Outcomes of School-aged Children Using
Outcomes
of School-aged
Using
Advanced
Hearing AidChildren
Features
Advanced Hearing Aid Features
Susan Marshall, M.A.
1
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
2
What is the impact of adaptive directionality
and NR on Language Development?
Modern Directional and NR Hearing Aid features
AAA Pediatric Guidelines 2003
Directional 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. “
3
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?
4
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?
5
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)
6
Directional mics for infants
Ching et al (in review)
Child playing, one or more
adults present
One-on-one
(conversation)
(at home)
Four senarios
Child playing outdoors
with more children and
more adults present
Small group of children
playing, more adults
present
(playground)
(mother group)
7
Directional mics for infants
Ching 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?
8
Directional mics for infants
Ching 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!
9
Findings..
Ching et al (in review)
Based on calculations of head orientation, STI and
everyday listening situations…
Directional mics do not significantly disadvantage
children of any age between 11 months and 6
years
Message for clinicians on optimising outcome..
– Fit children early in life
– Fit with adaptive microphone
– Council on maximizing the directional
advantages
10
Impact of DNR on pediatric
performance
Bentler 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
11
Impact of NR on pediatric
performance
Bentler 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?
12
Impact of NR on pediatric
performance
Bentler 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
13
Findings..
Bentler et al (Como, 2008)
Speech perception is
enhanced
Novel word learning
is not compromised
Sound quality is
improved
Overall positive
indications for the use
of DNR with NH
children!
14
Directional Microphone Technology
Directional Microphone and Noise Reduction
Technology
15
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 switchingfully adaptive
16
Widex Directional Microphone Systems
• 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
17
Widex Noise Reduction Systems
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
18
Effects of digital noise
reduction
Speech 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
19
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
20
Speech Enhancement System
“Safest” kind of NR in terms of preserving audibility
Use of the SII in noisy environments
Driving in Car
Vacuum
21
Retrospective Study of Children Using
Directional Microphones and Noise Reduction
System
Retrospective Study
of Children Utilizing
Automatic Directional Microphone and
Noise Reduction Systems
22
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
00
Participating Facilities
250
250
Frequency
Frequency (Hz)
(Hz)
500
500
1000
1000
2000
2000
4000
4000
Arkansas Children’s Hospital, Little Rock AR
Cincinnati Children’s Hospital, Cincinnati OH
Hearing Health Center, Chicago, IL
House Ear Institute, Los Angeles, CA
Integris Baptist Medical Center, Oklahoma City, OK
Kansas University Medical Center, Kansas City, KS
Long Island Jewish Medical Center, New Hyde Park, NY
New England Center for Hearing Rehabilitation, Hampton, CT
Oakland Children’s Hospital, Oakland , CA
University of Miami Medical Center, Miami FL
Enrolled < 5 yrs 
Enrolled >5 yrs 
Hearing
Hearing Loss
Loss (dBHL)
(dBHL)
10
10
20
20
30
30
40
40
50
50
60
60
70
70
80
80
90
90
100
100
Figure
Figure1:2:Average
AverageAudiogram;
Audiogram;Children
Children< >5 5Years
YearsofofAge
Age
23
Language Outcomes
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
24
Samples: Standard Tests of
Language
Preschool
Language
Scale (PLS)
Oral and Written
Language Scales
(OWLS)
25
Vocabulary
• PPVTIII
Ages / Grades: 2:6 - 90+ Years
26
26
Bell Curve, Standard Scores,
Percentile Rank
27
Changes in Average Standard Score over
Time for normal-hearing children
Standard Score
100
Time- Post Fitting
28
Progress on Standard Language
Tests
• Each dot is a child’s
score on a standard
speech or language
test
Progress of Individual Children
140
120
Standard Score
100
• Dot’s are connected
when there is
longitudinal data for
the same test
80
60
40
20
3
2.
5
2
5
1.
1
5
0.
• Horizontal line=
Average progress
Time Post-Fitting (Years)
• Upward-sloping
line= greater than
average progress
Ba
se
l
in
e
SS
(a
te
nr
ol
lm
en
t
)
0
29
Progress of Children by Age
Progress of Children < 5 Years of Age
140
• Note: Dark line is average progress
120
100
Standard Score
• Each line represents progress of an
individual child over time on a specific
speech/language assessment tool
80
60
40
• Children enrolled in PHAP and using
advanced features early (enrolled < 5
years) progress at a rate faster than
average: Upward sloping line
20
Time Post-Fitting (Years)
0
Baseline
0.5
1
1.5
2
2.5
3
Progress of Children > 5 Years of Age
140
• Children enrolled later (> 5 years) do
not experience the same rate of
progress but still progress at a rate
higher than average
Standard Score
120
100
80
60
40
20
Time Post-Fitting (Years)
0
Baseline
0.5
1
1.5
2
2.5
3
30
Example of Assessment Data
for a Child Enrolled at age 1.5
Test
Baseline
SS
PLS 4
AC
6 Mos
1 Year
1.5 Year
2 Year
2.5 Year
3 Year
119
123
118
106
110
112
PLS 4
Tot
al
114
118
116
REEL 3
EL
105
REEL 3
RL
103
GFTA 2
110
115
OWLS
LCS
115
121
PLS 4
EC
OWLS
OE
S
85
121
31
II. Sub-group of Preschool
Children
Frequency(Hz)
(Hz)
Frequency
250
250
1000
2000
4000
10
10
Average - Right
Average - Right
AverageLeft
AverageLeft
20
20
Hearing
Hearing Loss
Loss (dBHL)
(dBHL)
•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
500
500
00
30
30
40
40
50
50
60
60
70
70
80
80
90
90
100
100
Monaural Aided SF Thresholds - Fitting N=7
Monaural Aided SF Thresholds- 1 Year Post Fit N=9
32
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
Group Progress (PLS4 Total Language)
160
PLS 4 Total Language Score
•
140
120
198
201
152
129
150
158
182
185
128
200
100
80
60
40
20
0
0
6
12
18
Months Post Fitting
33
Longitudinal
Longitudinal
Findings ofFindings
Children Utilizing
Directional Microphone
and NR Systems
34
Acknowledgement
Susan Marshall
Patti Stenger
Natalie Thiele
Debra Quick
Margaret Pikora
35
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)
36
Locator Adaptive Directional
Microphones
Frequency (Hz)
• Adaptive Directional Microphone
• Noise Reduction
• Omnidirectional Mode
500
1000
2000
4000
0
10
20
Hearing Loss (dBHL)
19 Children from 2 facilities
examined in 3 conditions:
250
30
40
50
60
70
80
90
100
Double-blind design
Frequency (Hz)
250
500
1000
2000
4000
0
10
20
Hearing Loss (dBHL)
• 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
Figure 1: Average Audiogram; Children < 5 Years of Age
30
40
50
60
70
80
90
37
100
Figure 2: Average Audiogram; Children > 5 Years of Age
What audiologists measured: Speech
Recognition
3 conditions: Omni, Locator(adaptive
directional, Omni + NR
38
Research findings
Dir 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)
39
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
40
Speech Recognition over time
41
Speech Recognition over time
*
*
*At SNR =0, 2 yr post sig
from 1 yr post
*At SNR =-10, 1 yr post sig
from baseline
42
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
43
Receptive and Expressive Speech/Lang
OWLS Progress
* OWLS
Composite (most
pairs significant)
44
44
An additional measure- CASL
Receptive and Expressive Speech/Lang
45
45
Higher order Language Progress
*
46
46
Receptive and Expressive Vocabulary
Progress
*
*
47
47
Speech/Language Outcomes:
3 Years Post Use of Adaptive Directional and
Noise Reduction Systems
48
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
49
Receptive and Expressive Progress (OWLS):
One Year Outcomes
50
50
Receptive and Expressive Progress (OWLS):
One and Two Year Outcomes
51
51
Receptive and Expressive Progress (OWLS):
One, Two and Three Year Outcomes
52
52
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
53
Linear Frequency Transposition in School
Aged Children
Linear Frequency Transposition in
School-aged Children
54
Linear Frequency Transposition
Widex 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
55
Why Lower Frequency?
• Allows audibility of previously
“inaudible” 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!
O
X
OX
OX
X
O
O
X
X
O
X
O
– Not for mild losses
56
AE Studies
– Information in the high
frequencies moved/lowered to
lower frequencies that are
aidable
– High frequency sounds are
heard as low frequency
sounds
AE Studies
Analogy: Good Hearing, Good
Resolution
Low to High Frequencies
57
Analogy: Poorer Hearing, Poorer
Resolution
Good
resolution
Moderate
resolution
Poor
resolution
No
resolution
AE Studies
O
O
Dead
region
O
O
O
O
58
Analogy: Why Transpose?
Good
resolution
Moderate
resolution
Poor
resolution
No
resolution
AE Studies
O
O
O
O
Dead
region
O
O
59
Analogy: Why Not Compress?
Good
resolution
Moderate
Poor
resolution resolution
No
resolution
AE Studies
O
O
O
O
Dead
region
O
O
60
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
61
Audibility Extender Fitting
Range (Updated)
Figure 1: Average Audiogram, N=10 Children
Frequency (Hz)
250
• Primary Group
2000
4000
10
20
30
40
AE protocol Update
Secondary group
Milder/moderate loss to provide
consistent audibility and/or special
needs. SF at 4 or 6 KHz typically
1000
0
Hearing Loss (dBHL)
• Regions of unaidable or
unreachable hearing
(>80 dB HL) along with
regions of aidable
hearing (<70/80 dB HL)
– speech focus
500
50
60
70
80
90
100
62
Audiological Histories, Protocols
and Findings
Susan Marshall, M.A.
Margaret Pikora, M.A.
Deb Quick, M.S.
Natalie Thiele, AuD.
.
63
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
64
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
65
Participants
• 10 Children, age 6 years 3 months to 13
years 6 months
• All hearing losses were primarily sensorineural in nature.
• Precipitously sloping hearing loss no worse
than moderate in the LF’s no better than
severe in the HF’s
66
Average Audiogram
67
Unaided Monaural SF Thresholds
68
• 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.
69
Hearing Aid and FM Usage
Participant
#
Initials
1
Widex
Model
R& L
Age
Own Aid Make/Model
(Right)
Own Aid Make/Model
(Left)
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
FM used
70
71
• 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
•
72
Checklist of Everyday
Sounds
Kitchen:
1. Dripping faucet
2. Gas stove ignition
3. Microwave buttons
4. Microwave alarm
5. Cracking ice
6. Aluminum foil
7. Candy wrappers
8. Whistling tea kettle
9. Plastic bag/wrap
10. Dripping faucet
Dining:
11. Silverware
12. Spoon stirring a drink
13. Ice clinking in a glass
14. Glasses clinking for a toast
15. Tapping glass with a spoon
16. Hitting chop-sticks together
17. Soda fizzing
18. Other people eating
19. Chair scraping the floor
Office:
20. Keyboard buttons
21. Rustling paper
22. Paperclips on hard surface
23. Clicking a pen
24.
25.
26.
27.
28.
Scissors
Stapler
Computer sounds
Computer mouse click
Phone ring (in same room)
29. Phone ring (in other room)
30. Phone button tones
Family Room:
31. Squeaky furniture
32. Door hinge
33. Ticking clock
34. Coo-coo clock
35. Adjusting window blinds
36. Fire crackling in fireplace
37. Door bell
38. Door locking
39. Rain on the roof
40. Various light switches
a. Pull chain
b. Standard flip switch
Children:
41. Child’s squeaky toy
42. Child’s toy that plays music or beeps
Pets:
43. Pet toe nails on tile
44. Pet collar tags
45. Whining dog
46. Meowing cat
47. Pet toys with bell or squeak
Personal:
48. Clothes rustling
49. Brushing hair
50. Jewelry (ring on hard surface,
noisy bracelet, etc.)
51. Watch alarm
52. Tapping fingernails
53. Hearing aid held in hand
54. Snap closures
Sounds in Public
55.
56.
57.
58.
59.
60.
61.
Elevator bell
Coins jingling
Wet shoes on tile
Shopping carts
Instruments (ex: piccolo)
Cash register printing receipt
Music in stores over intercom
(doctor’s office/waiting area)
62. High heel shoes on hard floor
Sounds outdoors
63. Cracking ice
64. Rustling leaves
65. Birds
66. Crickets
67. Whistling
68. Wind chimes
69. Bicycle bell
Car sounds
AE protocol Update
Sounds at home
70. Car turn signal
71. Left key in ignition with
door open (warning ding)
72. Door locking
73. Screeching tires
74. Checking air in tires (hiss)
75. Washing window or mirror
76. Shaking keys
73
Inteo Hearing Aid Details
 Inteo IN-9M selected if:
500 Hz
< 35 dB HL
2000 Hz
< 65-70 dB HL
 Inteo IN-19M selected if:
500 Hz
> 35-40 dB HL
2000 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 HL
2.0 mm vent 500 Hz = 25-40 dB HL
1.5 mm vent 500 Hz = 40-50 dB HL
1.0 mm vent 500 HZ = 50-55 dB HL
pressure vent 500 Hz.< 55 dB HL
74
 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
75
• HA is on child via
earmold
• Programming
software accessed to
deliver and adjust
level of signals at
various frequencies
76
• 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
77
• 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
78
• Output for various input
levels adjusted to match
DSL 5.0 target to the
extent possible
• Generally successful
through ~ 3000 Hz
79
Protocol to Ensure Effective Use of the
Audibility Extender
• 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
80
Protocol to Ensure Effective Use of the
Audibility Extender-continued
• 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
81
82
Objective Results
83
84
• 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
85
NST Results- 30 dB HL
3-months post
X
100
Identification score /%
90
80
.
70
60
50
40
30
20
Consonant
Vowels
10
0
Own aid
Default
Master Default-3
Masterwks
baseline
post AT
AE
AE
baseline
AE AE
-3 weeks
post AE
AEpost
post6 weeks
AT1
AT2
NST vowel and consonants for 30 dB input level at each measurements
86
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
87
NST Results- 50 dB HL
100
3-months post
X
Identification score /%
90
.
80
70
60
50
40
30
20
Consonant
Vowels
10
0
Own aid
Default
wks AE AE
AE -3 weeks
AE post 6AE
weeks
Master Default-3
Master
AE post
post
baseline
post AT
baseline
AT1
AT2
NST vowel and consonants for 50 dB input level at each measurement
88
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
89
Efficacy of AE in Children
100
90
90
80
80
70
60
50
40
30
20
Consonant
10
AE Studies
100
Identification score /%
Identification score /%
• FT has the additional benefit of
ensuring the audibility of soft
sounds, not just sounds from the
“dead” region
70
60
50
40
30
20
Consonant
Vowels
Vowels
10
0
0
Own aid
Master
baseline
Master
post AT
AE
baseline
AE post
AT1
50 dB HL input
AE post
AT2
Own aid
Master
baseline
Master
post AT
AE
baseline
AE post
AT1
AE post
AT2
30 dB HL input
90
One Student’s Progress
8 y.o. male “C.S.”
91
Grade Level
Reading
Recovery
A, B
1
Kindergarten
2
3
4
5
6
7
8
Grade 1
Grade 2
9
10
11
12
13
14
15
16
18
20
Fountas-Pinnell Guided
Reading
1
A
1A
1B
B
2
2A
C
2B
10/8/2007
3
D
3A
11/12/2007
3B
4
E
4A
F
G
2/12/2008
H
I
4/28/2008
J, K
L, M
4B
5
5A
5B
6
6A
6B
7
7A
92
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
93
Subjective Results
94
Paired Comparisons
990% + preference
for AE (or no
difference for AE
(or no difference)
95
60% preference
for AE (or no
difference)
0% + AE (or no difference)
96
Paired Comparisons
Preference-Speech
60 % preference for AE (or no difference)
100
90
Same
80
Better
70
60
50
40
30
20
10
0
AE Baseline
AE Post 3 weeks
AE Post 6 weeks
97
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
98
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
99
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)
100
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
101
Next Question…
• Do these new auditory cues carry over
into the child’s speech?
102
Special School District of
St. Louis County
Patti Stenger, M.A.
Alison LeGrand, AuD.
103
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/.
104
Auditory Training Session /s/
105
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 Sounds
Took less than 3 minutes
106
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.
107
Examples of Lesson Activities
•
•
•
•
•
Bingo
TIC-TAC-TOE
Minimal Pairs worksheets
Sentences read aloud
Look Whose Listening: Auditory
Discrimination Tasks
108
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
109
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
110
B Bingo/
111
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
112
ExamTic -Tac -ToeToe
113
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
114
Example of Minimal Pairs
Worksheet
115
Articulation Errors (GFTA2)
N=9
# Errors- 3 Months AE
25
20
15
10
5
0
0
10
20
30
# Errors- Own HA's
116
117
Those with a Poorer Speech Score
Showed Greater Benefit
100
80
60
40
20
30 dBHL
0
80
60
AE Studies
AE post second training /%
AE post second training /%
100
40
20
50 dBHL
0
0
20
40
60
Master at fitting /%
80
100
0
20
40
60
80
100
Master at fitting /%
118
• 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
119
120
• Reading "Ice Cream"Baseline/Own HA's
(DC)Video-reading Ice
Cream
• Reading "Ice Cream"- Post
Audibility Extender (DC)
121
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
122
123
124
125
LFT/Audibility

LFT+ Auditory Training/Speech
Identification and Production
• Aided thresholds
• Nonsense Syllables or Consonant Tests
• Audibility of Ling Sounds, i.e. /s/,
• Environmental Sound Checklist
/sh/
• Nonsense Syllables or Consonant
Tests
• Teacher Survey
(Teacher inventory of student intelligibility,
Linguisystems)
• Articulation
• Paired Comparisons (older children)
-Standardized test,
• Environmental Sound Checklist
- Reading passage, conversational sample
i.e. Goldman Fristoe Pictures
• Reading Scores
126
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 carryover to articulation
127
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)
128
Thank you very much!
129