About Being Hard of Hearing

What Does "Hard of Hearing" Mean?

The term "hard of hearing" refers to people who have a mild to profound hearing loss. These individuals have some degree of hearing, and make use of this "residual hearing" to communicate, often supplemented with devices (hearing aids or assistive listening systems) or techniques (speech-reading or lip-reading). Culturally, most hard of hearing people consider themselves to be hearing people who just don't hear well. In general, most identify more with hearing people than with the Deaf community. Some may have difficulty admitting they have a hearing loss and may try to hide it. According to Hearing Loss Web (www.hearinglossweb.com), hard of hearing people generally have the following characteristics:

·    Have some degree of audiological hearing loss, from mild to profound.

·    Rely primarily on spoken or written English for communication with others

·    Function in the hearing world in all aspects of their lives (friends, relatives, employment)

·    Can benefit to some extent from the use of hearing aids and assistive listening devices (ALDs)

·    Generally know no or very little sign language

·    Are uninvolved in the Culturally Deaf community

·    May or may not have taken steps to deal with their hearing loss (audiological assessment, use of hearing aids, etc.)

Hearing problems are extremely common. There are more hard of hearing people than any other group of disabled people (see Disabilities in America: Statistics). Worldwide, more than 500 million people are hard of hearing. In Europe, for example, one out of ten people would benefit from hearing aids. Almost four in five people who need a hearing aid do not have one. According to Hearing Loss Web (HTUwww.hearinglossweb.comUTH), "the vast majority of people who are hard of hearing have not yet taken any action to help them deal with their hearing loss." One indication of this is the fact that approximately 1.7 million hearing aids are sold each year-and yet some 30 million American people have some degree of hearing impairment!

Most people recognize that the difference between hard of hearing and Deaf individuals is more a cultural distinction than an audiological one. That is, especially in the more severe and profound ranges of loss, the person's response to such loss and the accommodations chosen are more a matter of personal preference and identification than of hearing ability. In general, however, the term "hard of hearing" refers to a hearing loss of less than 90 dB (see Degrees of Hearing Loss table on this page), while "deaf" or "profound hearing loss" refers to individuals with hearing loss exceeding 90 dB.

Why Not Use "Hearing Impaired"?

The term "hearing impaired" is an umbrella term that is used to describe people with any degree of hearing loss. Most people who are Deaf or hard of hearing prefer to use those specific terms, however, over the term "hearing impaired" because first, hearing impaired does not give enough information about the person's status or how to communicate best, and second, because this term is perceived as negative, emphasizing what the person can't do.

What is Hearing Loss?

The term "hearing loss" is used when audiometric tests show that a person is not responding to sounds that are established as normal hearing levels. Hearing loss does not necessarily mean a complete inability to hear, because there are many degrees of hearing loss (see Degrees of Hearing Loss section on this page). A mild hearing loss may go unrecognized, while severe and profound loss can have definite personal, social, and psychological effects. Severe and profound hearing loss makes it almost impossible for a child to develop speech and language skills without appropriate help.

What are the Types of Hearing Loss?  

There are two main types of hearing loss: conductive and sensorineural. Some people may exhibit a combination of these two types of hearing loss; this is referred to as mixed hearing loss. More rarely, people speak of a central hearing loss, which results from damage or impairment to the nerves or nuclei of the central nervous system, either in the pathways to the brain or in the brain itself.

Conductive Loss 

Conductive hearing loss indicates that there is a problem with the mechanism that conducts sound from the environment to the inner ear. It is caused by an obstruction in or damage to the sound pathway into the inner ear. There may be a problem with the ear canal, the eardrum, and/or the three bones near the eardrum (the ossicles). Most cases of conductive hearing loss are temporary and are cured by means of appropriate medical treatment, so it is very important to seek immediate medical assistance. This type of loss may be caused by middle ear infections, earwax accumulation, a build-up of fluid behind the eardrum, eardrums ruptured from injury or disease, an abnormal condition in the bones of the middle ear between the eardrum and the inner ear, or other causes. Conductive hearing loss can be caused by disease, or by damage and physical changes in the middle ear, such as otosclerosis, cholesteatoma, tumors, and otic barotrauma. Conductive losses are often characterized by a loss of sensitivity to hearing soft sounds. If a conductive hearing loss cannot be corrected, the person with the loss may be helped by some hearing aids.

Sensorineural hearing loss (SNHL) refers to damage or destruction of the inner ear mechanisms, such as the cochlea and auditory nerve, or to damage to the sensory cells and/or nerve fibers of the inner ear. This type of hearing loss causes reduced sensitivity to sounds and difficulty in understanding speech. There may be a distortion of speech sounds even when the sounds are loud enough to hear. Sensorineural hearing loss is seldom correctable with surgery or medical treatments.

Sensorineural loss can be the result of a genetic disorder. It also can be caused by excessive exposure to loud noise, which can cause the fine hair cells in the cochlea to break down. Certain medical conditions-such as high blood pressure, arteriosclerosis, thrombosis, some coronary conditions, mumps, measles, extreme high fever, and some viruses-can contribute to sensorineural hearing loss. There are other specific medical conditions linked to hearing loss, such as Usher Syndrome, Waardenburg Syndrome, and otitis media. Meniere's Disease, for example, is characterized by too much fluid in the inner ear, which can cause a fluctuating hearing loss as well as dizzy spells, ringing in the ears, and a feeling of fullness in the ears.

Some medications, called ototoxic drugs, can also lead to hearing loss. The causes of hearing loss can vary by age: the most common cause of hearing loss in children is otitis media, while for the elderly (the largest group affected by hearing loss), excessive noise, drugs, toxins, and heredity are the most frequent contributing factors.

People with sensorineural loss often have decreased sensitivity to sounds as well as impaired discrimination. Sensitivity refers to a person's ability to detect soft sounds. If you have decreased sensitivity, you may not be able to hear a quiet voice or bird singing, but if the sound is made loud enough, you can recognize it correctly. Discrimination is the ability to distinguish one sound from another and to interpret sounds correctly. This is very important in understanding speech. If a person has a discrimination problem, even when the sound is loud enough to perceive, they may still misunderstand the sound or what is being said.

Age of Onset of Hearing Loss

One of the factors that has a profound effect on a person's experience with hearing loss is the age at which hearing loss occurs. People who experience hearing loss or deafness before learning their first language are referred to as having a pre-lingual loss of hearing. If the hearing loss or deafness occurs after the acquisition of language, it is called a post-lingual loss.

For infants and children with hearing loss, the most profound effects are related to the acquisition of language. The earlier that hearing loss or deafness is identified, the better the chances a child will acquire language, whether spoken or signed. Early hearing screening, while infants are still in the hospital or within the first month of life, can be a very important indicator of hearing loss or deafness in a child. For this reason, all infants should be screened while still in the hospital or within the first month of life. This examination and follow-up testing can confirm the extent and type of hearing loss. It also allows parents, health professionals, and teachers to determine the best intervention strategy for the child, to overcome communication barriers caused by a hearing loss.

On the other hand, hearing loss is one of the most common conditions affecting older adults. One in three people older than 60 and half of those older than 85 have experienced hearing loss. This type of hearing loss can make it hard to understand and follow a doctor's advice, to respond to warnings, and to hear doorbells and alarms, for example. It can also make it hard to enjoy talking with friends and family. All of this can be frustrating, embarrassing, and even dangerous. People with later-onset hearing loss typically live most of their lives as hearing people, so the loss of hearing later in life can require significant changes in communication strategies and lifestyle, and this adjustment can have social and psychological effects more profound than the "mere" physical fact of not hearing as well as in the past. (See Late Deafened page for related information.)

Some hard-of-hearing people have a progressive hearing loss, which may or may not include some congenital or early-onset loss, which then grows more severe over time. People in this category tend to develop a range of alternative communication strategies over time, such as speech-reading (formerly called lip-reading) and other adaptive listening habits. In contrast, others may have normal hearing most of their lives and then experience hearing loss or sudden deafness through injury or illness (this is sometimes called adventitious deafness). (See Late Deafened.)

Another type of hearing loss is called presbycusis. This is the loss of hearing that gradually occurs with many people as they grow older, whether or not there is a prior hearing loss. Presbycusis usually occurs in both ears, affecting them equally. Approximately 30 to 35 percent of all adults between the ages of 65 and 75 have presbycusis, and perhaps 40 to 50 percent of those 75 and older have this type of hearing loss. With this condition, people typically have greater losses in the higher frequency ranges (higher-pitched sounds). For example, they may no longer hear bird songs as well, but may still detect the low-pitched sound of a truck in the street. There are many causes of presbycusis; it usually arises from changes in the inner ear of a person as he or she ages, but it can also result from changes in the middle ear or from complex changes along the nerve pathways leading to the brain. Because the process of loss is gradual, people who have presbycusis may not always realize that their hearing is diminishing. Sometimes people with presbycusis will complain that others are always mumbling or speaking too softly.

Degrees of Hearing Loss  

How is hearing loss measured, and what do these measurements mean? The basic unit of measurement is the decibel (dB), a unit that measures the intensity of sound (a decibel is one-tenth of a bel). The scale runs from the faintest sound the human ear can detect, which is labeled 0 dB, to over 180 dB, or the noise at a rocket pad during a launch (see Table of Sound Levels). According to the American Academy of Otolaryngology, for every six decibels, the intensity of the sound doubles. Thus, with this logarithmic scale, as decibel intensity increases by units of 10, each increase is 10 times the lower figure. Thus, in the chart below, 20 decibels is 10 times the intensity of 10 decibels, and 30 decibels is 100 times as intense as 10 decibels. This increase is important when considering the effects of prolonged exposure to noise, because the damaging effect is also cumulative. At 90 dB of uninterrupted sound, the limit of safe noise exposure is eight hours. For each six dB increase of uninterrupted sound thereafter, the limit of safe exposure is reduced by half. Most experts agree that continual exposure to more than 85 decibels is dangerous to one's hearing.

When people talk about degrees of hearing loss, they usually use the terms Mild, Moderate, Severe, and Profound. (Often an intermediate level called "Moderately Severe" is also used.) These terms refer to certain decibel ranges of loss. For example, a "Mild" loss is one in the range of 25-40 dB. (A hearing loss in the 0-25 dB range is considered a slight loss and not usually recognized as significant.) The Degrees of Hearing Loss chart shows the most common classifications, and the resulting impact on the person affected. Decibel loss, however, is only one dimension of hearing loss. Discrimination ability is also very important in communication.

For more information on how the ear functions, visit the website at for the Virtual Tour of the Ear (ctl.augie.edu/Perry/ear/ear.htm). This comprehensive, detailed "tour" includes illustrations of and descriptions about the ear and its functions. Also, see:

How Hearing and Balance Work (www.asha.org/public/hearing/anatomy)

Understanding the Ear (clerccenter.gallaudet.edu/SupportServices/series/5001.html)

How's That? The Aural Mechanics (www.audiology.org/consumer/guides/aural.php)

Hearing Aids

A 2000 survey of hard-of-hearing Americans and hearing aid use found that more than 28.6 million Americans, or 10.3 percent of the population, had some degree of hearing loss. Of this number, 22.3 million did not have a hearing aid, and only about 22.2 percent of hearing-impaired Americans actually use hearing aids. For people of working age, the figures are even worse. Nine million hearing-impaired Americans aged 35 to 54 do not own a hearing aid, while a minority (approximately 1 million or 10 per cent), have accepted their hearing loss and are using hearing aids. This study also found that the reasons first-time owners purchased hearing aids included: the perception that their hearing loss got worse (68.5 percent), recommendations of a family member (45.2 per cent), audiologist recommendations (40.5 per cent), and other ear specialist recommendations (22.1 per cent).

What Hearing Aids Do-and What They Don't Do

Many people compare hearing aids to corrective eyeglasses, but this analogy is misleading. Corrective lenses (glasses and contact lenses) help the eyes to adjust visual input so that the perceived image is in focus-that is, projected on the right focal plane.

A hearing aid, in contrast, does not "correct" hearing, nor does it restore the user's lost hearing. Instead, it makes the sounds louder in the range of a particular hearing loss and adjusts the quality of that sound. It amplifies both speech and environmental sounds. People who wear eyeglasses may expect a person who wears a hearing aid to have more normal hearing, based on this false analogy.

Colorado audiologist Jay Tinglum, of ADCO Hearing Products, Inc., says that a better example is to compare hearing aids to the crutches used by a person who has a broken leg. The crutches do not restore full mobility, and the person is not truly walking, but he or she can get around better than before. Similarly, a hearing aid can help a person to perceive speech and other sounds better by making the sounds louder in certain frequencies and by other adjustments. But this is not the same as having "corrected" hearing.

It takes time to learn how to use a hearing aid. The aid may make sounds louder but cannot necessarily make words or sounds clearer. The "clarity" of the sound is more dependent on the ear itself rather than the hearing aid, and the user must learn to make sense of the distorted sounds from the hearing aids to interpret the meaning of the sounds.

All hearing aids have limitations. For example, they amplify the sounds we want to hear (such as speech), as well as those we don't (noise and background sounds). A hearing aid does not "cure" hearing loss. A hearing aid cannot amplify sound across all frequencies, and a hearing aid cannot make sound more clear if the cochlea is damaged. Hearing aids may not help people with auditory processing disorders. And some people have problems using hearing aids for other reasons. (See Hearing Loss in America.)

Hearing aid technology is changing rapidly. If you have not investigated hearing aids in recent years, you may be surprised at the variety of options available today. Today's hearing aids can also interact with and be assisted by a variety of assistive listening devices (ALDs) to help hard of hearing people keep in contact with the world of sound. While hearing aids remain the most important means of assisting Hard of Hearing people, they are no longer the only available choice (see the Cochlear Implants and Assistive Technology pages). A variety of other options has emerged in response to the particular listening challenges that hearing-aid users face.

How Do Hearing Aids Work?  

While there are several distinct types of hearing aids, all share some basic features. A microphone picks up sounds from the environment. The sounds are carried to a signal processor or amplifier, which makes them louderT (increases the intensity of the signals)T. It also shapes the incoming sounds to match the individual's hearing loss profile, adjusting frequency (or pitch-high, low, and mid-tones) and intensity (loudness). TFilters modify the sounds so that only sounds that are relevant for the person's individual loss are amplified. TThe sound is then sent through a receiver, which converts the electrical impulses into sounds that can be heard. T(This term can be confusing, since it functions more like a "loudspeaker," amplifying sounds from the microphone.) TFinally, the amplified and modified sounds are sent to the ear by way of the earmold, which is custom-fitted to the hard-of-hearing person's ear. THearing aids are equipped with volume controls and other control functions, which can be used for individual adjustments.

In digital hearing aids, a small computer can be programmed to manipulate the signals to fit the hearing loss of the individual user. Many of these aids also have switches to use in selecting different programs, or pre-programmed settings for specific situations, such as general conversation, telephone use, conversation in noisy backgrounds, settings designed for listening to music, and so on.

Many hearing aids have special Tele-coil switches, or "T-coil" settings, for use in telephone conversations. It is very important to discuss the need for a T-coil switch while you are considering hearing aid options, since this option is needed for many assistive listening devices. For example, a conference room at a local library might be set up with an induction loop system connected to a speaker's microphone. Hard-of-hearing patrons would switch their hearing aids to the "T-coil" setting within that room, and the speaker's voice is transmitted directly to their hearing aids, instead of traveling through the air space, resulting in much clearer sound quality.

Types of Hearing Aids

All hearing aids consist of three major components: microphone, processor, and receiver. They are held together in a protective case, which is often made of plastic. For a complete discussion of hearing aid technology, see:

¨      Frequently Asked Questions about Hearing Aids

¨      What are Hearing Aids?

¨      Information on Hearing Aids

¨      Hearing Aid Information  

There are several basic types of hearing aids, differentiated mainly by where the aid is worn. Your particular hearing loss and listening needs, the size and shape of your ear and ear canal, and the dexterity of your hands will all be considered in determining which type of hearing aid is best for your needs.

Behind the Ear (BTE): The main part of this type of hearing aid is positioned above and behind the ear, and a flexible tube connects the aid and the custom-fitted earpiece called the earmold. The aid itself is encased in a durable plastic shell, while the tube and earmold are made of softer, more flexible plastic or silicone. BTE aids are often less easily damaged than other types of aids, and may be more reliable. They can usually offer users a wider range of choices, since a number of accessories (such as FM systems or other assistive listening devices) may connect with them. And a BTE aid can offer greater power than some smaller aids, so it may be a better choice for those with more severe losses. One advantage of a BTE aid is that if it needs repair or servicing, the owner can use their custom-fitted earmold piece with a replacement or loaner hearing aid while the original is being serviced. Because of their robust design, BTE aids are especially recommended for children.

In the Ear (ITE): This type of hearing aid fills the bowl of the ear and part of the ear canal. This aid can accommodate larger sound amplifiers and contain more features than ITC or CIC aids. Some people who wear eyeglasses may prefer ITE aids because they do not interfere with eyeglass temple pieces that go over the ear. Because the inner workings of this hearing aid are contained within a custom-fitted earmold shell, the user must send off the entire unit when it needs servicing and cannot make use of "loaner" aids, as with BTE models. In addition, because of the shorter distance from the earmold to the aid's electronics, this type of aid is more vulnerable to earwax and moisture accumulation, and may need more frequent servicing and cleaning.

In-the-Canal (ITC): Smaller versions of In-the Ear hearing aids are called half-shell or In-the-Canal aids. This type of hearing aid works much the same as the ITC aid, and is usually used for cases of mild to moderate loss, as the hearing aid shell is not large enough for more powerful amplification. Like the ITE aids, the ITC aid is also more susceptible to problems with moisture and earwax accumulation. 

Completely-in-the-Canal (CIC): The least visible aids are called Completely-in-the-Canal hearing aids, which are almost invisible in the ear. These hearing aids are restricted to people with ear canals large enough to accommodate the whole hearing aid. Again, the user must be aware of potential problems from moisture and from earwax build-up.

Where Can I Get More Information About Hearing Loss?

The Internet contains a wealth of useful information on hearing loss. We have collected a sample listing of articles on our Hard of Hearing Resources page, drawn from a variety of organizations, with links to original articles. In addition, Hard of Hearing Organizations page gives contact information for different state, national, and international organizations that work with hearing loss issues. Many of the websites for these organizations have additional resources for the public.