leading to confusion among the public, the profession and third-party payers. Through the years there have been various squabbles, so to speak, about what the identifying term should be. Some terminology examples include aural rehabilitation, rehabilitative audiology, auditory rehabilitation, audiologic rehabilitation, lipreading, speechreading, auditory training, and hearing therapy. Titles of textbooks, journal articles, and professional presentations verify this lack of agreement.

It was not until World War II when a military aural rehabilitation program was started that the term audiology came into existence. At that point in history, audiology was defined by the Veterans Administration (VA) (Newby, 1964). The VA defined an audiologist as one concerned with the assessment of hearing as well as habilitation and rehabilitation of children and adults with hearing impairment. Even at that time, there was concern about the lack of audiologists to provide services in aural rehabilitation. At the same time, there appeared to be a division between educational services and the provision of audiology services for individuals with hearing impairment. There also was concern about emphasis on audiology diagnostic services rather than on aural rehabilitation. Despite this, the term aural rehabilitation continued to be used widely to describe a process distinct from diagnostic audiology. (Editor’s note: For further information about the terminology of AR, the reader is referred to Chapter 2 of this text.)

The American Speech-Language-Hearing Association (1984) defined aural rehabilitation as referring to “services and procedures for facilitating receptive and expressive communication in individuals with hearing impairment. These services and procedures are intended for those persons who demonstrate a loss of hearing sensitivity” (p. 1). This definition is not so much what aural rehabilitation is but refers more to the procedures performed. the American Speech-Language-Hearing Association then describes specific procedures that can be found in the guidelines. The main categories are (a) identification and evaluation of sensory capabilities; (b) interpretation of results, counseling, and referral; (c) intervention for communication difficulties; (d) reevaluation of the client’s status; and (e) evaluation and modification of the intervention program.

One major reason for describing procedures as well as training requirements for aural rehabilitation is the interdisciplinary nature of the field whereby speech-language pathologists can perform these activities without a Certificate of Clinical Certification in Audiology (CCC-A) or an audiology license. In fact, there are some Medicare and third-party payer guidelines that will only reimburse speech-language pathologists, not audiologists, for services typically considered under the rubric of aural rehabilitation (e.g., speechreading). In some ways, audiologists see this as a turf battle in which another profession has co-opted part of their scope of practice without the requisite training. It could be argued that if the process were called “audiologic rehabilitation,” it might be more clearly seen as requiring the expertise of an audiologist. (Editor’s note: For more information on defining AR and reimbursement issues, the reader is referred to Chapter 2.)

Further confusion has arisen with the various titles used by professionals engaged in rehabilitation with adults with hearing loss. For example, many professionals want to be called audiologists as an umbrella title that encompasses the entire scope of practice including aural rehabilitation. Others have preferred to use an adjective that specifies his/her primary expertise in the profession such as “rehabilitation audiologist” or “diagnostic audiologist.” These terms typically have no basis in credentialing. Furthermore, insurance companies are more apt to reimburse when procedures are listed and the professional has certain credentials.

Terminology also can be confusing to the public and raises some interesting questions. Does aural rehabilitation include deaf individuals who might use sign language as their primary mode of communication? Do some persons hear the word oral (for aural) and think of a dentist? Does the consumer with hearing loss even know what the term aural rehabilitation encompasses? One speech and hearing clinic ran an advertisement in a newspaper indicating that it provided speechreading therapy. A respondent to the ad called to request an appointment for a class in speed-reading. To a certain degree, terminology has caused somewhat of an identity crisis!

While there is no right answer as to what the process should be correctly called, audiologists in the 21st century are increasingly using the term audiologic rehabilitation. This term gives ownership to the profession of audiology and encompasses the vast scope of the rehabilitation process. Audiologists have an extensive armamentarium of knowledge, skills, and tools that prepare them to engage successfully in the rehabilitation process. As discussed throughout this textbook, the rehabilitation process does not begin and end with surgery (e.g., cochlear implants, implantable hearing aids, etc.) or the dispensing of amplification (e.g., hearing aids, hearing assistive technology, etc.). As such, we strongly suggest use of the term audiologic rehabilitation in current practice.

From the Ear Trumpet to Lipreading (Early Origins)

In our technosophisticated world, the idea of using ear trumpets as amplification is archaic and amusing. Yet ear trumpets were creative developments to increase speech intensity initially used by sailors and others who needed to communicate at distances. Ear trumpets were later used to help persons with hearing impairment communicate better. One of the earliest descriptions of ear trumpets (Figure 1–2) was by Jean Leurechon in his 1624 book, Recreation Mathematique.

Ear trumpets were generally custom made, and their use as hearing aids began around 1800 (Berger, 1984.) Hearing aid trumpet styles and prices varied, as did the rate of success by the user. (It is interesting that the same could be said of hearing aids in the 21st century!) Technology in the 17th century was even of concern in the development of the ear trumpet. Robert Hooke in 1668 worked toward improving hearing by developing a glass receiver, which produced stronger sound (Berger, 1984). He also produced two receivers: one which was latten, and conical in nature; the other of glass and round. Both were sharp at one end. The former produced a stronger sound. It appears that, starting with ear trumpets, amplification became a significant factor in helping individuals with hearing impairment.

Even before the emergence of ear trumpet amplification, lipreading played an important role in the rehabilitation and education of individuals with hearing loss. Lipreading was taught in various countries such as France, England, Germany, and Spain since at least the 17th century. Children and adults received instruction through both analytic and synthetic methods. The analytic approach emphasized the learning of individual sounds on the lips; the synthetic approach had a more broad-based communication orientation. Some of the prominent names in the development of these approaches include Bruhn (1955), Bunger (1961), Nitchie (1950), and the Kinzie sisters (1920). Electronic amplification technology did not exist in those days. Therefore, lipreading served as one of the only viable methods for teaching the “deaf and dumb” (Peet, 1851). For a comprehensive and fascinating review of lipreading the reader is referred to The Story of Lipreading by DeLand (1931).

While lipreading schools and teachers have become a thing of the past, the role of visual cues in communication cannot be underemphasized in adult AR in the 21st century. Best-practice hearing aid fitting protocols stress the synergistic benefits of bisensory stimulation that result from amplification and the use of visual cues in communication. (Editor’s note: In keeping with the authors’ discussion of consumers confusing terminology, the term lipreading is often used interchangeably with the term speechreading. While speechreading is meant to be more inclusive, both identifiers refer to visual communication. The reader is referred to Chapter 14 in this text for a review of the contemporary research related to lipreading and visual communication.)

World War II Era: Birth of Audiology

If they were still alive, those responsible for the creation of audiology as a profession might be chagrined that some 60 years later, audiologists have strayed a bit from our rehabilitative roots. Indeed, the profession was created in response to the needs of the World War II “aural casualties requiring rehabilitative measures” (Truex, 1944). In response to these needs, both the U.S. Army and Navy developed aural rehabilitation centers: three by the Army (Deshon, Borden, and Hoff General Hospitals) and one by the Navy (Philadelphia Naval Hospital) (Spencer, 1946; Truex, 1944). Raymond Carhart, the acknowledged father of audiology, served in the Army Medical Corps (1944–1946) as the director of the Acoustics Clinics in the Veterans Rehabilitation Center of Deshon General Hospital before beginning the first academic program in audiology at Northwestern University in 1947 (Olsen, Rose, & Hedgecock, 2003) (Figure 1–3).

The purpose of the “listening clinics” was to allow people to communicate effectively with others in their environment (Spencer, 1946). The rehabilitative process began with a hearing examination and fitting of the most satisfactory hearing instrument. But this was truly just the beginning of the 8-week process. An intense course of instruction was designed for each patient to reorient him to sounds transmitted by the hearing instrument. Use of the term reorient suggests an understanding that fitting the hearing aid was only the first step in the process. Special instruction involved cerebral reorientation to the auditory stimuli newly introduced with hearing aid use (Truex, 1944). The curriculum included daily individual and group lipreading instruction; counseling regarding personal, economic, or domestic problems; maintenance of contacts with the patient’s family; and bridging the gap between the veteran’s facility and civilian agencies and clinics that would provide follow-up rehabilitation post-discharge (Truex, 1944). The fact that a veteran with hearing impairment might need “additional rehabilitative measures” beyond the 8-week course is evidence that rehabilitative measures were respected and essential in the 1940s (Newby, 1964). Almost seven decades later, just a few hours, not weeks, of post-hearing aid fitting rehabilitation is standard.

Hearing aid satisfaction and outcome measurement were critical parts of the rehabilitation process. The Army and Navy programs administered satisfaction questionnaires and reported that “94% of the boys” were still using their hearing aids 3 months to 2 years post-fitting (Spencer, 1946). Captain Grant Fairbanks reported that more than 350 hearing aid prescriptions were possible with various combinations of microphones, receivers, amplifiers, and batteries. Yet there still were complaints like “I can hear everything in the room except the guy I’m trying to listen to” (Spencer, 1946), thus supporting the adage that the more things change, the more they stay the same.

Even in the 1940s, unrealistic hearing aid expectations were prevalent as some patients wanted “miracles from their hearing aids” (Spencer, 1946). Auditory training (“expertly supervised listening”) was designed to help patients adjust to electronic amplification and to improve sound perception and discrimination. Groups of six to 10 participated in Army and Navy listening clinics that provided a variety of sound experiences including phoneme discrimination tasks, music, radio programs, and speeches. Attention was also given to vocational/occupational issues presented by hearing loss. (Editor’s note: For more information on the stigma associated with hearing loss, the reader is referred to Chapter 4.)

Motivation for engaging in the rehabilitation process was an issue for these early military programs. To combat the pessimism and fatigue of soldiers and sailors with hearing impairment returning from World War II, some interesting motivational methods were employed. For example, an “orientation girl” was used to brief the new patient and because he could not “hear the bugle,” a “pretty WAC” would wake him in the morning. Furthermore, lipreading teachers were mostly women who were “easier to look at” and “vocally better groomed” (Spencer, 1946). Certainly, recognizing the role of motivation was laudable despite the rather sexist methods employed!

Compared to the rehabilitative processes offered in the 1940s, what new concepts or strategies have emerged in the past six decades? The aural rehabilitation centers designed by the Army and Navy addressed amplification, adjustment, and “cerebral reorientation” to hearing aids, motivation, expectations, self-assessment, auditory training, lipreading, counseling, family support, psychosocial and vocational issues, group sessions, and the need for follow-up rehabilitation. The new hearing aid user in the early 21st century who is receiving all of those services is indeed rare.

Post-World War II: Walter Reed Army Medical Center and Veterans Administration

The provision of AR services during and post-World War II established it as a priority for service personnel and veterans with hearing loss. Since that time, hearing loss has continued as a major health concern during both peace and war times. As such, many of the major trends in AR have emerged as the result of the efforts of the Veterans Administration (VA, currently the Department of Veterans Affairs) and the Walter Reed Army Medical Center (WRAMC). The VA established the largest hearing aid dispensing system in the United States and became the model for provision of diagnostic and rehabilitative services to eligible veterans with hearing loss. The WRAMC became the foremost center in the provision of audiologic rehabilitative services for active duty personnel and their dependents and emerged as the leading center for audiologic rehabilitative research. In the 21st century, these agencies continue to lead the way in research and development of rehabilitative technology, methods, amplification, service delivery, and outcome measurement.

“What’s Happening” in the 1960s

American adult AR was enhanced in 1966 with the emergence of the Academy of Rehabilitative Audiology (ARA). Prior to this time, there had been no major effort to establish a formal organization to emphasize the rehabilitation aspect of audiology. The name itself helped to institutionalize the concept of “audiologic” in lieu of “aural” rehabilitation.

The impetus for the development of the ARA came from a group of audiologists, led by John O’Neill and Herbert Oyer, who were concerned about the lack of interest in aural rehabilitation programs, including in the training of university students. As a result of this concern, the ARA was inaugurated in 1966 with assistance from the Federal Office of Vocational Rehabilitation in Washington, D.C. The purpose of the academy was to generate interest in AR and offer a mechanism for interest and participation in this area of the profession.

Interestingly, various issues that have faced AR since its inception mirror the activities of the ARA. There seemed to be turf concerns regarding the ownership of audiological rehabilitation between rehabilitation and clinical audiologists. To track the development of aural rehabilitation, the ARA approved a position for an archivist. In her role as archivist, Skalbeck (1984) provided a rationale for the transition of AR through the years by invoking Santayana’s warning that those who do not know history are destined to repeat it. She cautioned audiologists to review the past and plan for the future of AR.

Audiology continued to grow at a logarithmic pace during the years from 1966, particularly in the development of diagnostic techniques. Unfortunately, there appeared to be a continuing decline in interest related to the remediation aspects of audiology. Some colleagues even took a position that it was more important to test than to engage in AR. There seemed to be a widespread attitude that if rehabilitation was ignored, the use of diagnostic equipment and techniques would become more professional and valued. Surveys of audiology journals illustrated the trend of publishing many more diagnostic articles than rehabilitative.

4. The issues were complex and somewhat confusing regarding who would perform the various audiology procedures.

Even in the 1970s, audiologists were frustrated by adults with hearing loss who could improve their communication efforts via rehabilitation but chose not to do so. Based on their observations that adults with hearing loss frequently did not follow through with AR recommendations, Oyer et al. (1976) sought to determine some of the reasons for this lack of follow-up. A questionnaire was sent to 45 adults who had been evaluated and advised to participate in rehabilitation programs yet chose not to participate. A review of their results and insights into audiologic service delivery suggests their conclusions differ little from what we hear in the 21st century. Some examples include:

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