The Risks of Poor Programming for Low-Gain Hearing Aids

When we talk about low-gain hearing aids (LGHAs), the stakes might not seem high—no one dies from a bad programming session. But that doesn’t mean the risks are negligible, or that LGHAs should be treated as a one-size-fits-all commodity.

Despite growing interest in LGHAs, very few audiologists have deep experience fitting them for children or individuals with normal hearing thresholds who struggle with auditory processing. Even if a provider offers “low-gain programming,” it’s essential to check references and ask about their experience. These devices are the same powerful hearing aids used for hearing-impaired patients—the only difference is how they’re programmed.

“Low-gain” simply means reduced amplification. But beyond that, programming approaches vary widely. In fact, audiology forums are full of debate about what the “ideal” LGHA settings even are. There is no universal standard—just a growing need for expertise and caution.

Having pioneered this method myself, I built upon the early work of Dr. Francis Kuk at Widex, who began publishing about the use of low-gain hearing aids in 2009 and 2014. His clinical insights laid the foundation for this model, and over time I’ve refined it through direct feedback from more than 3,000 patients—many of whom had no measurable hearing loss but struggled profoundly with access to sound.

This type of work—fitting low-gain hearing aids specifically for children and adults with normal audiograms but disordered auditory processing—is still extremely rare in the field of audiology.

Most audiologists either focus on APD testing and auditory training without amplification, or they recommend FM systems, which are often funded through the school system and occasionally provided privately. A small number may offer low-gain hearing aids, but only as a supplement to traditional hearing loss fittings—not as a dedicated service.

Very few providers, if any, have built their entire clinical model around using low-gain hearing aids for central auditory dysfunction the way I have. This focus has allowed me to develop a level of depth and refinement in my programming that goes well beyond conventional protocols—because for my patients, this isn’t an add-on. It’s the foundation of their treatment.

The Harm of Poor Programming

Poorly programmed LGHAs can deliver output levels above 130 dB (per Phonak), which is well into the danger zone for noise-induced hearing loss. In some cases, overamplification has led to long-term sound sensitivity, tinnitus, and even hearing damage—especially in children.

On the other end of the spectrum, underamplification or poor physical fitting can be just as harmful. Early in my career, I worked under a supervisor who fit a young child with a mild hearing loss and clear signs of sound hypersensitivity. Instead of supporting his access to meaningful sound, she fit him with hearing aids that had completely occluding earmolds—no venting at all—and programmed them with such low gain that virtually no useful sound got through.

The result? His ears were physically sealed off from the outside world, but not meaningfully supported. The combination of blocked canals and minimal amplification created an unnatural, echoey, and overly silent soundscape—essentially placing him in a sensory deprivation chamber.

He didn’t just lose access to high frequencies or soft speech—he lost access to the foundational sounds of language itself. His hypersensitivity to sound wasn’t addressed; it was amplified through isolation.

He was functionally given more of a hearing loss by the very devices meant to help him. And worse, he lost a full year of auditory development—a year of missed speech cues, missed phonological input, and missed growth during a critical window of brain plasticity.

It’s no wonder he was behind in school and struggling with reading. He couldn’t hear the sounds of speech. And if you can’t hear the sounds, you can’t learn to decode them, blend them, or spell them. That one poorly informed fitting may have cost him years of catch-up work in both language and literacy.

When the Audiogram is Normal but the Access is Missing

That experience has stayed with me and permanently shaped how I program and fine-tune low-gain hearing aids today. I’ve since seen many similar cases—kids and adults who were unintentionally deprived of access, not because of their ears, but because of their equipment.

And here’s the part that most people miss: the children I work with now—those with auditory processing challenges—often have normal hearing on paper.

They can detect tones in a sound booth. But when it comes to understanding fast, messy, real-world speech—especially in noisy environments—they function very similarly to that child with a mild hearing loss.

They miss critical pieces of language. They struggle with phonics and reading. They get overwhelmed by sound, fatigued by listening, and often misunderstood by adults.

Their brains are not getting clean, consistent auditory input—and like that boy, they’re falling behind not because of a hearing loss on the audiogram, but because they cannot access the signal in a usable way.

Why Real Ear Isn’t Enough

In audiology, real ear measurements (REM) are often held up as the gold standard. And when you’re working with a typical peripheral sensorineural hearing loss, that’s absolutely appropriate.

But for children with normal audiograms and central auditory processing challenges, REM is not only insufficient—it can be misleading.

REM only measures gain at the eardrum. Not gain in the brain.

And for this population, hearing is not the problem—processing is. These children need better access to clarity, not just louder sound. They need predictability, tolerance, and reduced effort.

REM also fails to account for the many children with chronic otitis media, eustachian tube dysfunction, tympanic membrane scarring, or even Ehler’s Danlos (hypermobility type) syndrome and other connective tissue differences. It also does not consider differences in preference of volume or loudness intolerance differences common in neurodiversity.

And most importantly, there is no prescriptive target for this population. The children I serve are incredibly heterogeneous, neurologically and audiologically. One-size-fits-all approaches—especially those based on linear gain targets—don’t work here.

That’s why I rely on a combination of audiometry as well as in-situ thresholds, subjective listening effort, real-world feedback and functional hearing testing, fatigue tracking, and aided vs. unaided speech-in-noise performance. I frequently program in patients’ homes, schools, and places of recreation or work.

The goal isn’t to hit a graph. The goal is to give the brain something it can work with.

Why I Use Frequency Compression

Nonlinear frequency compression (NLFC) is typically used for high-frequency hearing loss, but I use it even in children with normal audiograms—especially those with auditory processing challenges, misophonia, hyperacusis, or suspected mild ANSD.

These children often miss fast or high-frequency consonants like /s/, /sh/, or /f/, not because they can’t hear them, but because their brains can’t decode them. Or worse, the signals are distorted and trigger aversion responses.

Frequency compression lets us gently remap those cues into a range where the brain can use them. I implement it conservatively—usually starting compression around 4500–6000 Hz—to maintain natural sound quality while improving intelligibility.

In doing so, I’ve seen considerable improvements in recognition of high-frequency speech sounds, understanding and expressive use of past tense and plurals, enhanced tolerance for previously painful or irritating sounds, reduced listening fatigue (as well as reduced overall fatigue), and less overall irritability and meltdowns from sound overload. In these cases, frequency compression isn’t just about clarity—it’s about comfort, stability, and survival.

Creating the Conditions for Growth

Thoughtfully programmed hearing aids provide more than just access to sound—they create space for growth.

By delivering cleaner, more stable, and more predictable input, they reduce the reactivity and fear that so often dominate the listening experience for children with APD, hyperacusis, and misophonia. They lower the noise floor—literally and emotionally. And in that calmer space, the brain becomes more receptive, more organized, and more resilient.

It’s like a life vest in a river. The child still has to swim. They may be given some “scaffolding” by the assistive technology of low-gain hearing aids, but it remains that they still have to do the work of listening, decoding, and engaging. With the hearing aids’ help, they often perceive that they can go about it safely, as they now perceive mainly signals they can both hear and tolerate without missing information or overwhelm from sound.

When children are given access to their own volume controls, even at a young age, something powerful happens: they begin to advocate for themselves. They learn to monitor their needs. They adjust their tools. They develop agency—not just in how they hear, but in how they live and learn.

Because when a child has control over how they hear, they begin to trust the world around them. They stop bracing. They start engaging. And in that space, the brain begins to self-correct, to adapt, and to thrive.

Visual Description

This cartoon-style digital illustration depicts a joyful young child floating on their back through a mild whitewater river. The child is wearing a bright orange life vest, navy blue shorts, and a red safety helmet, arms spread wide with a big, open-mouthed smile—relaxed and exhilarated at the same time.

The river is shown with gentle rapids, stylized white swirls and splashes indicating movement, but not danger. The surrounding landscape features soft brown canyon walls under a warm beige sky, suggesting that the child is being carried through a challenging but beautiful environment.

This image was chosen to visually represent the metaphor used throughout the article: that low-gain hearing aids act like a life vest for children navigating the unpredictable currents of real-world sound, both the portions of the “river” where they miss information (rocks, drops, eddies), as well as the areas where they are overwhelmed by sound stimulation (hydrolics or waves).

The child isn’t in a boat or being rescued—they’re learning to float, balance, and navigate on their own, safely supported. The life vest doesn’t remove the current; it makes the current manageable.

It allows the child to remain present, open to learning, and confident in their ability to respond. This illustration captures that balance of safety, independence, and growth—and reinforces the core message that properly programmed support allows children with auditory challenges to thrive.

References

Bellis, T. J. (2003). Assessment and management of central auditory processing disorders in the educational setting (2nd ed.). Delmar Cengage Learning.

Chermak, G. D., & Musiek, F. E. (2014). Handbook of Central Auditory Processing Disorder, Volume I: Auditory Neuroscience and Diagnosis (2nd ed.). Plural Publishing.

Ching, T. Y. C., Dillon, H., & Hou, S. (2015). Impact of nonlinear frequency compression on speech production of children with hearing loss. International Journal of Audiology, 54(5), 294–305.

Kuk, F. K., Korhonen, P., Peeters, H., & Keenan, D. (2009). Enhancing clarity in children with auditory processing disorders using low-gain hearing aids. Hearing Review, 16(11), 32–38.

Kuk, F. K., Korhonen, P., Peeters, H., & Keenan, D. (2014). Use of low-gain hearing aids in children with normal hearing and auditory processing difficulties. Hearing Review, 21(12), 24–29.

Mejstad, L., Heiling, K., & Svedin, C. G. (2009). Mental health and self-image among deaf and hard of hearing children. American Annals of the Deaf, 153(5), 504–515.

Narne, V. K., Prabhu, P., & Vanaja, C. S. (2013). Temporal processing and speech perception in noise by listeners with auditory neuropathy. ISRN Otolaryngology, 2013, 1–9.

Peelle, J. E. (2018). Listening effort: How the cognitive consequences of acoustic challenge are reflected in brain and behavior. Ear and Hearing, 39(2), 204–214.

Stropahl, M., Plotz, K., Schönfeld, R., Lenarz, T., & Sandmann, P. (2015). Visual activation of auditory cortex reflects maladaptive plasticity in cochlear implant users. Brain, 138(3), 647–660.

Tremblay, K., Kraus, N., McGee, T., Ponton, C., & Otis, B. (2001). Central auditory plasticity: Changes in the N1-P2 complex after speech-sound training. Ear and Hearing, 22(2), 79–90.