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1
Outcomes of School-aged Children Using Advanced Hearing Aid Features Outcomes of School-aged Children Using
Advanced Hearing Aid Features
Susan Marshall, M.A.
2
Agenda• Review current research regarding
directional microphones
• Outcomes of children using Widex Directional and NR systems
• Review Linear Frequency Transposition
• Outcomes of children using Widex Linear Frequency Transposition
• Summary
3
Modern Directional and NR Hearing Aid features
AAA Pediatric Guidelines 2003Directional Microphone Use: “Type of
microphone should be dictated by the age and abilities of child…Benefits and limitations of
directional microphones with children currently unknown”
Noise Reduction System Use“cannot be recommended until data relative to
their effectiveness become available. “
What is the impact of adaptive directionality and NR on Language Development?
4
Questions:
It is 2010; what do we know now?
Are these features appropriate to use in pediatric amplification?
Are they efficacious?
Is there a negative impact on language?
5
Importance of improving SNR
Greater audibility than adults for equivalent sentence recognition (Stelmachowicz et al,
2000)
Greater SNR than adults to recognize speech in multi-talker babble (Fallon 2000, Fallon
2002)
The best way to improve SNR is an FM system
FM systems are not used all day or every day
What about HA directional microphones?
6
Part II: Adaptive Directionality and NR Amplification needs of infants
Infants require a broader frequency bandwidth when identifying high frequency fricatives in speech to learn
structures and grammar of language consistently(Kortekaas and Stelmachowicz 2000)
Infants require a higher signal-to-noise ratio (SNR) than adults, to reach the best possible speech understanding in
noise(Fallon et al. 2002; Scollie 2005)
Infants require a higher Speech Intelligibility Index to reach the same speech understanding as adults
(Scollie, 2008)
7
Directional mics for infantsChing et al (in review)
One-on-one
(conversation)
Child playing, one or more adults present
(at home)
Child playing outdoors with more children and
more adults present(playground)
Small group of children
playing, more adults
present (mother group)
Four senarios
8
Directional mics for infantsChing et al (in review)
Quantify the potential benefit of directional mics for young children (11 month to 6 years) in their real life listening environment
Defining the limitations of directional mic use due to head movement and acoustics of listening environment
How often does the child turn to a speaker in a real life situation?
What proportion of a childs everyday life would he/she benefit from a directional microphone system?
What is the effect of directionality measured with STI?
9
Directional mics for infantsChing et al (in review)
The effect of directionality was quantified by the STI showing:
Increase (1,5 to 3 dB) when facing forwards Decrease (-1.5 to -2.8 dB) when facing sideways
and backwards
No significance of age and hearing status on head movement!
Significant effect for scenario on directional benefit measured with STI!
10
Findings..Ching et al (in review)
Based on calculations of head orientation, STI and everyday listening situations…
Message for clinicians on optimising outcome..– Fit children early in life– Fit with adaptive microphone– Council on maximizing the directional
advantages
Directional mics do not significantly disadvantage children of any age between 11 months and 6 years
11
Impact of DNR on pediatric performanceBentler et al (Como, 2008)
Determining the effectiveness of DNR in use with children
50 subjects, NH 6-10 year olds
Childrens HINT – SNR 50 % as reference point for each subject
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Impact of NR on pediatric performanceBentler et al (Como, 2008)
Aim to investigate impact of digital noise reduction on pediatric performance
Does DNR for children impact: Speech perception? Novel word learning?Sound quality?
13
Impact of NR on pediatric performanceBentler et al (Como, 2008)
Outcome measures made using:– CASPA (Boothroyd, 2006)– Novel word learning paradigme (Stiles et al,
2008)– Happy faces categories (Wong et al, 2001)
Different stimuli used:– Two settings of DNR-on, plus DNR-off– Two noise types (babble, random)– Four different SNR
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Findings..Bentler et al (Como, 2008)
Speech perception is enhancedNovel word learning is not compromisedSound quality is improved
Overall positive indications for the use of DNR with NH children!
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Directional Microphone Technology
Directional Microphone and Noise Reduction Technology
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Adaptive Directional Microphone Systems
Keeping directional “safe” for children
An Adaptive Directional Microphone System Should-
• High Activation Threshold• Only operate at poor SNR’s• Use a slow activation time• Work in tangent with a very
low CT• Do not require any switching-
fully adaptive
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• Integrate safety features to ensure audibility:- Low compression threshold, high activation threshold, etc
• Provide consistent audibility of speech from all directions
• Maintain an omni-directional mode when speech is dominant
Optimize signal-to-noise ratio (SNR) in noisy listening situations
– Meeting the requirements of children for a higher SNR– Ease of listening in acoustically challenging situations
Widex Directional Microphone Systems
18
Integrate safety features to ensure audibility:
- Classic NR: high activation threshold, slow activation time, sensitive to speech
frequencies, etc-Speech Enhancer: Optimize SII in noise
- Ease of listening in acoustically challenging situations
Widex Noise Reduction Systems
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Effects of digital noise reductionSpeech Enhancer based on SII
In noise or reverberation the noise reduction system dampens unwanted noise enhancing the SNR making
speech more audible
The theory of the Speech Intelligibility Index (SII) is used for optimization of signal-to-noise ratio (SNR)
Combining directional microphone and noise reduction gives a further SNR improvement
Ii band importance function
Ai band audibility function
n number of bands / channels
20
Speech Enhancer
Audible speech with classic noise reduction
Considerably more audible speech with the Speech Enhancer
Guarantees highest possible SII in all listening conditions!
SII is correlated with speech recognition scores
21
Speech Enhancement System “Safest” kind of NR in terms of preserving audibility
Use of the SII in noisy environments
Driving in Car Vacuum
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Retrospective Study of Children UsingDirectional Microphones and Noise Reduction
System Retrospective Study of Children Utilizing Automatic Directional Microphone and Noise Reduction Systems
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I. Language Outcomes• Many clinicians utilize advanced technology/
special processing for their pediatric fittings• This has presented us with some outcome
information for standard tests of speech/language, ie. PLS, OWLS, GFTA
Participating FacilitiesArkansas Children’s Hospital, Little Rock ARCincinnati Children’s Hospital, Cincinnati OHHearing Health Center, Chicago, ILHouse Ear Institute, Los Angeles, CAIntegris Baptist Medical Center, Oklahoma City, OKKansas University Medical Center, Kansas City, KSLong Island Jewish Medical Center, New Hyde Park, NYNew England Center for Hearing Rehabilitation, Hampton, CTOakland Children’s Hospital, Oakland , CAUniversity of Miami Medical Center, Miami FL
Figure 1: Average Audiogram; Children < 5 Years of Age
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Frequency (Hz)
He
ari
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Lo
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dB
HL
)
250 500 1000 2000 4000
Enrolled < 5 yrs
Enrolled >5 yrs
Figure 2: Average Audiogram; Children > 5 Years of Age
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Frequency (Hz)
Hea
ring
Loss
(dB
HL)
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I. Adaptive directional and NR strategies for 49 children fit with adaptive features at various ages
II. Sub-group of 10 pre-school aged children
Language Outcomes
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Samples: Standard Tests of Language
Preschool Language Scale (PLS)
Oral and Written Language Scales (OWLS)
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Vocabulary
• PPVTIII
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Ages / Grades: 2:6 - 90+ Years
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Bell Curve, Standard Scores, Percentile Rank
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Changes in Average Standard Score over Time for normal-hearing children
Time- Post Fitting
Sta
ndard
Sco
re
100
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Progress on Standard Language Tests
Progress of Individual Children
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80
100
120
140
Baseli
ne S
S (at e
nroll
men
t) 0.5 1
1.5 2
2.5 3
Time Post-Fitting (Years)
Sta
nd
ard
Sco
re• Each dot is a child’s score on a standard speech or language test
• Dot’s are connected when there is longitudinal data for the same test
• Horizontal line= Average progress
• Upward-sloping line= greater than average progress
30
Progress of Children by AgeProgress of Children < 5 Years of Age
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Baseline 0.5 1 1.5 2 2.5 3
Time Post-Fitting (Years)
Sta
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Progress of Children > 5 Years of Age
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Baseline 0.5 1 1.5 2 2.5 3
Time Post-Fitting (Years)
Sta
ndar
d S
core
• Each line represents progress of an individual child over time on a specific speech/language assessment tool
• Note: Dark line is average progress
• Children enrolled in PHAP and using advanced features early (enrolled < 5 years) progress at a rate faster than average: Upward sloping line
• Children enrolled later (> 5 years) do not experience the same rate of progress but still progress at a rate higher than average
Example of Assessment Data for a Child Enrolled at age 1.5
TestBaseline
SS 6 Mos 1 Year 1.5 Year 2 Year 2.5 Year 3 Year
PLS 4 AC 119 123 118
PLS 4 EC 85 106 110 112
PLS 4 Total 114 118 116
REEL 3 EL 105
REEL 3 RL 103
GFTA 2 110 115
OWLS LCS 115 121
OWLS OES 121
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II. Sub-group of Preschool Children
Monaural Aided SF Thresholds - Fitting N=7
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Frequency (Hz)
He
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dB
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Average - Right
Average- Left
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Monaural Aided SF Thresholds- 1 Year Post Fit N=9
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Frequency (Hz)
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Average - Right
Average- Left
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•10 children age 4 months- 3 years - received services at same facility - for 7, advanced HA’s were first HA’s - followed for at least one year post-fitting
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0 6 12 18
PLS
4 To
tal L
angu
age
Scor
e
Months Post Fitting
Group Progress (PLS4 Total Language)
198201152129150158182185128200
II. Sub-group of Preschool Children
• Total Language Score is displayed as a function of time post-fitting with advanced hearing aids
• Average performance is indicated in bold black line
• On average, the group achieves average (SS=100) performance by 6 months post-fitting and exceeds average by 12 months post-fitting
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Longitudinal Findings Longitudinal Findings of Children Utilizing Directional Microphone
and NR Systems
35
Susan MarshallPatti StengerNatalie ThieleDebra Quick
Margaret Pikora
Acknowledgement
Special School District of St. Louis County
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School-aged Children Using Adaptive Directional and NR Systems
• 19 children in original study, fit with Widex Diva 9 or 19 • 10 from same facility followed 3 years post• 10 Children age 6, 1 to 12,9 years• Experienced HA users• Essentially normal Speech/Lang development (within 1-1/2 years of chronological age)
19 Children from 2 facilities examined in 3 conditions:
• Adaptive Directional Microphone• Noise Reduction• Omnidirectional Mode
Double-blind design• Children/parent/clinician unaware
of condition• Wore each for 6 weeks• Subjective assessment after 1
week• WR (%) after 6 weeks of use at
various SNR’s
Locator Adaptive Directional Microphones
Figure 1: Average Audiogram; Children < 5 Years of Age
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100
Frequency (Hz)
He
ari
ng
Lo
ss (
dB
HL
)
250 500 1000 2000 4000
Figure 2: Average Audiogram; Children > 5 Years of Age
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10
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30
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60
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Frequency (Hz)
Hea
ring
Loss
(dB
HL)
250 500 1000 2000 4000
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What audiologists measured: Speech Recognition
3 conditions: Omni, Locator(adaptive directional, Omni + NR
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Research findingsDir mics for school-age children
In speech front vs. noise back stituations school-age children have a SNR advantage of ..
4.7-8 dB in the sound field (Gravel, 1999) 5.5-8 dB in the sound field (Kuk, et al,
1999)3 dB in the classroom (Ricketts and
Galster, 2007)7.5 dB in the sound field (Auriemmo, et al,
2009)
40
Efficacy of Adaptive Directional Microphones
• Directional benefit estimated at 7.5 dB• No benefit measured for NR, but no detriment either• Subjective findings support Locator use, even in environments where a
traditional directional instrument would not be ideal, i.e., desired sounds originating from behind or sides
41
Speech Recognition over time
42
*At SNR =0, 2 yr post sig from 1 yr post
*At SNR =-10, 1 yr post sig from baseline
**
Speech Recognition over time
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Acclimatization: Word Recognition Performance Over Time
*At SNR =0+5 3 yr post sig from baseline
*At SNR =-10, 3 yr post sig from baseline
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Receptive and Expressive Speech/LangOWLS Progress
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* OWLS Composite (most pairs significant)
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An additional measure- CASLReceptive and Expressive Speech/Lang
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Higher order Language Progress
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*
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Receptive and Expressive Vocabulary Progress
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* *
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Speech/Language Outcomes:3 Years Post Use of Adaptive Directional and Noise
Reduction Systems
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Scatter plots: Looking at Individual Data
- Group data is important for making statistical inferences
- Individual scores are also important for learning about the particular child and his or her progress over time and re: his or her peers
50
Receptive and Expressive Progress (OWLS): One Year Outcomes
50
5151
Receptive and Expressive Progress (OWLS): One and Two Year Outcomes
5252
Receptive and Expressive Progress (OWLS): One, Two and Three Year Outcomes
53
Results With Widex Adaptive Directional Systems Reveal:
I: Retrospective study of 49 children and subgroup of 10 toddlers
– Average Standard scores of Children using these features early (< 5 years) increase over time
– Average Standard scores of children using these features later (> 5 years) do not experience the same rate of progress but still progress at a rate higher than average
II: Longitudinal study of 10 school-aged children:- Receptive and expressive language scores are stable or
significantly improved over the three years these features are used
- Long term use of adaptive directional microphone and noise reduction systems does not negatively impact language progress
54
Linear Frequency Transposition in School Aged Children
Linear Frequency Transposition in School-aged Children
55
Linear Frequency TranspositionWidex Audibility Extender
• Mechanism of Linear Frequency Transposition (LFT)
• Audiological Candidacy, LFT Fitting and Parameters
• Monitoring Audiological Progress
• Facilitating Adjustment: Auditory Training
• Monitoring Speech/Language Progress
• Summary
56
Why Lower Frequency?• Allows audibility of previously
“inaudible” sounds
– Information in the high frequencies moved/lowered to lower frequencies that are aidable
– High frequency sounds are heard as low frequency sounds
• May be an unfamiliar percept – Avoid comparison to normal
perception– It’s natural to be “unnatural”
• Do not lower if it can be amplified!– Not for mild losses
X X
X
X X X
X
O
O
O
O
OO O
AE S
tudi
es
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Analogy: Good Hearing, Good Resolution
Low to High Frequencies
AE S
tudie
s
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Analogy: Poorer Hearing, Poorer Resolution
O
O
O
O
O
O
Good resolution
Moderate resolution
Poor resolution
Noresolution
Dead region
AE S
tudie
s
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Analogy: Why Transpose?
O
O
O
O
O
O
Good resolution
Moderate resolution
Poor resolution
Noresolution
Dead region
AE S
tudie
s
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Analogy: Why Not Compress?
O
O
O
O
O
O
Good resolution
Moderate resolution
Noresolution
Dead region
Poor resolution
AE S
tudie
s
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How is the AE Different From Others?
• It does not operate on all frequencies – only those at and above the start frequency– Others compress ALL frequencies once a decision on
compression is made
• It does not compress the transposed sounds – “linear “(and retain temporal and spectral cues)– Others compress some or all frequencies
• It allows programming flexibility to meet individual needs - choice of start frequencies, bandwidth of transposed signal, and gain
• It can be used as the main program or as an optional listening program and for a wide range of hearing losses
62
Audibility Extender Fitting Range (Updated)
• Primary Group• Regions of unaidable
or unreachable hearing (>80 dB HL) along with regions of aidable hearing (<70/80 dB HL) – speech focus
Figure 1: Average Audiogram, N=10 Children
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Frequency (Hz)
He
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(d
BH
L)
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Secondary groupMilder/moderate loss to provide consistent audibility and/or special needs. SF at 4 or 6 KHz typically
AE p
roto
col U
pdat
e
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Audiological Histories, Protocols and Findings
Susan Marshall, M.A.Margaret Pikora, M.A.
Deb Quick, M.S.Natalie Thiele, AuD.
.
Special School District of St. Louis County
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Difficulties fitting precipitous hearing loss
• Limited success fitting precipitous sensori-neural with traditional amplification due to dead regions
• Over amplify lows, can’t reach highs
• Limited success with previous transpositional schemes
• Anecdotal case studies with newer technology revealed optimistic results
• Goal- To look at hearing and speech performance of these children with newer technology
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Goal: To look at hearing and speech performance of these children more systematically
Audibility (aided SF thresholds) Speech identification HF Environmental sounds Paired Comparisons Speech Production
How to Achieve Goal-
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Participants• 10 Children, age 6 years 3 months to 13
years 6 months• All hearing losses were primarily sensori-
neural in nature.• Precipitously sloping hearing loss no worse
than moderate in the LF’s no better than severe in the HF’s
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Average Audiogram
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Unaided Monaural SF Thresholds
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• All experienced hearing aid users
• All used digital technology
• Nine utilized FM systems in the classroom setting
• All of the students received S/L therapy from an SLP
• Speech-articulation of the /s/, /z/, [sh], [ch], /r/ and blends
• Language-grammar, literacy and content area vocabulary
• Service time ranged from 90-150 m.p.w.
Hearing Aid History and FM Usage
Hearing Aid and FM UsageParticipant
#Initials Age
Own Aid Make/Model (Right)
Own Aid Make/Model (Left)
Widex Model R& L
FM used
1 AD 9.1 Phonak Supero 412 Phonak Supero 412 IN-19M Yes
2 CS 8.2 Phonak Maxx 411 Phonak Maxx 411 IN-19M Yes
3 MC 10.3 Phonak Maxx 411 Phonak Maxx 411 IN-19M Yes
4 TD 12.4 Phonak Claro 311 Phonak Claro 311 IN-19M No
5 PO 7.7 Starkey Destiny 1200 Starkey Destiny 1200 IN-19M Yes
6 NM 6.3 Widex P38 Widex P38 IN-19M Yes
7 LE 13.5 Oticon Adapto P Oticon Adapto P IN-9M Yes
8 QW 10.8 AVR Nano XP-D AVR Nano XP-D IN-19M Yes
9 DC 7.8 Phonak Maxx 411 Oticon Adapto P IN-19M Yes
10 ZH 13.6 Widex Bravo B-32 Widex Bravo B-32 IN-19M Yes
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Time-line of Visits
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• Aided Monaural SF Thresholds
• Nonsense Syllable Test (NST)• Edgerton and Danhauer, 1979
– Administered 30 dB and 50 dB HL, randomized– CD, 0° azimuth, 1 meter from speaker– Form A, Lists 1-6 counterbalanced– Full 25 item lists, CVCV
• Environmental High Frequency Sounds Survey– Administered by audiologist, interview style
• Paired Comparisons- Birds/Music/Speech– Administered at 50 dB HL– Randomized which programs were presented AE vs. Default– Randomized birds/music/speech– Participant indicated preference for program #1, #2, or
no difference•
•
Audiological Assessments
Checklist of Everyday Sounds
Sounds at home
Kitchen:1. Dripping faucet 2. Gas stove ignition3. Microwave buttons4. Microwave alarm5. Cracking ice6. Aluminum foil7. Candy wrappers8. Whistling tea kettle9. Plastic bag/wrap10. Dripping faucetDining:11. Silverware12. Spoon stirring a drink13. Ice clinking in a glass14. Glasses clinking for a toast 15. Tapping glass with a spoon 16. Hitting chop-sticks together17. Soda fizzing18. Other people eating19. Chair scraping the floorOffice:20. Keyboard buttons21. Rustling paper22. Paperclips on hard surface23. Clicking a pen
24. Scissors25. Stapler26. Computer sounds27. Computer mouse click28. Phone ring (in same room)
29. Phone ring (in other room)30. Phone button tones Family Room:31. Squeaky furniture32. Door hinge33. Ticking clock34. Coo-coo clock35. Adjusting window blinds36. Fire crackling in fireplace37. Door bell38. Door locking39. Rain on the roof40. Various light switches a. Pull chain b. Standard flip switchChildren:41. Child’s squeaky toy42. Child’s toy that plays music or beepsPets:43. Pet toe nails on tile44. Pet collar tags45. Whining dog46. Meowing cat47. Pet toys with bell or squeak Personal:48. Clothes rustling49. Brushing hair50. Jewelry (ring on hard surface, noisy bracelet, etc.)51. Watch alarm52. Tapping fingernails
53. Hearing aid held in hand54. Snap closuresSounds in Public
55. Elevator bell56. Coins jingling57. Wet shoes on tile58. Shopping carts59. Instruments (ex: piccolo)60. Cash register printing receipt61. Music in stores over intercom (doctor’s office/waiting area)62. High heel shoes on hard floor Sounds outdoors
63. Cracking ice64. Rustling leaves65. Birds66. Crickets67. Whistling68. Wind chimes69. Bicycle bell Car sounds
70. Car turn signal71. Left key in ignition with door open (warning ding)72. Door locking73. Screeching tires74. Checking air in tires (hiss)75. Washing window or mirror76. Shaking keys
AE p
roto
col U
pdat
e
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Inteo IN-9M selected if:500 Hz < 35 dB HL2000 Hz < 65-70 dB HL
Inteo IN-19M selected if:500 Hz > 35-40 dB HL2000 Hz > 65-70 dB HL
Custom skeleton softex earmolds:Venting based in 500 Hz threshold and space permitting:
2.5 mm vent 500 Hz < 25 dB HL2.0 mm vent 500 Hz = 25-40 dB HL1.5 mm vent 500 Hz = 40-50 dB HL1.0 mm vent 500 HZ = 50-55 dB HLpressure vent 500 Hz.< 55 dB HL
Inteo Hearing Aid Details
75
Measuring in-situ threshold at 1/3 octaves
Feedback test, active feedback cancellation enabled
Output vs. frequency screen utilized to make adjustments
Simulated real-ear measurements
Further adjustments if necessary
Default Fitting and Fit Verification
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Default Fitting: In-situ Threshold MeasurementProgramming interface, programming software, HA
• HA is on child via earmold
• Programming software accessed to deliver and adjust level of signals at various frequencies
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• Parameter settings of hearing aids: Multiband automatic directionality Noise reduction activated Speech Enhancer deactivated Program and volume controls deactivated
• Fit verification
Output vs Frequency (pre-verification) Aided sound-field thresholds obtained at 500, 1000, 2000, 3000,
and 4000 Hz, masking or plugging non-test ear Simulated real ear measurements used to verify settings closely
matched DSL 5.0 targets through ~3000 Hz
Fitting of Default Program (continued)
78
• Examine output for inputs of different levels
• Adjust hearing aid parameters for optimal audibility of soft, high frequency inputs
• Ensure output for loud inputs is below predicted UCL values
• This is done prior to hearing aid analyzer measurements
Fit Verification: Output vs Frequency
79
• Output for various input levels adjusted to match DSL 5.0 target to the extent possible
• Generally successful through ~ 3000 Hz
Hearing Aid Analyzer- Matched DSL 5.0 Target through 3000 Hz
80
• Individual Fitting – Pre-select start frequency
• Present /s/ at 30 dB HL
• If child detects /s/ appropriately, record settings– Adjust to higher SF– Present /s/ at 30 dB HL– Adjust AE gain for detection of /s/
• If /s/ is not audible, increase AE gain in 2 dB steps until /s/ is audible or max AE gain is reached. Record setting if /s/ is audible
Protocol to Ensure Effective Use of the Audibility Extender
81
• Go to the next lower Start Frequency, reset AE gain. Present /s/ at 30 dB HL until response.
• Repeat previous steps (descending start frequency & bracketing AE gain). Record highest start frequency by lowest AE gain for reliable response
Protocol to Ensure Effective Use of the Audibility Extender-continued
82
SoundTracker was used to Assist in Adjusting Parameters
Objective Results
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• Aided sound field thresholds in the LFT (AE program) indicated average responses in the normal hearing region for the low frequencies and mild hearing loss region for the high frequencies
• This is a considerable improvement over unaided, own aids, and default condition
Objective Results
86
0
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40
50
60
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100
Own aid Masterbaseline
Masterpost AT
AEbaseline
AE postAT1
AE postAT2
Ide
ntif
ica
tion
sco
re /
%
Consonant Vowels
NST vowel and consonants for 30 dB input level at each measurements
NST Results- 30 dB HL
Default Default-3 wks AE AE -3 weeks AE post 6 weeks
X
.
3-months post
Results- NST 30 dB HL
Statistical Analysis (Bonferonni Comparisons):
Performance of Inteo hearing aid in either default program or AE program (with or without training) was better than the children’s own hearing aids
Performance of AE program after 6 weeks of training was significantly better than that of the default program (baseline and after 3-weeks training) and the AE program after 3 weeks of training (p < 0.001)
All other comparisons non-significant
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10
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30
40
50
60
70
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90
100
Own aid Masterbaseline
Masterpost AT
AEbaseline
AE postAT1
AE postAT2
Ide
ntifica
tio
n s
co
re /
%
Consonant Vowels
NST vowel and consonants for 50 dB input level at each measurement
NST Results- 50 dB HL
Default Default-3 wks AE AE -3 weeks AE post 6 weeks
X
.
3-months post
Results- NST 50 dB HL
• Similar trend at 50 dB HL-Default program and AE program significantly different than own HA’s
• Results in AE not significantly different than results in default program at 50 dB HL
• Potential to achieve significance with more participants based on a power analysis
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Efficacy of AE in Children
• FT has the additional benefit of ensuring the audibility of soft sounds, not just sounds from the “dead” region
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Own aid Masterbaseline
Masterpost AT
AEbaseline
AE postAT1
AE postAT2
Iden
tific
atio
n sc
ore
/%Consonant Vowels
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Own aid Masterbaseline
Masterpost AT
AEbaseline
AE postAT1
AE postAT2
Ide
ntif
ica
tion
sco
re /%
Consonant Vowels
50 dB HL input 30 dB HL input
AE S
tudi
es
One Student’s Progress
8 y.o. male “C.S.”
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Reading Progress- CSGrade Level
Reading Recovery
A, B 11 1A
1B2 B 23 2A
2B4 10/8/2007 35 D 3A6 11/12/2007 3B7 48 4A
9 4B10 511 5A
5B12 2/12/2008 613 6A14 6B15 I16 4/28/2008 718 J, K 7A20 L, M
G
H
Fountas-Pinnell Guided Reading
Kindergarten
Grade 1
Grade 2
A
C
E
F
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Summary- Objective Results
• Linear frequency transposition as utilized in the Widex Inteo Audibility Extender improves audibility of consonants for school age children with precipitous high frequency hearing loss
• Significant improvements were measured in NST consonant scores at 30 dB HL with LFT
Subjective Results
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Paired Comparisons
990% + preference for AE (or no difference for AE (or no difference)
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Paired Comparisons
60% preferencefor AE (or nodifference) 0% + AE (or no difference)
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Paired ComparisonsPreference-Speech
60 % preference for AE (or no difference)
AE Baseline AE Post 3 weeks AE Post 6 weeks0
10
20
30
40
50
60
70
80
90
100
Same Better
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HF Environmental Sound Survey
• Awareness of environmental sounds limited with own HA’s
• Increase in number of sounds with Inteo default
• After 6 weeks of use children hear more environmental sounds outdoors, in dining room, car, pets
Above: results for 9 children
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Subjective Results• Heard soda fizzing in a cup for the first time, pets walking
on tile floors, telephones ringing from different room
• All ten participants stayed in AE program
• At a wedding reception, “Daddy you don’t have to yell in my ear, I’m right here!”
• Hears me calling his name even with the T.V. on.
• Mom reports more S’s on the ends of words
• Another student corrected mom’s speech when she dropped “-ing” off of a word
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Summary- Subjective Results• Children hear more environmental sounds
• Report ‘firsts’ ; heard soda fizzing, telephone from other room for first time
• Preference: Children report AE program is better or same for speech than default program
• Preference is consistent; unlike adults where preference grows over time (acclimatization)
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Summary- Facilitation• Choose start frequency with individualized approach if possible
• Counseling of parents, child-Everyday sounds are important too!
• AE should be first, only program and linked to FM-Use time Acclimatization
• SLP, teacher, itinerant and other professionals should be involved
• Auditory training should be included• Group, pair or individual• Variety of activities, materials, levels
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Next Question…
• Do these new auditory cues carry over into the child’s speech?
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Special School District of St. Louis County
Patti Stenger, M.A.
Alison LeGrand, AuD.
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Auditory Training
• Nancy Tye-Murray (1998) states that the goal (auditory training) is to “develop their ability to recognize speech using the auditory signal and to interpret auditory experiences.” The goal of this particular auditory training focused on the perception and production of certain speech sounds with the use of frequency transpositional hearing aids. Those speech sounds included /s/, /f/, /z/, /sh/, /ch/.
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Auditory Training Session /s/Auditory Training Session /s/
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Start of Session• Check the functioning of the aid by
doing a listening check.• Short discussion with student about
their day. • Receptive and expressive activity
with Ling SoundsTook less than 3 minutes
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Goals• Be able to discriminate /s/ sound in
quiet environments in all word positions.
• Be able to identify targeted /s/ sound in quiet environments in all word positions
• Be able to produce the /s/ sound.
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Examples of Lesson Activities
• Bingo • TIC-TAC-TOE• Minimal Pairs worksheets• Sentences read aloud• Look Whose Listening: Auditory
Discrimination Tasks
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Materials
• Spotlight on Articulation – S
• Contrasts for Auditory & Speech Training (CAST)
• No Glamour Articulation all from LinguiSystems, Inc. (2003)
• Look Whose Listening: Auditory Training Board Game
• Webber Photo Phonology SuperDuper, Publications
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Bingo /S/• No Glamour Articulation
• Bingo cards were created from picture card worksheets.
• Child was required to listen to the word and find it on his/her card.
• Child was then required to say a sentence using the target word
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B Bingo/
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Tic Tac Toe /s/• Spotlight on Articulation /s/ • Tic Tac Toe cards were created from
picture card worksheets.• Child was required to listen to the
word and find it on his/her card.• Child was then required to say a
sentence using the target word
• Spotlight on Articulation /s/, LInguiSystems, Barb Truman, Lauri Whiskeyman, Margaret Warner, 2006
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ExamTic -Tac -ToeToe
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Minimal Pairs• CAST Cards• Child was required to listen and
determine the target word.• Child was then required to use the
word in a sentence• Child was the teacher by telling the
adult which picture to point to and make a judgment about accuracy of response
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Example of Minimal Pairs Worksheet
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Goldman Fristoe Errors (3 months Post)
Articulation Errors (GFTA2)N=9
0
5
10
15
20
25
0 10 20 30
# Errors- Own HA's
# E
rror
s- 3
Mon
ths
AE
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Goldman Fristoe Errors (1 year Post)
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30 dBHL
0
20
40
60
80
100
0 20 40 60 80 100
Master at fitting /%
AE
pos
t sec
ond
trai
ning
/%
50 dBHL
0
20
40
60
80
100
0 20 40 60 80 100
Master at fitting /%
AE
pos
t sec
ond
trai
ning
/%
Those with a Poorer Speech Score Showed Greater Benefit
AE S
tudi
es
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• Articulation of /s/ and /z/ phonemes:
Repeated-measures ANOVA
Reading: Significant improvement in /s/ and /z/ fricative articulation in both default and AE program compared to own HA’s
- Articulation in AE program significantly better than that in default program after 6 weeks of use (i.e., AE- AT2)
Conversation: Similar trend although comparison between the children's’ own aids and default program after 3 weeks of use not significant
Results-Articulation
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Sample tools to assess articulation
Video-reading Ice Cream
• Reading "Ice Cream"- Baseline/Own HA's (DC)Video-reading Ice Cream
• Reading "Ice Cream"- Post Audibility Extender (DC)
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Teacher Survey
• Teacher Checklist for articulation• Reformatted to email and be
teacher friendly (quick to complete)
• Teacher Survey: pre and post Auditory training- but it was pre/baseline (own HA’s) and then post auditory training in AE
• The Assessment Companion, LinguiSystems, 1993, Rosemary Huisingh, Mark Barrett, Linda Zachman, Jane Orman, Carolyn Blagden and the staff of LinguiSystems
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Teacher Survey-Pre
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Teacher Survey-Post
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Assessing Effectiveness of Auditory Training (+ LFT Feature)Tools for Monitoring Progress:
• Aided thresholds
• Audibility of Ling Sounds, i.e. /s/,
/sh/
• Nonsense Syllables or Consonant
Tests
• Paired Comparisons (older children)
• Environmental Sound Checklist
LFT/Audibility LFT+ Auditory Training/Speech Identification and Production
• Nonsense Syllables or Consonant Tests
• Environmental Sound Checklist
• Teacher Survey (Teacher inventory of student intelligibility,
Linguisystems)
• Articulation
- Standardized test, i.e. Goldman Fristoe Pictures
- Reading passage, conversational sample
• Reading Scores
Summary• Use Individualized Approach to Selecting Fitting Parameters
• Look further than word list % for monitoring audiological progress– Use Aided SF thresholds– Consonant Test Results– Environmental Sound Checklists– Chronicle hearing aid experience in diary– Paired comparisons
• Facilitate adjustment with counseling (parents) and auditory training– Implement innovative sessions to increase interest, i.e., team teaching, etc
• Collect speech samples and assess carry-over to articulation
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Summary
• Significant improvements in audibility as measured by– Aided thresholds– NST scores at 30 dB HL– Environmental HF sounds
• Data from adults is useful, however subjective results (paired comparisons) different from those of adults proving yet again that children are not “little adults”
• The Audibility Extender (LFT) has the potential to improve phoneme articulation (at least in children)
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Thank you very much!
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