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<zdoi; 10.1097/AUD.0000000000000338>
0196/0202/16/XXXX-0000/0 • Ear & Hearing • Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved • Printed in the U.S.A.
1
Objectives: The aim of this study was to investigate parent learning and
support needs related to hearing aid management for young children,
and factors that influence parent-reported hours of hearing aid use.
Design: A cross-sectional survey design was used to collect survey data
in seven states. The child’s primary caregiver completed a demographic
form, a questionnaire to explore parent learning and support needs as
well as their challenges with hearing aid use, and the patient health ques-
tionnaire to identify symptoms of depression. Three hundred and eigh-
teen parents completed the questionnaires.
Results: Responses were analyzed for 318 parents of children
(M = 23.15 months; SD = 10.43; range: 3 to 51) who had been wear-
ing hearing aids (M = 15.52; SD = 10.11; range: <1 to 50 months).
Even though the majority of parents reported receiving the educational
support queried, approximately one-third wanted more information on
a variety of topics such as loaner hearing aids, what their child can/
cannot hear, financial assistance, how to meet other parents, how to
do basic hearing aid maintenance, and how to keep the hearing aids
on their child. The most frequently reported challenges that interfered
with hearing aid use (rated often or always) were child activities, child
not wanting to wear the hearing aids, and fear of losing or damag-
ing the hearing aids. Forty-two percent of parents reported that, on
good days, their child used hearing aids all waking hours. Multiple
regression was used to compare the effect on parent-reported typi-
cal hours of hearing aid use based on good days for the variables of
(1) presence of depressive symptoms for the parent, (2) child age,
(3) family income, (4) primary caregiver education level, (5) presence
of additional disabilities for the child, (6) degree of hearing loss, and
(7) length of time since the child was fitted with hearing aids. There
were statistically significantly fewer hours of reported hearing aid use
when parents reported mild to severe symptoms of depression, lower
income, less education level, and when children had mild hearing loss
or additional disabilities.
Conclusion: Although parents reported overall that their needs for
hearing aid education and support had generally been met, there were
important suggestions for how audiologists and other service providers
could better meet parent needs. Hearing aid use for young children was
variable and influenced by a variety of factors. Understanding parent
experiences and challenges can help audiologists more effectively focus
support. Audiologists are more likely to meet the needs of families if
they take care to provide access to thorough and comprehensive educa-
tion and ongoing support that is tailored to address the unique needs
of individual families.
Key words: Hearing aids, Management, Parent, Support.
(Ear & Hearing 2016;XX;00–00)
INTRODUCTION
Congenital hearing loss is routinely identified within the first
few months of life in the United States (Centers for Disease
Control and Prevention 2012), providing an opportunity for
early amplification and intervention. Even though many fami-
lies have had timely access to hearing aid services (Muñoz et al.
2013), as recommended by the Joint Committee on Infant Hear-
ing (JCIH) (2007), it has been challenging for others (Holte et
al. 2012). Early fitting and consistent use of appropriately pro-
grammed hearing aids are critical for spoken language develop-
ment (Moeller et al. 2010) and has been shown to correlate with
better speech and language outcomes (Tomblin et al. 2014).
Even when hearing aids are fitted at an early age, many parents
encounter difficulties in achieving effective daily management
that supports consistent hearing aid use.
Audiologists have an essential role in providing parent edu-
cation and support for parents’ emotional needs related to their
child’s hearing loss (American Speech-Language-Hearing Asso-
ciation (ASHA) 2008). When audiologists have a clear under-
standing of the challenges parents are encountering, they may be
more prepared to partner with parents to identify the underlying
problems and effective management strategies.Through ongoing
monitoring and support, audiologists may be able to work with
parents to jointly resolve difficult issues. For communication to
be effective, audiologists need to be aware of their own presence
(e.g., body language, tone, attitude) and how they approach the
conversation, as well as have skills to effectively listen to under-
stand, affirm parents’emotions, respond in ways that encourages
parent learning, and help parents explore challenges and solu-
tions (Rollnick et al. 2008; Clark & English 2014).
Hearing Aid Use
For children fitted with hearing aids, a foundational aspect
of their auditory experience is dependent on the ongoing man-
agement of their amplification including consistent use of well-
functioning hearing aids. Recent research, however, has shown
that hearing aid use is highly variable for young children. Based
on hearing aid data logging, Walker et al. (2013) found an aver-
age of 8 hr of daily hearing aid use (range 2 to 10 h) for children
ages’ 5 months to 7.3 years (N = 272). In two studies conducted
by a hearing aid manufacturer, data logging was collected from
centers throughout the United States, and findings indicated that
children birth to 4 years used their hearing aids on average 4 to
5 hr per day (N = 5000; Jones & Launer 2010; N = 2162; Jones
2013). Similarly, Muñoz et al. (2015) found an average of 4.6 hr
of use per day for children birth to 5 years (N = 29).
Regardless of the degree of hearing loss, children who
are deaf or hard of hearing are at risk for developmental
consequences as a result of their hearing. Recent research
Pediatric Hearing Aid Management: Parent-Reported
Needs for Learning Support
Karen Muñoz,1,2
Stephanie E. P. Rusk,1
Lauri Nelson,1
Elizabeth Preston,1
Karl R. White,2,3
Tyson S. Barrett,3
and Michael P. Twohig3
1
Department of Communicative Disorders and Deaf Education, 2
National
Center for Hearing Assessment and Management, and 3
Department of
Psychology, Utah State University, Logan, UT.
Supplemental digital content is available for this article. Direct URL cita-
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2 MUÑOZ ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX
(Tomblin et al 2015) suggests that children who wear hearing
aids at least 10 hours per day show steeper growth trajectories
in language outcomes compared to children who wear hearing
aids less than 10 hours. Parents, however, have reported chal-
lenges related to hearing aid management that interfere with use
beyond one of the most commonly recognized problems—child
behavior that creates difficulty with keeping hearing aids on
young children (Moeller et al. 2009; Muñoz et al. 2013, 2015;
Walker et al. 2013). Other challenges may include emotional
issues (e.g., acceptance), parent frustrations, and lack of confi-
dence (Muñoz et al. 2015).
Emotional factors can also influence how effectively parents
navigate daily hearing aid management. Parents have reported
that difficulty accepting their child’s hearing loss (Muñoz
et al. 2013) and experiencing symptoms of depression (Muñoz
et al. 2015) interfered with their ability to manage daily tasks.
A family-centered approach to service delivery, based on trust,
kindness, and compassion, may provide a better foundation for
a supportive parent–audiologist partnership. When parents feel
safe to be open about their underlying struggles, and audiolo-
gists are responsive in ways that facilitate the problem-solving
process, parents may be more likely to learn how to successfully
manage their children’s hearing aids (Muñoz et al. 2014).
Parent Education
Almost 95% of children with hearing loss are born to hear-
ing parents (Mitchell & Karchmer 2004), and many are commu-
nicating with their children using listening and spoken language
(Alberg et al. 2006). Many parents have a steep learning curve
related to hearing loss and amplification and rely on their audi-
ologist to provide them with complete information, support for
skill acquisition, and help in resolving barriers to effective daily
management. Having accurate information is an essential foun-
dation for parents, and when accompanied by support to inte-
grate new information and skills into daily routines, parents can
learn to navigate challenges more effectively.
Parents are the experts regarding their child and family, they
know what will work within their daily lives (DesGeorges 2003;
Joint Committee on Infant Hearing 2013), and their perspective
is essential in identifying effective support for hearing aid man-
agement. To better understand hearing aid management and use
challenges experienced by parents, Muñoz et al. (2015) devel-
oped the parent hearing aid management inventory (PHAMI), a
parent-report questionnaire. Based on responses to the PHAMI,
mothers and fathers (N = 55) of children birth to 3 years of age
reported challenges in three main areas: (1) daily management
tasks, including their confidence levels for performing hear-
ing aid management skills (e.g., hearing aid listening check,
troubleshooting problems), (2) hearing aid use challenges (e.g.,
child behavior, activities during the day), and (3) emotional
adjustment (e.g., accepting the hearing loss; Muñoz et al. 2015).
The Muñoz et al. study focused on issues such as where parents
obtained information and skills training, preferences for deliv-
ery of training, perceptions and expectations, confidence levels
with hearing aid management skills, communication with the
audiologist, hearing aid use challenges and hours of use.
Although Muñoz et al. (2015) provided useful information,
a more in depth understanding was needed related to parent per-
spectives about the support they desire to manage hearing aids
effectively, challenges faced, and factors that influences hearing
aid use. For this reason, the present study was completed using a
modified version of the PHAMI to expand our understanding of
parent-reported needs and to gain perspectives from a broader
geographical area for the following research questions: (1) are
there gaps and/or desires related to information and skills for
hearing aid management; (2) what challenges do parents have
related to hearing aid use, (3) is communication and support
from audiologists meeting parent needs, and (4) does caregiver
reported symptoms of depression in parents influence hours of
hearing aid use?
METHODS
This study used a cross-sectional survey design. Utah State
University Institutional Review Board approval was obtained,
and parents received a letter of information with the study
materials.
Recruitment Procedures and Participants
Families were recruited from seven states (i.e., CO, NC,
OH, MS, UT, MN, NE) through the early hearing detection and
intervention programs. State early hearing detection and inter-
vention coordinators collaborated with their early intervention
programs to identify and invite families that indicated their
primary language was English to participate whose children
met the following eligibility criteria: (1) birth to 3 years of age,
(2) bilateral hearing loss, and (3) currently using hearing aids.
The packet mailed to parents included a flier describing the pur-
pose of the study, the institutional review board letter of informa-
tion, three questionnaires (i.e., PHAMI, family demographics,
patient health questionnaire [PHQ-9]), and an incentive of $5
for their time to complete the questionnaires. Responses were
anonymous and returned to the researcher in a postage paid
envelope. A reminder post card was mailed to families 2 weeks
after the initial mailing. Of the 1105 surveys mailed, completed
surveys were received from all the seven states and included
344 families for a response rate of 31%. Some responses could
not be included because the child did not have hearing aids (n =
6), the child had received a cochlear implant (n = 9), the child
was using a bone-anchored hearing aid (n = 7), and/or the forms
were not completed (n = 4). The analysis included responses
from 318 parents; 33 were for children over 36 months of age
(37 to 51 months). The information received from families with
children over 3 years of age was included because challenges
related to hearing aid management are relevant beyond the birth
to three-age range targeted for the study.
Instruments
Parent Hearing Aid Management Inventory • The instru-
ment used in Muñoz et al. (2015) was modified (see Muñoz et
al. 2015 for a description of the initial instrument development)
to explore parent education received, support needs desired
by parents, and their current challenges. Modification of the
PHAMI was based on recommendations from parents of chil-
dren with hearing loss who are on the parent advisory board
for the national center hearing for assessment and management.
Parents on the advisory board hold positions in their organi-
zation and/or state representing interests of parents of children
with hearing loss. Recommendations included simplifying the
questionnaire and clarifying wording (see questionnaire in the

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MUÑOZ ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX 3
Supplemental Appendix, http://links.lww.com/EANDH/A292).
The revised version included three sections: (1) information and
skills, (2) hearing aid use, and (3) communication and support.
See supplemental appendix A (http://links.lww.com/EANDH/
A292).
Family Demographic Form • The demographic form
included 16 questions about child’s current age, child’s age at
hearing aid fitting, degree of hearing loss in each ear, presence
of other disabilities, primary mode of communication, other
family members with hearing loss, primary caretaker, custodial
parent, child’s ethnicity and race, primary caretakers ethnicity
and race, language spoken in the home, number of children
in the home, primary caretaker’s educational level, and family
income.
Patient Health Questionnaire • The PHQ is a validated nine-
item questionnaire designed to identify symptoms of depres-
sion experienced over the past 2 weeks (Kroenke et al. 2001).
Responses are reported on a 4-point scale (0 = not at all; 1 =
several days; 2 = more than half the days; 3 = nearly every day).
A total score is obtained for interpretation. If problems are indi-
cated on the screen, a 10th question is included to query how
difficult the problems made it to do work, take care of things at
home or to get along with other people. Responses range from
not difficult at all to extremely difficult (Pfizer 1999).
Analysis
Data were double entered and matched for accuracy with
any discrepancies verified and corrected for the final dataset.
Data were analyzed using SPSS (v22). Descriptive statistics
and correlations were used to determine individual associations
between parent-reported hearing aid use and various demo-
graphic variables. Due to the correlations between the various
demographic variables, multiple regression models estimated
the associations of these relationships simultaneously, control-
ling for the effects of the other variables in the model.
RESULTS
Responses were analyzed for 318 parents of children
(M = 23.15 months; SD = 10.43; range: 3 to 51) who had been
wearing hearing aids for more than 1 year (M = 15.52 months;
SD =10.11; range: 0 to 50). The mother was most frequently
reported as the primary caregiver (n = 232; 73%). The primary
caregivers were predominately White (n = 266; 85%) and non-
Hispanic (n = 284; 95%). For 33% (n = 99) of families, this
was their only child living in the home, 37% (n = 114) had 2
children in the home, and 30% (n = 92) reported 3 or more
children in the home. Primary caregivers reported the follow-
ing educational levels: graduate degree (n = 69; 25%), bach-
elor’s degree (n = 69; 25%), associate’s degree (n = 36; 13%),
some college education (n = 54; 19%), a high school diploma
(n = 43; 15%), or less than a high-school diploma (n = 8;
3%). Family incomes were reported for the following catego-
ries: greater than $80,000 per year (n = 114; 37%), $41,000 to
$80,000 (n = 87; 28%), $21,000 to $40,000 (n = 53; 17%), and
less than or equal to $20,000 (n = 56; 18%).
Demographic information for the children, as reported by
the parent, indicated that the degree of hearing loss was mild
bilateral for 26% (n = 74), mild to moderately severe for 55%
(n = 156), and severe to profound for 19% (n = 54). Most
children were White (n = 251; 80%), non-Hispanic (n = 280;
93%), and living with both parents (n = 267; 85%). Additional
disabilities were reported by 30% (n = 93) of the parents, spo-
ken language was the primary mode of communication (n =
243; 81%), and 20% (n=62) had another family member with
hearing loss (sibling or parent of the child).
Hearing Aid Information
For each of the 10 items that addressed hearing aid infor-
mation, parents were asked to report if they had received the
information and if they wanted more information related to
each item (Table 1). The majority of the parents reported receiv-
ing information for 7 of the items (range: 83 to 95%; n = 260
to 295); however, fewer parents reported receiving information
about loaner hearing aids, how to help their child hear in noisy
places, and how to meet other parents or find parent support
organizations. A desire for information was reported by approx-
imately one-third of the parents for loaner hearing aids (32%;
n = 101), what their child can and cannot hear without hear-
ing aids (36%; n = 114) and with hearing aids (35%; n = 109),
financial assistance options (37%; n = 116), and how to help
their child hear better in noisy places (31%; n = 100). Even
when most parents reported receiving the information, many
continued to want more information on the topic. For exam-
ple, 94% of families indicated they received information about
what their child can and cannot hear with hearing aids; yet 36%
wanted more information.
Skills
For each of the eight items that addressed skills, parents were
asked to report if they had received training for the skill and
if they desired more training (Table 2). For seven of the items
most parents reported receiving training (range: 81 to 99%;
n = 256 to 310); however, fewer parents reported receiving
training for hearing aid maintenance (67%; n = 209). For four
of the skills, many parents reported a desire for more training:
how to do hearing aid maintenance (40%; n = 123), how to
keep the hearing aids on when their child resists wearing them
(35%; n = 110), how to teach others to help manage the hearing
aids (25%; n = 79), and how to do a Ling Sound check (26%;
n = 82). The majority of parents reported having tools to moni-
tor and manage hearing aid function; however, approximately
one-quarter of the parents did not receive an air blower (25%),
cleaning tool (24%), battery tester (22%), and/or a listening
stethoscope (21%).
Hearing Aid Use
For each of the 14 items related to hearing aid use chal-
lenges, parents were asked to report how frequently the situation
described in the item interfered with hearing aid use (Table 3).
Responses for frequent or always were combined. For approxi-
mately one-quarter of the parents, child activities (28%; n = 89),
child not wanting to wear the hearing aids (27%; n = 84), and
fear of losing or damaging the hearing aids (20%; n = 63) were
frequently or always a challenge.
Parents were asked to estimate, based on their percep-
tion, how much their child typically used their hearing aid
on good days and on bad days. The number of hours for “all
waking hours” was not associated with a specific number

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4 MUÑOZ ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX
because this may differ for children based on their age. For
good days parents reported: all waking hours (42%; n = 132),
8 to 9 hr (23%; n = 72), 5 to 7 hr (16%; n = 51), and less than
5 hr (19%; n = 60). For bad days parents reported: all waking
hours (18%; n = 56), 8 to 9 hr (20%; n = 64), 5 to 7 hr (18%;
n = 56), and less than 5 hr (44%; n = 137). Parents generally
reported more good days (M = 73%; SD = 29.71; range: 0
to 100%) than bad days (M = 26%; SD = 29.46; range: 0 to
100%). The amount of time children spend with other caregiv-
ers was queried and parent reports varied on the amount of time
others provided care on a routine basis for the children (M = 4 hr;
SD = 3.85; range: 0 to 12 hr).
Parents completed a screening questionnaire that explored
if they had depressive symptoms during the previous 2 weeks.
Results of the PHQ-9 primarily revealed minimal symptoms
of depression (M = 2.27; SD = 3.59; range: 0 to 19). Scores of
1 to 4 indicate minimal, 5 to 9 mild, 10 to 14 moderate, 15 to
19 moderately severe, and 20 to 27 indicate severe symptoms
of depression. Of the responses, 47% (n = 132) reported no
symptoms of depression, 38% (n = 109) reported minimal
depression, and 15% (n = 43) reported mild to severe symp-
toms of depression. Some parents reported that their symp-
toms of depression were causing their ability to manage to be
somewhat difficult (20%; n = 54), or very/extremely difficult
(1%, n = 3).
Due to the correlations between the independent variables,
multiple linear regression estimated the effects of each variable
while controlling for the other variables in the model. Because
income and years of education were highly correlated (r = 0.63),
the estimation became unreliable with both in the model simul-
taneously. Therefore, two models were estimated (Table 4), one
with income as the SES measure and the other with years of
education as that measure.
Model 1, with income as the SES measure, demonstrated
five significant effects. As income increased from $40,000
to $80,000, hearing aid use per day increased by 24 min. The
severely depressed used their hearing aids nearly 2.5 hr less than
those with no depression. Those individuals with hearing losses
of moderate, moderately severe, and severe degrees used their
hearing aids 1.82, 1.09, and 1.65 hr longer than those with a
mild loss, respectively. Those with severely profound loss and
profound loss did not use their hearing aids significantly lon-
ger than those with mild loss. Additional disabilities, age, and
months since the hearing aid was fit were not significant when
controlling for the other variables.
Model 2, using years of education as the SES measure,
demonstrated six significant effects. As parental education
increases by 3 years, there is an associated increase of nearly
a half hour of hearing aid use per day. Furthermore, those with
severe depression used their hearing aids 2.4 hr less than those
with no depression, respectively. There was also an associated
increase of 2.1, 1.2, 1.8, and 1.1 hr of hearing aid use per day
more than those with mild hearing loss for moderate, moderate
severe, severe, and profound hearing loss, respectively. Similar
to Model 1, additional disabilities, age, and months since the
hearing aid was fit were no longer significant. In addition, there
were 9 individuals with missing values in the parent education
variable and were thus not used for Model 2. Although there are
slight differences between the models, both models came to the
same overall conclusions.
Communication and Support
For each of the 13 items related to communication and
support from the audiologist, parents were asked to report if
the type of communication or support described was meet-
ing their needs or if they desired that type of communication
more often (Table 5). The majority of parents reported that
their needs related to communication with the audiologist
were being met; however, 27% (n = 86) reported they would
like the audiologist to check in with them more frequently to
see if support or help was needed. Some parents also provided
written comments related to communication (n = 20) with
suggestions such as “Call me at home to see how it’s going”;
“Keep monitoring so I know what else I need to do”; “Meet
with me alone because when I have the baby I don’t even get
a second to concentrate or ask questions or have a thorough
discussion, and I’m usually frazzled from the preparation for
and drive to the appointment!”
TABLE 1. Information parents received and desired
Information
Received
% (n)
Desired
% (n)
Ways I can prevent losing the hearing
aids (e.g., clips to secure aids)
95 (295) 22 (66)
How to determine if the hearing aids are
benefiting my child
94 (293) 23 (72)
What my child can and cannot hear
without the hearing aids
94 (294) 36 (114)
Hearing aid options (e.g., colors, assistive
devices, tamper proof battery door)
90 (284) 21 (65)
What my child can and cannot hear while
wearing hearing aids
88 (274) 35 (109)
When the audiologist needs to check the
hearing aid settings
87 (273) 29 (91)
Financial assistance options 83 (260) 37 (116)
How to meet other parents/find parent
support organizations
78 (247) 31 (100)
How to get loaner hearing aids 67 (209) 32 (101)
How to help my child hear better in noisy
places
65 (205) 31 (100)
TABLE 2. Skill training parents received and training desired
Training
Received
% (n)
Desired
% (n)
Tell when to change the hearing aid
batteries
99 (310) 9 (26)
Clean the earmolds and reattach the
tubing
96 (297) 11 (34)
Tell when my child needs new
earmolds
94 (293) 17 (50)
Keep the hearing aids on when my
child resists wearing them
91 (286) 35 (110)
Teach others to help manage the
hearing aids (e.g., check function)
88 (277) 25 (79)
Use a listening stethoscope 86 (270) 18 (56)
Do a Ling 6 Sound Check (ah, ee, oo,
mm, sh, s)
81 (256) 26 (82)
Do hearing aid maintenance (e.g.,
change tone/ear hook)
67 (209) 40 (123)

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MUÑOZ ET AL. / EAR & HEARING, VOL. XX, NO. X, XXX–XXX 5
DISCUSSION
Early hearing aid fitting offers developmental benefits for
children with permanent hearing loss—when the devices are
well functioning and used on a consistent basis. This study
explored how much information and support parents’ want and
factors that were associated with how much the child used the
hearing aids. Findings from the study were primarily positive
and indicated that the needs of many parents are being met;
however, areas where audiologists could improve to better meet
parent needs were also identified.
Access to Information and Skills
Access to comprehensive information is an important compo-
nent for parents as they learn to navigate challenges they encoun-
ter in the day-to-day management of their child’s hearing aids.
Even though most of the children in this study had been wear-
ing their hearing aids for more than a year, and parents had been
provided with information previously, many parents still wanted
more information. Topics such as what their child can and cannot
hear both with and without hearing aids, how to prevent losing
the hearing aids, options for financial assistance, how to access
loaner hearing aids, how to determine if their child is benefiting
from the hearing aids, and how to meet other parents were of par-
ticular interest. In a related study, Meibos et al. (2015) explored
parent hearing aid education and support practices of pediatric
audiologists in 22 states (n = 349) and found that audiologists did
not routinely report that they provided information about finan-
cial support options to assist with hearing aid-related costs (36%),
loaner hearing aids (30%), and how parents can meet other par-
ents (25%). Connecting with other parents who are going through
a similar experience can provide emotional support, help parents
gain confidence, and may help them improve competence with
daily management challenges (Henderson et al. 2014).
Because hearing aids will malfunction and require mainte-
nance, daily hearing aid checks are important. It was encour-
aging that most parents had the necessary tools to check their
child’s hearing aids (75%). Almost half (40%) of the parents
also wanted to learn how to do basic hearing aid maintenance
(e.g., changing the tone hook), suggesting that many parents
would like to take a more active role in routinely maintaining
their child’s hearing aids.
Factors Influencing Hearing Aid Use
Parent report of hearing aid use provides important informa-
tion about parent perceptions related to how much their child is
wearing their hearing aids. In this study, only 42% of the parents
reported that their child wore their hearing aids all waking hours
on good days, and 35% reported use of less than 8 hr per day.
This low rate of use is particularly concerning, because parent
report has been found to over-estimate hours of use when com-
pared with hearing aid data logging (Walker et al. 2013; Muñoz
et al. 2015), indicating that actual hearing aid use for children in
this study may be even less.
TABLE 3. Hearing aid use challenges
Hearing Aid Use Challenge
Frequent or Always
% (n)
Sometimes
% (n)
Never
% (n)
Activities (e.g., playing outside, riding in car) 28 (89) 42 (131) 30 (95)
My child not wanting to wear the hearing aids 27 (84) 43 (135) 31 (98)
Fear of losing or damaging the hearing aids 20 (63) 37 (117) 43 (135)
Difficulty getting a set routine 16 (50) 24 (74) 61 (191)
Other caregivers’ ability to manage the hearing aids 14 (42) 35 (109) 52 (164)
Frequent feedback 13 (41) 42 (132) 45 (142)
Costs (e.g., batteries, earmolds, repairs) 11 (33) 25 (78) 65 (204)
Distractions and needs of other children in the home 8 (23) 36 (114) 56 (177)
Not seeing the benefit 8 (24) 22 (70) 70 (221)
Frequent ear infections 6 (20) 23 (73) 71 (223)
Not being convinced that my child needs hearing aids 6 (18) 13 (42) 81 (256)
The hearing aids not working 4 (13) 24 (75) 72 (227)
Pressure from others not to use the hearing aids 3 (11) 11 (35) 86 (271)
Concerns about how the hearing aids look 3 (10) 10 (31) 87 (275)
TABLE 4. Factors associated with parent-reported hours per
day of their child’s hearing aid use
Model 1 Model 2
Independent
Variables Estimate p Estimate p
Income (per $1,000) 0.01 0.04
Years of education 0.15 0.04
Parent depression
None Reference Reference
Minimum 0.02 0.94 0.06 0.86
Mild −0.03 0.95 0.14 0.81
Moderate −1.11 0.11 −0.65 0.40
Severe −2.47 0.03 −2.36 0.03
Child degree of
hearing loss
Mild Reference Reference
Moderate 1.82 0.001 2.05 0.001
Moderate-severe 1.09 0.02 1.23 0.01
Severe 1.65 0.01 1.76 0.01
Severe-profound 1.01 0.07 1.11 0.05
Profound 0.78 0.13 0.60 0.77
Other disabilities −0.54 0.12 −0.63 0.07
Age −0.02 0.39 −0.03 0.23
Months since HA
fitted
0.03 0.18 0.04 0.11
Model 1 includes incomes as the measure of socioeconomic status. Model 2 includes years
of education as the measure of socioeconomic status. When both measures were included,
the model estimates were highly unreliable because of the high correlation between income
and years of education. Model 1: R2
= 0.181, n = 243. Model 2: R2
= 0.198, n = 234.
Bold indicates significance at the .05 level.

6. Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
6 MUÑOZ ET AL. / EAR HEARING, VOL. XX, NO. X, XXX–XXX
The factors associated with less hearing aid use, includ-
ing lower educational level for the mother, and milder degree
of hearing loss, were similar to findings from other stud-
ies (Walker et al. 2013; Marnane Ching 2015). Walker et
al. found from parent interviews for children, ages 7 months
to 7 years, hearing aid use was less for children with milder
degrees of hearing loss and lower levels of maternal education.
Questionnaire findings from Marnane and Ching indicated that
degree of hearing loss and maternal level of education were
significantly related with parent-reported hearing aid use for
children at 3 years of age. They also found that usage time
did not change for 50% of the children when compared with
earlier parent report. Structured interview results reported by
Moeller et al. (2009), with a small sample size of nine chil-
dren showed hours of use increased during the second year of
life, and Walker et al. showed younger children used hearing
aids less than older children (7 months to 7 years of age). The
current survey study did not find a relationship between hours
of hearing aid use and child age, for children between birth
and 3 years. Differences in hearing aid use trends found among
studies is likely due to the different metrics and methods used
to query hearing aid use; however, what is evident, both from
parent report and data logging, is that significant variability in
hours of use among children exists.
For spoken language development, children with hearing
loss need consistent auditory access from well-functioning
hearing aids. Parents have reported in multiple studies
the extent of challenges they experience on a daily basis
as they try to address hearing aid management tasks. It is
clear that many parents need more extensive support and
that audiologists may need to attend to parent support needs
differently, particularly when the mother has a low educa-
tional level, reports severe depressive symptoms, and when
children have a mild degree of hearing loss. It is impor-
tant to recognize; however, that maternal educational level,
family income, and degree of hearing loss explained less
than a quarter of the variation in hearing aid use, suggest-
ing a wide range of factors influence wear time. Parents
may need more frequent, ongoing, and/or targeted support
to overcome challenges with daily management, and the
PHAMI may be a helpful clinical tool for audiologists to
check in with parents to prompt discussion about parent
learning and support needs. This may also represent a need
to explore how audiologists can more effectively collabo-
rate with early intervention providers related to daily hear-
ing aid management.
Limitations
There were limitations to the study that should be noted.
Even though parent-reported needs from this study reflected
responses from parents of young children in various geo-
graphical regions of the United States, the majority of the
parents were White, had a college education, and were from a
mid to high socioeconomic level. The responses may reflect a
self-selection bias for parents that chose to complete the sur-
vey and an underestimation of parent education and support
needs for a broader and more diverse demographic. Because
the study relied on parent report, the degree of hearing loss
may not be an accurate reflection for all children; audiograms
were not reviewed. Similarly hearing aid use was not reported
based on data logging measurement. Studies of hearing aid
use based on data logging reveal that parent report typically
over-estimates hours of use.
CONCLUSIONS
Parents reported that their needs for hearing aid education
and support were generally being met; however, areas where
audiologists could better meet parent needs were also identi-
fied. Hearing aid use for young children varied from less than
5 hr to all waking hours and were influenced by a variety of
factors, including mothers’ educational level, degree of hearing
loss, and presence of severe depressive symptoms. Understand-
ing parent experiences and challenges can help audiologists to
more effectively focus support for parents. Audiologists are
more likely to meet the needs of families if they take care to
provide access to thorough and complete education and ongo-
ing support that is tailored to address the unique needs of indi-
vidual families.
ACKNOWLEDGMENTS
The work reported in this article was funded in part by the Maternal and
Child Health Bureau under Cooperative Agreement # U52MC04391 with
the National Center for Hearing Assessment and Management at Utah State
University. The opinions expressed in the article are those of the authors and
do not necessarily reflect those of the Bureau.
The authors declare no conflict of interest.
Address for correspondence: Karen Muñoz, Department of Communicative
Disorders and Deaf Education, Utah State University, 2620 Old Main Hill,
Logan, UT 84321. E-mail: karen.munoz@usu.edu
Received April 16, 2015; accepted April 26, 2016.
TABLE 5. Communication with audiologists
Communication Needs
Desired More
Often
% (n)
Checks in with me to see if I need help or
support
27 (86)
Helps me explore solutions to problems with
hearing aid use
18 (55)
Helps me monitor problems until the concern is
resolved (e.g., contact is frequent enough to
help me tell if I am making progress)
18 (57)
Provides me with concrete resources 16 (49)
Helps me gain confidence in managing my
child’s hearing aids
14 (43)
Asks for my thoughts and opinions, and listens
to what I have to say
13 (42)
Gives me an opportunity to talk about how I am
feeling
12 (39)
Helps me recognize what I am doing right 12 (37)
Responds to my input in a way that I feel
understood (e.g., includes what I have brought
up in the discussion/planning)
11 (36)
Is accepting of my challenges (e.g., does not
judge me)
11 (32)
Teaches me in the ways I learn best (e.g., visual,
auditory, written, hands-on)
10 (30)
Talks in a way I can understand 6 (18)
Respects my culture and beliefs by taking into
account my views
2 (7)

7. Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
MUÑOZ ET AL. / EAR HEARING, VOL. XX, NO. X, XXX–XXX 7
REFERENCES
Alberg, J., Wilson, K., Roush, J. (2006). Statewide collaboration in the
delivery of EHDI services. Volta Rev, 106, 259–274.
American Speech-Language-Hearing Association (ASHA). (2008). Guide-
lines for audiologists providing informational and adjustment counsel-
ing to families of infants and young children with hearing loss birth to 5
years of age. Accessed November 1, 2014. Retrieved from http://www.
asha.org/policy/GL2008-00289.
Centers for Disease Control and Prevention (CDC). (2012). Annual data
early hearing detection and intervention (EHDI) program. Accessed
October 30, 2014. Retrieved from http://www.cdc.gov/ncbddd/hearing-
loss/ehdi-data.html.
Clark, J., English, K. (2014). Counseling-infused Audiologic Care. Bos-
ton, MA: Allyn Bacon.
DesGeorges, J. (2003). Family perceptions of early hearing, detection, and
intervention systems: Listening to and learning from families. Ment
Retard Dev Disabil Res Rev, 9, 89–93.
Henderson, R. J., Johnson, A., Moodie, S. (2014). Parent-to-parent support
for parents with children who are deaf or hard of hearing: A conceptual
framework. Am J Audiol, 23, 437–448.
Holte, L., Walker, E., Oleson, J., et al. (2012). Factors influencing follow-up
to newborn hearing screening for infants who are hard of hearing. Am J
Audiol, 21, 163–174.
Joint Committee on Infant Hearing. (2007). Year 2007 position statement:
Principles and guidelines for early hearing detection and intervention
programs. Pediatrics, 120, 898–921.
Joint Committee on Infant Hearing. (2013). Supplement to the JCIH 2007
position statement: Principles and guidelines for early hearing detection
and intervention after confirmation that a child is deaf or hard of hearing.
Pediatrics. doi:10.1542/peds.2013-0008.
Jones, C. (2013). Fittings and usage of hearing instruments in pediatrics.
Presentation presented at A Sound Foundation Through Early Amplifi-
cation 2013, Chicago, IL. Retrieved from http://www.phonakpro.com/
content/dam/phonak/gc_hq/b2b/en/events/2013/chicago/Fitting_and_
usage_of_HIs_in_Peds_SF2013_Jones.pdf.
Jones, C., Launer, S. (2010). Pediatric fittings in 2010: The Sound Foun-
dations Cuper Project. Presented at A Sound Foundation Through Early
Amplification 2010, Chicago, IL.Accessed December 3, 2014. Retrieved
from http://www.phonakpro.com/content/dam/phonak/gc_hq/b2b/en/
events/2010/Proceedings/Pho_Chap_12_Jones_Final.pdf.
Kroenke, K., Spitzer, R. L., Williams, J. B. (2001). The PHQ-9: valid-
ity of a brief depression severity measure. J Gen Intern Med, 16,
606–613.
Marnane, V., Ching, T. Y. (2015). Hearing aid and cochlear implant use
in children with hearing loss at three years of age: Predictors of use and
predictors of changes in use. Int J Audiol, 54, 544–551.
Meibos, A., Munoz, K., White, K., et al. (2015) Audiologist practices: Par-
ent hearing aid education support. Presentation at the National Early
Hearing Detection and Intervention Conference, Louisville, KY.
Mitchell, R. E., Karchmer, M. A. (2004). Chasing the mythical ten per-
cent: Parental hearing status of deaf and hard of hearing students in the
United States. Sign Language Studies, 4, 138–163.
Moeller, M. P., Hoover, B., Peterson, B., et al. (2009). Consistency of hear-
ing aid use in infants with early-identified hearing loss. Am J Audiol, 18,
14–23.
Moeller, M. P., McCleary, E., Putman, C., et al. (2010). Longitudinal devel-
opment of phonology and morphology in children with late-identified
mild-moderate sensorineural hearing loss. Ear Hear, 31, 625–635.
Muñoz, K., Blaiser, K., Barwick, K. (2013). Parent hearing aid experiences
in the United States. J Am Acad Audiol, 24, 5–16.
Muñoz, K., Preston, E., Hicken, S. (2014). Pediatric hearing aid use: how
can audiologists support parents to increase consistency? J Am Acad
Audiol, 25, 380–387.
Muñoz, K., Olson, W. A., Twohig, M. P., et al. (2015). Pediatric hearing aid
use: parent-reported challenges. Ear Hear, 36, 279–287.
Pfizer. (1999). Patient health questionnaire (PHQ) screeners. Accessed
March 2, 2014. Retrieved from http://www.phqscreeners.com/pdfs/02_
PHQ-9/English.pdf.
Rollnick, S., Miller, W. R., Butler, C. C. (2008). Motivational Interviewing
in Health Care. New York, NY: The Guilford Press.
Tomblin, J.B., Harrison, M., Ambrose, S.E., Walker, E., Oleson, J.J.,
Moeller, M.P. (2015). Language outcomes in young children with mild
to severe hearing loss. Ear Hearing, 36, 76S–91S.
Tomblin, J.B., Oleson, J.J., Ambrose, S.E., Walker, E., Moeller, M.P.
(2014). The influence of hearing aids on the speech and language devel-
opment of children with hearing loss. JAMA Otolaryngol Head Neck
Surg, 140(5), 403–409. doi: 10/1001/jamaoto.2014.267
Walker, E. A., Spratford, M., Moeller, M., et al. (2013). Predictors of hear-
ing aid use time in children with mild-to-severe hearing Loss. Lang
Speech Hear Serv Sch, 44, 73–88.