Determining Need and Benefit of FM Use: Measurement of Outcomes Shortened Handout Version

1. Determining Need and Benefit of FM Use: Measurement of OutcomesShortened Handout Version Karen Anderson, PhD karenlanderson@earthlink.net

2. Many new challenges in pediatric audiology • Probe microphone measurements • Using electrophysiological data to infer hearing thresholds for early hearing aid fitting • Hearing aid fittings on babies 1-3 mos old! • Fitting programmable and digital hearing aids rather than familiar analog aids • Letting go of relying on behavioral measures of hearing until a child is 5-6 months old • Etc.

3. How do you know when you have had a successful hearing aid fitting? • Match the gain and output to DSL targets • Earmolds fit snugly so no feedback • Parents understand that they need to return for new earmolds when feedback occurs • Parents have been instructed in earmold insertion and the care and operation of the hearing aids • THESE ARE ALL THINGS THAT THE AUDIOLOGIST DOES

4. How do you know when a hearing aid fitting is REALLY successful? • The child wears the hearing aids consistently! • Parents make an appointment for new earmolds as soon as they notice feedback • Parents have a real understanding of the child’s hearing loss and its affects

5. So what approach should the audiologist take when talking with parents when a child is first diagnosed? AVOID • Describing hearing loss by using labels (mild, moderate, Deaf, HOH) • Teaching parents about the audiogram, they can learn it later • Giving the impression that amplification will fully take care of the child’s hearing problems TRY TO DO • Talk about how the hearing loss affects speech perception • Describe hearing in terms of daily listening situations (listening range, communication access) • Encourage parents to observe their child’s responses to sound

6. Effects of Hearing Loss on Speech and Language without Intervention • Slight Hearing Loss or Unilateral Hearing Loss • May miss some consonants; mild difficulty with auditory language learning, listening at a distance and in noise • Mild Hearing Loss • Only hears louder speech sounds; difficulty with auditory learning, some speech/language delays, inattention • Moderate Hearing Loss • Hears almost no speech sounds at normal levels; articulation differences, language delay, learning dysfunction related to language delays, inattention Assume communication from 6 feet

7. Effects of Hearing Loss on Speech and Language without Intervention • Severe Hearing Loss • Hears no speech sounds at normal levels; very reduced speech intelligibility, verbal language delay, learning dysfunction related to language delay, inattention to verbal communication • Profound Hearing Loss • Hears no speech or other sounds; little or no speech intelligibility, little or no verbal language, learning dysfunction related to language delay, learns by visual cues or manually coded language systems, inattention to verbal communication

8. RELATIONSHIP OF DEGREE OF LONGTERM HEARING LOSS TO PSYCHOSOCIAL IMPACT ANDEDUCATIONAL NEEDS - handout • English and Spanish handouts at: • www.kandersonaudconsulting.com Hint: use to help describe effect of hearing loss in reports, parent counseling, teacher inservice

9. Little People in Families – Not Just Ears • True management of hearing loss goes beyond diagnosis and hearing aid fitting • Interpreting hearing loss in a way that the parent can integrate the knowledge into their daily lives and share it with other people who care for the child • Ongoing consultation, information, support to the family • Listening NOT advising

10. Parent Buy-In is Necessary Buy-In or recognition that: • The hearing loss is • It WILL affect the child’s development if it is not addressed • Communication access is JOB #1 in preventing delays from developing • They – the daily caregivers – are the people who must be involved most in helping their child learn language --- parents are the magic • The prognosis for normal or near-normal development is good but it requires their investment of time and energy real

11. Purpose of today’s presentation: 1. Suggest some ways in which people who work with children with hearing loss can involve parents so that they will develop a higher level of buy-in 2. Discuss ways in which we can validate the degree of benefit experienced with their choice or adjustment of hearing instrument 3. Discuss birth to five, but also present tools for school-age and adolescents when teacher buy-in is critical to the child’s success

12. We have made huge gains in minimizing the effects of hearing loss • The key to successful development and learning is effective access to speech from as early as possible • Regular screening of functional ability in typical environments assures that children will not develop or increase gaps in learning • School accommodations, including FM, are necessary to maximize learning and performance in school • The ‘age of accountability’ requires documentation beyond the audiogram to support a child’s need for S/N enhancing technology

13. Test instruments are now available for children • Test instruments involve the parent or teacher in thinking about the child’s behavior and making a judgment • By involving them we are showing that we respect their opinion – that they have valuable insights to offer • Auds set hearing aids for audibility of speech at different levels of input but people who are with the child everyday observe his or her functional use of hearing

14. Infants and Toddlers: Family Centered Services • Hearing loss and audiograms do not make much sense to most people, especially soon after a diagnosis • Parents cry and then go home and bang pots • Audiologists can recognize the parent’s need to understand the hearing loss in terms of the child’s listening/communicating at home • We need to ask parents to participate in the discovery process to foster their understanding and buy-in to the diagnosis and amplification use

15. Parents as advocates • Educational audiologists are not in all school districts and often are not involved at length with any one child • Use of instruments completed by parents and teachers is more efficient and may provide valuable and different information than obtaining full academic assessment • Parents involved early in recognizing their child’s hearing needs have the power to influence their educational program

16. ELFEarly Listening Function • Why: Hearing is a distance sense. A child with a hearing loss will have a reduced hearing range, or a smaller listening bubble, than a child with normal hearing. • Audiologists test to find out what tones a child can detect, but only someone who is with the child for hours everyday can observe how the child is using hearing in daily situations. • Hearing instruments will improve the size of the listening bubble. With use of amplification during all waking hours, auditory skills will usually improve over time.

17. Observing child behavior when presented with contrived listening activities at different distances and in quiet and noise • 6 inches, 3 feet, 6 feet, 10 feet, 15+ feet • 12 Activities: • 4 quiet, 4 typical loudness, 4 loud • Loudness calibration is not critical – parent participation in typical environments is critical • Quiet and noise: develop awareness of how having the TV always on limits the child’s perception of other sounds

18. Other benefits of the ELF • Gives the parents something “to do” to feel like they are helping their child • Can be a first activity with early intervention • Motivating for following through with hearing aids or new earmolds • Tuning into auditory development over time • Involve all caregivers • Provides parents with a clear way of describing the hearing loss

19. ELF as a Validation Tool • Each activity has a point value do a possible score out of 100 can be obtained • Audiologist scores and compares over time • Reveals improvements in perception of quiet input or across distance • Separate form for parents to complete 1-2 weeks after new amplification is fit • May be beneficial to family compliance (Example: Dad’s who get involved in ‘measuring’)

20. ELF Infant & Young Child Amplification Use Checklist Parents circle 1-5 scale: Agree, No Change, or Disagree My child appears to:   1. Be more aware of my voice 2. Be more aware of environmental sounds   3. Search more readily for the location of my voice   4. Have an increased amount of babbling or talking   5. Have more interest in communicating   During ELF listening activities, the size of my child’s listening bubble: 1. Has improved for quiet sounds voices   2. Has improved for typical sounds and voices   3. Has improved for loud sounds and voices   4. Has improved for listening in background noise   Describe specific situations when you noticed improvements in listening ability:

21. DIAL: Developmental Index of Audition and Listening • Developmental sequence of listening skills for children with normal hearing • Helpful for parents of children with “little hearing losses” • Underscores that children’s listening skills aid in the development of socialization and verbal development

22. IT-MAIS: Infant-Toddler • Interview format – 10 questions for parent to answer • Oriented to speech use and intelligibility • Good format for discussion • Good back-up if family does not follow through completing the ELF • Also available: MAIS and MUSS • Advanced Bionics – call customer service to request copies

23. FAPI: Functional Auditory Performance Indicators • Takes over where the ELF begins • Assesses the functional auditory skills within a sequence of development – not just detection • Each skill rated as not present, emerging, in process, or acquired • Could be an integrated part of early intervention; assistance to parents in observing and completing • Update on a regular basis (i.e., monthly)

24. Beyond Toddlerhood • The following instruments can be used to: • Involve the parent or teacher to improve buy-in and understanding of the child’s abilities and need for accommodations • Screen classroom performance to determine if educational assessment, change in services or accommodations need to be considered • Provide an indication of the need for a trial period with a personal FM system or other assistive devices • Provide a pre-test/post test format following implementation of FM, new hearing instruments, improved accommodations

25. The COW: Children’s Outcome Worksheets • Available from Oticon • 3 worksheets: child’s needs, parent’s needs, teacher’s needs • 3 or 4 very general situations with blanks to add 1 or 2 more situations • Judgment is made “Because of the new hearing instrument, I now hear…’ • Second judgment is made “I can hear satisfactorily, 10-95% of the time”

26. CHILD: Children’s Home Inventory of Listening Difficulties • For ages 3 years to approximately 12 years (plays with others, not parallel play) • Provides 15 listening situations typical of the home environment • Understand-o-meter • 2 Forms: • Parent completes items • Child completes items (age 7-8+) • Can compare parent and child responses; use as a means to discuss need for home FM, assistive devices, changes in family communication dynamics

27. General Functioning • FEW – Family Expectation Worksheet • Child is successful in this situation… • Parents list goals in order of priority • Rate the level of child’s success (pre/post-test) • Pediatric Hearing Demand, Ability, and Need Profile • Descriptions of communication activities • Parents rate if a communication problem is present if the hearing aid is on or off • Parents check if problem is due to hearing, noise, distance, visibility and the current compensation

28. School Age • Typically a child will enter preschool or kindergarten and the educational audiologist or speech language pathologist may be informed that they have a hearing loss or hearing aids • Their role is to make recommendations on if the child requires any accommodations to be able to access verbal instruction

29. The move to inclusion • Increasingly, children with hearing loss are in full-time regular education settings • 504 accommodations are often more difficult to obtain than special education services from an education specialist • Children with hearing loss will continue to require acoustic accommodations, regardless of their early intervention successes • Parents who are knowledgeable of their child’s auditory needs and who have the documentation to advocate for appropriately intense accommodations are empowered • If a school does not provide accommodations and the child’s performance decreases over time, the school could potentially be held liable for providing insufficient accommodations

30. We Know…. • Acoustic signals degrade with distance • Integrity of the speech signal is compromised by background noise and reverberation typical of classrooms • Children with auditory disorders are at greater risk for speech perception difficulties under adverse listening conditions • FM technology addresses conditions of distance and background noise and provides benefits to speech perception of the primary signal for persons with normal and impaired hearing

31. With the known benefits of FM, why don’t all children with hearing loss have appropriate S/N enhancing technology? • Ignorance by school administrators of FM • Concern over school budgetary expense • Only required to provide an appropriate program, not the most appropriate • Aim is for “average” achievement (within the range of the classroom), not optimal • Definition of “need” for FM – varies widely

32. Documentation is needed to make the case that there is need for FM • Quoting research helps get the attention of teachers and administrators but is not child specific • Looking at academic grades or asking the teacher or parent “how the child is doing” is too vague • The audiogram does not provide a complete picture of a child’s speech perception, listening in noise abilities, and coping skills • Speech in noise tests in the sound suite provide a 2-dimensional indication of speech perception, functional listening evaluation is more “realistic”

33. What do we really need to find out? • How well does the child perform in different typical communication situations • Verbal instruction • Class discussion • Peer conversations • Home situations • Quiet and noise • Relatively near and far

34. Teacher completed forms PURPOSE • Compare students functioning to peers (Is there a functional deficit in any area?) • Determine areas of non-strength (Based on these, what accommodations or assessments are indicated?) • Monitor functioning over time (Do the accommodations/services meet the child’s speech perception needs and deficit areas so that level of functioning is improved/maintained?) • Determine degree of benefit of classroom technology on overall function after an extended period of use (Are there improvements?)

35. Hearing Loss Specific Scales • Preschool SIFTER – age 3- kindergarten • SIFTER – grade 1 – grade 5 / 6 • Secondary SIFTER grade 6-12 • CHAPS – kindergarten – grade 5 / 6 OTHER BROADBASED SCALES • Psychological Scales: Social Emotional Function • Behavior Assessment System for Children • Achenbach Scales (Teacher Rating Form) • Burk’s Behavior Rating Scale • Connors’ Rating Scale • Behavior Evaluation Scale

36. Teacher completed amplification benefit scales Listening Instrument For Education • Collects information on child’s function with and without amplification (hearing aids, new hearing aids, CI, FM, compare FM types) and indicates need for accommodations (504) • Student LIFE – self report; grade 3+ • Teacher LIFE – pretest and post-test

37. Additional efficacy measures • Observation study performed in the classroom: time on task without amplification device and again when student is using device of interest • Functional Listening Evaluation with and without device of interest • Teacher observation of following typical directions in the classroom setting • Word discrimination in classroom • Spelling tests • Wepman Auditory Discrimination Test • California Consonant Test in classroom

38. Documentation of a child’s functional listening is necessary • TEAMS make decisions on children’s needs based on information • The more compelling and reality based the information the better the chance that appropriately intense accommodations will be provided for the child • Documenting auditory needs related to noise and distance early will create valuable track record supporting avocation

39. Functional Listening Evaluation • Defined procedure to determine how listening abilities are affected by noise, distance, and visual input • Not a sound booth test; done in a “typical environment” • Verbal language response required; 3-word sentences (common phrases and nonsense phrases) • 8 lists of words or phrases needed • Can use to show benefit of any type of FM use • A “staple” in educational audiology

40. Speech in Noise test • The SIN Test audio compact disk is required for test administration. • On this CD, test sentences were recorded at "soft" and "loud" levels 30 dB apart. • Each of these levels is presented at four signal-to-noise ratios (SNRs) with multi-talker babble as the background noise.

41. CHAPS: Children’s Auditory Performance Scale • An intense look at auditory attention • Difficult and time consuming for teacher (or parent) to complete, but good information • Especially useful for obtaining indepth information on children with unilateral, minimal, mild, or cookie-bite hearing loss • Scoring grid shows abilities that fall into normal and at-risk performance categories • Can do following a trial period with sound field amplification in the classroom or personal FM use at home/school

42. Preschool SIFTER: Screening Instrument For Targeting Educational Risk • To be completed by the preschool teacher • Teacher must be aware of what is developmentally normal for the child’s age • 15 questions: preacademics, attention, communication, class participation, school behavior • Scoring: pass or at-risk for expressive communication or socially appropriate behavior

43. SIFTER: Screening Instrument For Targeting Educational Risk • Very similar to Preschool SIFTER • 15 questions, 5 content areas • Scoring grid results in pass, marginal or fail • Valuable for parents of children with hearing loss who are concerned about school progress; audiologist can assist them in determining if concern is warranted • Parent can bring to teacher and return to audiologist (or provide SASE) • Recommendations for FM can be made based on SIFTER results • Valuable to use May SIFTER to inservice new teacher in September

44. LIFE: Listening Inventory For Education – Student appraisal • 15 common school listening activities • Best for elementary, but can use in secondary • Student appraisal: child judges if a listening situation is always easy, mostly easy, sometimes difficult, mostly difficult, or always difficult

45. LIFE – Teacher Appraisal • Pretest (or any time) and Post-test following trial with a new or adjusted amplification device (any type of FM, digital aids after having worn analog) • 15 common classroom situations • Teacher rates student’s apparent degree of listening challenge in the different situations • Total appraisal score plotted on a continuum

46. Buy-in from older children • By the time a child is about 10, they should be fully independent with checking their hearing aids and advocating for classroom accommodations • The LIFE provides a format for the child to develop an awareness of how classroom environments affect listening and understanding and what he or she should do to make it better • Secondary SIFTER can screen for functional classroom performance • Even students who are academically successful are entitled to 504 accommodations such as written assignments, appropriate acoustics, seating, FM, etc).

47. In Determining the Need and Benefit of FM Use…. DOCUMENTATION is the KEY

48. Where can I get these instruments? • ELF, CHILD, SIFTERs, LIFE : www.kandersonaudconsulting.com • CHAPS: www.edaud.org (not free) • DIAL: edaud.org; Members; downloadable reference items • COWS: Oticon – http://otikids.oticon.nl/eprise/main/Oticon/com/SEC_AboutHearing/LearnAboutHearing/Products/SEC_OtiKids/Parents/Networking/91180310cow_counsellingtool.pdf • Functional Listening Evaluation and FAPI: http://www.colorado.edu/slhs/mdnc/assessment.html • IT-MAIS: from Advanced Bionics http://www.bionicear.com/professionals/rehabmaterials.asp • Speech in Noise Test: information at http://www.ausp.memphis.edu/harl/rsin.html