How does NAL-NL prescribe maximum output?
- Simplistically: the maximum SSPL likely to be acceptable at each frequency is assumed to equal the LDL of the person at each frequency. NOTE: does not allow entry of measured LDLs.
- The minimum SSPL likely to be acceptable is assumed to be the point where speech peaks start getting clipped (assuming peak clipping is the means of limiting). NAL assumes this to be 75 dB SPL input + NAL gain.
What does NAL software prescribe?
- Insertion gain curves
- Input-output curve
- REAG curves
- Coupler & ear simulator responses
- Crossover frequencies
- Compression Thresholds
- Compression Ratios
- Gain for 50 dB SPL input
- Gain for 65 dB SPL input
- Gain for 80 dB SPL input
How does NAL-NL prescribe compression?
- CR: prescribed for each channel
- Crossover frequencies: prescribed by audiogram configuration
- CT: defaults to 52 dB SPL; NAL believes that soft (50 dB SPL) speech should be just entering compression. Assumes lower levels are not very important or are noise. Also, NAL studies showed listeners preferred CTs ~ 60 vs. CTs ~ 50.
- AT/RT: not prescribed (although Dillon thinks dual compression is best)
What’s different in NAL-NL2?
- Dead regions: If a particular frequency region contributes little to intelligibility, we don’t want to amplify much in that region. (don’t want to add to overall loudness when there’s no intelligibility benefit)
- When gain isn’t provided, frequency response has a smooth roll-off (NAL-NL1 just didn’t give any values when gain wouldn’t improve intelligibility)
- Gain reduced ~4 dB at mid-input levels, and more at high input levels, compared to NAL-NL1 (based on listeners’ preferred gains)
- Lets user specify fast or slow compression and adjusts gain/compression characteristics accordingly
DSL v 5.0 goals
- Avoid loudness discomfort
- Ensure audibility of important cues in conversational speech as much as possible
- Prescribe compression appropriate for the degree and configuration of the hearing loss, but attempt to make a wide range of speech inputs available to the listener (audibility again!)
- Goals: audibility and comfortable loudness of important speech cues (NOT loudness normalization)
DSL v 5.0 features
- Groups i/o calculations together to create channels, each unified by a set of compression characteristics
- Everything specified as dB SPL in ear canal (does not prescribe REIG targets)
- Predict real ear SPL using the RECD, then fit the hearing aid in a coupler (helpful for kids!)
- Corrects for conductive (+25% of 4-freq ABG)
- Corrects for binaural (- 3 dB)
- For speech in noise, lower gain & higher CR.
DSL for Children
- Higher gain & output for children/congenital loss
- Lower gain & output, lower CR for adults
- Age-appropriate RECDs (specified in months)
- Allows for conversion of tone-burst ABR thresholds from nHL
- Child-specific input speech spectra
DSL v 5 stages:
(1) Expansion
(2) linear gain
(3) compression
(4) output limiting
Hearing Aid Verification (Purposes of Real-Ear)
- confirms that the hearing aid(s) meet(s) a set of standards for quality control
- includes electroacoustic measurements performed according to the ANSI standard (ANSI-S3.22-2003)
- rules out excessive circuit noise, intermittency, and/or poor sound quality
- assesses physical fit through examination of cosmetic appeal, physical comfort/security, absence of feedback, ease of insertion and removal, ease of control, and placement of microphone port
- uses real-ear measurements to establish audibility, comfort, and tolerance of speech and sounds in the environment and to verify compression, directionality, and automatic noise management performance
- incorporates sound field functional gain testing when fitting bone-anchored hearing aids
Speaker Location
Speaker distance from patient: Should be close enough to receive a strong sound level at the ear without speaker overdrive, and reduce influence of other noises in the room.
Fonix 7000: 45 degree azimuth, 12” away from patient
Audioscan Verifit: 0 degree azimuth, 18-36” away from patient.
What types of signals can you use for real-ear testing?
Use speech or speech-like signals or disable digital noise reduction – otherwise the hearing aid will interpret the test signal as noise and attempt to reduce gain.
REUR
Real Ear Unaided Response
The SPL, as a function of frequency, at a specified point in the un-occluded ear canal for a specified sound field. Can be expressed in dB SPL, or as gain (dB) relative to the stimulus level
REOR
Real EAr Occluded Response
- The SPL, as a function of frequency, at a specified point in the ear canal for a specified soundfield, with the hearing aid in place and turned off. Expressed in dB SPL or as gain (dB) relative to the stimulus level
REAR
Real Ear Aided Response
- The SPL, as a function of frequency, at a specified measurement point in the ear canal for a specified soundfiled, with the hearing aid in place and turned on. Expressed in dB SPL or (less commonly) as gain (dB) relative to stimulus level
RESR
Real Ear Saturation Response
The SPL, as a function of frequency, at a specified measurement point in the ear canal with the hearing aid in place and turn on. Stimulus level is intense enough to operate the hearing aid at maximum output (typically 90 dB SPL)
REIR
Real ear insertion response
The difference, in dB as a function of frequency, between the REUR and the REAR measurement taken at the same measurement point in the same soundfield
What is REAR minus REUR?
If expressed as gain relative to stimulus level, you may see REAG or REUG. REIG is always “gain” relative to unaided response.
What levels do you test REARs?
60
70
80
Why do we do REAR measures?
accounts for the aid (including earmold effects, like venting) and the ear/head. It realls to the sound level at the patient’s TM, regarless of what influences that sound level (ear or aid). It is easy to consider in terms of dynamic range/audibility
REIG
REIG = REAG - REUG
REIG tells you what the patient is getting with the hearing aid that they didn’t have before.
Requires you measure an inidividual REUR (or you can use average REURs, but they won’t account for your patient’s individual ear canal effects)
Which to use, REIR or REAR?
•
REIR (has fallen out of favor among clinicians):
–
Tells you what the patient is getting with the hearing aid that they didn’t have before
–
Requires you measure an individual REUR (or you can use average REURs, but they won’t account for your patient’s individual ear canal effects)
•
REAR:
–
Just tells you the sound level at the patient’s TM. Doesn’t care where gain comes from (ear or aid)
–
Easier to consider in terms of dynamic range (threshold to UCLs) to assess audibility
What is important while measuring RESR levels?
Be sure the RESR is not exceeding LDL levels – make any necessary MPO adjustments. Remember general complaints of “loudness” may be the MPO, or perception of lower levels
RECD
The RECD procedure consists of: (1) a 2cc coupler-based measurement and (2) a real-ear measurement. The 2cc coupler measurement is made on the same coupler used for hearing aid fitting. A transducer from the real-ear system delivers a signal into the coupler and defines the SPL of the signal as a function of frequency. Most probe-microphone systems have the capability to permanently store the coupler response
The same signal is delivered from the same transducer into the ear via a custom earmold or foam tip. The system again measures the level of the signal (this time in the ear) as a function of frequency. The difference between the signal on the ear and the coupler is the real-ear-to-coupler difference.
Instead of using the signal from the real ear system, you can measure RECD with an audiometer and insert phone (shown here) or with the same hearing aid, same earmold, same settings. The only requirement is that the sound source be exactly the same for both coupler and in-ear measures.
Potential problems doing real ear with open fits
- sound escapes from vent/open canal and “tricks” the reference mic into thinking there is more sound from the speaker than there really is
- reference mic thinks it is output from loud speaker, and so loudspeaker output to ear is turned down
- the result will be less measure hearing aid output
Solutions to problems doing real ear with open fits:
Solution #1: calibrate or “level” the equipment, then turn the reference mic off.
Solution #2: If you can’t turn off the reference mic, you could try lowering the reference mic (recall that distance away from the point of leakage is one of the factors).
Solution #3: You could simply assume that you’re making ~5 dB error around the peak of the REAR
Suggested Test Order for Real-Ear
1.
Enter audiogram into real ear system
2.
Choose prescriptive target
3.
Retrieve client data and connect aid. Program to first fit for the same prescription as will use in real ear.
4.
Otoscopic exam
5.
Verify physical fit, cut earmold tubing if BTE
6.
Instruct patient on real ear, place probe mic
7.
Measure REAR and adjust to match conversational target (adjust overall gain, frequency-gain bands)
8.
Measure REARs and adjust to match for soft/loud targets (adjust soft/loud gain, compression)
9.
Measure RESR and adjust at/below LDLs (adjust MPO)
10.
Verify directionality
How close to target do you need to be for real ear?
•
Two separate sources (Dillon & Fabry) suggest:
–
Aim to be within 5 dB of target from .25-4 kHz. As much as 10 dB deviation may be ok in some cases.
–
When all measures are above target (or all are below) can be corrected with VC adjustments. If below target at some frequencies and above target at others frequencies (poor match to slope), consider adjusting
–
Try to match soft speech target, but remember goal is audibility while maintaining appropriate range of loudness (soft speech should sound softer than conversational speech)
–
Try to match loud speech target, but remember goal is loud but ok, while maintaining appropriate range of loudness (loud speech should sound louder than conversational speech)
Using Real Ear to verify directional microphone
•
Compare 0 to 180 degrees (or the null of the polar plot, if not 180 – you can let the signal play and rotate the patient until the response is at its lowest point) at same level
•
Verifit’s Directional Test uses two speakers at 0 and 180 degrees
- presents over 1000 tones simultaneously at different frequencies from both front and back sound-field speakers. Tones are individually controlled to produce a precise spectrum from each speaker at the on-ear reference mic
- The ear canal SPL is analyzed into two real-time response curves, labeled F (front) and B (back) to indicate which speaker generated the curve.
Some Real Ear topics for discussion/Practice
•
Matching a single-level target (how close is close enough, and how to get there quickly)
•
When not to chase the target (considering severity of loss and dead regions – usually high frequencies)
•
Matching multiple targets (when to adjust overall gain versus compression)
•
Verifying signal processing (directional microphones, digital noise reduction, frequency lowering)
•
Understanding real ear for open canal fittings (hint: you can’t affect the lows by changing hearing aid settings). Also when to give up and use an occluding earmold.
•
Fitting conductive losses
•
Using non-standard signals as demos/counseling
Conversions between measurements in real ear
The RECD is the difference between output in the coupler and output in the ear. The CORFIG is the difference between gain in the coupler and gain in the ear. CORFIG considers: that when an aid is placed in the ear, the REUR is lost; the RECD is gained, because the ear is smaller than the coupler; and there may be some resonance because of the position of the microphone (only for ITE/ITC/CIC).
REAR – 2CCR = RECD REAR – REUR = REIR Target REIG + CORFIG = Target 2CCR 2CCR + GIFROC = REIR or 2CCR – CORFIG = REIR CORFIG = REUR – RECD – AID/MIC EFFECT AID/MIC EFFECT IS NEGLIGIBLE FOR BTES
Hearing Aid Validation
1.
documents that the disability has been reduced and audiologic treatment goals have been addressed
2.
includes self-assessment tools that measure benefit and satisfaction
3.
measures speech perception using either objective or subjective techniques. The effects of stimulus selection, presentation levels, noise type, signal-to-noise ratio, and the number of test items on the reliability and validity of speech perception measures should be indicated.
What are the three WHO concepts that effect a health condition (disorder/disease)
- Body function & structure (Impairment)
- Activities (limitation)
- Participation (restriction)
Within these there are environmental factors and personal factors.
What are the two types of measures when assessing hearing?
objective and subjective
What are some objective hearing measures for determining hearing aid needs?
speech in quiet
speech in noise
aided threshold (functional gain)
audibility (aided threshold + count-dot audio)
What are some subjective hearing measures for determining hearing aids needs?
sound quality ratings
loudness ratings
questionnaires
What are some questionnaires that are customized, individual (“open ended”)
- COSI (benefit, direct change)
- GHABP (disability, handicap, use, benefit, satisfaction)
What are some questionnaires that are standard (“closed ended”)
- APHAB (benefit, activity limitation)
- HHIE and HHIE-S (handicap/participation, restriction, pre-post state)
- SADL (satisfaction, post)
- IOI-HA (benefit + satisfaction + HRQoL)
What makes a good self assessment measure?
• Relevance • Reliability • Inter-patient variability • Appropriate for population • Well-validated • Easy to administer and score • Short • Administered after benefit, etc. has stabilized (suggest ~ 6 wks post-fit)
Self-assessment measures
• At evaluation – Helps determine candidacy – Helps identify unrealistic expectations – Good audiometric candidate, but poor motivation • At follow-up visit to assess HA benefit – Is benefit adequate? • Direct • Unaided vs aided comparison – Identify situations needing improvement
Problems with self-assessment tools
•
Patients may not like, or will not complete
•
Audiologists may not like to administer and/or score
•
Standard questionnaires may not identify specific priorities
•
Some patients may have difficulty understanding complex questionnaires (note availability of questionnaires for CPs, such as the IOI-HA-SO and SOS-HEAR)
Therefore….COSI
COSI
- at consultation, patient identifies 3-5 listening priorities
- after fitting, patient rates
- degree of change with hearing aids
- how well they can hear in that situation now
If the COSI was completed prior to fitting, the patient can assess the amount of improvement with the hearing aid
- is included in some manufacturer’s modles with NOAH
Self-assessment tools assessing multiple domains
Glasgow Hearing Aid Benefit Profile (GHABP, 1999)
•Assesses 6 domains: Hearing Handicap, Hearing Disability, Hearing Aid Use Time, Benefit, Residual Disability, Satisfaction
•Provides 4 situations and can nominate 4 individualized situations
International Outcomes Inventory (IOI-HA, 2002)
•7 questions: Hearing Aid Use, Benefit, Residual Activity Restriction, Satisfaction, Residual Participation Restriction, Impact on Others, QoL
APHAB
- 24 questions across 4 domains
- 7 point response
- unaided and aided
- computer or pencil and paper version
- Ease of Communication (EC scale)
- Background noise (BN Scale)
- Reverberation (RV scale)
- Aversiveness (AV scale)
- global score (average EC, BN, RV)
Using the APHAB
•Unaided –Assess candidacy –Select appropriate features •Measuring benefit –Decreased disability in each subscale –Compare to norms to decide to keep (borderline) •Troubleshooting –Identify situations w/ low benefit –Assess expectations –Consider technology change
SADL
• Post-fitting (can use ECHO pre-fit) • 15 questions (Reversed items 2, 4, 7, 13) • 7-scale response format • 4 subscales – Positive effect (decreased communication problems, better self confidence, sound quality – Service and cost (reliable, clinician, $) – Negative features (BN, phone, FB) – Personal image (appearance, others’ opinion) (+ Global score)
What are three reasons to educate the patient?
- provide realistic patient choices
- encourage self-efficacy
- convey sense of unique issues and abilities (one size does not fit all)
Principles of self-management
- targeted assessment
- evidence-based information to guide shared decision making
- collaborative problem solving
- patient self-efficacy (choices)
- active follow-up
- multifaceted intervention
Medical Model
- top-down communication
- authoritarian
- clinician determines diagnosis and treatment
- clinician does something “to” client
- assumes clinician knows what is best for client
Rehabilitative model
- horizontal communication
- interactive and facilitative
- clinician does something “with” client
- assumes client’s perceptions and needs will determine treatment goals
Informational counseling
- provide patient with relevant information to understand nature of the disorder and the steps recommended to manage it
Personal adjustment counseling
- process of guiding the family and patient in dealing with the emotional impact of the information
What affects patient adherence to treatment?
- rapport with provider
- patient expectations
- patient perception of usefulness of treatment
- communication
- complexity of treatment
- continuity of care
- family stability and social support
- cognitive abilities
What are the four main things that affect patient adherence to treatment?
- rapport with provider
- patient expectations
- patient perception of usefulness of treatment
- communication
How much effect does good communication have on patient adherence to treatment?
good provider to patient communication improves adherence to treatment by nearly 20%
What are the four types of “social styles” we discussed in class?
Analytical
Driver
Amiable
Expressive
What were some of the ways to describe an Analytical social style
critical indecisive stuffy picky moralistic industrious persistant serious exacting orderly
What were some of the ways to describe a Driver social style
pushy severe tough dominating harsh strong willed independent practical decisive efficient
What were some of the ways to describe an Amiable social style
conforming unsure pliable dependent awkward supportive respectful willing dependable agreeable
What were some of the ways to describe an Expressive social style
manipulative excitable undisciplined reacting egotistical ambitious stimulating enthusiastic dramatic friendly
What things would an analytical person do?
- takes time to do things right
- walks in even strides
- speaks slowly and distinctly
- seldom interrupts
- gathers all data prior to making decision
- precise, thorough, uses detailed facts
- expresses thoughts regarding a task rather than personal feelings
What things would a driver person do?
- gets down to business quickly
- walks briskly
- speaks quickly, using change in tone
- often interrupts
- seeks options and efficiency
- processes info evaluating facts and probability of success
- expresses thoughts regarding a task rather than personal feelings
What things would an amiable person do?
- takes time to get to know you
- walks slowly and purposefully
- patient
- warm and friendly
- talks about relationships
- sensitive to other’s feelings
- processes information by considering how it affects others
What things would an expressive person do?
- moves rapidly to generate excitement
- walks and talks quickly
- energetic
- often interrupts
- can appear loud
- enjoys being the center of attention
- shares ideas, feelings, stories
- process information with examples or analogies
What are the 5 personality traits that can affect self reported hearing aid outcomes (according to cox et al.)
neuroticism extraversion openness agreeableness conscientiousness
How do the 5 personality traits described by Cox et al affect self-reported hearing aid outcomes?
more “neurotic” points had more negative expectations & reported more problems
extroverted - open and agreeable, reported more positive expectations, fewer problems and were less bothered by loud (unaided) sound
General counseling tips
- Don’t negate patient’s opinion “oh, you shouldn’t feel that way”
- Face patient, speak clearly & slowly, good vocal strength
- Extract info from patient (“then what”?) Describe expected effects, ask patient if that happens
- *Adapt to patient’s level of technical knowledge, intelligence
- Keep control of the conversation with talkative patients
- Be professional, confident but patient is focus. Dress appropriately. Don’t fidget, chew nails, arms crossed. Maintain appropriate personal space. Address as Mr/Ms/Mrs until told otherwise.
Describing the hearing loss (at assessment stage)
- Tools: speech sound audiogram, anatomical view of ear
- Degree of loss, configuration, effect on speech sounds
- Location of loss in auditory system, potential for repair
- Relate to things the patient reports/can understand
- Could also use hearing handicap scales
Discussing hearing aid options (at selection stage)
- Tools: demo aids (don’t let patient put in own ear for infection control reasons), demo remotes
- You’ll have previously decided what is essential, out of the question, most beneficial
- Pros & cons of: style, features
- Assess patient needs, desires & expectations
- Benefits & limitations of the aid
- Use terms & examples patient can understand
- If patient wants something completely unreasonable, refuse (give reasons). If patient wants something possible but doubtful, counsel then check strength of preference. If adamant, might fit with reservations
How-to’s of hearing aids (at fitting)
- Tools: patient’s new aids, instruction book, batteries, dri- aid kit, cleaning tools
- Explain parts/function of hearing aid
- Don’t wash, dry in microwave, stick things into receiver (except cleaning tool – gently), leave on car dashboard, use hairspray
- Insertion/removal, with practice until proficient
- Cleaning: demonstrate
- Battery changing: demonstrate. Write down battery size. Warn against swallowing.
- Aid features: switches, push buttons, what will happen automatically
- Troubleshooting (often in the manual)
- Using the phone: appropriate instructions & have patient practice.
Good listening strategies/adjusting to the hearing aid
- Tools: written info, simulated loss recording for family
- Tools to demonstrate benefit at fitting or f/u: functional gain, real-ear targets, APHAB or SADL scores
- Begin in quiet situations, few hours/day, gradually increase use
- Explain brain needs to adapt to new sounds/retrain gradually
- Use visual cues/speechreading
- Manipulate environment when possible: reduce noise, educate family, close to speaker/good side if there is one
- Positioning if using directional microphones
- Emphasize realistic goals. Patients forget they couldn’t hear perfectly in a noisy restaurant when they had normal hearing
Difficult situations
- Dexterity problems
- Confusion/cognitiveissues,Alzheimer’s • Depression
- Denial
- Know-everything patients
- Dishonest
- Time-wasting patients
- Careless patients
- Angry patients
Describing the hearing loss (at assessment stage)
- Tools: speech sound audiogram, anatomical view of ear
- Degree of loss, configuration, effect on speech sounds
- Location of loss in auditory system, potential for repair
- Relate to things the patient reports/can understand
- Could also use hearing handicap scales
Discussing hearing aid options (at selection stage)
- Tools: demo aids (don’t let patient put in own ear for infection control reasons), demo remotes
- You’ll have previously decided what is essential, out of the question, most beneficial
- Pros & cons of: style, features
- Assess patient needs, desires & expectations
- Benefits & limitations of the aid
- Use terms & examples patient can understand
- If patient wants something completely unreasonable, refuse (give reasons). If patient wants something possible but doubtful, counsel then check strength of preference. If adamant, might fit with reservations
How-to’s of hearing aids (at fitting)
- Tools: patient’s new aids, instruction book, batteries, dri- aid kit, cleaning tools
- Explain parts/function of hearing aid
- Don’t wash, dry in microwave, stick things into receiver (except cleaning tool – gently), leave on car dashboard, use hairspray
- Insertion/removal, with practice until proficient
- Cleaning: demonstrate
- Battery changing: demonstrate. Write down battery size. Warn against swallowing.
- Aid features: switches, push buttons, what will happen automatically
- Troubleshooting (often in the manual)
- Using the phone: appropriate instructions & have patient practice.
Good listening strategies/adjusting to the hearing aid
- Tools: written info, simulated loss recording for family
- Tools to demonstrate benefit at fitting or f/u: functional gain, real-ear targets, APHAB or SADL scores
- Begin in quiet situations, few hours/day, gradually increase use
- Explain brain needs to adapt to new sounds/retrain gradually
- Use visual cues/speechreading
- Manipulate environment when possible: reduce noise, educate family, close to speaker/good side if there is one
- Positioning if using directional microphones
- Emphasize realistic goals. Patients forget they couldn’t hear perfectly in a noisy restaurant when they had normal hearing.
Benefits of group counseling
Support network
Allow individual to take responsibility for managing their loss, and identify realistic expectations
Supports more assertive problem-solving behavior
Educating family members, friends, caregivers
Cost effective – one audiologist can train several people at once
AuD students’ concerns about interacting with patients and families
- patient becomes angry
- not knowing answer to patient’s questions
- telling parent baby has heaing loss
- appearing nervous or incompetent
- patient is confrontational
- patient challenges my credentials
- patient rambles, cannot get conversation on track
- patient is non-communicative
- patient cries
The golden rules for fitting children
- Fit as early as possible. ABR thresholds can be used.
- Fit binaurally unless contraindicated
- BTE + soft mold for infants & young children (up to 8 yrs+)
[remember BC aids & CIs may also be options] - Children have small ears so need less gain. Use individual
RECDs (or, if that isn’t possible, age-appropriate average
RECDs). Match to target can then be done in coupler.
(Note: patent PE tube increases RECD; OME decreases RECD) - DAI & tcoil for use with classroom ALDs (include FM+mic option!)
- DSL is most child-appropriate prescription
- Counseling parents (review Dillon section 16.7-8)
Processing considerations for children
- Remember kids are learning language. Need greater hf gain/better hf audibility -> different targets (use DSL)
- Prefer higher outputs for soft and medium inputs -> different targets (use DSL)
- Young children and babies cannot adjust volume -> use WDRC
- Children need better SNR -> reduce BN. BUT: do not use full-time directionality on infants/young children
Things we don’t know for certain but could make reasonable decisions about:
• Feedback reduction – good or bad? – Improves audibility (good)
– May introduce artifacts (bad) – Can you fit w/o FB reduction?
• Frequency lowering – good or bad?
– Improves high-frequency sound detection for some
losses (good)
– Alters speech input (bad)
– Use if needed (can you think of an example audio?)
Miscellaneous issues with fitting kids with hearing aids
• Safety considerations
– Batteries (tamper-resistant doors)
– Poison control center
– Earmolds (soft materials)
– Retaining the hearing aids (huggies, toupee tape, clips)
• When does a child (teenager) become “adult”?
– When to go to ITE style
Goals for Amplification (kids)
- Appropriate gain for a variety of input signals
- Comfortable listening without distortion or feedback
- Broad bandwidth for audibility of high Hz
- Audibility in quiet and in noise
- Accessibility to assistive technology (e.g., FM)
- Appropriate for children’s unique needs
Family-centered care
• Familieswilllooktoyouastheexpert
– You should be able to provide appropriate options
• Familieswilloftenbeoverwhelmedattheprospect
of a first hearing aid fitting or changes in technology – Sometimes there are too many options!
• TheAudiologistprovidesguidanceandchoices, then listens to the families as experts in their child’s care
• Involveandconsiderfamilyfeedbackwhen selecting technology, features and fine-tuning
– Other members of the care team can provide insight
Assessing the needs of children and families
- how old is the child?
- what are the characteristics of the hearing loss?
- what are the different listening situations he or she will encounter over the next several years?
- will the instrument meet changing needs of the child?
- does the hearing aid need to be compatible with other devices and at what age?
Important information to consider with infants and todlers
- may have limited diagnostic information
- sometimes ABR only
- acoustics are different, where is baby compared to caregiver, positioning and feedback, growth and ear acoustics
- retention (remember fine motor improvement in toddlers increases chance of them removing the aid)
What to consider when fitting elementary school kids?
Assessment
- we should now have complete diagnostic information
- child is not growing as quickly
Acoustics, noise and distance
- now where is the speaker? considerations for additional features
- classroom set up and acoustics
- other activities (retention!) and noise
Technology
- using the telephone more
- other devices
Issues
- changes to care team include more school personnel and need to educate about challenges
- fatigue and social issues become more apparent
- empower child to take more responsibility
Why do we use BTEs for kids?
- BTE hearing aids are durable, do not need to be recased with growth, safer, less likely to produce problems with acoustic feedback, and more flexible for use with assistive devices. Earmolds can be remade for better fit while still wearing the aid with the previous earmold - no downtime
- switches - what turns the hearing aid off?
- battery door - tamper resistant?
- volume control - continous, discrete, can it be deactivated or removed
- earhook (use pediatric hooks)
- notification of program switching or function
- remote control - when is it worthwhile?
Teens and Young adults
Assessment
- complete evaluations with speech recognition
- minimal growth
Acoustics
- much more challenging situations connectivity
Issues
- cosmetic concerns
- need for more features; ability to make independent choices
- changing social-emotional needs
- self-advocacy
Older kids - changing style and needs
needs assessment based on listening environment, cosmetic considerations and other equipment used
Why do we use DSL for kids?
- takes into account differences in dB HL to dB SPL with different transducers
- enter ABR thresholds for infants and those children who cannot be tested behaviorally: dBnHL
- Has ability to enter bone conduction values, additional gain for conductive and mixed losses
- choice of monaural vs binaural fitting, prescribed targets reduced by 3 dB for binaural summation
- age-appropriate LTASS (as when parent is holding infant - closer speaker distance)
- normative RECD values to 1 month of age (for when you can’t get individual RECD)
- type of amplification: BTE, ITE, ITC, CIC, Open, Body, FM
- Safety of signal: MPO targets to avoid over amplification
- Multiple inputs: soft, average, loud speech, different speakers
RECD = real ear to couple difference
children
- Measurement in the child’s ear with his own earmold or an insert earphone, difference between measurement of sound in the 2 cc coupler and the ear canal
- quick, reliable
- eliminates variability associated with soundfield probe mic measures (movement, noise, etc)
- allows all subsequent setting to be accomplished without the child being attached to equipment
Measuring the RECD (steps)
- preform otoscopy
- align probe tube with earmold to extend just beyond the end of canal and mark, should be 3 mm for infants and 5 mm for older children beyond end of canal on earmold
- if earmold is not available, measure with foam tip + insert phone
- place probe tube in canal; may be helpful to use lubricant or tape
- insert mold with transducer attached
- measure
Hearing aid orientation & counseling (children)
- wearing schedule
- incorporating HAs into daily life
- when & where NOT TO WEAR AIDS
- retention
- child removal of HAs
- Expectations for child’s responses to sound
- impact of noise and distance
- enhancing communication
Wearing schedule - children
- infants and toddlers, start in quiet at child’s “best” time of day
- older children, start in quieter environments, talk with teachers, educate peers
- goal: full time use in 2-3 weeks after fitting
- keep a calendar or journal to record wear and experiences
Encouraging wear in infants and children
- parent needs to maintain control and not overreact if child removes, try again later
- wear during fun activities, but not with a lot of background noise
encouraging wear in older children
- school
- some may need a short break
- at home during family activities and media use
What happens when the child’s hearing aid is first turned on?
- set it up so the child’s first reaction can be to a family member’s voice
- this can be a very powerful, emotional time for families
- make it natural, positive, give encouragement
- for older children discuss new sounds they hear
Communication with hearing aids in children
Communicate naturally
- use visual cues
- point out sounds
- listening bubble, noise and distance
- if older children notice new sounds and noises, discuss what is important and what may just be “background” that others hear, too
Realistic expectations of child’s response
Other family members or school mates
Ways to measure subjective outcomes for children with hearing aids.
PEACH: Parent’s evaluation of Aural/Oral performance of children (also teach)
IT-MAIS: Infant-toddler meaningful auditory integration scale
SIFTER: screening instrument for targeting educational risk
PEACH:
PEACH: Designed for parents to record how child is communicating with HAs/CIs. Observe for at least one week, and record observations for 13 questions.
Topics : USE of amplification & Loudness DISCOMFORT; communicating in QUIET; communicating in NOISE; TELEPHONE; responsiveness to ENVIRONMENT sounds
- preschool to 7 years
- available in other languages including: arabic, turkish, vietnamese, chinese
SIFTER
- screening questionnaire
- teacher completes
- school age (preschool version is the p-sifter, available)
What to do if someone fails the SIFTER?
Action to take: fail in content area: further assessment. E.g., fail Academics => educational assessment; fail Communication => speech-language assessment; fail School Behavior => assessment by a psychologist or a social worker; fail Attention and/or Class Participation area in combination with other areas => evaluation by educational audiologist. In marginal area: monitor or assess
IT-MAIS
- birth to 3 years
The IT-MAIS (Zimmerman-Phillips, 2000) is a structured interview designed to assess the child’s spontaneous responses to sound in his/her everyday environment.
The assessment is based upon information provided by parent(s) in response to 10 probes (3 main areas) 1) vocalization behavior, 2) alerting to sounds; and 3) deriving meaning from sound.
Why do we use BTEs for kids?
- BTE hearing aids are durable, do not need to be recased with growth, safer, less likely to produce problems with acoustic feedback, and more flexible for use with assistive devices. Earmolds can be remade for better fit while still wearing the aid with the previous earmold - no downtime
- switches - what turns the hearing aid off?
- battery door - tamper resistant?
- volume control - continous, discrete, can it be deactivated or removed
- earhook (use pediatric hooks)
- notification of program switching or function
- remote control - when is it worthwhile?
Teens and Young adults
Assessment
- complete evaluations with speech recognition
- minimal growth
Acoustics
- much more challenging situations connectivity
Issues
- cosmetic concerns
- need for more features; ability to make independent choices
- changing social-emotional needs
- self-advocacy
Older kids - changing style and needs
needs assessment based on listening environment, cosmetic considerations and other equipment used
Why do we use DSL for kids?
- takes into account differences in dB HL to dB SPL with different transducers
- enter ABR thresholds for infants and those children who cannot be tested behaviorally: dBnHL
- Has ability to enter bone conduction values, additional gain for conductive and mixed losses
- choice of monaural vs binaural fitting, prescribed targets reduced by 3 dB for binaural summation
- age-appropriate LTASS (as when parent is holding infant - closer speaker distance)
- normative RECD values to 1 month of age (for when you can’t get individual RECD)
- type of amplification: BTE, ITE, ITC, CIC, Open, Body, FM
- Safety of signal: MPO targets to avoid over amplification
- Multiple inputs: soft, average, loud speech, different speakers
RECD = real ear to couple difference
children
- Measurement in the child’s ear with his own earmold or an insert earphone, difference between measurement of sound in the 2 cc coupler and the ear canal
- quick, reliable
- eliminates variability associated with soundfield probe mic measures (movement, noise, etc)
- allows all subsequent setting to be accomplished without the child being attached to equipment
Measuring the RECD (steps)
- preform otoscopy
- align probe tube with earmold to extend just beyond the end of canal and mark, should be 3 mm for infants and 5 mm for older children beyond end of canal on earmold
- if earmold is not available, measure with foam tip + insert phone
- place probe tube in canal; may be helpful to use lubricant or tape
- insert mold with transducer attached
- measure
Hearing aid orientation & counseling (children)
- wearing schedule
- incorporating HAs into daily life
- when & where NOT TO WEAR AIDS
- retention
- child removal of HAs
- Expectations for child’s responses to sound
- impact of noise and distance
- enhancing communication
Wearing schedule - children
- infants and toddlers, start in quiet at child’s “best” time of day
- older children, start in quieter environments, talk with teachers, educate peers
- goal: full time use in 2-3 weeks after fitting
- keep a calendar or journal to record wear and experiences
Encouraging wear in infants and children
- parent needs to maintain control and not overreact if child removes, try again later
- wear during fun activities, but not with a lot of background noise
encouraging wear in older children
- school
- some may need a short break
- at home during family activities and media use
What happens when the child’s hearing aid is first turned on?
- set it up so the child’s first reaction can be to a family member’s voice
- this can be a very powerful, emotional time for families
- make it natural, positive, give encouragement
- for older children discuss new sounds they hear
Communication with hearing aids in children
Communicate naturally
- use visual cues
- point out sounds
- listening bubble, noise and distance
- if older children notice new sounds and noises, discuss what is important and what may just be “background” that others hear, too
Realistic expectations of child’s response
Other family members or school mates
Ways to measure subjective outcomes for children with hearing aids.
PEACH: Parent’s evaluation of Aural/Oral performance of children (also teach)
IT-MAIS: Infant-toddler meaningful auditory integration scale
SIFTER: screening instrument for targeting educational risk
PEACH:
PEACH: Designed for parents to record how child is communicating with HAs/CIs. Observe for at least one week, and record observations for 13 questions.
Topics : USE of amplification & Loudness DISCOMFORT; communicating in QUIET; communicating in NOISE; TELEPHONE; responsiveness to ENVIRONMENT sounds
- preschool to 7 years
- available in other languages including: arabic, turkish, vietnamese, chinese
SIFTER
- screening questionnaire
- teacher completes
- school age (preschool version is the p-sifter, available)
What to do if someone fails the SIFTER?
Action to take: fail in content area: further assessment. E.g., fail Academics => educational assessment; fail Communication => speech-language assessment; fail School Behavior => assessment by a psychologist or a social worker; fail Attention and/or Class Participation area in combination with other areas => evaluation by educational audiologist. In marginal area: monitor or assess
IT-MAIS
- birth to 3 years
The IT-MAIS (Zimmerman-Phillips, 2000) is a structured interview designed to assess the child’s spontaneous responses to sound in his/her everyday environment.
The assessment is based upon information provided by parent(s) in response to 10 probes (3 main areas) 1) vocalization behavior, 2) alerting to sounds; and 3) deriving meaning from sound.
