Characteristics of Hearing Aid Use in Adolescents Who Are Deaf and Hard of Hearing

Abstract

Purpose:

Children who use hearing aids show large individual differences in the amount of time they wear their devices, but the vast majority of research studies have focused on infants and preschoolers who are deaf and hard of hearing (D/HH). There is limited empirical evidence regarding hearing aid use in adolescents or published data on adolescents' attitudes toward hearing aids. The overarching aim of the current study was to characterize hearing aid use in adolescents who are D/HH.

Method:

One hundred twenty-nine adolescents who are D/HH (12–19 years old) and their parents completed questionnaires about hearing aid use and attitudes toward amplification. Examiners collected data logging at research visits. Adolescents and parents estimated the average amount of time hearing aids were worn during the week and weekend. We conducted a linear regression analysis to investigate the relationships among the independent predictor variables (chronological age, age at hearing aid fitting, maternal education level, proximity of hearing aid fitting to prescriptive targets, and better ear pure-tone average) and the dependent variable (adolescent self-report of average daily hearing aid use).

Results:

Severity of hearing loss and maternal education level accounted for variation in hearing aid use among adolescents who are D/HH, whereas chronological age, age at hearing aid fitting, and proximity of fitting to prescriptive targets did not. Parent report, adolescent self-report, and data logging were in high agreement, although both parents and teenagers tended to overestimate the amount of daily hearing aid use by around 30 min.

Discussion:

In general, the results of the current study are inconsistent with the notion that adolescents decrease hearing aid use when they reach adolescence. Furthermore, many of the adolescents who participated in this study expressed positive attitudes about amplification, demonstrating emerging self-advocacy.

Permanent childhood hearing loss affects approximately one in 1,000 infants (Butcher et al., 2019), making it one of the most common health conditions that can be screened for at birth. Untreated hearing loss, even in cases of slight or mild hearing loss, can lead to communication delays, academic and vocational challenges, and psychosocial and mental health issues (Idstad & Engdahl, 2019; Tomblin, Harrison, et al., 2015; Walker et al., 2015; Worsfold et al., 2018). For parents who seek to improve their child's auditory access and spoken language skills, one of the most common clinical recommendations is to fit the child with hearing aids soon after diagnosis. Since the early 2000s, most developed countries have implemented early hearing detection and intervention (EHDI) programs, which has resulted in a substantial decrease in the age at which children are fit with amplification (Harrison et al., 2003; Holte et al., 2012; Marnane & Ching, 2015).

Recommendation and early fitting of amplification does not necessarily lead to consistent use of hearing aids, however. Studies have shown large individual differences in the amount of time children wear their hearing aids (Appleton & Bamford, 2006; Barrera et al., 2023; Booysen et al., 2022; Brigham et al., 2024; Kelly et al., 2025; Marnane & Ching, 2015; Marttila & Karikoski, 2006; Moeller et al., 2009; Muñoz et al., 2013; Nailand et al., 2022, 2023; Salamatmanesh et al., 2022; Visram et al., 2021; Walker et al., 2013, 2015). Most researchers have focused on early childhood, with only a few studies specifically addressing adolescent hearing aid use (Dammeyer et al., 2017; Flynn et al., 2022; Gustafson et al., 2015). Despite the sparse evidence on hearing aid use in older children, it has been suggested that middle schoolers and high schoolers with hearing loss are less inclined to wear hearing aids consistently compared to elementary-age children, perhaps due to social pressures, self-consciousness, or the stigma attached to using hearing technology (Dammeyer et al., 2017; Gustafson et al., 2015; Punch & Hyde, 2011). For example, Dammeyer et al. (2017) found that parents reported older children (6 years old or older) were more likely to try to hide their devices (hearing aids or cochlear implants) compared to younger children (5 years old or younger). In a study with Australian teens, Punch and Hyde (2011) noted that adolescents with cochlear implants felt self-conscious about the visibility of their devices. However, the data to support these claims in adolescents who use hearing aids are limited. The overarching aim of the current study is to characterize hearing aid use in adolescents who are deaf and hard of hearing (D/HH). We were primarily interested in examining the average amount and variability in daily hearing aid use, associations between parent report and adolescent self-report measures of hearing aid use with objective measures such as data logging (i.e., an automatic feature built into most current hearing aids that tracks average hours of hearing aid use per day; Mueller, 2007), and factors that drive variation in hearing aid use for older children. An additional goal of this study was to explore adolescents' attitudes toward amplification, particularly with respect to their perceptions of the benefits and challenges of using hearing aids.

Hearing Aid Use in Young Children

Hearing aid use in early childhood is a well-studied topic (for reviews, see Muñoz & Hill, 2015; Nailand et al., 2022; Salamatmanesh et al., 2022). Prior work has investigated pediatric hearing aid use from several different angles, including examining the associations between parent report measures of hearing aid use and data logging, the amount of and variability in hearing aid use at different ages, and the parent- and child-related factors that affect consistency of device use (Brigham et al., 2024; Caballero et al., 2017; Fitzpatrick et al., 2019; Kelly et al., 2025; Marnane & Ching, 2015; Moeller et al., 2009; Muñoz et al., 2015, 2016; Walker et al., 2013, 2015; Visram et al., 2021). Across these studies, hearing aid use is usually reported as data logging and/or parent report values, with the consistent finding that data logging is lower than parent report, though both measures of hearing aid use are also highly correlated with one another for a given child (Muñoz et al., 2014; Walker et al., 2013, 2015). To our knowledge, only one study to date has included child self-report measures of hearing aid use (Flynn et al., 2022). In that study, which included 14 children with hearing aids (ages 9–13 years), the authors reported that children tended to overestimate the amount of hearing aid use when compared to parents.

Two large-scale cohort studies have documented the amount of hearing aid use in younger children: Outcomes of Children With Hearing Loss (OCHL; United States) and Longitudinal Outcomes of Children With Hearing Impairment (LOCHI; Australia). In the OCHL study, Walker et al. (2013) asked parents of 272 children (ages 5 months to 7 years) to estimate the average number of hours each day that their child wore hearing aids. Researchers collected data logging for a subset of participants (n = 133). Average daily hearing aid use based on parent report was 10 hr, and average hearing aid use with data logging was slightly lower at 8 hr. In the LOCHI study, Marnane and Ching (2015) asked 297 parents of 3-year-olds to report on the frequency of hearing aid use categorically. They reported that 65% of the children wore hearing aids “always,” 19.5% used them “often,” and 15% used them infrequently. Thus, most children were considered full-time hearing aid users, which they defined as more than 8 hr per day, but a large minority (~35%) were inconsistent users.

Given the large variability in hearing aid use in young children, researchers have tried to determine the variables driving these individual differences, in the hopes that this knowledge would provide information about effective techniques to increase hearing aid use in families who are having difficulty achieving full-time use (Ambrose et al., 2020). Chronological age, degree of hearing loss, and socioeconomic factors (e.g., parental education level, income, insurance status) have all been shown to have a significant impact on hearing aid use, as children who are older, who have a more severe hearing loss, and who come from more economically advantaged backgrounds display greater amounts of hearing aid use (Caballero et al., 2017; Dammeyer et al., 2017; Gustafson et al., 2015; Marnane & Ching, 2015; Marttila & Karikoski, 2006; Moeller et al., 2009; Muñoz et al., 2013, 2014; Walker et al., 2013, 2015). Brigham et al. (2024) demonstrated that having a shared language with the child's audiologist may also be a contributing factor in the United States, as children who had parents with limited English proficiency showed fewer hours of hearing aid use compared to children whose parents were English-proficient. Marttila and Karikoski (2006) examined age at hearing aid fitting in 328 Finnish children and found that children who were fit at younger ages were significantly more likely to wear hearing aids than children fit at older ages; however, it is important to note that hearing aid use was treated as a nominal variable (bilateral user, unilateral user, or nonuser) based on retrospective reports from teachers, speech therapists, and hospital records, rather than a continuous variable of daily hours of use. Sex has also been examined but has not been shown to be a significant predictor of the amount of daily hearing aid use (Marnane & Ching, 2015; Walker et al., 2013). To date, there are no published findings looking at whether the optimality of hearing aid fitting impacts hearing aid use (as reviewed by Muñoz & Hill, 2015), although studies indicate that children with hearing aids show variability in fitting outcomes and a wide range of proximity of hearing aid fitting to prescriptive targets (McCreery et al., 2013, 2015; Wiseman et al., 2023). It could be posited, therefore, that children may be less inclined to wear hearing aids that are fit substantially above or below prescriptive hearing aid targets.

Hearing Aid Use in Adolescents

As previously noted, there are few peer-reviewed studies about hearing aid use during adolescence. Flynn et al. (2022) reported on hearing aid use from 14 children, ranging from 9 to 13 years of age, with mild bilateral hearing loss. They compared parent report and child self-report measures of the amount of hearing aid use to data logging and also compared parent report and child self-report measures of situational use of hearing aids. Results indicated that both parents and children overestimated hearing aid use compared to data logging, although a greater number of children overestimated use than parents. Children reported wearing hearing aids an average of 9.9 hr per day, whereas average data logging was 6.6 hr. Parents and children were consistent in their reporting of frequency of device use across different situations, with hearing aid use at school and in the car being the two most common situations and sports being the least common. The findings of this study are limited in that they only included children with mild hearing loss, there were a small number of participants, and they only included children up to 13 years of age; thus, they did not include participants at later stages of adolescence or greater degrees of hearing loss. There is a need to better understand hearing aid use patterns throughout the teenage years, and such research requires a larger sample size with a wide range of hearing levels.

Gustafson et al. (2015) examined 38 children, ages 6 through 13 years, with mild-to-moderate hearing loss. They measured hearing aid use by having research assistants go into each participant's classroom four times and document if the child was wearing their hearing aids. Children were then categorized as nonusers if they never wore hearing aids; variable users if they were seen wearing hearing aids one, two, or three times; and consistent users if they wore hearing aids at all four observations. Gustafson and colleagues' primary goals were to determine what factors predicted hearing aid use and how parent report of hearing aid use was correlated with the researchers' classroom observations. They found that grade level impacted consistency of use; children in older grades (fifth to seventh grades) were less likely to be consistent hearing aid users compared to children in younger grades (first to fourth grades). They also found that children with more severe hearing loss were more likely to wear hearing aids consistently in school than children with milder hearing loss. Parent report was significantly associated with the classroom observations, although parents of older children were less accurate than parents of younger children. Like Flynn et al. (2022), the conclusions that we can draw about hearing aid use in adolescence from this study are limited due to a small number of participants and the lack of data after 13 years of age. However, the results would suggest that older students are less likely to wear hearing aids and parents become less accurate reporters over time, consistent with predictions from the broader literature on decreasing use as adolescents increase in age.

The third study to include adolescents with hearing aids was a survey-based study from Denmark (Dammeyer et al., 2017). The researchers contacted parents of 126 pediatric hearing aid users. Children ranged in age from birth to 15 years and were divided into two age groups (0–5 years and 6–15 years) for data analysis. Approximately two thirds of the parents of the older age group reported that their children wore their hearing aids more than 10 hr per day, while approximately one third of parents reported that their children did not wear their hearing aids at all. A regression model indicated that the 0- to 5-year age group was more likely to own hearing aids than the 6- to 15-year age group, although it is unclear if the older children never had hearing aids or had discontinued use as they grew older. The study did not separate the older age group into more discrete categories (e.g., preadolescents and adolescents), so frequency of hearing aid use and factors related to hearing aid use in teenagers could not be explored.

In summary, empirical data on hearing aid use in adolescence are substantially lacking. However, it is often assumed that teenagers are reluctant to wear hearing aids, and there is a strong social stigma surrounding device use in this age range (Gustafson et al., 2015). It is important to examine characteristics of and attitudes toward hearing aid use during the teenage years; in doing so, we can increase our understanding of factors related to device use, which will inform strategies for clinicians to facilitate full-time hearing aid use and improve outcomes. The current study will address four questions related to hearing aid use in adolescents who are D/HH:

1. How many hours and in what contexts do adolescents wear hearing aids on a daily basis based on parent report, their own self-report, and data logging measures? Based on prior research (Gustafson et al., 2015), we predict that average hearing aid use during adolescence will be lower than past reports of use during early school-age years (Walker et al., 2013, 2015).

2. Is hearing aid use measured via parent report and adolescent self-report associated with data logging? Based on prior research (Muñoz et al., 2014), we predict that there will be strong, positive correlations between parent report, self-report, and data logging measures. Correlations with self-report measures and data logging may be lower than parent report measures and data logging (Flynn et al., 2022). Correlations with parent report measures and data logging may be lower than past reports during early school-age years (Gustafson et al., 2015).

3. What variables predict the amount of daily hearing aid use in adolescents who are D/HH? Based on prior research, we predict that adolescents with more severe hearing loss and adolescents who have mothers with higher education levels will wear hearing aids more frequently than adolescents with milder hearing loss and adolescents who have mothers with lower education levels (e.g., Walker et al., 2013, 2015).

4. What are the benefits and challenges with hearing aids from the perspective of adolescents who wear them? This is a descriptive analysis of adolescents' attitudes toward hearing aid use. We do not have a priori predictions about this research question.

Method

Participants

One hundred twenty-nine adolescents (57 females, 72 males) and their parents participated in this study during junior high or high school. All participants were part of a longitudinal, multicenter cohort study (OCHL) that started enrolling participants in 2009. Participants were originally enrolled in OCHL between 6 months and 7 years of age. The three research sites consisted of The University of Iowa; Boys Town National Research Hospital in Omaha, NE; and University of North Carolina–Chapel Hill. All procedures were approved by The University of Iowa Institutional Review Board (IRB) and at participating sites via SMART IRB (i.e., the Streamlined, Multisite, Accelerated Resources for Trials IRB Reliance platform, designed to streamline the human subjects review process for multisite studies). Participants were recruited in these catchment areas through records maintained by EHDI programs. In addition, audiologists, speech-language pathologists, teachers of the D/HH, or early interventionists who served children with hearing loss in Iowa, Nebraska, North Carolina, and surrounding states provided recruitment brochures to parents of children who were D/HH. Thus, recruitment was primarily driven by service providers and state EHDI programs, limiting participants to those who were receiving clinical and educational services for hearing loss. For additional information about ascertainment of OCHL participants, see Tomblin, Walker, et al. (2015). Participants all used spoken English as their primary communication mode and did not have additional disabilities (e.g., significant cognitive or developmental delays, autism spectrum disorder, vision impairment). At the time of data collection, all participants were enrolled in regular education classrooms: 31% (n = 40/129) had classroom accommodations through Section 504, 36% (n = 47/129) had an individual education plan (IEP), and 33% (n = 42/129) had no IEP or 504 plan.

Participants were included in the current study if they had bilateral hearing loss (sensorineural, permanent conductive, or mixed). Seventy-six percent (n = 98/129) of participants were identified with hearing loss through newborn hearing screening (NHS). An additional 23% (n = 30/129) received an NHS but were not identified with hearing loss at birth (either due to an acquired hearing loss, because their hearing levels were mild and they did not refer on the NHS, or because the NHS results were inconclusive due to noise). One child was not screened for hearing loss at birth because he was born outside of the United States. The median age at confirmation of hearing loss was 4 months (M = 17.55 months, SD = 21.53, range: 0.25–92), and the median age at hearing aid fitting was 7 months (M = 22.85 months, SD = 25.52, Mdn = 7, range: 1–120). All participants used unilateral or bilateral hearing aids or had previously worn hearing aids but discontinued use. One hundred nine participants (84%) had bilateral behind-the-ear (BTE) hearing aids and seven (5%) had unilateral BTEs and no hearing aid in the opposite ear. Four participants (3%) were bimodal (cochlear implant in one ear and a hearing aid in the opposite ear). Two participants (1.5%) had bilateral osseointegrated devices (i.e., bone-anchored hearing aids [BAHAs]), and one (0.8%) had a unilateral BAHA and no hearing aid in the opposite ear. Six (4.6%) had discontinued hearing aid use. The participants who had discontinued hearing aid use were included in the data set and recorded as having 0 hr of hearing aid use.

Participants ranged in age from 12 to 19 years (M = 15.90 years, SD = 1.97). Most participants identified as White/not Hispanic or Latino (87%; n = 112/129). Eighty-three percent (n = 107/129) were from urban areas, and 17% (n = 22/129) were from rural areas. We determined which participants were urban or rural by categorizing them based on rural–urban commuting area (RUCA) codes. RUCAs classify ZIP codes using integers of 1–10, which delineate between metropolitan, micropolitan, and rural areas based on U.S. census data (i.e., population density, urbanization, and daily commuting distance). Participants with RUCA codes 1–3 were classified as being from urban areas, and participants with RUCA codes 4–10 were classified as being from rural areas (Martin et al., 2024).

Degree of hearing loss ranged from slight to profound; the average four-frequency better ear pure-tone average (BEPTA) was 48.22 dB HL (SD = 15.53, range: 16.25–90). Thirty percent (38/128) had hearing loss in the mild range (i.e., 16–40 dB HL), 52% (66/128) had hearing loss in the moderate range (i.e., 41–60 dB HL), and 19% (24/128) had hearing loss in the moderately severe–profound range (i.e., 61 dB HL or greater). One child was missing audiometric data from their most recent visit. Average age at hearing aid fitting was 22.85 months (SD = 25.52, range: 1–120).

Parents completed an intake form during the test visits and indicated family income level and father and mother's highest level of education. Among these three variables, maternal education level was used as a proxy for socioeconomic status based on research indicating that higher maternal education serves as a unique protective factor for children with developmental delays (Putnick et al., 2024). Parents completing the intake form identified highest level of education from one of 12 levels, that is, (a) completed elementary school; (b) completed junior high; (c) received general education diploma; (d) completed high school; (e) completed 1 year or more of vocational/technical school; (f) completed vocational/technical school; (g) completed 1 year or more of university/college; (h) bachelor's degree; (i) completed 1 year or more of graduate school; (j) master's degree; (k) coursework completed for PhD but no dissertation, law degree without bar, medical degree without internship completed; and (l) PhD, law degree with bar, medical degree with internship completed. Prior studies from this cohort of participants have used these same categories of education level (e.g., Tomblin, Walker, et al., 2015; Walker et al., 2013, 2015). Because of the large number of maternal education categories, we reduced the data into three arbitrary ordinal levels: (a) some college or less, (b) college degree, or (c) postgraduate education or greater. These three levels were selected so that sample sizes were fairly even across the three levels. Table 1 displays information about the number of participants included within each ordinal level for maternal education.

Table 1.

Arbitrary levels for maternal education (N = 129).

Maternal education level	n
Some college or less	45
College degree	40
Postgraduate school or greater	44

Procedure

Testing occurred at a research laboratory, a facility near the family (e.g., library, audiology, or otolaryngology clinic), or a van that was equipped as a mobile testing unit. The test battery included audiologic and hearing aid assessment and administration of language, cognitive, and reading measures. Test visits took approximately 5–6 hr.

Audiologic Assessment

An audiologist obtained air-conduction thresholds at 250, 500, 1000, 2000, 4000, 6000, and 8000 Hz and bone conduction at 500, 1000, 2000, and 4000 Hz. We calculated the four-frequency BEPTA for analysis purposes. Pure-tone thresholds for the four bimodal users were obtained from the nonimplanted ear.

Hearing Aid Verification Measures

For participants with BTE hearing aids, the audiologist conducted probe microphone measures to quantify the real-ear-to-coupler difference (Bagatto et al., 2016). In situ or simulated real-ear measures were then used to calculate the aided speech intelligibility index at users' device settings using the standard male speech signal (Cox & McDaniel, 1989) presented at a conversational input level of 65 dB SPL following ANSI S3.5 (American National Standards Institute, 1997).

To assess proximity of the hearing aid fitting to prescriptive targets, we compared the obtained hearing aid verification data to Desired Sensation Level (DSL) Version 5 (Scollie et al., 2005) targets using the root-mean-square error (RMSE) or quadratic mean. We calculated RMSE by taking the square root of the mean of the squared differences between the aided output and the DSL targets at 500, 1000, 2000, and 4000 Hz. The RMSE estimates the proximity of the hearing aid output to the prescriptive targets without indicating the direction (±) of the error. Previous studies have used the RMSE value as a metric to assess proximity to prescriptive target in adult and pediatric hearing aid research (Baumfield & Dillon, 2001; Byrne & Cotton, 1988; Cox & Alexander, 1990; Folkeard et al., 2020; McCreery et al., 2013, 2015; Moore et al., 2001; Wiseman et al., 2023). Higher RMSE indicates more poorly fit hearing aids. For the current study, we divided RMSE data into three categories: < 3, 3–5, and > 5 dB SPL. This decision was based on prior work by Wiseman et al. (2023), which showed that children who had fittings that met a < 3 dB SPL criterion for RMSE had higher aided audibility than children with > 5 dB, and children with < 3 dB had stronger morphosyntactic skills than children with 3–5 and > 5 dB RMSE.

Parent Report and Self-Report Hearing Aid Use Questionnaire

During the test visit, an examiner conducted separate interviews with the parent and the adolescent using a questionnaire about pediatric hearing aid use. The two versions of the hearing aid use questionnaire (parent report version and self-report version) are in Appendices A and B and are similar to the parent report questionnaire described in other manuscripts (Walker et al., 2013, 2015).

Parents and adolescents estimated the average amount of time the adolescents used hearing aids per day during the week and on the weekends, as well as for the school year and the summer. Estimates of weekday use were multiplied by 0.71 (5/7 days of the week) and weekend use was multiplied by 0.29 (2/7 days). These values were added together for the school year and multiplied by 0.75 (9/12 months of the year). The values for the summer were added together and multiplied by 0.25 (3/12 months). Weighted school year and summer values were then added together to give us single measures of parent report and self-report of device use.

Parents and adolescents also indicated consistency of use across situational contexts using a 5-point Likert scale. The questions related to consistency of use were adapted from prior work (Moeller et al., 2009; Walker et al., 2013, 2015) to be age-appropriate for adolescents. Examiners asked the caregiver or adolescent to rate how often they wore their hearing aids in nine different listening environments: in the car, at school, after school, during mealtimes, during recreation with friends, during sports and extracurricular activities, while alone, at their job, and in public (e.g., in a store or restaurant). The scale included the following ratings: 0 = never, 1 = rare, 2 = sometimes, 3 = often, 4 = always, and not applicable.

The questionnaire also included the following open-ended questions for the adolescents:These open-ended questions were posed to give the adolescents an opportunity to share what they liked and what they did not like about wearing hearing aids. Participants were given the option to read through the open-ended questions and type their answers into a REDcap database, or they could respond verbally and an examiner transcribed them online.

1. Where do they particularly benefit from their hearing aids?

2. Are there challenging times or situations where they preferred not to wear their hearing aids and what did they do in those situations?

3. Is there anything that bothers them about their hearing aids and how did they typically handle these situations?

4. Is there anything else that the respondent wants to say about their hearing aids?

We used an inductive thematic analysis approach (Braun & Clarke, 2006) to identify patterns in the responses to the open-ended questions regarding self-perceived benefits and challenges of hearing aid use. We chose this approach given the lack of prior research on this topic and because it allowed us to review and code the qualitative data without having predetermined sets of themes. The first author (E.A.W.) determined the themes and coded the responses, and the second author (M.S.) coded the responses independently for all participants. We calculated reliability as total agreement divided by total agreements plus disagreements. Mean interrater reliability for all responses to open-ended questions was 86% (range: 81%–88%). Any differences in codes were resolved through consensus after reliability had been calculated.

Hearing Aid Data Logging

Audiologists obtained data logging whenever possible. Hearing aids were connected to the appropriate manufacturer software using a programming interface (e.g., HiPro, Noahlink Wireless). If values differed between ears, the higher value was used for the analysis. For bimodal users, data logging was collected only from the hearing aid. We did not collect data logging from the three BAHA users.

Statistical Analysis

We conducted Pearson correlations to examine relationships between parent report, self-report, and data logging values of hearing aid use. We used linear regression analysis to investigate the relationships among the independent predictor variables (chronological age, age at hearing aid fitting, maternal education level, BEPTA, and RMSE) and the dependent variables (self-report estimates of average hearing aid use). For maternal education level, ordinal levels were introduced to combine the large number of maternal education categories into three groups (some college or less, college degree, postgraduate school). With an analysis of variance (ANOVA), we evaluated the impact of sex, maternal education level, severity of hearing loss (i.e., mild, moderate, severe–profound) and optimality of hearing aid fitting (RMSE < 3, 3–5, > 5 dB SPL) on the dependent variable of self-reported hearing aid use. Severity of hearing loss and RMSE were treated as both a continuous and categorical variable, depending on the analysis (linear regression and ANOVA, respectively). All statistical analyses were conducted with SPSS.

Results

Research Questions 1 and 2: How Many Hours and in What Contexts Do Adolescents Wear Hearing Aids on a Daily Basis Based on Parent Report, Their Own Self-Report, and Data Logging Measures? Is Hearing Aid Use Measured via Parent Report and Adolescent Self-Report Associated With Data Logging?

Figure 1 displays hearing aid use data based on self-report, parent report, and data logging. On average, adolescents (n = 127) reported that they wore their hearing aids 11.35 hr per day (SD = 5.69, range: 0–24), and parents (n = 124) reported that their children wore their hearing aids 11.82 hr per day (SD = 5.86, range: 0–24). Data logging was collected for 78 out of 129 participants. The average data logging values equaled 10.94 hr (SD = 5.38, range: 0.06–23.5). Correlations among parent report and self-report (r = .83), parent report and data logging (r = .66), and self-report and data logging (r = .72) were significant (all ps < .001; see Figure 2).

Figure 1.

Box plot of the amount of hearing aid use based on adolescent self-report, parent report, and data logging. The central lines represent the median values, and the box limits are the 25th and 75th percentiles. The lower fence is from the 10th to 25th percentile, and the upper fence is from the 75th to 90th percentile. HA = hearing aid.

Figure 2.

Daily hearing aid time as recorded with data logging (x-axis) and reported by adolescents and parents (y-axis). The pink line represents the regression line for parent report and data logging, and the green line represents the regression line for adolescent self-report and data logging. HA = hearing aid.

Based on data logging, we calculated the percentage of participants who were routine hearing aid users versus limited hearing aid users. Routine use was defined as 8 hr or more per day and limited use was defined as 4 hr or less per day, to be consistent with prior results with the same cohort of children during early childhood (Walker et al., 2015). Seventy-three percent (n = 57/78) met our arbitrary criteria for routine hearing aid users, and 15% (n = 12/78) were designated as limited hearing aid users. Similar percentages were obtained when we calculated adolescent self-report of hearing aid use instead of data logging (72% and 16%, respectively).

Situational Ratings of Hearing Aid Use

Figure 3 displays the frequency of ratings (never to always) for hearing aid use across nine different listening environments (school, public, recreation, car, sports, mealtime, after school, job, and in quiet). The “not applicable” responses were excluded from the figure (job n = 22, sports n = 3, car n = 1). The frequency of “always” responses ranged from 85.5% (106/124) at school to 44.7% (55/123) when alone/quiet. Approximately one fifth of the participants reported they never wore their hearing aids during sports and extracurricular activities (19%, 23/121) and when alone/quiet (18.7%, 23/123). Notably, there was overlap in these situational ratings with the teenagers who were designated as limited hearing aid users based on data logging, where 83% (n = 10/12) of the limited hearing aid users indicated they never or rarely wore hearing aids during sports and extracurriculars or when they were alone. In contrast, over 90% of adolescents designated as routine hearing aid users indicated they always, often, or sometimes wore hearing aids during sports, extracurriculars, and when they were alone (see Table 2 for a comparison of situational ratings for sports/extracurriculars and alone/quiet between limited and routine hearing aid users, based on data logging).

Figure 3.

Adolescent self-report ratings for consistency of hearing aid use across different situations.

Table 2.

Comparison of situational ratings for sports/extracurricular activities and alone/quiet between limited and routine hearing aid users based on data logging.

Hearing aid use category	Sports/extracurricular activities		Alone/quiet
	Always/often/sometimes	Never/rarely	Always/often/sometimes	Never/rarely
Limited hearing aid users based on data logging (n = 12)	17% (n = 2/12)	83% (n = 10/12)	17% (n = 2/12)	83% (n = 10/12)
Routine hearing aid users based on data logging (n = 57)	91% (n = 52/57)	9% (n = 5/57)	91% (n = 52/57)	9% (n = 5/57)

Research Question 3: What Variables Predict the Amount of Daily Hearing Aid Use in Adolescents Who Are D/HH?

Because self-report, parent report, and data logging measures were highly correlated with one another and we had the most data with self-report measures, we used self-report of hearing aid use as the dependent variable in the regression model to determine factors that were associated with variation in hearing aid use. Table 3 shows descriptive statistics summarizing the independent variables in the analysis.

Table 3.

Summary of descriptive statistics for regression analysis.

Variable	M	SD	Mdn	Min	Max	n
Chronological age (years)	15.90	1.97	15.33	12.31	19.24	129
BEPTA (dB HL)	48.22	15.53	49.38	16.25	90.00	128
Age at HA fitting (months)	22.85	25.52	7.00	1.00	120.00	129
RMSE (dB SPL)	6.08	4.84	4.90	0.71	32.50	95
Self-report daily HA use (hr)	11.35	5.69	14.00	0.00	24.00	127

Note. BEPTA = better ear pure-tone average; HA = hearing aid; RMSE = root-mean-square error.

The linear regression model resulted in an R² value of .29, indicating that the independent variables (chronological age, age at hearing aid fitting, maternal education level, BEPTA, and RMSE) accounted for approximately 29% of the variance in hearing aid use (R = .54, R² = .289, p < .001). BEPTA (p < .001) and maternal education level (p = .003) had statistically significant effects on hearing aid use after accounting for other variables. Children with higher thresholds and higher maternal education levels tended to wear hearing aids more hours per day than children with lower thresholds and lower maternal education levels. Chronological age, age at hearing aid fitting, and RMSE did not have a statistically significant impact on hearing aid use. Table 4 provides the summary statistics for the linear regression model for self-reported daily hearing aid use.

Table 4.

Summary of linear regression analysis for self-reported daily hearing aid use.

Predictor variables	B	B (SE)	t	p
Chronological age	0.065	0.237	0.276	.783
Maternal education level	1.688	0.552	3.060	.003*
Age at hearing aid fitting	−0.024	0.022	−1.125	.264
Better ear pure-tone average	0.138	0.033	4.201	< .001*
Root-mean-square error	−0.088	0.097	−0.908	.367

Note. B = unstandardized coefficient; B (SE) = unstandardized coefficient standard error.

^*Significance with α = .05.

In addition to conducting a regression analysis, we also examined the effects of sex, IEP/504 status, BEPTA, maternal education levels, and RMSE category on hearing aid use separately as categorical variables (see Table 5). There was no significant differences in hearing aid use between males (M = 11.27, SD = 5.73) and females (M = 11.47, SD = 5.69), t(125) = −0.194, p = .846, or participants who had an IEP/504 plan (M = 11.80, SD = 5.47) compared to those who did not (M = 10.45, SD = 6.08), t(125) = −1.257, p = .211. Our metric for optimality of hearing aid fitting, RMSE, was separated into three categories: adolescents with RMSE of < 3, 3–5, or > 5 dB SPL. The ANOVA was not significant, F(2, 92) = 0.270, p = .76, partial η² = .006, indicating that proximity of hearing aid fitting to prescriptive targets did not impact hearing aid use time in adolescents. The results from the ANOVA are consistent with the linear regression analysis that also did not show a significant effect of RMSE on hearing aid use.

Table 5.

Summary statistics for t tests and analyses of variance comparing self-reported hearing aid use (in hours) by sex, individual education plan (IEP)/504 status, severity of hearing loss, maternal education level, or root-mean-square error.

Sex	Male (n = 72)	Female (n = 55)		t statistic	p
M	11.27	11.47		−0.194	.846
SD	5.73	5.69
IEP/504 status	Has IEP/504 plan (n = 85)	No IEP/504 plan (n = 42)		t statistic	p
M	11.80	10.45		−1.257	.211
SD	5.47	6.08
Root-mean-square error	< 3 dB SPL ( n = 22)	3–5 dB SPL ( n = 28)	> 5 dB SPL ( n = 45)	F statistic	p
M	11.90	12.79	12.00	0.27	.764
SD	5.36	4.61	5.11
Severity of hearing loss (HL)	Mild HL ( n = 37)	Moderate HL ( n = 65)	Severe–profound HL ( n = 24)	F statistic	p
M	6.89	12.69	14.74	23.58	< .001
SD	6.06	4.50	3.77
Maternal education level	Some college or less ( n = 44)	College degree ( n = 40)	Postgraduate (n = 43)	F statistic	p
M	9.57	13.17	11.48	4.44	.014
SD	6.13	3.88	6.18

For degree of hearing loss, participants were separated into three groups: mild hearing loss (BEPTA = 16.25–40 dB HL), moderate hearing loss (BEPTA = 41–60 dB HL), and moderately severe–profound hearing loss (BEPTA = 61 dB HL or greater). An ANOVA was significant, F(2, 123) = 23.58, p < .001, partial η² = .277. Pairwise comparisons adjusted for multiple comparisons indicated that children with mild hearing loss showed significantly lower amounts of hearing aid use compared to children with moderate and severe–profound hearing loss (all ps < .001). There was no significant difference between children with moderate or severe–profound hearing loss (p = .25). Figure 4 displays the mean and median values for self-reported hours of use as a function of degree of hearing loss.

Figure 4.

Box plot of hearing aid use based on adolescent self-report by degree of hearing loss. The central lines represent the median values, the black dots are the mean values, and the box limits are the 25th and 75th percentiles. The lower fence is from the 10th to 25th percentile, and the upper fence is from the 75th to 90th percentile. HA = hearing aid.

Maternal education level was separated into three categories: some college or less, college degree, or some graduate school or more. The ANOVA was significant, F(2, 124) = 4.44, p = .014, partial η² = .067. Follow-up tests indicated significantly lower hearing aid use in adolescents who had mothers with some college or less compared to mothers with college degrees (p = .01) but no differences between some college or less and graduate school (p = .33) and college degrees and graduate school (p = .50). Figure 5 displays the mean and median values for self-reported hours of use as a function of maternal education level.

Figure 5.

Box plot of hearing aid use based on adolescent self-report by maternal education level category. The central lines represent the median values, the black dots are the mean values, and the box limits are the 25th and 75th percentiles. The lower fence is from the 10th to 25th percentile, and the upper fence is from the 75th to 90th percentile. HA = hearing aid.

Our metric for optimality of hearing aid fitting, RMSE, was separated into three categories: adolescents with RMSE of < 3, 3–5, or > 5 dB SPL. The ANOVA was not significant, F(2, 92) = 0.270, p = .76, partial η² = .006, indicating that proximity of hearing aid fitting to prescriptive targets did not impact hearing aid use time in adolescents. The results from the ANOVA are consistent with the linear regression analysis that also did not show a significant effect of RMSE on hearing aid use.

Research Question 4: What Are the Benefits and Challenges With Hearing Aids From the Perspective of Adolescents Who Wear Them?

We examined adolescents' responses from four open-ended questions from the hearing aid use questionnaire. As described in the Method section, we used an inductive thematic process to generate codes for the data. The first question asked the participant to describe any situations where they felt they particularly benefited from their hearing aids. One hundred nineteen of the adolescents answered this question. We classified the responses into eight categories based on trends in responses: (a) always, (b) conversations with others or hanging out with friends, (c) at school/work/extracurricular activities (e.g., sports, church), (d) connectivity (e.g., listening to music or talking on the phone), (e) in quiet settings, (f) in noisy settings, (g) no benefit, or (h) other. Data are presented descriptively as a percentage of responses (number of responses per category/total number of responses). Some respondents reported on several situations where they benefited; these answers were classified across multiple categories; thus, the number of responses is greater than the number of participants who answered the question.

The most frequent response included school, work, and/or during extracurricular activities (31%, n = 44/141). One student noted: “Because I have hearing aids, I feel that even after a long day of learning, my hearing fatigue is much more minimal than if I were not to wear them.” The second most common response was during conversations or when talking with friends. Eighteen percent (n = 26/141) of respondents indicated that hearing aids were beneficial in these contexts. Examples of these responses include “In every conversation” and “Any situation where I talk to others.” For the other categories, 13% (n = 19/141) stated they benefited in noisy situations, 12% (n = 17/141) stated that they benefited from their hearing aids all time, 6% (n = 9/141) indicated benefit in situations where they used the connectivity features such as streaming music or talking on their cell phone, and 1% (n = 2/141) noted quiet locations like the library. Only 2% (n = 3/141) reported that they never benefited from their hearing aids or were unsure of a situation that was beneficial. Twenty-one adolescents provided responses that were vague or did not specifically answer the question, for example, “I feel like if I did not have hearing aids that it would be very hard for me to focus, so I love being able to have the benefits of hearing aids,” “Yes, they help me in multiple ways,” or “My life depends on me hearing really.”

The second open-ended question asked the adolescents to identify challenging times or situations when they preferred not to wear their hearing aids. One hundred eighteen participants responded to this question. There was also a follow-up question asking how they dealt with those challenging situations. Responses were classified in the following categories: (a) loud situations (e.g., concerts, noisy restaurants); (b) sleeping; (c) risk of loss or damage (e.g., water, weather); (d) sports or physical activity; (e) at home or on the weekends; (f) when they are feeling anxious, overstimulated, or are seeking quiet; (g) never; and (h) other. The most frequent response was situations where there were loud noises like concerts, band, construction, or fireworks. Twenty-nine percent (n = 39/134) indicated that they preferred not to wear their hearing aids in these contexts, for example, “Sometimes in a crowded event where I know I don't have to listen much.” The second most frequent response was “never”; 28% (n = 38/134) indicated that there were no situations that were challenging or that they did not want to wear their hearing aids. Some of these responses demonstrated the positive attitudes that some of the teenagers had toward their hearing devices, such as “I always wear my hearing aids unless I HAVE to take them out.” The participants who indicated they never had challenges tended to have a moderate hearing loss or worse (average BEPTA = 54 dB HL). Eight percent (n = 11/134) indicated that they would take out their hearing aids when they felt anxious or needed it to be quiet. Examples of these comments included “I turn them down/off when too overstimulated/anxious” and “When I am sick, I like to take them out because it's more calm and quiet.” Other responses were categorized as situations where they could be lost or damaged by water or weather conditions (8%, n = 11/134), at home or on the weekends (6%, n = 8/134), during sports or physical activities (5%, n = 6/134), or when they were sleeping (5%, n = 6/134). Fifteen participants provided responses that were vague or did not fall into one of the more prevalent categories, such as listening to music/playing an instrument (n = 1) or wearing earbuds (n = 1). One student noted that they did not wear their hearing aids “in my 10th grade English class, but that is it.” Another student commented that they did not wear hearing aids at school due to bullying. When asked how they deal with challenging situations, 98 adolescents provided a response. The majority (63%, n = 62/98) said that they take their hearing aids out or turn the volume down. Twenty-three percent (n = 23/98) said that they still wear their hearing aids even in challenging situations.

The third question asked if there was something that bothered the participant about their hearing aids at home or at school and, if so, how did they typically handle that. One hundred eighteen adolescents answered the first part of this question. Responses were classified in six categories: (a) sound quality (e.g., feedback, background noise, or lack of clarity), (b) having to change or recharge batteries, (c) physical discomfort of wearing the hearing aids, (d) other people's attitudes about their hearing aids, (e) nothing, or (f) other. Again, some adolescents provided answers that could be categorized in more than one way. The most frequent answer by 60% of the participants (n = 73/122) was that nothing bothered them about their hearing aids. Some participants expanded on this response; for example, “No, it's normal life,” “Nope, I enjoy using my hearing aids,” or “Nothing bothers me when I'm at home or at school.” The participants who indicated nothing bothered them tended to be consistent hearing aid users (average self-reported use = 12 hr). The second most common response involved the sound quality of the hearing aids. Seventeen percent (n = 21/122) noted that feedback, background noise, or how they sounded in certain situations bothered them. For example, one teenager noted: “I stopped wearing them because during online learning/COVID it was hard to adjust because things sound different with them in. It was annoying to hear white noise sound of hearing aids at home in the quiet.” This participant had become a nonuser following the COVID-19 pandemic. Several students commented that their hearing aids squealed, which was uncomfortable. Having to get batteries or recharge batteries was noted as a problem by some adolescents (7%, n = 8/122). For example, one teen commented, “I recently got rechargeables, and it can be an issue when the battery goes out because I have to wait for them to charge. I do miss swapping my batteries on the spot, but it is also nice not having to carry them with me everywhere.” On the follow-up question of how they deal with this problem, this teen said, “I try to keep a charger in my pickup. Although, it would be nice to have an AirPods-like case.” Six adolescents (5%) made remarks about having to deal with other people's attitudes toward their hearing loss or hearing aids. For example, one teen noted, “Nothing really bothers me about it. Except when I am questioned about if I really have to wear my hearing aids because my hearing loss is not severe.” In the follow-up question, she said, “I usually will explain the type of loss that I have and help them to understand that I actually do need them.” Other teens made comments such as “I don't like when people treat me differently,” “Sometimes the attention and questions it brings,” and “Getting asked over and over about them.” These teens' responses to the follow-up questions reflect their determination to advocate for themselves: “I ask them to treat me the same,” “Answer most questions even if they don't make sense,” and “Tell them they are hearing aids.” Five adolescents (4%) commented on the physical discomforts of daily hearing aid use, with responses like “They do get itchy rarely,” and “At one point they hurt because they were pushing on a pimple in my ear.” Nine adolescents provided responses that were vague or did not fit into other categories, such as “Losing them” or “When I go swimming with friends.”

At the end of the interview, we included an open-ended question that asked if there was anything else the participants wanted to say about their hearing aids. Ninety-nine of the participants responded to this question, and the majority (70%, n = 69/99) said they did not have anything additional to add. The 30 participants who did provide additional comments were evenly split into three groups of 10 teens each. One group had highly positive things to say about their hearing aids. Comments included that their hearing aids were “awesome,” “great,” or “I like them and do not like to be without them.” Another 10 participants made comments about features of their hearing aids, specifically relating to Bluetooth capabilities or having rechargeable batteries. For example, one teen commented, “These are my first Bluetooth hearing aids and I like them by far. The audio might go out of sync or pitch here and there, but that is easy to fix with a reset and I am overall satisfied with them.” The third group of 10 participants noted problems with the sound quality or the physical discomfort of wearing hearing aids, for example, “My right one is frustrating because it squeals A LOT.”

Discussion

It is commonly assumed that as children who are D/HH reach adolescence, hearing aid use will decline due to social pressures and a desire to hide their disability. To date, there are only a few empirical studies that support that assumption (Gustafson et al., 2015). Adolescents' attitudes toward hearing aids are also largely unknown. The primary goal of the current study was to characterize hearing aid use for adolescents who were between 12 and 19 years. To accomplish this goal, we queried a cohort of teenagers who had participated in a longitudinal study on outcomes of children with hearing loss since early childhood. In general, the results are inconsistent with the notion that adolescents decrease hearing aid use when they reach adolescence. Furthermore, the majority of adolescents who participated in this study expressed positive attitudes about amplification, demonstrating an acceptance of their hearing loss and emerging self-advocacy.

Research Question 1: How Many Hours and in What Contexts Do Adolescents Wear Hearing Aids on a Daily Basis Based on Parent Report, Their Own Self-Report, and Data Logging Measures?

Both adolescents and their parents completed questionnaires that asked them to estimate their average hours of hearing aid use per day. In addition, data logging was collected at the same research visits for 60% of the participants. Comparing the current hearing aid use data to data reported on this same cohort of participants at 5–9 years of age (Walker et al., 2015), descriptively we see a small increase in hearing aid data logging from 10.15 to 10.94 hr. The current data logging values are higher than the 6.6 hr reported by Flynn et al. (2022) with a different cohort of Swedish children; however, Flynn et al. collected data from a much smaller group of 14 adolescents who all had mild bilateral hearing loss. Given the consistent finding that children with milder degrees of hearing loss wear hearing aids less often that children with more severe hearing loss, this discrepancy is not surprising.

We can also compare the percentage of routine hearing aid users (defined as 8 hr or more per day) in Walker et al. (2015) and the current study. This percentage remained quite similar: 75% of the 108 school-age children in Walker et al. (2015) used hearing aids consistently compared to 73% in the current study. However, the percentage of limited hearing aid users (defined as less than 4 hr per day) did increase from 4% to 15%. Thus, while the percentage of routine hearing aid users appears to have remained the same nearly 10 years later, the number of adolescents who wore their hearing aids infrequently rose, although it remains a small proportion of the total cohort of participants. All participants who fell into the “limited” user group had thresholds in the mild–moderate range (BEPTA range: 21–50 dB HL), suggesting that hearing levels may have been driving this increase in limited use. In addition, nearly all the limited users commented in the open-ended questions that loud, noisy situations were challenging for them, and they would often remove their hearing aids when they encountered situations that were noisy. Listening in background noise is one of the major complaints of adult hearing aid users (Gygi & Hall, 2016), although recent advances in signal processing (e.g., directional microphones and noise reduction algorithms) have shown improvements in speech understanding in noise with age-related hearing loss (Morvan et al., 2024). An important future direction of research is to investigate variables that contribute to the effective management of childhood hearing loss while also developing and testing novel hearing aid fitting strategies and processing algorithms for children.

The current pattern of results can be contrasted with the findings by Gustafson et al. (2015), who reported that only 42% of fifth through seventh graders were observed wearing hearing aids consistently at school. Gustafson et al.'s results may have been limited by the small sample size of 19 children, compared to the larger sample size in the current study. There also were limitations in their approach to measuring hearing aid use, which involved documenting whether hearing aids were on or off during four classroom observations over 2 days, rather than using data logging, which would provide a more nuanced picture of device use.

Research Question 2: Is Hearing Aid Use Measured via Parent Report and Adolescent Self-Report Associated With Data Logging?

Based on a number of previous studies that have compared parent report of hearing aid use to data logging (Flynn et al., 2022; Gustafson et al., 2015; Muñoz et al., 2014; Walker et al., 2013, 2015), we expected to see a strong and significant correlation between the two metrics. Our results were consistent with our predictions: Both parent report and self-report measures were highly associated with data logging, suggesting that both parents and adolescents are reliable reporters of average hearing aid use. There continues to be a tendency to overestimate hearing aid use, as data logging values were consistently lower than parent report or self-report measures. Unlike prior reports (Flynn et al., 2022), we found a higher correlation between self-report measures and data logging (r = .72) than parent report measures (r = .66). This small difference may be attributed to the older ages of the participants in the current study compared to Flynn et al. It seems plausible that children would become more reliable reporters of the amount of time they wear hearing aids as they get older and are better able to estimate daily use. Similar to the findings in Gustafson et al. (2015), we did see that the correlation between parent report measures and data logging decreased with increasing age of our cohort. In our prior work when this same cohort was on average 3 years old, we found a correlation of .76 between parent report and data logging (Walker et al., 2013). The current results showed a correlation of .66—still highly correlated but less so than when the children were much younger and parents had more control over their device use and more knowledge about what their children were doing throughout the day. This finding that adolescents had a better sense of how often they are using their devices than their parents may have clinical implications for audiologists who work with teenagers. Given that adolescents are reaching a point in their lives where they will be transitioning into adulthood, it may be beneficial for both the audiologist and the pediatric client to begin discussing self-management of personal audiological health care (English & Pajevic, 2016). Such discussions would facilitate the transition from pediatric and family-centered care to adult-level services and would allow teenagers to take a more active role in their own health care.

Research Question 3: What Variables Predict the Amount of Daily Hearing Aid Use in Adolescents Who Are D/HH?

Severity of hearing loss and maternal education level (as a proxy for socioeconomic status) were the two variables that accounted for a unique and significant proportion of variance in hearing aid use in adolescents. These findings align with our predictions and with much of the previous research on factors that drive individual differences in hearing aid use (Caballero et al., 2017; Dammeyer et al., 2017; Gustafson et al., 2015; Marnane & Ching, 2015; Marttila & Karikoski, 2006; Moeller et al., 2009; Muñoz et al., 2013, 2014; Walker et al., 2013, 2015). With regard to the impact of severity of hearing loss, teenagers with hearing loss in the mild range may be able to get by in different situations without having to wear hearing aids, although the impact of reduced or inconsistent hearing aid use on daily activities and participation during adolescence is largely unknown. Extant literature suggests that limited hearing aid use in children with mild hearing loss can lead to deficits in early language acquisition (Walker et al., 2015); however, there is also evidence to suggest that children who have unaided audibility levels of at least .80 or higher may not need amplification to reach age-appropriate language levels (McCreery et al., 2020). As children get older and are better able to use top-down skills to fill in the gaps of unclear or inaudible input, it is possible that they can perceive a message without having to rely on additional cognitive resources. On the other hand, not wearing hearing aids, particularly in poor acoustic conditions, could result in increased fatigue, listening effort, and alterations in the neural dynamics of the brain (Heinrichs-Graham et al., 2022). Additional research is needed to understand the implications of hearing aid nonuse in teenagers with any degree of hearing loss.

Even after controlling for the effects of hearing loss severity, we continue to see an impact of maternal education level on hearing aid use in teenagers. Teenagers who have mothers with less education wear hearing aids less often than teens with mothers who have higher education levels. This persistent trend is likely due to barriers that families from lower socioeconomic backgrounds encounter when accessing hearing health care. There is a plethora of literature documenting health disparities and health inequalities for less advantaged social groups, including in the domain of pediatric hearing loss (for reviews, see Bush et al., 2017; Cadieux et al., 2024; Kingsbury et al., 2022). These barriers are due to both patient-level and system-level factors, such as rurality and distance to diagnostic centers, insurance coverage, and access to qualified professionals. There is a need for more education and research on the impact of social drivers of health on pediatric audiology to foster health equity at both the macro- and microlevels of service delivery.

Research Question 4: What Are the Benefits and Challenges With Hearing Aids From the Adolescents' Perspective?

To our knowledge, this is one of the first studies to ask adolescents who are D/HH to describe their own perspectives about using amplification. All the participants in the study had been identified with hearing loss by 7 years of age and therefore had grown up with some degree of permanent hearing loss since early childhood. Many participants who answered the open-ended questions identified benefits from wearing hearing aids, whereas only a small percentage (2% or three teenagers) said they never benefited or could not identify any benefits. Conversely, more than half of the participants reported that nothing bothered them about their hearing aids, and almost one third reported that they experienced no challenges. The participants who indicated that nothing bothered them about their hearing aids and experienced no challenges tended to have hearing levels in the moderate or worse range, again highlighting how severity of hearing loss may impact attitudes toward hearing aids. Taken together, most of the adolescents' responses indicate positive attitudes about wearing hearing aids and, in some cases, feelings of pride, self-efficacy, and self-advocacy about their hearing loss. These findings may explain, in part, why so many of the participants wore their devices consistently. We can also compare the current results to an older study by Punch and Hyde (2011), in which they conducted semistructured interviews with adolescents who used cochlear implants. Punch and Hyde reported that adolescents felt self-conscious about their external cochlear implant equipment in the interviews. Six of the adolescents in the current study noted that other people's attitudes toward their hearing aids bothered them, suggesting that self-consciousness about amplification still exists among some of the participants. Teens who are D/HH may benefit from structured support focused on self-advocacy and social–emotional counseling provided during aural habilitation or other clinical services.

Limitations and Future Directions

One significant limitation in the current study is the lack of diversity in the cohort of participants. Around 87% of the adolescents were White/non-Hispanic or Latino. The remaining 13% varied in racial and ethnic backgrounds (Black, Asian, Native American, Hispanic or Latino, or mixed racial background). All participants used spoken English as their primary mode of communication. This limited racial, cultural, and linguistic diversity prevented an in-depth exploration into the impact of social drivers of health on hearing aid use (Cadieux et al., 2024), which is a critical question to address in today's society. Two recent studies showed that young children from families of limited English proficiency have less hearing aid use than families who are English proficient and share a common language with their audiologist (Brigham et al., 2024; Wiseman et al., 2025). Because the participants relied on spoken language to communicate, we were also unable to investigate device use and attitudes about hearing aids among adolescents who sign and identify with Deaf culture. Given the importance of providing culturally and linguistically responsive practices among audiologists and speech-language pathologists, future studies on hearing aid use and attitudes about hearing aids in adolescents from diverse backgrounds are highly warranted.

One approach to addressing the lack of diversity in longitudinal research is through community-based participatory research (CBPR; Marrone et al., 2022). CBPR studies involve community members at all stages of the research process, including development of research questions, recruitment and testing procedures, and dissemination (Ingram et al., 2016; Marrone et al., 2021; Warren et al., 2024). There are few instances of CBPR in the pediatric hearing loss literature; however, one recent example, the Hearing Norton Sound Project (Robler et al., 2020), involved a community-based randomized trial to improve EHDI in rural Alaska. Through the use of CBPR, the researchers were able to recruit and retain a cohort of children from rural Alaska Native communities and demonstrate the effectiveness of a telemedicine model for school-based hearing screenings (Emmett et al., 2022; Robler et al., 2023). Based on the results of the Hearing Norton Sound Project and other studies, CBPR approaches may be a promising direction to advance the inclusion of racially, linguistically, and ethnically minoritized populations in pediatric hearing health care research and address the need to examine hearing loss management in more diverse samples (Girolamo et al., 2023; Pittman et al., 2021).

Although there are substantial benefits in conducting observational longitudinal studies (e.g., tracking change over time, determining causal relationships), it is also critical to acknowledge the inherent limitations of such research, particularly the potential for sample or participation bias. For example, families and children who chose to participate in a longitudinal study for over a decade may have a greater interest in engaging in research than families who did not volunteer to participate. There is also the possibility of a “Hawthorne effect,” when research participants begin to act differently because they know they are part of a study. In both cases, the end result could be more consistent hearing aid use and more positive attitudes about amplification for the children who have participated in the study than the children who have not. It is difficult to determine at this stage whether the teens in this study altered their behavior due to their participation, or whether families who agreed to participate and remained engaged in the study are fundamentally different in their approach to hearing health care than families who did not. Given the dearth of research on device use and perceptions of hearing technology for adolescents who are D/HH, however, we hope that the current study will serve as a starting point for new investigations in this population, which could include cross-sectional designs or qualitative interviews that address factors related to a Hawthorne effect (Rezk et al., 2021).

A third limitation of this study is that we did not collect data on participants' perspectives of their device use when they were younger and we did not ask parents about their own attitudes regarding hearing aids. It could be useful to obtain such information, as it may provide better insight into when children begin developing self-determination and self-advocacy skills regarding their hearing loss and hearing aid use.

Conclusions

The current study characterized hearing aid use in a large cohort of adolescents who are D/HH. On average, adolescents wore hearing aids during most waking hours (~11 hr per day), and the majority were routine hearing aid users. Around 15% wore hearing aids minimally. Parent report and adolescent self-report of hearing aid use was significantly correlated with data logging, although both parents and teens tended to overreport hearing aid use. Adolescents with greater degrees of hearing loss and adolescents from higher socioeconomic backgrounds wore hearing aids more often than adolescents with less severe hearing loss and adolescents from less advantaged backgrounds. Teenagers noted both benefits and challenges with wearing hearing aids and also expressed self-efficacy and self-advocacy about their hearing loss.

Data Availability Statement

The data sets generated and/or analyzed during this study are available from the corresponding author upon reasonable request.

Appendix A

Checklist for Hearing Aid and Remote Microphone: Parent Version

Subject #: ____________________ D.O.B. _____________ Date Completed: ____________

1. Does your child use one hearing aid or two?  ☐ 1  ☐ 2

2. Does your child use different hearing aids at home and at school?  ☐ Yes  ☐ No

3. During the school year, how many hours a day does your child wear the hearing aid(s)?

      Monday–Friday _________     Saturday–Sunday ________

4. During the summer, how many hours a day does your child wear the hearing aid(s)?

      Monday–Friday _________     Saturday–Sunday ________

Put an X in the boxes below to indicate how consistently your child uses hearing aids in the situations listed:

Situation	Never (0)	Rare (1)	Sometimes (2)	Often (3)	Always (4)	N/A
5. Car
6. School
7. After school
8. Meal time
9. Recreation with friends
10. Sports/extracurricular
11. Quiet/alone time
12. Job (after-school or summer)
13. Public (store, zoo, restaurant)

• 14.  Describe any situations when your child does not typically wear the hearing aid (not covered above). ________________________________________________________________________

• 15.  Describe any situations where you see your child particularly benefit from their hearing aid(s). _________________________________________________________________________

• 16.  Are there any challenging times or situations where your child prefers NOT to wear the hearing aid(s)? ______________________________________________________________________________

• 17.  If so, how do you typically handle this? _____________________________________________________________________

• 18.  Is there anything that bothers your child about using hearing aids at home or at school? ______________________________________________________________________________

• 19.  If so, how do you typically handle this? ________________________________________________

• 20.  Has your child been without her/his hearing aid(s) for an extended period of time (> 7 days) in the past year?  ____ Yes  ____ No

• 21.  If yes, please estimate how long your child was without hearing aid(s)

  •   _____ 8–14 days  _____ 15–21 days  _____ 22–30 days  _____ 1–2 months

  •   _____ 2–3 months  _____ 3–6 months  _____ 6–12 months  _____ > 12 months

• 22.  Were one or both ears affected?  ____ One ear  ____ Both ears

• 23.  What prevented your child from wearing her/his hearing aid(s)? (Choose all that apply)

  •   _____ Ear infection

  •   _____ Ear pain (ex: swimmer's ear, sore spot in ear)

  •   _____ Hearing aids were damaged and needed repair

  •   _____ Hearing aids were lost and needed replacement

  •   _____ Earmolds needed to be replaced due to loss, damage, or child's growth

  •   _____ Other (Please specify) ________________________________________________________

Anything else we should know about your child's hearing aids? ______________________________________________________

Appendix B

Checklist for Hearing Aid and Remote Microphone: Student Version

Subject #: ____________________ D.O.B. _____________ Date Completed: ____________

1. During the school year, how many hours a day do you wear your hearing aid(s)?

     Monday–Friday _________     Saturday–Sunday ________

2. During the summer, how many hours a day do you wear your hearing aid(s)?

     Monday–Friday _________     Saturday–Sunday ________

Put an X in the boxes below to indicate how consistently you use your hearing aids in the situations listed:

Situation	Never (0)	Rare (1)	Sometimes (2)	Often (3)	Always (4)	N/A
3. Car
4. School
5. After school
6. Meal time
7. Recreation with friends
8. Sports/extracurricular
9. Quiet/alone time
10. Job (after-school or summer)
11. Public (store, zoo, restaurant)

• 12.  Describe any other situations when you do not typically wear your hearing aid(s) (not covered above). ________________________________________________________________________

• 13.  Describe any situations where you feel you particularly benefit from your hearing aid(s). _________________________________________________________________________

• 14.  Are there any challenging times or situations where you prefer NOT to wear your hearing aid(s)? ______________________________________________________________________________

• 15.  If so, what do you do in these situations? ______________________________________________________________________________

• 16.  Is there anything that bothers you about using hearing aids at home or at school? ______________________________________________________________________________

• 17.  If so, how do you typically handle this? ________________________________________________

• 18.  Have you been without your hearing aid(s) for an extended period of time (> 7 days) in the past year?  ____ Yes  ____ No

• 19.  If yes, please estimate how long you were without hearing aid(s)

  •   _____ 8–14 days  _____ 15–21 days  _____ 22–30 days  _____1–2 months

  •   _____ 2–3 months  _____ 3–6 months  _____ 6–12 months  _____ > 12 months

• 20.  Were one or both ears affected?     _____ One ear     _____ Both ears

• 21.  What prevented you from wearing your hearing aid(s)? (Choose all that apply)

  •   _____ Ear infection

  •   _____ Ear pain (ex: swimmer's ear, sore spot in ear)

  •   _____ Hearing aids were damaged and needed repair

  •   _____ Hearing aids were lost and needed replacement

  •   _____ Earmolds needed to be replaced due to loss, damage, or my growth

  •   _____ Other (Please specify) ________________________________________________________

• 22.  Anything else we should know about your hearing aids? ______________________________________________________________________________

Publisher Note: This article is part of the Forum: Changemakers Igniting Innovation.

Funding Statement

This work was supported by National Institute on Deafness and Other Communication Disorders (NIDCD) Grant R01 DC019081 (Principal Investigator: Elizabeth A. Walker). The content of this project is solely the responsibility of the authors and does not necessarily represent the official views of the NIDCD or the NIH.