Orlans, 1985). This distress, which may be manifested in heightened anxiety, depression, sleep disturbance, and the like, is observed not only among those who seek audiological evaluation, but also among those reluctant to acknowledge a hearing problem (Hallberg and Barrenas, 1995; Hetu, Riverin, Getty, Lalande, and St-Cyr, 1990; Hetu, Riverin, Lalande, Getty, and St-Cyr, 1988) and among those who have already acquired hearing aids (Thomas, 1984, 1988). This psychological distress can significantly impact the family or significant others as well as the individual (Schein, Bottum, Lawler, Madory, and Wantuch, 2001).

Similarly to what has been found for psychosocial adjustment, studies to date have consistently demonstrated that there is no overall association between hearing loss and psychopathology. Rosen (1979) has confirmed this for individuals with acquired hearing loss, and Pollard (1994) has confirmed it from an analysis of public mental health records on deaf and hard-of-hearing individuals in the Rochester, New York, vicinity. Despite this lack of association, it is important to acknowledge that psychological distress can be a factor in adjustment difficulties.

Knutson et al. (1998) have investigated whether the use of cochlear implants can affect the social adjustment of those with acquired hearing loss. In a study of psychological change over 54 months of cochlear implant use by 37 postlingually deafened adults, the researchers used standard psychological measures of affect, social function, and personality prior to implantation, and then at regularly scheduled intervals after implantation, to assess the impact of audiological benefit. There was evidence of significant improvement on measures of loneliness, social anxiety, paranoia, social introversion, and distress. To a lesser extent, improvement was also noted for depression. Improvement of marital distress and assertiveness took comparatively longer to emerge. One caveat is that because of the complexities of individual life issues and personality attributes, it is not possible to attribute the improvement in psychological measures solely to the influence of audiological benefits. How well the improvement noted on self-report measures translates into actual social and job situations has not been determined.

Hearing in the Workplace

Prevalence of Hearing Loss in the Workplace

Although there have been numerous surveys used to estimate the prevalence of hearing loss in the general population, there is no comparable survey of prevalence in the workplace. Prevalence rates in the general population, broken down with respect to age and gender, can be used, with appropriate weights, to derive such estimates. For example, according to a survey of 80,000 households in the National Family Opinion (NFO) panel conducted in November 2000, 275 per 1,000 households reported having a person with a hearing difficulty, in one or both ears, without the use of hearing aid (Kochkin, 2001). The NFO panel is balanced to reflect U.S. census information, and the survey results translate to an estimated 28.6 million households reporting hearing loss.1 Although the age distribution reported by Kochkin leads to an estimate of 17.4 million adults of working age (18-64) in the United States, it is very difficult to estimate the numbers actually in the workplace. The disabling outcomes of hearing loss are likely to reduce this number, but as discussed by Mital (1994), the median age of the population is increasing and many older workers are delaying retirement for financial reasons, thereby increasing the numbers of older adults in the workplace.2

Despite our inability to derive an estimate of the number of individuals with hearing loss in the workplace, it is clear that many such individuals function, and function quite well, despite their impairment. As noted in Chapter 1, a great many factors influence employability and performance, and these must be taken into account when accurate prediction of disability for an individual is needed.

Employment Status of Adults with Hearing Loss

Educational level is a key factor in understanding the employment status of adults with hearing loss. For those individuals with early onset of hearing loss, the challenges for acquisition of spoken language, development of reading skills, and educational achievement result in limited job opportunities. These problems, combined with needs for better career guidance, job training, and job placement, result in poor preparation for entering the workforce on a competitive basis (Phillippe and Auvenshine, 1985).

Positive career outcomes are statistically related to educational level, although this relationship does not imply a causal linkage. Clarcq and Walter (1997-1998) compared graduates of high schools for the deaf ages 28-32 with individuals who had attended or graduated from the postsecondary National Technical Institute for the Deaf (NTID). They found that 33 percent of the high school graduates were receiving SSI benefits compared with 12 percent of those with some college education and 0 percent of those who had graduated from NTID. Schroedel and Geyer (2000) examined the long-term career attainments of deaf and hard-of-hearing college graduates and found that most were successfully employed and satisfied with life. Many had completed graduate degrees and were employed in white-collar positions.3 Similarly, Welsh (1993) examined factors affecting the career mobility of deaf adults and recommended that they pursue the highest degree of education possible and that they target careers in which the demand for workers is greatest.

When hearing loss occurs during adulthood, after the completion of formal education and after establishment of a work history or career, it poses challenges for job performance and future job mobility. Because these adults have already acquired the knowledge and skills needed to perform their jobs, the difficulties they face are related to communication barriers, such as working conditions and employer attitudes, as discussed in the following sections.

Communication Barriers

For an individual with hearing impairment, the most obvious communication problem in the workplace is the presence of background noise. Noise is highly prevalent in industrial settings and, among workers with noise-induced hearing loss, noise is mentioned most frequently as an obstacle and a source of annoyance in the workplace (Hetu, 1994; Laroche, Garcia, and Barrette, 2000). Other surveys and focus groups of workers with hearing loss have highlighted physical aspects of the work environment, the need to use telephones or videoconferencing, the difficulty of group communication situations, and difficulties presented by various speaker characteristics (Laroche et al., 2000; Scherich and Mowry, 1997).

Employer attitudes are another barrier. According to the National Association of the Deaf, “employer attitudes create the largest single barrier to employment opportunities” (National Association of the Deaf, 2000, p. 123). Schroedel and Geyer (2000) cite studies indicating that communication stress, social isolation, and unsupportive supervisors are among the difficulties encountered by many deaf and hard-of-hearing workers. Of concerns expressed by employers of adults with hearing loss, 62 percent were communication-related and 24 percent were safety-related (Dowler and Walls, 1996). When these concerns are addressed, employer satisfaction tends to increase (Dowler and Walls, 1996).

Effectiveness of Sensory Aids, Prostheses, and Assistive Devices

As described in Chapter 5, there are a great many devices available today that can restore some of the function that is lost as a result of hearing impairment. However, most studies of the potential effectiveness of these devices are based on laboratory or clinical research, not on assessment of actual functioning in the workplace.

For persons with severe or profound hearing loss, the literature on cochlear implants provides data showing significant restoration of function for many implant recipients. Studies have confirmed, however, that individuals with lifelong profound deafness who undergo cochlear implantation do not do as well with speech recognition as individuals with late-onset hearing loss (e.g., Dorman, 1998), primarily because of limited exposure to auditory experiences and limited understanding of what auditory stimuli mean. Nonetheless, an increasing number of these adults with strong ties to the deaf community are considering cochlear implants in order to gain access to the world of sound (Christiansen and Leigh, 2002). For the most part, these individuals desire to maintain contact with the deaf community and do not necessarily reject the values of Deaf Culture. The level of hearing loss is important only insofar as it qualifies them to become candidates for the surgery, if they are so inclined. After implantation, rarely do they pick up skills such as using telephones effectively or understanding speakers in groups and in other listening situations.

ADA and Accommodation

Although the ADA has mandated accommodations in the workplace, and there are devices and other methods of accommodation that can reduce or eliminate disability for those with hearing loss, there is evidence that such accommodations are underutilized. According to results of a series of focus groups with over 100 members of Self Help for Hard of Hearing People (SHHH) (Stika, 1997), several factors account for this. Lack of knowledge on the part of both employees and employers concerning what is available and what is required by the ADA is one factor. Perhaps more pervasive, however, are apprehension, concern, and anxiety about the consequences of making one’s hearing loss known to others (Glass and Elliott, 1993; Stika, 1997). Workers with hearing loss report high levels of psychological stress associated with fears of appearing (or being) incompetent, feelings of self-consciousness, overcompensation, and lowered self-esteem. Indeed, Hétu and his colleagues (Hetu, Getty, and Waridel, 1994) found that fears of stigmatization due to hearing loss are not without foundation. Mark Ross (1994, p. xii) states that “the greatest challenge we face regarding communication access is neither technological nor legislative, but societal attitudes toward hearing loss— attitudes that seem to be shared fully by many people with hearing losses.” These findings point to the need for education and intervention both with the individual with hearing loss and with his or her coworkers and supervisors.

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DISABILITY DETERMINATION

Different Perspectives

As discussed in Chapter 1, the term “disability” has been defined in different ways over time, and this is quite apparent in the differing approaches to disability found today. The earlier conceptualization, based on a medical model, viewed disability as a direct consequence of impairment and therefore measurement of impairment could be used, with suitable medical criteria, for disability determination. This approach is embodied in the medical listings used by the Social Security Administration (SSA) to determine that an individual is unable to work.

In contrast, the approach taken by the World Health Organization, and embodied in the ADA, is based on a social model of disability. This approach is a more positive one, in which the emphasis is on what an individual with an impairment can do, and the capabilities the person does have. The new emphasis is on accommodation and restructuring of the environment so as to maximize each individual’s functioning in daily life.

These differing perspectives on disability create challenges and apparent inconsistencies in disability determination. For example, is it reasonable for deaf adults to claim on one hand that they are disabled and hence entitled to accommodations at work, while at the same time arguing forcefully that hearing loss is not a disability and that the only thing a deaf person cannot do is to hear? In the sections that follow, disability assessment is discussed from a measurement perspective, and elements of both of these approaches are apparent. In agreement with the social model, however, we note that disability is usually not absolute, and that as conditions change and accommodations are made available (and accessed), disability may be reversed.

Direct Assessment

In previous chapters the nature of hearing loss and its impact on auditory function was described in terms of clinical tests that have proven diagnostic value or that are assumed to assess auditory skills that are important in daily life. Conspicuously lacking, however, are empirical studies establishing the link between the clinical measures and performance in natural settings. In their review of the literature on sound localization, Middlebrooks and Green (1991) note that laboratory studies are designed to isolate the effects of one particular variable, with the effects of other factors controlled and held constant. In daily life, these factors are free to vary and to interact, and hence generalization from the laboratory to the real world cannot readily be made. As they state: “there is often no evidence to indicate the importance of that cue in a more realistic setting” (p. 136).

As discussed in Chapter 1, the social model of disability implies that disability, as an outcome, is a function not only of the individual’s hearing loss, but also of other factors internal and external to the individual. This highlights the dilemma posed by trying to predict the consequences of hearing loss that occur in daily life: the farther one moves from testing the ear per se, the more meaningful the measure may be, but the less it is a function of hearing ability alone. This implies that impairment in a specific auditory ability may not be strongly correlated with disability, and indeed this has been shown to be true for the relation between degree of hearing loss measured audiometrically and self-reported communication function in daily life. Correlations are high enough to support the assumption of a causal link between impairment and disability (as well as the validity of the self-reports), but low enough to preclude accurate prediction of disability for individuals from the auditory measures alone.

In principle, it is possible to develop clinical tests with acceptable predictive validity, but in practice it will likely require testing conditions that are more representative of how the person functions in the real world. Some of the issues that would need to be considered are binaural versus monaural hearing, free field testing versus testing using headphones, testing with more complex stimulus materials (such as real-world sounds and sentences, connected discourse, or competing noise), and the role of visual information and auditory-visual integration, to name just a few.

The challenge of validating clinical tests in terms of performance in daily life is magnified by the complexity of real-world auditory environments and by the fact that clinical tests differ from those that are needed for functional assessment. A model for the functional approach (Laroche et al., 2003) illustrates the complexity of identifying hearing requirements and noise environments in specific jobs. Laroche et al. used the Hearing in Noise Test (Nilsson, Soli, and Sullivan, 1994) to screen for functional hearing. First, hearing-critical tasks and locations in the workplace (the Canadian Coast Guard and the conservation and protection departments of Fisheries and Oceans Canada) were identified, and performance parameters for those tasks (e.g., accuracy level, distance) were determined. Noise recordings were made in those environments, simulated in the laboratory, and used with normal-hearing listeners to develop a screening test. Statistical modeling was used to derive performance tables, and the listening tests were then validated on listeners with hearing loss. In the final stage, minimal acceptable performance criteria were established and screening scores were determined. This comprehensive and systematic approach, integrating theoretical and statistical models, psychometric instrument evaluation, and empirical determination of workplace characteristics, clearly illustrates the challenges involved in direct assessment of functional hearing abilities.

Indirect Assessment

Many forms of assessment can be considered indirect; that is, they do not involve direct observation of target behaviors. One way, discussed in previous chapters, is the use of a measurement on one variable (such as a clinical test of pure-tone thresholds) to predict or estimate performance on a different target variable (such as speech communication at work). A strong relation between the predictor and the target validates the use of the predictor in place of direct measurement of the target.

Another type of indirect assessment occurs when a self-report or self-assessment is used in lieu of direct behavioral observation. This method has been used extensively in audiology to obtain information about communication problems and communication strategies that could, in principle, be measured by direct observation. Interestingly, such instruments have also been used to obtain direct measures of the respondent’s attitudes, beliefs, feelings, and reactions to experiences in everyday life. These cognitive and affective variables are not directly observable and, as a result, they are usually measured using self-reports.

A third type of indirect assessment may be termed doubly indirect. This occurs when a self-report on one variable, or a difference between two such reports, is used as a measure of another variable. For example, self-reported communication with a hearing aid (an indirect measure of aided communication) might be interpreted as measure of “health-related quality of life” (another variable), or a change in self-reported communication problems after receiving a cochlear implant (a difference between two indirect measures of communication) might be used as a measure of “benefit from the implant” (another variable). These measures are quite different from asking the individual to report on quality of life per se or using behavioral measures of performance to evaluate benefit from the cochlear implant. Doubly indirect assessment compounds the difficulties in arriving at valid conclusions because of the many additional assumptions that must be made about the relation between the target variable and the one actually assessed. In the sections that follow, examples of all three types of indirect assessment can be found.

Assessment of Hearing Disability, Handicap, and Benefit from Interventions

Efforts to assess hearing handicap and disability through self-report questionnaires have been ongoing since publication of the Hearing Handicap Scale by High, Fairbanks, and Glorig (1964) and the Hearing Measurement Scale (Noble and Atherley, 1970). The essential role of self-report in assessment of disability and handicap and the unique perspective of the affected individual are widely acknowledged and now generally accepted (Baldwin, 2000; Dobie and Sakai, 2001).

The earliest scales focused on self-reported abilities and difficulties experienced by the hearing-impaired individual in daily life. The use of terminology has been inconsistent, however, and the targeted constructs suggested by an instrument’s name have not always been consistent with the content of its questions or items. The Hearing Handicap Scale, for example, contains items dealing primarily with detection of sounds and understanding of speech—functions that today are considered aspects of hearing disability. Similarly, early surveys of hearing aid users did not adequately distinguish among hearing aid use, hearing aid benefit, and satisfaction with a hearing aid. Attention to psychometric principles in the development, evaluation, and application of self-assessment tools has been strongly advocated (e.g., Demorest and Walden, 1984; Hyde, 2000), and surveys and recent critical reviews of self-assessment instruments (e.g., Bentler and Kramer, 2000; Demorest and DeHaven, 1993; Noble, 1998) have generally been positive.

As sophistication in instrument design has increased, so has the conceptualization of the constructs to be measured. The most dramatic changes have occurred in the assessment of hearing aid outcomes, as documented by a collection of eight articles devoted to that topic in two issues of the 1999 volume of the Journal of the American Academy of Audiology (Cox, 1999a, 1999b). Distinctions between objective and subjective outcomes, and conceptual distinctions among hearing aid benefit, satisfaction, and use, along with statistical analysis of their interrelationships, have led to the conclusion that hearing aid outcomes are truly multidi-mensional (Humes, 1999). Another important development has been the recognition that standardized assessments, in which the same questions are asked of all respondents, can fail to assess areas of function that are important to the individual. Examples of personalized assessments are the Client Oriented Scale of Improvement (COSI) (Dillon, Birtles, and Lovegrove, 1999) and the Glasgow Hearing Aid Benefit Profile (GHABP) (Gatehouse, 1999).

Quality of Life. Among the most popular approaches to outcomes assessment has been the attempt to measure a global outcome called “quality of life.” Quality of life is a concept that encompasses physical, social, psychological, and environmental aspects of an individual’s life. In the social and medical sciences, the concept has defied precise and distinct conceptualization (Rogerson, 1995), and operational definitions range from health economists’ quality-adjusted life years (QALY) to scores on disease-specific self-report questionnaires. In Rogerson’s conceptualization, environmental and health-related quality of life are each viewed as a sense of satisfaction and well-being that is multiply determined: by external factors and their characteristics and by the characteristics of the individuals themselves. Palmore and Luikart (1972), Flanagan (1978), and Bowling (1995) have taken an empirical approach to determining what is most important to adults in the general population. Their studies revealed similar factors, with health (both one’s own and that of significant others) high on the list and physical welfare/finances/standard of living also in the top five. Bowling reported that “relationships with family and relatives” was the most frequently mentioned and most frequently first-ranked item.

Health-Related Quality of Life. Given the impact of hearing loss on communication and interpersonal functioning and the importance of interpersonal relationships in determining quality of life, it is not surprising that there has been significant interest in incorporating health-related quality-of-life measures into the diagnosis of rehabilitative needs of persons with hearing loss and the evaluation of rehabilitative interventions. In a causal chain that begins with hearing loss and its effects on disability and handicap (World Health Organization, 1980), quality of life is an ultimate state or outcome that is a function of all three (Ebrahim, 1995). As might be expected, issues of conceptualization and operational definition have been no less difficult in audiology than in other behavioral domains.

Global measures of health-related quality of life (HRQL) serve several purposes, both at a population level and at an individual level. Clinically, they may be useful in diagnosis of disease, assessment of prognosis, treatment outcome evaluation, and determination of etiology (Ebrahim, 1995). Examples of global HRQL instruments include the Self Evaluation of Life Function (SELF) scale (Linn and Linn, 1984), the Sickness Impact Profile (Bregner, Bobbitt, Carter, and Gilson, 1981), the EuroQOL (The EuroQol Group, 1990), the Medical Outcomes Study Short Form 36 (SF-36) (Ware and Sherbourne, 1992), the World Health Organization’s WHOQOL (1993), and the Dartmouth COOP Functional Health Assessment (Nelson, Wasson, Johnson, and Hays, 1996).

There is evidence of an association between some global quality-of-life scales and degree of hearing loss. Bess, Lichtenstein, Logan, Burger, and Nelson (1989) found a systematic relation between degree of hearing impairment and scores on the physical, psychosocial, and overall scales of the Sickness Impact Profile. Similarly, Dalton et al. (2003) have reported that hearing loss, self-reported hearing handicap, and communication difficulties were associated with small but significant differences in quality of life, as measured by the SF-36.

Despite the attractiveness of having such global measures, their usefulness has been questioned on conceptual and psychometric grounds (Ebrahim, 1995), and they have not been found to be sufficiently sensitive to detect clinically meaningful changes in adults with hearing loss. Bess (2000) reviewed studies that used the Sickness Impact Profile, the SELF, the SF-36, and the Dartmouth COOP Functional Health Assessment to evaluate the outcomes of hearing-aid fitting, often in conjunction with more communication-specific assessments. The benefits of amplification were typically found on the latter measures but not on the more general quality-of-life measures. This lack of sensitivity is understandable, given the myriad factors that influence outcomes far removed from the causal agents one wishes to evaluate. Perhaps for this reason, Ebrahim concludes that measures of impairment, disability, and handicap have advantages over global health-related quality-of-life measures for clinical purposes. Disease-specific instruments that are grounded in an understanding of predictable disease consequences and precise treatment outcome goals afford greater potential, ipso facto, of being sensitive to treatment effects.

Appropriate Uses of Self-Assessment Instruments

Self-assessment scales have been used widely in research and in clinical settings. Scales focusing on disability and handicap have been used successfully to evaluate the need for audiological rehabilitation and to measure the outcomes of treatment interventions, such as hearing aids, cochlear implants, and specific rehabilitation programs. Such uses are appropriate when there is psychometric evidence of the tests’ validity for these purposes. However, despite the considerable progress that has been made in the conceptualization and assessment of hearing disability and handicap (as defined by the World Health Organization), these measurements have little to offer in disability determination as defined by SSA. When a client seeks treatment for a hearing loss, it is usually assumed that symptoms are reported conscientiously. In contrast, when assessment is conducted for purposes of determining compensation, there is an inherent conflict of interest, and self-reports cannot be used with confidence (Dobie, 1996).

What, then, is the role of self-assessed disability or handicap in a compensation context? Dobie and Sakai (2001) argue that direct measurement of disability and handicap through self-report constitutes a gold standard, but that surrogate measures must be used in contexts in which compensation is involved. Despite the fact that audiometric measures of pure-tone threshold and speech recognition are imperfectly correlated with disability/handicap, they argue that these (more objective) measures can serve as surrogates in a compensation context. Moreover, based on the available data, they find insufficient evidence to support a change from the 1979 AAO-HNS/AMA (American Medical Association, 2001) method of estimating hearing handicap. Research is needed to more fully understand the relations and interactions among objective measures of hearing abilities, demographic and psychological factors, and self-reported communication outcomes and to evaluate the unique contribution of hearing loss among these other influences.

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RECOMMENDATIONS

Disability Determination

The committee examined the use of self-reports and concludes that self-reports should not be used as criteria for disability determination. In clinical settings, there is little motivation for exaggeration of problems, but in the context of disability determination, conflict of interest poses a serious threat to the validity of self-reports.

The committee examined the potential usefulness of quality of life as an outcome variable. First, because quality of life is assessed through self-report, the conflict of interest that arises with all self-reports in disability determination applies equally to measures of quality of life. In addition, the committee concludes that definitions of quality of life, including health-related quality of life, are not sufficiently precise for such assessments to provide useful outcome measures. Finally, the labeling of hearing-related self-assessments as measures of quality of life is to be discouraged, as it is a doubly indirect form of assessment.

Self-reports can provide valuable, albeit indirect, information about an individual’s functioning in daily life. For this reason, they can and should be used as outcome measures in predictive validation studies that do not involve claimants.

Tests that purport to measure or predict functional hearing ability in daily life must be validated against real-world criteria measured in natural settings. Validation in a simulated test environment is appropriate if a strong relation between the simulated and naturalistic settings can be demonstrated or assumed.

Research Recommendation

Research Recommendation 6-1. Research is needed on the prevalence of hearing loss in the workplace and on its effects on worker performance. In conjunction with this, the effectiveness of workplace accommodations, including devices and other types of accommodation, needs to be established.

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Footnotes

1

Although the sampling unit for this estimate is the household, the estimate is often reported and interpreted as the number of individuals with hearing loss. Because a given household can have more than one individual with hearing loss, 28.6 million is probably an underestimate of the prevalence of hearing loss in the population that was sampled. Current estimates (see Chapter 1) are closer to 34 million individuals.2

A recent report (National Research Council, 2004) from the National Academies, Health and Safety Needs of Older Workers, may be of interest to readers concerned with the aging workforce and its special needs.3

It is clear that many variables, such as intelligence, motivation, family support, and academic preparation, influence which young people attend and graduate from college, among youth with normal hearing as well as those who are deaf and hard-of-hearing. These comparative studies did not control for such factors, but they provide evidence that, like their hearing peers, those deaf and hard-of-hearing youth who are able to attain a college education fare better in the world of work.

Six Questions to Ask a Personal Injury Lawyer During a Free Consultation

After recovering from a car accident, you may begin to focus on a legal claim against the party who caused your injury. Filing a personal injury case can result in compensation for your injuries, suffering, and damages. However, you might need help gathering evidence and handling the legal aspects of an injury claim.

A personal injury lawyer assists accident victims as they fight for the compensation they deserve. An attorney investigates the cause of your injury and gathers evidence proving that the other party is responsible for your damages. An injury lawyer will work with your doctors to document your injuries and will work with you to document your damages.

The first step in hiring a personal injury lawyer is requesting a free consultation. Most personal injury attorneys offer free consultations so that accident victims can get answers to their questions about injury claims.

QUESTIONS TO ASK THE ATTORNEY DURING YOUR INITIAL CONSULTATION

It is common to have numerous questions that you want to ask a personal injury lawyer about your accident case. It is helpful to write down all of your questions before the consultation.

When you create your list of questions to ask the attorney, make sure that you add these six questions:

1.  What Types Of Injury Cases Do You Handle?

Personal injury encompasses a wide variety of situations and injuries. Personal injury claims can arise because of car crashes, burn injuries, livestock accidents, workplace injuriesnursing home abuse, and many other situations.

Ask the attorney how much experience he has handling cases similar to your case. It is generally best to hire an attorney who has experience in the same area of law that relates to your case. The attorney already understands the law and the issues related to cases similar to your case.

2.  How Much Are Your Attorneys’ Fees?

It is essential to understand how much it costs to hire a personal injury attorney before signing a retainer agreement.

Many personal injury law firms are paid based on a contingency fee. The attorney does not receive any fees for his services unless he recovers money for your personal injury claim.

The contingency fee is a percentage of the amount of money recovered for your injury claim. The fee is agreed upon when you hire the attorney. It does not include costs of the case, so make sure you ask how the attorney bills for costs and expenses.

3.  What Is Your Success Rate?

An attorney cannot guarantee a specific result in your case. Many factors affect the outcome of a personal injury case. A great success rate does not mean you will recover millions of dollars for your personal injury claim or even win your case.

However, you should ask about the attorney’s success rate. While you cannot base your case on another case, it is good to hire an attorney with a high success rate. A high success rate can indicate the attorney’s skills and dedication to fighting for maximum compensation for clients.

4.  How Much Trial Experience Do You Have?

Make sure to ask how often the attorney settles cases versus going to court. Many injury claims settle with the insurance company for the other party without the need to file a lawsuit or go to court. However, your case might be one of the cases that need to go to trial.

It is important to hire an attorney who is a talented and skilled trial attorney. Going to trial is different from negotiating a settlement outside of court. The attorney needs to be comfortable arguing cases in front of a judge and jury.

The only way an attorney becomes a skilled trial lawyer is through experience in the courtroom. If the attorney does not take any cases to trial, you might want to meet with another attorney before deciding which personal injury attorney to hire for your case.

5.  How Much Is My Personal Injury Claim Worth?

It is natural that you want to know how much money you can receive for your personal injury claim.

The value of your injury claim depends on several factors, such as:

  • The severity and type of injuries
  • The total economic losses, including medical bills and lost income
  • Whether you sustained permanent impairments or disabilities
  • Allegations of comparative fault
  • The availability of insurance coverage
  • The strength of the evidence in the case

Generally, an experienced injury attorney does not tell you how much your case is worth during a free consultation.

The lawyer may explain the types of damages you can seek in a personal injury claim and factors that could impact your claim’s value. However, it is impossible for an attorney to know the value of your injury claim until the attorney investigates the claim and documents the damages.

TYPES OF DAMAGES

The attorney may review the types of damages you could claim. Examples of damages in injury claims include:

  • Cost of medical care, medications, therapies, and medical equipment
  • Loss of income and benefits, including decreases in earning potential
  • Emotional, mental, and physical pain and suffering
  • Permanent impairments, scarring, disabilities, and disfigurement
  • Loss of enjoyment of life

Telling you that he cannot place a value on your claim during the consultation is an indication that the attorney is honest and ethical. If an attorney promises to recover a specific amount of money for your injury claim before the attorney does any work on your case, consider meeting with another attorney for a second opinion.

6.  How Long Will It Take To Settle My Injury Claim?

The timeline for a personal injury case depends on the facts and circumstances of the case. One of the overriding factors that determines how long it takes to settle an injury claim is your medical treatment.

MEDICAL CARE

You do not want to settle a claim until you complete your treatment plan and your doctor releases you from care. Settling an injury claim before you complete treatment could result in a much lower recovery amount.

It is impossible for you to know whether you sustained permanent impairments until you finish your medical care. Permanent impairments tend to increase the value of a personal injury claim.

OTHER FACTORS

Other factors that could impact the time it takes to settle your injury claim include the complexity of the case, the length of the investigation, the insurance company’s willingness to negotiate a fair settlement, and whether you need to file a personal injury lawsuit.

Questions to Ask Your Lawyer During a Consultation

Knowing that questions to ask your lawyer during this consultation can make finding the right attorney much easier. These should include:

1) What kind of experience do you have with similar cases?

You need to know how comfortable the lawyer is with cases like yours. While every case is somewhat different, the attorney will likely find some similarities between your case and a case s/he handled previously.

Related questions may include:

  • Where did you attend law school?
  • How long have you been practicing in Pennsylvania?
  • What types of cases do you handle?
  • How often do you handle cases similar to mine?
  • Can you tell me about a case you handled similar to mine? What was the result?
  • Do you have any client testimonials?

2) What would be your strategy for my case?

Most lawyers do not offer specific legal advice in an initial consultation, but s/he should explain the possible approaches to handling your case. S/he may also offer a general overview of the strategy s/he will follow.

Related questions may include:

  • What strategies have you used for similar cases in the past?
  • How long do you think this case could take using this strategy?
  • What are the pros and cons of this strategy?

3) Are there any alternatives to going to court?

Especially in personal injury cases, there is often a good chance you can avoid going to court. A lawyer will usually try to negotiate a fair and just settlement with the insurance company before resorting to filing a lawsuit. Even once you file a suit, mediation and arbitration may be possible. Both of these options can help you avoid going to court.

Related questions may include:

  • What percentage of your cases has settled out of court?
  • Do you consider yourself an effective negotiator?
  • Are you comfortable taking this case to trial if you cannot reach a just settlement?
  • Will you prepare my case for court even if you plan to settle out of court?

4) What are my possible outcomes?

Some lawyers may only tell you what you want to hear. The right lawyer, however, will give you an honest look at how your case may conclude. No lawyer can give you an exact value of your case or promise that you will reach an out-of-court settlement, but s/he can offer possibilities based on his/her experience.

Related questions may include:

  • Do see us running into any major issues?
  • What are our chances of avoiding a lawsuit?

5) Who will actually handle my case?

While you may meet with one lawyer, others in the legal office may work on your case. This often includes other attorneys and paralegals. You will want to know who your point of contact is within the office, and the experience of those working on your case.

Related questions may include:

  • Who should I call with questions about my case?
  • How often can I expect updates or reports? How will I receive these updates?
  • Will you represent me in settlement negotiations and/or court?

6) What is my role in my case?

Attorneys desire different levels of participation from their clients. Your attorney probably will not want you to talk to witnesses or the insurance company without prior approval, but s/he may need you to compile documentation of your injuries and other similar tasks.

Related questions may include:

  • What do you need from me to build the strongest possible case?
  • What should I avoid in order to win my claim?

7) How much will this cost me?

It is never fun to talk about money, but this is the time to do it. Most personal injury lawyers charge based on contingency. This means you pay nothing until you receive your settlement. There may, however, be another fee structure or additional fees you need to pay.

Related questions may include:

  • What is your fee structure? Contingency? Hourly? Flat fee?
  • Will there be any additional costs?
  • Can you give me an estimate of the total cost of my case?
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