VR and people who are hard of hearing: where do we go from here?

VR and people who are hard of hearing: where do we go from here? – vocational rehabilitation

George N. Kosovich

Times are changing dramatically in the vocational rehabilitation of people with hearing disabilities. Children born with or who acquire hearing loss in their first 5 years are now identified earlier and, through intervention programs, they are provided more options for developing both auditory and visual modes of language/communication skills. More and more of these children are being educated in mainstream programs where the focus is on inclusion in the general society. The emphasis is on developing as many communication tools as possible to aid in building a brighter future for each individual child.

Those who must rely on visual means of communication find many more tools available than in the past to enable them to gain access to the larger hearing society, which becomes more essential with our evergrowing dependence on communication systems in this “information age,” especially in the workplace. For children able to benefit from amplification technology, improvements continue to be made in hearing aids, assistive listening devices, and other related technology.

At the same time, it is important to note that 79 percent of the people with impaired hearing in the United States experience their hearing loss after the age of 19, with another 15 percent having onset between 3 and 18 years of age (Ries, 1992). People losing their haring as adults will, of course, have been functioning primarily in the world of people without hearing loss–in the verbal, speaking community. Hearing impairment has the potential to become a considerable impediment in all facets of life, depending on a number of variables. Adjustments will be required by the individual with the hearing loss and those with whom he/she interacts.

Available Assistance

Out of the overall population of people with hearing loss, about 43 percent are over the age of 65. Over 30 percent of the people past age 65 have some degree of hearing loss, compared to 8.8 percent of the total population. With the “greying” of our society over the next 25 years, it is expected that more and more people past the age of 65 will need to remain in the work force. As is the case with younger people, new advances in technology can assist older people in remaining vocationally active.

One major hitch to the above projections and one which clouds the picture significantly is the general public’s attitude about hearing loss. Denial, indifference, and dependence are attitudes that can prevent people from effectively adjusting to this condition. There are numerous misconceptions about hearing loss prevalent among the general population, even among those professionals who provide health and social services in our communities. Consequently, many people with hearing loss experience a variety of communication and attitudinal barriers when trying to access community programs, including services essential to their overall well-being (Trychin, 1991).

Since a great deal of research has and is being done regarding the education and rehabilitation of individuals with early onset, severe to profound hearing loss, this article will focus on the population commonly referred to as hard of hearing adults. The Rehabilitation Services Administration (RSA) is in the process of making a focused effort toward promoting awareness in the field of vocational rehabilitation regarding the unique needs of this population. Highlights of this effort will be detailed here.

The Population

The report of the Nineteenth Institute on Rehabilitation Issues (IRI) has as its theme, “Serving the Underserved–Principles, Practices and Techniques.” Chapters 2-6 of this document focus on people who are hard of hearing as an underserved population. Who exactly are we referring to when we use the term, hard of hearing, to describe a subpopulation of the larger group of people with hearing impairment? IRI offers a consumer’s definition of hard of hearing people as being “persons having a hearing loss ranging from mild to profound, but who can still benefit from amplification. Their speech is adequate for communication and they use, however imperfectly, the auditory mode to receive communications” (IRI, 1992). In its 911 coding system, RSA defines hard of hearing as “a hearing impairment resulting in a functional loss, but not to the extent that the individual must depend primarily on visual communication.” It should be noted that this coding system defines deafness as the need to depend primarily on visual communication.

How many people experience significant hearing loss to the point where they might need VR services? The 1990-91 Health Interview Survey (HIS) of the National Center for Health Statistics shows that 8.8 percent of the United States population over the age of 3 experiences some degree of hearing loss (Ries, 1992). This represents about 22 million people. A little over half of these–about 11.5 million people–have hearing loss in both ears, and about half of this group are 65 years of age or older.(1)

HIS does not report extensive data using deaf and hard of hearing definitions, but rather looks at the ability to hear and understand speech without the use of amplification/hearing aids. Of the population with hearing loss in both ears, 42 percent–almost 5 million people–cannot hear words spoken in a quiet room. Of this group, over 1 million people cannot hear words shouted in a quiet room; at best, they can hear words shouted in the ear. This is a self-reporting survey that along with age at onset of hearing impairment also covers gender (Reis, 1992).

Present and Past VR Service Delivery

From the numbers given above, it is clear that there are many people who are hard of hearing and may be disabled by their hearing loss. How many could possibly benefit from vocational rehabilitation (VR) services? The number of people coded by state VR agencies as being hard of hearing who were considered successfully rehabilitated (status 26) in 1960 was 3,793;30 years later, in 1990, this number was 12,619. Current trends, however, indicate that the overall number of status 26 case closures are on the decline, including for those who are hard of hearing, which accounted for 10,874 such closures in 1991. Within the overall total of persons rehabilitated, the percentage of VR clients with hearing loss as their major disability has decreased from 9.1 percent in 1989 to 8.3 percent in 1991.

It is important to point out that the numbers reported from state VR agencies mentioned above are based on degree of hearing loss only, using the RSA-911 definitions given for deaf and hard of hearing people. A different perspective is gained by looking at the age at onset of the disability as well as the degree of loss. This is especially relevant to gaining a clearer understanding of how extensively state VR agencies are addressing the rehabilitation needs of people who lose their hearing while being part of the actual or potential work force.

The HIS reports for 1990-91 show that nearly 84 percent of the total population of those with hearing loss in both ears had adult onset hearing loss. Out of 9.4 million people with adult onset hearing loss in both ears, about 5 million were between the ages of 19 and 65 (Reis, 1992). In fiscal year 1990, 35.6 percent, or 6,929, of all people disabled by hearing loss that were rehabilitated were identified as being hard of hearing and had lost their hearing after age 19. Also, 625 people, or 3.2 percent of this total rehabilitated hearing impaired population, were coded as having adult onset deafness.

It was found that VR service delivery to individuals in the two “late-onset” sub-groups have much more in common with each other than they do with early onset hard of hearing and deaf populations. Case service costs, time in a VR program, and work status at closure are just some areas that demonstrate the commonality among people who have a late onset of hearing loss despite the degree of the loss.


As concisely stated in the title of an article about people who are hard of hearing in the Winter 1991-92 issue of Gallaudet Today, “It’s Not All Black and White.” Emphasis simply cannot be placed only on the degree of hearing loss, with no mention made of situational/environmental factors, attitudinal barriers, age at onset, or adjustment/coping considerations.

Certainly, communication difficulties resulting from hearing impairment are a major concern, but the emotional experience of losing the ability to easily communicate through hearing can have an equally strong impact on the individual. Ramsdell is quoted in IRI as stating that hearing loss “produces a psychological impairment more basic and more severe than the difficulty in communication.” Psychosocial issues are well addressed in IRI as well as the Gallaudet Today issue referred to previously, demonstrating the impact of these issues on the overall vocational rehabilitation process for persons with acquired hearing loss. These adjustment issues apply whether the individual has a total or partial loss of hearing, again, with many variables coming into play.

How well is this aspect of hearing loss being addressed in rehabilitation service delivery? It is unfortunate that there are still many people in our society, including rehabilitation professionals, who believe hard of hearing people are just like people with blurred vision who need to wear corrective lenses to restore their sight to 20/20. Just put a hearing aid on a hard of hearing person and he/she is returned to “20/20” hearing with all related problems disappearing. Right? Wrong!

A hearing aid is a good start, but by itself it usually is not enough. Assistive listening devices which help to filter out extraneous background noise and provide a clear speech signal are essential in a number of situations. Other related technology and communication strategies such as speechreading and communication facilitators are options needed and used by hard of hearing people as the situation demands. The biggest problem, however, is that of getting people to use these options. This is where attitudinal barriers come into play, blocking access to education, training, employment, and general social activities.

For example, “Joe,” with a severe to profound hearing loss has a much more severe impairment than “Bob,” who has a moderate degree of hearing loss. However, Bob refuses to acknowledge the hearing impairment (denial) and will not even consider the use of a hearing aid. Joe lost his hearing while a senior in high school, has used hearing aids and related technology for 10 years, and is a skilled speechreader who will readily let people know what his communication needs are. Bob is likely to experience more problems resulting in impediments to social and vocational functioning than Joe because of his attitude about his hearing loss. Considerable functional limitations would be the result of his ignorance about effective coping mechanisms that could benefit him.

Indications from the state VR agency reports to RSA are that the primary service provided to hard of hearing clients is assistance with the purchase of hearing aids. As stated earlier, this is an important first step in the overall rehabilitation of persons with hearing loss who can benefit from these devices. However, IRI shows that a national representative study reported that 93 percent of hard of hearing people state that hearing aids are not sufficient to eliminate communication problems (Armstrong, 1992). People have to be taught how to effectively use hearing aids and other related assistive technology, and indications from the IRI is that this is not happening.

Professionals in rehabilitation need to be able to effectively communicate with people with hearing loss in order to work with them. This necessity has been recognized in relation to serving individuals who use sign language to communicate, with a number of programs funded by RSA for the training of rehabilitation counselors for the deaf (RCD’s). Training is also needed to teach rehabilitation professionals about the communication needs of those persons with adult onset hearing loss. This includes not only VR counselors, but related professionals and health service providers, including mental health workers, educators, trainers, and rehabilitation facility staff.

Beyond the communication issues is the need for these professionals to be aware of the psychosocial issues people with adult onset hearing loss often have to deal with. Again, much research and training for these professionals has been provided over the past 20 years in the area of services to persons with early onset deafness. Consequently, services to this population have increased and improved dramatically in this time. The same needs to happen for the much larger population of people with adult onset hearing loss, including those persons 65 years of age and older.

In FY 1990, 34.5 percent of the people with adult onset hearing loss, identified as being hard of hearing and closed in status 26, were age 65 and older, with the same being true for 23 percent of the adult onset deaf group. This is in comparison to the 2.8 percent of the nonhearing impaired population closed in status 26 that year that was age 65 or older. It is not clear at this point whether this was an isolated phenomenon or if it is a general trend, but certainly this warrants further investigation. With laws prohibiting discrimination on the basis of age for both employment and the provision of government funded services, it can be expected that people over the age of 65 will represent a significant part of the VR client base in coming years. Many of these will experience hearing loss with or without other disabilities.

What Progress is Being Made?

In December 1987, RSA entered into a cooperative working relationship with Self Help for Hard of Hearing People, Inc. (SHHH), the National Institute on Disability and Rehabilitation Research (NIDRR), and the Counsel of State Administrators of Vocational Rehabilitation (CSAVR) via a Joint Statement of Principles of Cooperation. This took place at the urging of Howard E. “Rocky” Stone, founder and Executive Director of SHHH at that time. Mr. Stone and SHHH had become recognized as the leading consumer advocates for hard of hearing people in the country and, perhaps, the world.

Progress has come slowly in terms of achieving specific objectives laid out in this agreement. The goal of enhancing the provision of vocational rehabilitation services to individuals with impaired hearing was by no means expected to be a short-term venture. However, the pace of progress has quickened somewhat in recent years. In 1990, RSA expanded its staff to include a VR Program Specialist with a background in hearing loss rehabilitation to work in its Deafness and Communicative Disorders Branch (DCDB). A major focus of this position is the improvement of rehabilitation services to individuals disabled by adult onset hearing loss. Consequently, increased attention has been given to filling the gaps identified in service delivery to people who are hard of hearing.

Other avenues of notable and/or expected progress include:

* the participation of SHHH and DCDB staff in annual meetings of the CSAVR Standing Committee on Services for Individuals Who are Deaf or Hard of Hearing;

* NIDRR funding of a research project on adventitious hearing impairment from 1989 to 1992 conducted by Dr. Laurel Glass through the University of California/San Francisco; a report is pending;

* NIDRR funding of a contract with Westat, Inc., with SHHH as a subcontractor, for a 3-year project begun in October 1991 to research the overall rehabilitation needs of hard of hearing individuals;

* NIDRR funding in FY 1994 of a Research and Training Center in Mental Health and Hearing Impairment to focus on the psychosocial and adjustment needs of hard of hearing and late deafened adults;

* RSA funding of a 1-year short-term training project begun October 1992 at the Region VI Rehabilitation Continuing Education Program, University of Arkansas, for the training of rehabilitation professionals to work with individuals who are hard of hearing or late deafened; and

* development, publication and distribution in 1992-93 of the IRI document extensively referred to in this article under the sponsorship of RSA, NIDRR, and CSAVR.

There are great hopes that the training for trainers provided through the University of Arkansas RRCEP in 1993 will prove to be a major breakthrough in preparing more rehabilitation professionals to effectively serve persons with adult onset hearing loss. A good base of materials related to hearing loss and the rehabilitation of people with this condition is available through this training project, as well as those activities mentioned previously. This is a foundation upon which comprehensive awareness and knowledge of the specific needs of persons with adult onset hearing loss can begin to grow and be applied through relevant research, demonstration, and training programs.


1. This is not to imply that hearing loss in one ear does not carry with it significant consequences. Emphasis on hearing loss in both ears is made due to the previous RSA focus on “the more useful ear” audiological measurements for the purpose of defining severe disability for hard of hearing people. (It is expected that a specific definition for “severely disabled hard of hearing” will no longer be used in the revised RSA-911 coding system.)


Some printed materials presently available that could be of great value to VR and other rehabilitation professionals, as well as educators and trainers in this area include the following:

1. Rehabilitation of Individuals Who Are Hard of Hearing and Late Deafened. Three manuals, including: Trainers Guide, Guide for Rehabilitation Practitioners, and Administrators Guide. Region VI Rehabilitation Continuing Education Program, University of Arkansas, P.O. Box 1358, Bldg. #35, Hot Springs, AR 71902. Telephone: (501) 624-4411, Extension 315, or (501) 624-0079 (TTY).

2. Nineteenth Institute on Rehabilitation Issues: Serving the Underserved–Principles, Practices, and Techniques (Chapters 2-6); University of Wisconsin-Stout, Stout Vocational Rehabilitation Institute, School of Education and Human Services, Menomonie, WI 54751, David W. Corthell, Ed.D. (Ed.), October 1992.

3. Self Help for Hard of Hearing People, Inc., 7800 Wisconsin Avenue, Bethesda, MD 20814, (301) 657-2248. SHHH has numerous publications on all aspects of hearing loss, including an award winning bi-monthly Journal.

4. Gallaudet Today, Winter, 1991-92; Gallaudet University, Kendall Green, 800 Florida Avenue, N.E., Washington, DC 20002-3695; This edition focuses on persons with adult onset hearing loss and provides excellent anecdotal/case history perspective of this population.

5. Trychin, Samuel, Ph.D.; “Communication Issues Related to Hearing Loss” (1993), “Staying in Touch” (1993), co-authored by Janet Albright, M.A., “Manual for Mental Health Professionals, Part I (Basic Information for Providing Services to Hard of Hearing People and Their Families), co-authored by Debra Busacco, Ph.D., and Part II (Psycho-social Challenges Faced by Hard of Hearing People” (1991). Dr. Samual Trychin is a clinical psychologist who has been hard of hearing for many years and is presently on staff at Gallaudet University. The above texts are four of Dr. Trychin’s most recent works from a long list of publications that he has authored or co-authored related to hearing loss rehabilitation. He has traveled extensively throughout the USA meeting and working with hard of hearing people. These and his other publications and videos may be obtained through SHHH (address provided above).

COPYRIGHT 1993 U.S. Rehabilitation Services Administration

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