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267 Cards in this Set

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APD CANNOT be explained by disruption of which of the following neuro-biological developmental trends.
A. Synaptogenesis
B. Arborization
C. Myelination
D. Cell differentiation
E. Eye-hand coordination
E
According to the 2010 AAA APD Clinical Guidelines, the definition “identification and categorization of impairment or dysfunction“ is most appropriate for which of the following terms.
A. Detection and identification
B. True positive
C. Assessment
D. Diagnosis
E. Test battery
d
Among the following statements, select the most appropriate current definition of APD:
A. A learning disability that involves the auditory modality
B. A subgroup of patients with attention deficit disorder and difficulty hearing
C. A deficit in the processing of information that is specific to the auditory modality
D. An auditory form of specific language impairment (SLI)
E. All of the above
c
:An APD test battery should include which of the following:
A. Non-verbal tests
B. Tests with age-referenced normal data
C. Phonetically balanced sentence materials
D. a and b
E. All of the above
d
Characteristics of children with auditory processing disorder often include all of the following EXCEPT:
A. Poor academic performance
B. Inability to listen to the teacher and take notes
C. Hyperactivity
D. Poor listener
E. Low self-esteem
c
Fundamental problems underlying auditory processing disorders include which of the following:
A. Inadequate transmission of information in the auditory CNS
B. Inadequate analysis of information in the auditory CNS
C. Deficits in temporal auditory processing
D. Deficit in perceiving auditory information in background noise
E. All of the above
e
OAEs are always normal in children undergoing evaluation for APD.
True
False
f
The acronym LISN refers to:
A. Listening Is So Nice
B. Listening in Speech Noise
C. Low Integration (of) Speech Nuances
D. Listening in Spatialized Noise
E. None of the above
d
Which of the following abbreviations refers to a cortical auditory response that is now being used to study auditory processing mechanisms in children and adults.
A. SSER
B. ECochG
C. ENoG
D. VEMP
E. MMN
e
Which of the following abbreviations refers to an imaging technique that is being used to investigate basic auditory processing mechanisms.
A. CT
B. MRN
C. fMRI
D. ultrasound
E. BEAM
c
Which of the following acronyms is used for a new test of temporal auditory processing, specifically evaluating the auditory process known as gap detection?
A. LISN test
B. GDT
C. SSI-ICM test
D. SCAN test
E. GIN test
e
Which of the following factors contributed to the interest in assessment and management of APD since 1990?
A. Neuroanatomic studies confirming brain abnormalities
B. Neuroradiologic studies, e.g., Fmri
C. Neurophysiologic studies, e.g., P300 and MMN
D. 1996 ASHA Consensus Conference
E. All of the above
e
Which of the following is a screening measure for phonological (phonemic) awareness?
A. SCAN
B. TAAS
C. CELF-R
D. WISC
E. ACPT
b
Which of the following persons developed the SCAN test battery?
A. Jack Katz
B. James Jerger
C. Frank Musiek
D. Robert Keith
E. Carlo Calearo
d
Which of the following persons developed the SSI procedure?
A. Jack Katz
B. James Jerger
C. Frank Musiek
D. Robert Keith
E. Carlo Calearo
b
Which of the following persons developed the SSW procedure?
A. Jack Katz
B. James Jerger
C. Frank Musiek
D. Robert Keith
E. Carlo Calearo
a
Which of the following professionals would you want on your APD team (other than an audiologist)?
A. Speech pathologist
B. Psychologist
C. Occupational therapist
D. Developmental pediatrician
E. All of the above
e
Which of the following statements about APD is NOT true?
A. Procedures for assessment date back over 25 years
B. ALDs are useful in the management of some children with APD
C. Assessment is within the scope of practice of audiology
D. APD is generally a result of ADHD
E. Prevalence is estimated to be 3 - 5% in school-age children
d
Which of the following was not a “listener variable” cited in the report of the 2000 Dallas (Bruton) Conference on APD written by Jerger & Musiek (2000)?
A. Attention
B. Fatigue
C. Intellectual and developmental age
D. Gender
E. Motivation
d
Which two people contributed to the early development of the dichotic listening test paradigm before it was applied clinically in audiology?
A. Jerger and Hayes
B. Broadbent and Kimura
C. Hecox and Galambos
D. Northern and Downs
E. Selters and Brackmann
b
The principle of auditory plasticity helps to explain the benefits of early intervention for APD:
True
False
t
14.The auditory brainstem response (ABR) can be effectively elicited by speech stimuli.

True
False
t
A neuropsychological concept referring to the cognitive processes required to plan and direct activities is:
A. Articulation
B. Phonological awareness
C. Sustained attention
D. IQ
E. Executive functioning
e
Amplification never plays a role in the management of APD.
True
False
f
An accommodation in an educational setting changes instructional (difficulty) level, content, performance criteria, and the curriculum.
f
Children with APD may have clinically significant psychosocial problems:
t
Consistent use of a personal FM system (specifically the Phonak EduLink system) during the school year may improve:
d
Earobics is a commercial computer based program for the development of auditory and pre-reading skills:
t
Educational intervention for school children with academic problems are usually provided based on which one of the following:
a
For the child with APD, personalized FM technology (sound delivered to the ears) is LESS effective than classroom FM amplification.
f
If you suspect a child with APD might have dyslexia, assessment of which of the following would be most appropriate?
A. Blood chemistry
B. CT scan
C. Phonologic (phonemic) awareness
D. Expressive language skills
E. IQ
c
Language processing is synonymous with auditory processing:
True
False
f
Phonologic (phonemic) awareness is one of the 5 components of reading:
True
False
t
Recent research at Northwestern University confirms that sub-cortical deficits in differentiation of stop consonants contribute to poorer performance in reading and speech perception in noise.
True
False
t
Recent research shows that APDs and specific language impairment (SLI) are independent disorders.
True
False
t
The DIID training technique developed by Dr. Frank Musiek involves which of the following auditory processes:
A. Auditory figure ground
B. Sustained auditory attention
C. Difference limen for frequency
D. Dichotic listening
E. None of the above
d
The acronym EARS refers to:

A. Early Acquisition of Reading Skills
B. Electrical Acoustic Reflex Stimulation
C. Early Articulation Remediation System
D. Early Auditory Reading Success
E. None of the above
d
The study reported by Moncrieff & Wertz (2008) showed that intensive dichotic training resulted in improvement all of the following skills EXCEPT:
A. Dichotic listening performance
B. Language comprehension
C. Speech reception threshold
D. Word recognition
E. Symmetry of scores on dichotic digits test
c
The trend for assessment and eligibility of children with learning disabilities is moving from a discrepancy model to a response to intervention approach:
True
False
t
Which of the following are usually considered as risk factors for APD?
A. Family history of auditory processing disorder
B. Head injury
C. History of chronic otitis media
D. Poor academic performance with no clear explanation
E. All of the above
e
Which of the following best describes the goal of the EARS program.
A. Early detection of middle ear dysfunction
B. Improve speech skills
C. Early and effective intervention for reading disorders
D. Success in mathematics
E. All of the above
c
Which of the following disorders does NOT typically co-exist with APD in the pediatric population?
A. Dyslexia
B. Language impairment
C. Learning disability
D. ADD
E. Aural atresia
e
Which of the following is (are) characteristic (s) shared by both APD and ADHD:
A. More males than females are affected
B. Easily distracted
C. Poor academic performance
D. Seems not to listen
E. All of the above are characteristics of both APD and ADHD
e
Which of the following is NOT a bottom up strategy for intervention for APD
A. Auditory training
B. Environmental modification
C. An FM system
D. Cognitive strategies
E. Stimulus driven intervention approaches
d
Which of the following is a computer-based program of value in the management of children with APD?
A. Earobics
B. FastSpeech
C. LICE
D. SCAN
E. LISN
a
Which of the following is a multi-sensory program for remediation of auditory and language based reading disorders:
A. BAHA
B. Lindamood-Bell Phoneme Sequencing (LiPS)
C. Cued Speech
D. All of the above
E. None of the above
b
Which of the following is a non-verbal test of intelligence:
A. WISC-4
B. OWLS
C. CELF-4
D. MDTP
E. UNIT
e
Which of the following is a popular test of cognitive status:
A. SSW
B. WASP-1
C. ACPT
D. WISC-IV
E. LiPS
d
Which of the following is a test of phonological (phonemic) processing:
A. CELF-4
B. WISC
C. CTOPP
D. GFW Test of Articulation
E. SSW
c
Which of the following tests or inventories is used to evaluate psychosocial (behavior and personality) characteristics:

A. WISC-IV
B. CPT
C. Connors
D. SPIN
E. BASC
e (c)
According to Kricos, what is the recommended treatment for an older adult who does not acknowledge her hearing loss?
A. Educate her regarding the signs and symptoms of hearing loss
B. Inform her of the potential effects of hearing loss
C. Postpone her hearing aid fitting until she becomes more aware of her own hearing difficulties
D. All of the above
d
According to the Kricos lecture on “AR for Older Adults”, which of the following factors may account for under-utilization of hearing aids by older adults?
A. Lack of awareness of the social and emotional effects of hearing loss
B. Denial or lack of awareness of communication problems due to hearing loss
C. Lack of self-efficacy regarding the ability to successfully use hearing aids
D. All of the above
d
For an interactive group audiologic program, Kricos (2000) recommends that the audiologist talk no more than what percent of the time?
A. 10%
B. 30%
C. 50%
D. 70%
b
For face-to-face interview administration of the HHIE, what amount of change in results is the minimum in order to consider the change as being clinically significant?
A. Approximately 19% increase in score
B. Approximately 19% decrease in score
C. Approximately 36% increase in score
D. Approximately 36% decrease in score
b
For paper-and-pencil administration of the HHIE, what is the minimum amount of change in results in order to consider the change as clinically significant?
A. Approximately 19% increase in score
B. Approximately 19% decrease in score
C. Approximately 36% increase in score
D. Approximately 36% decrease in score
d
In Montgomery’s acronym WATCH, the C stands for:
A. Change or modify the environment
B. Communicate your hearing needs
C. Choose your communication partners carefully
D. Clear speech training
a
In the Weinstein and Amsel study (1986; cited in Kricos, 2009)), how great was the average improvement in cognitive abilities when older patients with a moderate degree of hearing loss were given a mental status test using amplification, compared to a non-amplified assessment?
A. Approximately 20
B. Approximately 30
C. Approximately 40
D. Approximately 50
d
Laplante-Levesque, at al (2010) provide several examples of activity limitations and participation restrictions that often occur as a result of untreated hearing loss. Which of the following is an example of a participation restriction?
A. Localization of sound
B. Avoidance of interpersonal interactions
C. Speech perception in adverse environments due to noise, distractions, etc.
D. Understanding radio and television communications
b
Which Transtheoretical Stages-of-Change Model stage would a person be in if they said the following to a friend: "Hmm, I'm starting to think I might have a hearing loss. I wonder if I should find out about hearing aids."
A. Pre-contemplation
B. Contemplation
C. Action
D. Preparation
b
Which of the assessment tools below asks the patient to nominate situations that they would like help with?
A. HHIE-S
B. HHIA
C. APHAB
D. COSI
d
Which of the following Ida Institute patient motivation tools below is focused primarily on helping people with hearing loss and their communication partner to develop shared goals?
A. Communication Rings
B. GPS
C. The Box
D. The Line
b
Which of the following does Norm Erber include in his assessment of an older adult’s hearing difficulties?
A. Vision
B. Audiometrics
C. Lifestyle
D. All of the above
d
Which of the following is an example of fluid mechanics intelligence?
A. Speed of information processing
B. Social intelligence
C. Vocabulary
D. Cultural knowledge
a
Which of the following is not a feature of clear speech?
A. Slight pause between each word that is spoken
B. Pausing between phrases
C. Slower
D. Louder
a
Which of the following is not a normal age-related change in cognition?
A. Confusion in time, place, and orientation
B. Slower speed of processing incoming information
C. Difficulties with divided attention tasks
D. Compromises in working memory
a
Which of the following is not one of the stages of the Transtheoretical Stages-of-Change model described by Prochaska?
A. Precontemplation
B. Self-efficacy
C. Preparation
D. Action
b
Which of the following is viewed as best practices for designing written materials for the majority of older adult patients who have vision problems?
A. Glossy paper
B. Dark background, light print
C. Light background, dark print
D. 12 point font minimum
c
Which of the following sources of listening difficulties is the most likely to be shared by both older and younger adults with hearing loss?
A. Temporal processing limitations
B. Central auditory processing disorders
C. Degree of hearing loss
D. Reduced working memory capabilities
c
Who said, “When someone in the family has a hearing loss, the entire family has a hearing problem”?
A. Sam Trychin
B. Mark Ross
C. Barbara Weinstein
D. James Prochaska
b
Why might an older adult with thresholds that are relatively good in low, mid, and high frequencies have difficulty understanding whether you said “pink cows” or “pink towels” when you spoke to her at an audible level in a fairly quiet environment?

A. Mild Cognitive Impairment
B. Dementia
C. Age-related frequency resolution issues
D. Working memory issues
c
Define Unilateral hearing loss.
UHL of +45 dB (.5,1,2kHZ) in poor ear, and no worse than 15dB in good ear, no known etiology for HL
Average ID age of HL 5-6 yrs
Only 50% satisfactory performance in school
35% repeated at least one grade
20% exhibiting behavioral problems
Slightly verbal IQ< performance IQ
WNL results on WISC-R
Lower full-scale IQ with more severe HL
Lower scores on word recognition and spelling subtest of the Wide Range Achievement Test
Self reported feelings of embarrassment, annoyance, confusion, and helplessness
Teacher reports of uncooperative and inattentive behavior, social withdrawal and aggression
How do children with unilateral hearing loss compare with normal hearing peers?
Compared to normal hearing showed:
Poor localization
Poor speech recognition scores
Need higher SNR
What are the effects of a mild bilateral hearing loss?
Hearing thresholds of 15-26dB
Not performing at expected academic level
Actual grade performance less than expected by 1.11 grade delay
On Comprehensive Test of Basic Skills (CTBS):
Low scores on reading, vocab, language mechanics, word analysis, reading comprehension, and spelling
Cooperative Information Project Adolescent Chart (COOP): Less energy= more tiered, stress, self-esteem
Difficulty in background of noise, need higher SNR
Spend more energy on listening, thus leaving them less energy or attention capacity for processing what they hear, taking notes, and other activities required of school children
Increased pragmatic and misarticulation errors
Comparison study of SLI and Mild to Moderate SNHL, AU
Briscoe et all
Children with HL were as impaired as SLI kids with normal hearing on tests of phonological discrimination, phonological awareness, and non-word repetition
Children did not show language and literacy that characterize SLI
How prevalent is Unilateral Hearing Loss (UHL) in children?
Previously thought to be only 2/1000 (Matkin, 1991). However, we now know it to be a greater degree of problem: 3% according to Bess, et al, 1998
Etiologies of UHL
1. Over half have no known etiology
2. Mumps – greatest cause of profound UHL
3. Inner Ear anomalies, head trauma, hereditary
Consequences of UHL:
1. Auditory perception – dependent on binaural hearing for in noise, localization, speech-language development (usually a more prominent problem for severe to profound losses)
2. Psychosocial impact – even with minimal UHL – leads to stress, self-esteem, behavior, energy & social support issues
3. Academic –
3. Academic –
a. According to Bess, et al.:
i. approx. half of kids with UHL will have academic difficulties,
ii. greater than one-third fail at least one grade (which is 10x the normal hearing retention rate),
iii. resource room assistance/behavioral problems noted by teachers
b. Oyler, et al:
i. Arizona kids with UHL
ii. 25% children with UHL failed at least one grade
iii. Again, 10x the normal hearing retention rate for the AZ area
iv. Similar results as the Bess, et al study
c. Dansler, et al – children with UHL have poorer SIFTER performance
Does ear affected matter?
Right ear tends to show greater risk of future educational & psychosocial problems
How about Age of Onset of UHL?
Earlier = more problems
More severe = more problems
Progression of hearing loss in children with UHL
1. one out of seven with UHL noted at birth will begin to show loss at the good ear, and some will also show additional loss at the impaired ear
2. Need to monitor for at least 3 months after identification
Intervention for unilateral hearing loss
1. Options: No fitting if the loss on the impaired ear is too great, personal HA, personal FM, HA w/ FM, CROS HA, Sound Field at school (***most who use some type of system will actually use a combination of systems)
2. Early Fittings v. Wait & See school of thought:
a. Early Fitting –
i. Is it better to be pro-active with a child with UHL to avoid potential problems later on in life?
ii. Neural Pruning – maximum # of synapses are in place in babies by the time they are 3 mos old. Not using the synapses at the impaired ear (when UHL >40dB) could lead to those unused synapses being eliminated by the body. This could become a problem if the decision is to wait until later in life to fit as the synapses may no longer be available for the child to utilize by the time a later fitting is done.
b. Wait & See –
i. Child ages & then can provide better threshold data
ii. Less chance of damaging residual hearing due to better threshold data being obtained
iii. Will there be effects of the UHL? There may not be if the loss is mild to moderate (<55dBHL).
iv. The child may actually do worse with amplification on the impaired ear due to distortion.
Infant Fitting Criteria Guidelines:
1. Colorado Infant Hearing Advisory Committee
a. Recommends a pro-active fitting at a permanent loss of 20dBHL in a proportion of the speech frequency range
b. ABR & Behavioral testing – baby should have measurable hearing and be fit to best estimate
2. Florida – fit the child if a baby has >50dB hearing loss in the worse ear
Older Children Fitting Criteria Guidelines:
Measurable hearing in affected ear and determine the recognition abilities. It is especially important to determine in quiet along with in noise at both normal conversational level (50dBHL) and a quiet level (35dBHL).
2. Older children can either work with or against a fitting of HA & FM devices – need to be prepared to gently work them into a fitting, or recognize when they will not adapt to it
3. McKay study –
a. UHL of 25-65dBHL: go ahead & fit the child
b. UHL of 70-75dBHL: use professional judgement
c. Study included a questionnaire by parents & child (when they were old enough) after having access to HA use regarding the changes that were noted as a result of HA use
i. Majority of parents expressed positive responses
ii. Majority of children liked the benefits, but not surprisingly, did not like the appearance of the HA’s
FM Considerations
1. Determine child’s performance with faint speech (30-35dBHL) and conversational level in both quiet & with the noise directed at the impaired ear. Use FM if poor results in noise. Offer FM even if the child shows ok results in noise. There may still be added benefit to the child to have the reduced SNR even if (s)he does ok in noise in the booth.
2. Use DIAL (Developmental Inventory of Auditory Learning) – helps to determine the child’s auditory needs and then adapt the FM to those needs
3. Updike study –
a. compared FM, HA & CROS in both quiet & +6dB SNR
b. little HA benefit noted & some detriment in noise
c. FM systems – improved speech recognition in all listening conditions with greatest losses showing the most benefit
4. Ear Coupling
a. Flexor found custom standard ear mold with short canal, belled bore, IROS vent & helix lock on better ear tended to have best results
b. Coupling to the UHL side must be on a case by case basis
5. Infants/Toddlers – personal HA on infants, then add FM later with toddlers on their existing HA
Verification:
1. Traditional methods: real ear, sound field with & without the system
2. Functional Listening Evaluation (Johnson, 2001) – done in the child’s natural environment with teachers, etc able to see results – shows how well the system can perform in a non-sterile environment (more realistic)
3. Parental Observations: MAIS, IT-MAIS, ELF, CHILD
4. Teacher Feedback: SIFTER, Secondary SIFTER (high schoolers)
5. Child & Teacher Feedback on technology – LIFE
Other Considerations beyond Amplification & Technology
1. Listening environment – may need to accommodate/modify for the child with UHL
2. Auditory Training/Communication Strategies – Communication Training for Older Teenagers & Adults (Tye-Murray); includes 18 lessons regarding listening, speech perception, discrimination, recognition, conversation in noise, self-advocacy, and communication strategies
3. Education & Counseling of Parents – must include such topics as protection of the good ear (especially related to sports activities), periodic monitoring annually, middle ear health, how to monitor the child’s technology, appropriate use of technology, hearing protection importance, ability to communicate with the child about hearing loss/ramifications of hearing loss, use of Clear Speech
4. Education of Classroom Teachers –
a. Present options as ways to make things easier for the teacher
b. Try to see things from the teacher’s point of view
5. Legal Rights
a. Even children with academic success are entitled to 504 accommodations (ie: written assignments, appropriate acoustics, preferential seating, use of FM devices)
b. IDEA – if adverse effects of UHL are documented, child may qualify for services
6. Educate the Child –
a. Encourage self-advocacy
b. Knowledge is Power Program – helps the child to develop coping skills, communication strategies, self-esteem building, understand the hearing loss, ear anatomy, how HA’s & ALD’s work, National & State resources (for the older child)
c. Coping Strategies for Hard of Hearing Children Curriculum – teaches the child basics of communication, helps them to understand how communication breaks down & how to repair it, also offers goals & objectives to be included in the child’s IEP
d. Chat rooms & websites designed for children to learn & interact with other children with similar problems
Outcome Measures: booth testing is limited & sterile; need info about the child’s real life experiences which can be obtained in self-report outcome measures with parents/teachers/children
1. Language Skills development – very young children can be evaluated with:
a. McArthur Skills of Language Development – checklist of what the child is doing, has normative data
b. Peabody test or subtest from Preschool Language Scale
2. Auditory needs – DIAL
3. Parent/Teacher Feedback – MAIS, IT-MAIS, ELF, CHILD, SIFTER(s), grade reports, McKay’s Unilateral Hearing Loss questionnaire (regarding child’s amplification benefit)
4. Functional Auditory Skills development – Functional Auditory Performance Indicators (FAPI) goes beyond simple detection to include localization, linguistic auditory processing
5. Auditory Attention – Children’s Auditory Performance Scale (CHAPS) – helps with UHL children to determine if their technology is actually assisting them attending in the classroom
6. Classroom Technology Benefit – LIFE (Listening Inventory For Education) – has both Student & Teacher appraisals
a. Student appraisal –
i. 15 common school listening activities
ii. Best for elementary level, but can be used for secondary level
iii. Allows child to provide feedback
iv. Gives suggestions on how the child can improve classroom listening & self-advocate
b. Teacher appraisal –
i. Post-fit evaluation
ii. 16 common classroom situations
iii. Teacher rates the technology based on how the technology has helped the child
iv. Offers suggestions for accommodations teachers can make
7. Checklists – wise to have a list of items to cover with parents of children with UHL so nothing is forgotten ranging in topics from potential effects of UHL on the child to outcome measures to parent/child/teacher feedback to support websites
“What Do Your Patients Remember?” Robert Margolis article
• Very little literature on patient retention following audiologic counseling. Other healthcare fields have published on this. But, are they any better than we are at patient retention?
• Informational Counseling – pt is provided with relevant information needed to understand the nature of the disorder and steps recommended to manage it (audio, effects of Hearing Loss on communication, etc)
• Personal Adjustment Counseling – process of guiding the patient and family in dealing with emotional impact of info (most audiology literature is on this topic)
• Pt outcomes and follow through are generally better when patients understand informational counseling
• 50% of information is remembered and 50% of that is remembered wrong. The little bit of information that they do remember may not be enough & the bits they remember incorrectly can actually be damaging for some patients.
• Patients don’t tend to remember the most critical things like their diagnosis (approx. 65-70%) and many times the patient and the provider do not agree on the problems that needed follow up (only 45%)
• Determining what patients will remember v. forget:
o 3 Factors:
 Patient factors
• Familiarity with the information
• Degree of understanding of issues related to the diagnosis
• Expected findings as well as desired findings are more often remembered than unexpected or unwanted/unwelcomed
• Anxiety – moderate anxiety can enhance recall while more severe anxiety inhibits retention of information
• Stress – causes “attention narrowing” and interferes with patient ability to redirect to different topics
 Clinician factors
• Clear language with simple sentence structure easier to remember
• Understanding what patients wish to learn and their level of understanding
• Dialog between patient and clinician enhances retention
• Clinician anxiety – less retention when clinician is more anxious
• Better retention with emphasis on importance of info rather than matter-of-fact presentation
• Non-verbal cues help relay importance of info to patient
 Mode of presentation
• Simple & easy to understand = better
• Less is more
• Primacy Effect – first presented = better recall
• Method of Explicit Categorization – information is categorized and presented in each category before moving on to the next topic category
• Written/graphic supplemental material
• Specific recommendations rather than generalized for better recall
• Wrong Recollections
o Busy life/Worried minds can interfere with the way that people hear & remember what is said
o Denial – not receptive to information regarding hearing loss or suggestions regarding management of hearing loss
• Bringing someone with the patient – nice idea, but a bit impractical in today’s world
• Written patient-education materials available:
o “Understanding…” series available @ www.audiologyincorporated.com
What is the audiologist’s role in managing young children with hearing loss?
Ensure that auditory perception of individual is maximized
Assumption that optimal hearing will provide quality of life
To develop relationship with parents so that they recognize that amplification helps, but that they are the “magic” in preventing language delays
Preventing delays
Diagnose HL, fit with amplification to break down barriers to speech perception
Why are early identification and appropriate management so critical
Auditory brain development (Carol Flexor)
Develop early effective interaction patterns
Turn taking
Recognizing a response
Vigilance in proximity: Preventing decline in number of communication events due to lack of feedback
What is early intervention…

And what can we expect with it?
Appropriate amplification
Fit well
Daily/consistent use of hearing aid
Motivated parents effectively controlling child’s proximity to verbal language
Overall communication access/effective communication
We can expect one month of language development for each month of early intervention
What are the effects of degree of hearing loss on listening and development
Slight/unilateral
Miss some consonants
Mild difficulty with auditory learning/language at a distance
Noise will interfere with communication
Mild
Only hears louder speech sounds (vowels)
Difficulty with auditory learning
Speech/Language delays
Moderate
Almost no speech heard when spoken at normal levels
Articulation differences
Language delays/Learning dysfunction
Inattention to verbal communication
Severe
Doesn’t hear speech at normal levels
Learning dysfunction due to language delay
Inattention to verbal communication
Profound
No speech
Little or no speech intelligibility
No verbal language
Avoid labels and instead…
Describe effective HL on child’s listening/speech perception
How they will hear their parent
Predictions of speech and language development
What is the E.L.F.?
Early Listening Function Free test developed to address need of parents to experience that their child responding to sounds is diminished due to hearing loss
12 listening activities in quiet and noise at different distances
Used for detection only
Can be used as a validation tool
Includes an infant/young child amplification check list
What is the “Listening Bubble”?
Hearing range and proximity that the child can perceive speech in
What is the DIAL?
Developmental Index of Audition and Listening
Another check list
Developmental sequence of listening skills for children with normal hearing
Another test available from Advanced Bionics is the IT-MAIS
10 questions oriented to speech used and intelligibility
What are differences between Auditory-Oral and Auditory-Verbal communication options?
Auditory-Oral:
-audition
-gestures
-speech reading
-speech
-visual cues
-phonics
Auditory-Verbal
-audition
-speech
What is the Individuals with Disabilities Education Act Part C?
a comprehensive, family centered,
interdisciplinary program to provide supports and services to infants and toddlers with developmental disabilities or established conditions and their families
What is the criteria for a hearing disability preventing a child from receiving reasonable educational benefit?
Sound field word recognition of 75% or less in quiet
A receptive or expressive language delay
An impairment of speech, articulation, voice, and fluency
Significant discrepancy between nonverbal and verbal performance on a standardized intelligence test
Delay in reading comprehension due to language deficit
Poor academic achievement
Inattentive, inconsistent, and inappropriate classroom behavior
Children with mild bilateral HL and unilateral HL are at risk for:
Language and communication delays
Academic delays
Delays in historic literature
Early identification of HL
A study proved that early-identified children with mild hearing loss who were enrolled simultaneously in an appropriate intervention program had significantly better expressive language development than children with later-identified HL.
Yoshinaga-Itano reported a significantly better personal-social development for children with early-identified mild HL compared with those with later identified mild HL.
What are some important audiologic counseling for children with unilateral HL?
Noise reduction in the classroom or at home
Ear protection for the good ear to avoid noise induced hearing loss
Preferential seating in classroom settings
Information about the difficulties of localizing sound sources
Trials with amplification devices
What is the reason for amplification rejection with unilateral hearing loss?
The children with unilateral hearing loss are identified very late, often after the age of 5 years and above when they are having academic difficulties and lack of auditory stimulation for so many years theoretically impacts the ability to develop auditory skills.
How does age of onset or age of identification affects normal language development?
The probability of normal language and communication development if the hearing loss is acquired postlingually would be much higher than if the child had a congenital hearing loss.
Does degree of unilateral hearing loss have any effect on the academic achievement?
Studies have found that profound unilateral hearing loss(UHL) and possibly severe UHL could place a child at a greater risk for academic failure than children with lesser degrees of UHL.
36% of children with a profound UHL failed a grade compared with 18% of children with a mild to moderate UHL.
Children with profound UHL were 2 times more likely to fail a grade than were children with a mild to moderate UHL.
Children with UHL had poorer classroom behavior in the academic setting.
Are children with profound UHL good candidates for amplification?
Poor candidates for amplification
Lack of acceptance of amplification by children by this type and degree of HL
Not sufficient for the individual to access conversational speech in the ear with a profound HL
Quality of any sound provided could interfere with the good quality of the better ear
Poorer compliance for hearing aid use with later age at fitting of amplification
What is the effect of right ear versus left ear hearing loss in academic achievement?
Oyler et al. found that children with UHL in the right ear are at greater risk for academic failure than are children with hearing loss in the left ear
Early Identification (EI)
different counseling approach when identified in first few months of life versus identified at age 12 to 18 months
12-18months - sorrow is a common response
EI – shock a common response. Can start shaking, feel faint, experience intense grief regardless of whether HL is mild, moderate profound etc.
Need immediate counseling -need to provide generic information-don’t overload
Counseling Considerations
Bonding
Bond with baby as a child with hearing loss from outset.
Never have to readjust their thinking
Guilt rare
Hold off on major decision making regarding hearing aids, CIs, ASL, auditory verbal approach
have time to gather information in first few months.
Provide generic information useful for all families regardless of type of HL.
Positive outcomes EI results in faster progress of speech and language development, cognitive development and social development
Grief Process
Experience less stress and faster resolution of grief
Yoshinaga-Itano research - grief resolved within two years
The big decision – how to communicate with the child
Give all options for communication approaches
Collaborative approach - acknowledge the family as expert for their child AND also acknowledge the professional expertise and try to bring these two together
Decisions depend on:

sufficient information
Perceptions of assistive technology
Attitudes of professionals
Quality of support services
Parental knowledge, experience, personality
Hearing status
Prior experience with deaf/h-o-h
Factors Influencing Decision
Need to present all options
Communication is not either/or
Decisions may change over time
No evidence signs impedes development of speech
Signs may facilitate language development
Beyond Counseling Auditory Linguistic Learning
Focus on
Facilitating parents provision of communication-rich environments
Enhancing the auditory environment
Hierarchical Learning
Hierarchical tasks :
Detection
Discrimination
Identification
Comprehension
Hierarchical manipulations –
from closed set to open set
# of response options
linguistic complexity
Noise, distance intensity rate
Meaningful Listening
Available Curricula:
It Takes Two to Talk (Manolson)
Mealtime toys on a String (David Sindrey)
Listening Games for Littles (David Sindrey)
Bringing Sound to Life (Mary Cook) –the WASP
Incidental Learning
Takes place when a child acquires knowledge or skills through naturally occurring events
Ability to generalize is the key
Is the most efficient and perhaps the only way to master a spoken language
Functional assessment tools to measure progress
As audiologists less concerned with how much the child hears and more concerned with how much he is using his hearing aid/CI in everyday life.
MAIS
ITMAIS
Surveys have shown that satisfaction with hearing aids is directly related to the amount of counseling provided.
true
___________ _____________ provides the patient with the relevant information needed to understand the nature of the disorder and the steps that are recommended to manage it.
Informational counseling
________ __________ _________ is the process of guiding the patient and family in dealing with the emotional impact of the information.
Personal adjustment counseling
1) Encourage patient to confront denial
2) Help family get beyond grief so they can initiate early intervention with a hearing impaired child
3) Help patient understand the impact of their communication disorder on their family
About what percentage of information provided orally by healthcare providers is retained ____ and about what percent of the retained information is remembered incorrectly?
About what percentage of information provided Orally by healthcare providers is retained? ____ 50% and about what percent of the retained information is remembered incorrectly? (pg 12)____ 50%
Based on the vague vs. specific recommendations provided in the article, give an example of a vague aural rehab recommendation and a specific aural rehab recommendation.
Vague: “Enjoy using your new hearing aids”. Specific: “Wear your new hearing aids for 2 hours in a quiet setting and 2 hours in a noisy setting each day. Write in your daily journal the pros and cons noticed in the two situations.”
Factors Determining what Patients will Remember (remembering information from a healthcare visit is not related to intelligence!)
Patient Factors:
(Patient is MORE likely to remember information provided if)
Previous diagnosis of hearing loss
Family member has same diagnosis
Professional knowledge
Findings are expected
Patient Factors:
(Patient is LESS likely to remember information provided if)
Diagnosis is unexpected
Severe anxiety reduces recall
Stress causes “attention narrowing” which interferes with the patient’s ability to redirect to a different topic.
Factors Determining what patients will Remember (Remembering information is not related to intelligence!)
Clinician Factors:
(Patient is MORE likely to remember information provided if)
Clinician Uses clear language with simple sentences
Clinician Understands what the patient wishes to learn and their level of understanding
Clinician Factors:
(Patient is LESS likely to remember information provided if)
Clinician evades or inhibits the patient’s ideas
Clinician exudes anxiety
Clinician presents information matter-of-factly rather than in a manner emphasizing importance
Mode and Method of Presentation Matters
Information presented simplistically is BETTER remembered than information presented complexly

The more information provided, the LOWER the proportion of information that is recalled by the patient

Primacy Effect: Information presented 1st tends to be remembered best.
Method of Explicit Categorization
Diagnostic tests
Results
Prognosis
Recommendations
(tell the patient that information will be presented in these categories. Each category is announced and the patient is asked if he/she has any questions before moving to the next category)
This method can significantly enhance recall
True / False (pg 17)
Studies have shown that when healthcare providers followed specific strategies for enhancing communication, there were measurable improvements in patient recall
TRUE
What is the name of the website audiologists can access to implement informational counseling practices where they work?
www.audiologyincorporated.com
(pg 9) “Specific deficits that have been found in various research studies looking at children with unilateral hearing loss include slight decrement in verbal intelligence relative to performance I.Q.” Early studies of children and adults with UHL suggested the potential for psychosocial problems….”Excessive behavior problems including _________ __________ and ________________ were reported in 42% of the study children and 37% scored significantly below an acceptable range relative to normal hearing children in the areas of ____________________ and ___________ ______________.”
(pg 9) “Specific deficits that have been found in various research studies looking at children with unilateral hearing loss include slight decrement in verbal intelligence relative to performance I.Q.” Early studies of children and adults with UHL suggested the potential for psychosocial problems….”Excessive behavior problems including social withdrawal and aggression were reported in 42% of the study children and 37% scored significantly below an acceptable range relative to normal hearing children in the areas of interpersonal and social adjustment.”
TRUE / FALSE
Research has shown that children with UHL have significantly poorer speech-recognition performance compared to their normal hearing peers, whether the child had left ear or right impairment.
TRUE
Bess and colleagues, in their research assessing educational performance, found that the average grade-retention rate for all children with minimal hearing loss was _____ %.
37 %.
When researchers looked at the functional health of students in the 6th and 9th grades who had minimal hearing loss via the Cooperative Information Project Adolescent Chart Method, what did they find?
The students reported having less energy or were tired more frequently than their normal-hearing peers. Additionally, 9th graders with minimal hearing loss demonstrated more dysfunction in the domains of stress, social support, and self-esteem, than the students with normal hearing.
In contrast to the Tharpe article, Colorado researchers found that one out of six children with unilateral hearing loss will probably develop delayed or borderline language problems. (This was usually associated with children who have a ___________loss in the impaired ear). At 12 months of age what percentiles were listed for expressive and receptive language?
Colorado researchers found that one out of six children with unilateral hearing loss will probably develop delayed or borderline language problems. (This was usually associated with children who have a profound loss in the impaired ear). At 12 months of age what percentiles were listed for expressive and receptive language? 27th percentile and 15th percentile respectively.
_____% of school children with unilateral hearing loss had failed at least one grade (compared to 3.5% of school children with normal hearing), as per summarization of Bess’ studies.
37%
TRUE / FALSE
Children with hearing loss in the right ear are at greater risk for future functional problems.
TRUE
Other factors (besides which ear is affected) with unilateral hearing loss are: ________ _________ and ________ - __ - ___________ _________ _____.
Early onset
Severe-to-profound hearing impairment.
) ____ out of ____ children with UHL identified at birth will develop hearing loss in the better ear and children who are early identified with UHL should receive a minimum of ______ months monitoring audiologically.
1 out of 7
Although there should be a case-by-case consideration of technology assistance,
we should keep in mind that babies have the maximum number of synapses that they will ever have at three months of age,
so a key consideration of whether to fit infants has to do with the issue of _____________ _____________.
auditory deprivation.
What is the purpose of the Guidelines document?
The purpose is to provide evidence-based recommendations for the diagnosis, treatment and management of children and adults with (C)APD, provide direction and resources. It emphasizes 6 points:
1) variety of possible etiologies
2) the diversity of populations with CAPD
3) use of sensitive, specific, efficient behavioral tests and electrophysiological procedures to accurately diagnose
4) need to consider possible comorbidities which influence testing and interpretation of test results
5) pivotal role of neuroplasticity in reducing deficits and changing behavior
6) value of multidisciplinary team approach to assessment and intervention
Common behavioral manifestations and symptoms
* difficulty understanding speech in the presence of competing background noise or in reverberant acoustic environments

ƒ ƒ* problems with the ability to localize the source of a signal difficulty hearing on the phone

ƒ ƒ* inconsistent or inappropriate responses to requests for information
ƒ difficulty following rapid speech ƒ frequent requests for repetition and/or rephrasing of information ƒ difficulty following directions

ƒ ƒ* difficulty or inability to detect the subtle changes in prosody that underlie humor and sarcasm

ƒ ƒ* difficulty learning a foreign language or novel speech materials, especially technical language

ƒ ƒ* difficulty maintaining attentionƒ a tendency to be easily distractedƒ

ƒ* poor singing, musical ability, and/or appreciation of music
ƒ academic difficulties, including reading, spelling and/or learning problems
Candidates for Central Auditory Testing?
listening and related complaints (e.g., learning problems or reading problems)
young children to elderly adults.
Those persons with normal peripheral hearing sensitivity who exhibit auditory-related symptoms
Those with peripheral hearing loss whose difficulties are greater than would be expected for the degree of hearing loss
Those who report a significant history of otitis media
What are Tests of Specific Auditory Processes
Tests of Temporal Processes

Dichotic Listening (Speech) Tests

Tests of Monaural Low-Redundancy Speech Perception

Tests of Localization and Lateralization and other Binaural (Interaction) Functions
Auditory Discrimination Tests.

Selection of Behavioral Central Auditory Tests
Why has CAPD has received so much attention recently
Advances in neuroscience demonstrating the key role of auditory plasticity in producing behavioral change through intensive training, with documented potential of a variety of auditory training procedures to enhance auditory processes .
What are some descriptions of children with APD by parents and teachers?
Uncertain about what they hear
Have difficulty following directions
Have difficulty hearing in background noise
Difficulty following rapid speech
What is the definition of APD?
Broad: Deficit in processing of information that is specific to auditory modality
May be associated with difficulty in listening, understanding speech, language development, or learning
Pure Form: Deficit in processing of auditory input
May be exacerbated in unfavorable acoustic environments
What factors complicate and diagnosis of APD
Other disorders may exhibit similar behaviors
Some audiologic procedures fail to differentiate children with APD from other disorders
Other processes and functions can confound results
E.g. lack of motivation, attention, or understanding
What assumptions are basic to differential diagnosis of APD?
AP can occur independently or co-exist with other non-auditory disorders
Pure APD
Multi-sensory
Disorders that initially appear auditory but are not
Disorders that initially appear non-auditory but actually are
AP and methods of assessing AP can be influenced by deficits in other disorders
ADHD
Language impairment
Reading disability
Learning disability
Autism spectrum disorder
Reduced intellectual functioning
To effectively differentiate APD, which variables should be considered?
Attention
Auditory neuropathy
Fatigue
Hearing sensitivity
Intellectual and developmental age
Medication
Motivation
Motor skills
Native language, language age, language experience
Response strategies and decision making style
Visual acuity
What team members should be included in APD assessment?
Audiologist
Speech pathologist
Parents
Teachers
Other professionals as necessary
Behavioral tests
Measures of detection
PT
Temporal integration tests
Suprathreshold discrimination
Difference limens for frequency, intensity, duration
Temporal resolution
Backward/forward masking
MLD
Sound lateralization
Spatial localization
Measures of identification
Recognition of phonemes, syllables, words, phrases, sentences

Monotic
Stimulus to each ear separately
Diotic
Same stim to both ears simultaneously
Dichotic
Different stimuli to the 2 ears simultaneously
Electrophysiologic and Electroacoustic tests
Immittance
OAE
ABR/MLR
What do each of these tests assess?
Pure tone audiometry
Presence and degree of peripheral HL
Performance intensity function for word recognition
Exploration of word recognition over wide levels and comparing performance between ears
Dichotic tasks
Sensitive indicator of APD
Duration pattern sequence test
Key measure of auditory temporal processing
Temporal gap detection
Key measure of auditory temporal processing
What does CAPD result from?
Dysfunction of processes dedicated to audition
May coexist with more global dysfunction affecting performance across modalities
May exist where there is evidence of CNS or neurodevelopmental disorder
Also observed in older adults presumably due to nonpathologic changes associated with aging
CAPD involves a deficit in one or more of the central processes responsible for generating the auditory evoked potentials and the behaviors of:
Sound localization and lateralization
Auditory discrimination
Auditory pattern recognition
Temporal processing
Temporal resolution, masking, integration, ordering
Auditory performance with competing acoustic signals
Auditory performance with degraded acoustic signals
What does ADHD consist of?
Persistent pattern of inattention and/or hyperactivity/impulsivity that is more freuqent and severe than is typically observed in individuals at comparable developmental level
Most common childhood neurobehavioral disorder
Manifests in at least 2 settings
Present since prior to age 7
Interferes with developmentally appropriate social, academic or occupational functions
How do the inattention profiles differ for people with ADHD vs. CAPD?
ADHD
Difficulty initiating, tracking and remembering tasks, in addition to sustaining allocation of attentional resources
Hyperactive impulsive/combined ADHD subtypes are output or response programming and execution disorders
Inattention is a secondary deficit
CAPD
Inattentiveness is a primary deficit resulting from an input or information processing deficit
What is Executive Function?
Component of metacognition that refers to a set of general control processes that ensure that an individual’s behavior is adaptive, consistent with a goal, and beneficial to the individual
Coordinates knowledge (cognition) and metacognitive knowledge in support of task analyses, planning and reflective decision making
Ultimately transforms this knowledge into behavioral strategies
Executive Function Disorders

May underlie
Childhood neurologic disorders
Academic problems experienced by children with ADHD or learning disabilities
Executive dysfunction in CAPD has not been examined, but it is reasonable to expect that auditory perceptual deficits impede operation of executive functions
Difficulty organizing, monitoring and understanding acoustic signals may reflect limited use of executive function
What are the implications for intervention?
Managing CAPD usually involves acoustic signal modifications, auditory training, and metalinguistic/metacognitive approaches
Management of ADHD usually involves medication and metacognitive or executive control strategies
Signal enhancement
Auditory training
Environmental modifications
Metacogntive (executive) strategies
Linguistic strategies
Metalinguistic strategies
Collaboration
Learning strategies
What is auditory temporal processing?
The perception of the temporal characteristics of a sound or the alteration of durational characteristics within a restricted or defined time interval
It can also be viewed as the processing of the temporal features of sounds that unfold over time
What are 4 subcategorizations of temporal processing?

Temporal masking
Temporal ordering or sequencing
Temporal integration or summation
Temporal resolution or discrimination
Gap detection in the assessment of temporal resolution has been shown to be a powerful assessment tool for a variety of populations, T or F?
TRUE
What are the two GIN indices to measure temporal performance?
Approximate threshold (A.th.)
Percentage of correct responses
Prevelance of APD
Three out of 100 children are estimated to have auditory processing disorders, in the school population
That prevalence is actually 10 times greater than the prevalence for significant peripheral hearing loss in neonates which would be about three in 1000.
The concomitant with APD
low self-esteem
emotional problems
inappropriate behavior
clinical depression
Paper and Pencil Screening tools
SIFTER: stands for screening instrument for targeting educational risk
CHAPS
available from the Educational Audiology Association
APD Risk Factors
neonatal risk factors
Asphyxia
intraventricular hemorrhage
Hydrocephalus
Cytomegalovirus
meningitis
Test Battery
thorough survey
Peripheral auditory system evaluation:
OAE, utilize OAEs in APD evaluation in a diagnostic sense not in a screening sense
Acoustic reflexes, ipsi and contra (characteristic finding of auditory processing disorders if the reflexes are abnormal would be normal ipsilateral reflexes and elevated or absent contralateral reflexes.
Pure tone audiometry, and word rec. w/10 words.
Tympanograms
Dichotic listening (words or digit)
time-compressed words. Some were filtered. Low frequencies or high frequencies are filtered out of the speech
speech in noise tests

variation pattern test
the gap detection test
frequency of pitch pattern sequence test
Tests, cont'd
The SCAN-C is for children. The
SCAN-A is for adults. And the SCAN-C has norms for different ages from age five up to age 11. And here are the four subtests in the SCAN
Low pass filtered words
Auditory figure-ground test
The competing words test
competing sentences
criteria for an abnormality
there are no formal guidelines
No accepted guidelines
Dr. Hall’s Criteria: the abnormality must be apparent on at least two different procedures for at least one ear.
verbal abnormalities particularly on
procedures that definitely linguistically loaded need to be backed up, abnormalities in those
procedures need to be backed up by abnormalities on non-verbal procedures.
APD in children or any patient with unilateral loss and with other peripheral HL
dichotic tests are out of the question.
rely on procedures that are monaural.
Medical management for the hearing loss.
increase the signal intensity level by whatever is needed
Avoid single syllable word materials which have a lot of high frequencies to try to eliminate the effect of peripheral HL.
rely on procedures which
are less sensitive to the effects of peripheral hearing loss. Such as HINT and SSI-ICM
auditory evoked responses
three most useful clinically for evaluation of APD:
ABR, it is a brainstem measure
middle latency, primary auditory cortex response
P300 responses. Higher level response evaluating processes.
mismatch negativity
interpret the responses in APD
ABR: not much of help with APD
Middle latency: We look for asymmetries in the amplitude or amplitude reductions or the absence of response attributed to one of the hemispheres as opposed to the other hemisphere or the midline.
P300: P300 response for APD evaluation is that at least in part it’s
generated in the Limbic System, the Hippocampus
There is some evidence that the P300 can be used to document the effectiveness of medication for either ADD or for audition and that’s also an exciting prospect that we would have an objective electrophysiologic way to verify outcome for the management of our patients with APD.
The Listening in Spatialized Noise-Sentences test (LISN-S[R])
The software produces a three-dimensional auditory environment under headphones and was developed to assess auditory stream segregation skills in children.
the LISN-S has been designed to assess the ability of children with suspected (central) auditory processing disorder ([C]APD) to understand speech when background noise is present.
study supports the hypothesis that a high proportion of children with suspected (C)APD have a deficit in the mechanisms that normally use the spatial distribution of sources to suppress unwanted signals. The LISN-S is a potentially valuable assessment tool for assessing auditory stream segregation deficits, and is sensitive in differentiating various forms of auditory streaming.
What are the three main areas of APD management?
Counseling

Management

Advocacy
What are the goals in the management of APD?
Assure that the child:
Is an academic achiever
Learns to read
Performs to full potential in school and out of school
Reaches full academic potential
Communicates effectively
What are the characteristics of APD?
Psychological problems
greater than average effort to keep up with other children
Not picking on jokes as quickly
Low self-esteem
Poor self image
laziness
less paid attention
What are the critical elements in the counseling?
Understandable and complete explanation of the test findings.
Providing guidelines for the parents and the teachers on handling APD.
Leaving the parent with several major messages rather than a bunch of unconnected details.
Coordinating the diagnostic plan
Direct the parents to specific professionals
Advocacy for child/parents
Emotional support
What classroom modifications are needed for a child with APD?
Educating teachers and school personnel
Modifying the environment and teaching style
Preferential seating
Reduction of the classroom noise
Reduction of reverberation times
Feasible classroom modifications such as acoustic ceiling tiles, sound attenuation panels on the walls, carpet installation, quieter air-conditioning units
What are some types of assistive listening devices?
Hard-wired ALD  child that’s home schooled or receiving individual or small group therapy at school or home.
Personal device  used when child has a peripheral HL in addition to APD – headphones not recommended
The totable device  has high quality speaker that sits on child’s desk
The sound field or classroom ALD  the best option which the whole class could get benefit from – does not single out the child with APD
How can we document the value of the assistive listening device?
Pre and post aided evaluation in the clinic
Use any signal to noise ratio type procedure such as HINT
Evaluation is in the sound field with two speakers
One speaker with a signal and the microphone about 6 in. from the speaker
Noise coming from another speaker
Document the child’s performance which jumps up with assistive listening device
What are the most common disorders coexisting with APD?
Peripheral (conductive and sensory) hearing loss
Specific language impairment (SLI)
Learning disabilities (LDs)
Reading disorders (dyslexia)
Attention deficit/hyperactivity disorder (ADHD)
Emotional and psychological disorders
Developmental delay
Seizure disorders
PDD, autism, and autism spectrum disorders
What are the reasons for coexisting disorders in children with APD?
Children are all sharing the anatomy of the brain

Difficulties such as developmental delays

Problems in delayed maturation of the brain
These tend to affect the auditory system as well as other areas.
What are the functional deficits that may exist with the child with APD
Distractibility/inattention
Poor memory
Restricted vocabulary
Cognitive inflexibility
Poor listening comprehension
Reading, spelling problems and phonologic awareness (the most serious problem)
Maladaptive behaviors
Poor motivation
What is executive function?
Part of metacognition
Highest level of brain functioning
Needed for problem solving and learning
Demands attention, memory and sensory input
Can impact on auditory processing
Insufficient executive functioning together with inadequate auditory processing results in serious problem in the classroom
A child with intact executive functioning but inadequate auditory processing will develop compensation strategies.
Neural bases of executive function
Interaction and communication of varied regions of the brain
Temporal lobe
Parietal lobe
Frontal lobe
Occipital lobe when reading
Basal ganglia
Thalamus
Relationship between APD and executive function
Children with auditory processing disorders with neurologic basis may have difficulties with executive functions and the opposite is true as well.
APD affects strategic listening  child misses much of the information in the classroom because of difficulty hearing in the background noise  cannot process auditory information fast enough to understand speech  executive function is hampered by inadequate input  they make faulty decisions and demonstrate poor judgment because of insufficient information
Definition of Metacognition and relationship with APD
Metacognition is awareness and appropriate use of knowledge that affect performance
Spoken language processing is essential for metacognition
Experience in processing auditory signals develops metacognition
A person with APD do not use appropriate strategies to organize, monitor and understand acoustic signal
Metacognitive deficits in APD includes:
Inefficient approach to problem solving
Passivity
Inactivity
Low self-esteem
Low motivation
Fatigue and frustration
Lack of metacognitive awareness
Difficulty monitoring comprehension
Children with APD do not employ strategies spontaneously
Similarities between APD and ADHD
Male/female ratio is 2/1
Depressed clinical performance
Both are easily distracted
They both seem like they do not listen
Auditory decoding deficit
Is characterized by difficulty in:

Monaural separation/closure tests (e.g., time compressed)
Auditory speech discrimination
Gap detection
Binaural interaction (dichotic tests)
Difficulty hearing in noise
Reading and spelling (phonologic decoding)
What are five basic components of EARS program?
All kindergarten children are screened for hearing sensitivity and auditory processing.
Sound field FM amplification systems are installed in all kindergarten classrooms.
All kindergarten children complete Earobics computer based program for developing auditory and pre-reading skills.
Classroom teachers receive in-service training on phonological awareness and auditory skills, which they focus on for 15 minutes daily with students in small groups.
Children with abnormal performance on the Staggered Spondaic Words (SSW) test receive intensive one-on-one or small group instruction on auditory and pre-reading skills.
What combination of auditory measures is most efficient for screening hearing and auditory processing in the EARS program and what was the results?
Tympanometry
DPOAEs
Pure-tone Audiometry
Results of screening showed that pass and fail rates for pure-tone audiometry were highly correlated with pass and fail rates for tympanometry and OAEs alone (without pure tone screening) for screening peripheral hearing. The fail rate for the SSW was an alarming 46% while the combined fail rate for peripheral screening measures ( pure-tone audiometry, tympanometry, and OAEs) was 35% proving the effectiveness of combining all the mentioned tests for evaluation of APD.
Does Chronic OME produce language problems?
Two experimental observations revealed that:

Children only from socially deprived background tend to have longer term language problems (additive to the deprivation produced by the OME).
Only the most persistent OME results in poor auditory processing.
How does auditory training affect phonological awareness?
Engaging actively with the stimuli, even without marked sensory learning is sufficient to activate attention and/or linguistic circuits involved in phonological awareness and other cognitive processes
What is the relationship between central auditory processing disorder and speech language impairment (SLI)?
Dichotic tests were used to analyze problems in children with SLI.
The tests aimed at taking into account the dichotic listening possibilities using simple words (two-syllable words).
Central integration, temporal processing and short term memory quality could be evaluated.
The average number of correct responses was significantly lower in SLI children than in children from control group.
Results of the tests in children with SLI confirmed integration problems in the central perception area and the short-term memory disorder.
Auditory rehabilitation for interaural asymmetry: Preliminary evidence of improved dichotic listening performance following intensive training. Moncrieff DW & Wertz D. (2008) (Article 13)
What was the purpose of the Phase I of this study?
“A phase I clinical trial is a critical first step for developing appropriate therapy for children with unilateral deficits; To test the feasibility of an auditory training paradigm designed to remediate dichotic listening deficits in children”.
The ultimate goal was that children perform at normal levels in both ears on dichotic listening test.
What was the outcome/conclusion of Phase I?
7 out of 8 children showed improvement in the left ear performance after training;
In addition, 5 children demonstrated improvement in the right (better) ear performance post training.
Only 2 children performed at normal level binaurally on dichotic listening tests.
Between 3 to 6 of the children performed at a higher level on language and phonologic awareness tests following training, although the results were of modest value.
Auditory rehabilitation for interaural asymmetry: Preliminary evidence of improved dichotic listening performance following intensive training. Moncrieff DW & Wertz D. (2008) (Article 13)
What was the goal of Phase II clinical trials?
“to increase both the frequency and total number of training sessions in order to evaluate whether more training would produce greater enhancement of dichotic listening performance”.
What were the outcomes?
After training, Right and Left ear differences were no longer present on the digits tests, but there was still a significant difference between the ears on the words tests.
Greater gains were made for the Left ear than for the Right one.
Children with unilateral deficits showed greater improvement than those with bilateral dichotic listening deficits. What do you think influenced that?
Neither age nor # of sessions was linked to success - some children achieved optimum results in fewer sessions than others.
As in Phase I, many children showed improvement in language skills as well (not limited to auditory performance).
Auditory rehabilitation for interaural asymmetry: Preliminary evidence of improved dichotic listening performance following intensive training. Moncrieff DW & Wertz D. (2008) (Article 13)
Overall study conclusions:
unilateral deficit measured during dichotic listening tests can be eliminated following intensive training and that for others, left ear performance can improve.
continued improvement in dichotic listening observed in the children who received follow-up language therapy following phase I trial suggest that a combination of dichotic training and language therapy might be additive.
intensive training may have a positive impact on child’s ability to understand auditory information in general.
the sample size in both Phases was small, so the results should be interpreted with caution.
Multiple benefits of personal FM system use by children with auditory processing disorder (APD) (Article 14) Johnston  KJ,  John  A,  Kreisman  NV,  Hall  JW  III,  Crandell  CC
What was the objective of this study?
to evaluate the potential benefits in speech-perception and psychosocial function of a new personal FM system, the Phonak EduLink, when used in mainstream classroom environments by children with auditory processing disorder.
What were the criteria for the APD subjects?
Ten children (eight male, two female) with a positive diagnosis of APD ranged in age from 8 years, 2 months to 15 years, 7 months with a mean age of 11 years, 8 months. All subjects were screened and met the following selection criteria: normal hearing sensitivity, normal middle-ear function (type A tympanograms), and evidence of APD as defined by performance more than two standard deviations below the mean for at least one ear on two different measures of auditory processing (ASHA, 2005).
Multiple benefits of personal FM system use by children with auditory processing disorder (APD) (Article 14) Johnston  KJ,  John  A,  Kreisman  NV,  Hall  JW  III,  Crandell  CC
What were the criteria for the Control group?
Thirteen children (nine male and four female) were recruited as a control group. Children in this group ranged in age from 8 years, 2 months to 13 years, 2 months with a mean age of 10 years, 6 months. All subjects in the control group were screened and met the following criteria: normal hearing sensitivity, normal middle-ear function, and normal auditory processing function, as defined by the criteria for the APD group.
How was academic performance assessed?
Academic performance was assessed using the screening instrument for targeting educational risk (SIFTER; Anderson, 1989) and the listening inventory for education (LIFE; Anderson & Smaldino, 1998). The SIFTER and LIFE are rating instruments commonly used to evaluate learning difficulties and success of classroom interventions for children with auditory disorders.
Multiple benefits of personal FM system use by children with auditory processing disorder (APD) (Article 14) Johnston  KJ,  John  A,  Kreisman  NV,  Hall  JW  III,  Crandell  CC
How was speech perception assessed?
Administration on HINT in quiet and in noise.
How was the psychosocial function evaluated?
Using the behavior assessment system for children: second edition (BASC-2)
What were the main benefits after the use of FM, in speech perception? in academic performance? in psychosocial status?
As expected, speech-perception scores for speech-in-quiet and speech-in-noise conditions were significantly improved for students in the APD group when fit binaurally with the EduLink FM system.
The improvement in speech-perception was documented in the quiet condition with and, importantly, without use of the FM system; improvement in quiet (specifically, 3.8 dB improvement in unaided listening threshold and 2.2 dB improvement in aided listening threshold), after prolonged use of the FM system, suggests that enhanced hearing with the FM system contributed to improved auditory perception abilities. This improvement may reflect fundamental changes in the auditory system of the children with APD.
Speech-perception benefit from FM use was significantly greater for the children with APD than for age- and gender-matched children without a diagnosis of APD.
Children with APD showed improved academic status after the use of FM technology for approximately five months in the following situations: teacher talking in front of room, teacher talking with back turned, and other students making noise.
The benefits in psychosocial health were noted for the children in the APD group after use of the FM system. In particular, parents rated their children as less at risk for problems related to leadership and functional communication. More importantly, the children rated themselves as less at risk for problems related to locus of control, depression, anxiety, and interpersonal relationships.
Subcortical differentiation of stop consonants relates to reading and speech-in-noise perception. (Article 15) Hornickel J, Skoe E, Nicol T, Zecker S & Kraus N. (2009)
What was the purpose of this study?
The current study investigated whether this subcortical differentiation of stop consonants was related to reading ability and speech-in-noise performance. The speech stimuli used in this study were: [ba], [da], [ga].
What is the % of school aged children with reading disorders?
5-7%
Subcortical differentiation of stop consonants relates to reading and speech-in-noise perception. (Article 15) Hornickel J, Skoe E, Nicol T, Zecker S & Kraus N. (2009)
Children with reading impairments often show deficits in which areas?
phonological processing, impairments in speech sound discrimination (i.e., contrastive syllables) - especially prevalent for place of articulation and voice onset time contrasts; temporal judgments, frequency discrimination, sequencing sounds; they are affected more than normal-learning children by backward masking of tones; poor speech in noise perception.
Where does the neural differentiation of speech take place?
Phonemic contrasts are represented in both the cortex and auditory brainstem. In the cortex, temporal characteristics such as voice onset time are encoded in Heschel’s gyrus. In addition, tonotopicity is used to represent place of articulation (i.e., the initial formant frequencies of consonants) and the formant content of vowels.
The auditory brainstem response closely mimics the acoustics of a stimulus and response timing reflects stimulus features that cannot be encoded directly through phase-locking.
Subcortical differentiation of stop consonants relates to reading and speech-in-noise perception. (Article 15) Hornickel J, Skoe E, Nicol T, Zecker S & Kraus N. (2009)
What are the deficits in neural encoding of speech?
Abnormal neural representation of sound in the auditory system causes deficits in phonological awareness, reading, and temporal resolution.
Children with reading impairments show reduced cortical asymmetry of language processing and reduced amplitude or delayed latencies of the mismatch negativity, a cortical response reflecting preconscious neural representation of stimulus differences - the weakest MMN responses correlate with the lowest literacy scores.
What were the outcomes of this study?
The current study is the first to demonstrate an unambiguous relationship between reading ability and subcortical temporal encoding of contrastive speech sounds that present phonological challenges for poor readers.
By showing that children with poorer phonological awareness and speech-in-noise perception have smaller or absent latency differences among responses, the current study reinforces the notion that formant information is encoded less precisely in the reading-impaired population.
As hypothesized, subcortical differentiation of voiced stop consonants correlated with reading, phonological awareness, and speech-in-noise perception.
Children with reading disorders often have impaired phonological retrieval and short-term memory store, which, over time, may result in a failure to sharpen the subcortical auditory system, resulting in deficient encoding of sound elements important for phoneme identification in the auditory brainstem.
Define Learning Disability
one or more of a group of disorders that affect a person’s ability to interpret what they see or hear or to link information from different parts of the brain.
a discrepancy between the child’s ability to perform and the child’s actual performance.
Name the processing systems involved in communication
Visual
Auditory
Motor (tactile)
these processes are influenced by Attention, Exposure/Background, Development and Memory
Define Form, Content and Use of language
Form: sounds, syllables, stresses, rhythm and intonation(phonology), syntax and morphology
Content: ideas and meaning behind the sounds, words and structures (semantics)
Use: changes in language depending on a situation, conversational partners, reasons for speaking (pragmatics)
What are the areas of phonological processing?
phonological memory: coding info phonologically for temporary storage in working memory
phonological awareness: ability to access the sound structure of oral language---> phonemic awareness: the ability to manipulate individual sounds within words.
rapid naming: efficient retrieval from long term memory
What is language processing?
attaching meaning to auditory stimuli, from simple one-word associations to more complex, and then being able to formulate an expressive response
What are the characteristics of language processing seen in a child with language or auditory processing difficulties?
word retrieval problems
natural generic language
original creative words
response latency
rehearsal
inconsistent learning
pragmatic difficulties
"i don't know"
What are the tests of phonological processing
Comprehensive Test of Phonological Processing (CTOPP)
Lindamood Auditory Conceptualization Test (LAC-3)
Test of Phonological Awareness (TPA)
Illinois Test of Psycholinguistic Abilities (ITPA-3)
Which language processing tests can be used for APD assessment
Test of Language Development T OLD-P:3 has some purely auditory (no visual) subtests
Language Processing Test - has no visual stimuli
The Listening Test
Auditory Processing Abilities Test
What is the Difference between bottom-up and top-down intervention approaches?
Bottom-up: Stimulus driven and intended to improve encoding of the signal through adaptive stimulation;
Multi-sensory reading programs (Lindamood-Bell Phoneme Sequencing=LiPS), multi-sensory reading strategies (Orton Gillingham), auditory training-computer based instruction ( Fast Forward, Earobics) and auditory training (Dichotic Interaural Intensity Difference)
Top-Down: Focus on improving ability to use metalinguistic/metacognitive strategies and enhancing the student’s experiences and expectations to allow the strategies to be used;
Include contect-derived vocabulary building, visual imagery, multisensory reading strategies (Orton Gillingham), Auditory closure activities, speech language therapy
What is Earobics?
Teaches phonologic awareness, auditory processing and phonics skills for reading and spelling - similar to Fast ForWord
Less expensive than Fast ForWord
Trains sound blending
Auditory closure
Background noise introduced
When Dichotic Interaural Intensity Difference(DIID, F. Musiek) Training is appropriate?
for children who exhibit the“left-ear deficit” or integration deficit
to increase the performance of the left ear through increased stimulation using words, syllables, sentences numbers mono-and-binaurally for new neural pathways to form
What is meant by “Making movies in your mind
A visualizing and verbalizing intervention program to better language comprehension, critical thinking and expressive language by describing images in their mind so well that the listener be able to easily guess it.
Why is it important to understand the difference between accommodation and modification? Give an example of each
Because when Accommodation are made, the child obtains a regular education diploma; if Modifications are made, a non-regular ed diploma is awarded.
Examples:
accommodations: preferential seating, FM system, extended time for test taking.
modifications: changes the curriculum; modified performance criteria, lower instruction level; eliminating full assignments
Describe the difference between a fluid theory of intelligence v. crystallized theory according to Cattell & Horn.
Fluid involves more broad reasoning with the ability to perform novel problem solving & prestigal knowledge; Crystallized is more dependent on education & culture
What four areas are tested to determine overall Psychological Assessment?
Intellectual abilities, Memory skills, Behavior/Personality, Neuropsychological
Given the variety of different perspectives on intelligence, what aspects are common amongst them?
– Knowledge-based thinking, Apprehension, Adaptive purposeful striving, Fluid-analytic reasoning, Mental playfulness, Idiosyncratic learning
How is the WISC-IV scored? Why are the different scores useful?
Full Scale” Global IQ can be utilized, but it is comprised of 4 indices: Processing speed, Verbal comprehension, Working memory, and Non-verbal perceptual reasoning
1. Each index represents a different style/method of thinking
2. Global IQ uses verbal & non-verbal reasoning scores only to better represent child’s full abilities when the combination of all four indices cannot accurately do so
What circumstances might you use the UNIT?
Universal Non-Verbal Intelligence Test – good for child with hearing impairment, English as second language, severe language delays, avoids cultural influences
There is a common testing/scoring factor between APD and IQ mentioned in the lecture. What is it?
age 7 yrs – IQ not stable under age 7 yrs & APD not considered valid unless mental age is 7 yrs
How does working memory affect children with APD?
child with APD may not be able to process and maintain efficiently or long enough the sounds and words heard in order to integrate them into longer term memory; may ultimately affect reading abilities too
List the three defining features of ADHD.
Developmentally inappropriate symptoms of Inattention, Hyperactivity, Impulsivity
What are the IQ scores for the various levels of Mental Handicap or Mental Retardation?
– Educably Mentally Handicapped (EMH) = 55-70
Trainably Mentally Handicapped (TMH) = 40-55
Severely Mentally Handicapped (PMH) = <40
What effect does it have on our jobs in audiology when a child presents with Oppositional Defiance Disorder or Conduct Disorder?
child may refuse to do testing even though capable, may be prone to violent/mean temperament, child may not be capable of controlling own behaviors
What advantages are there to working with a school psychologist when a child has APD?
– The school psychologist is likely to be familiar with the school, able to go into classrooms to observe the child, can evaluate & report back on use of assistive technology, provide info on classroom management for helping with assessment and classroom intervention strategies, help in teaching self-advocacy
Counseling
Post fitting counseling sessions:
Group
Individual
Educate about:
Realistic expectations
Increased possibility of APD in geriatrics between 40-80%
Period of adjustments and learning new skills
Knowledge about sources of communication difficulties- reverb, background noise, lighting for facial gestures…
Compensation strategies
Patient Education
Patient focused education, emphasis on their needs and agenda, head on approach with focus on feelings:
Explain why they are having communication difficulties
Skills to use hearing aids
Skills to get back to a normal life
Address frankly the feelings associated with hearing loss and social stigma of HA
“Wear those hearing aids!”
Written instructions to supplement
Design of Patient Education Materials
Employ instructional design principles from the Bernier Instructional Design Scale (Bernier,1993)
White background, black bold print
Font size of min 16
Regular paper vs. glossy
Appropriate vocabulary, common words
Clear drawings and labels
3-4 main points in each page
Keep it simple
Montgomery’s WATCH (Brief Auditory Rehabilitation)
One hour program introduced by AL Montgomery. Spend about 12 mins covering each topic
W- Watch the talker’s mouth- lip reading
A- Ask specific questions if you need repetition, give specific directions as of how they could make it easier for you to understand.
T- Talk about your hearing loss, let people know how they could modify their ways to make the communication easier
C- Change the situation, be proactive and assertive, ask for repetition
H- Healthcare knowledge, hand outs and web sites for strategies and support
Group Vs. Individual
GROUPS:
Effective: positive atmosphere, sharing experiences, helping each other, learning from each other
Cost efficient, good marketing tool if open to friends
Helpful to family, friends, and significant other
Groups are fun!
Acceptance of hearing loss and hearing aid and not being the only one!
Realistic expectations
Time to assimilate and practice new skills
More interest in ALDs
Establishes rapport with clients
More satisfied clients
Topics For “Living With Hearing Loss Program”
Identify the problem: speaker, listener, or environment
Trychin, 1995 list of problems
Speaker: too soft, too fast, too far, no enunciation, talks while his back is turned, drops voice at the end of sentence,…
Environment: several speakers at the same time, poor illumination, rapid shifting conversation, reverb, background noise, distractions,…
Listener: tiered, emotionally upset, lack of motivation, fatigue, inattention, poor speech discrimination,…
Trychin 15 possible solutions- anticipate a difficult situation, and find possible solutions for it
Skills for AR groups
Facilitate the group, rather than instruct, encourage a lot of sharing to make the group successful
Active listening
Respect individual uniqueness
Adaptable
Excellent communication skills
Sense of humor
Have topics in mind: dining out, family dinners, grand kids,…
Inform the group of goals and purposes of the meetings
Use suggestions and questions, rather than constantly give advise
Draw out the group, rather than “tell” the group
Icebreaker Introductions
Name?
What brought you to the group?
What do you want to achieve from the group?
What are your interests?
Name three places you have lived or visited?
If you were not here right now, where would you like to be?

Introductory questions to get people to open up and make a group, rather than a few people just attending a meeting
Lipreading Research
Talker differences:
Mumble and how to read
Speak clearly, but barely move lips- Barbara Walters

Clear speech training
What is a Clear Speech?
Accurate, precise, and fully formed articulation
Naturally slower
Naturally louder
Lively
Full of distinct, meaningful pauses to give time to process
Not exaggerated speech in any manner
Clear Speech Benefits
Research shows;
Hefler showed, Both younger and older listeners with hearing impairment benefited from clear speech
Picheny, et all have demonstrated that clear speech is not characterized by making the sounds so precisely, but by temporal changes, especially reduced rate of speech and use of pauses
Schum, 2001
We can train people to have clear speech in just 5-10 mins of training and practice.
Would carry over to conversation
Would last over time- 1 month, maybe needs booster shot?
Importance of Clear Speech Research to Elders
Research has shown that speech-reading ability declines with age, even when visual acuity is controlled- after about age 71 (Benny and shoup)
Changes are due to neural conduction of visual images in the central system and temporal analysis of vision
Speech comprehension requires rapid on-line processing of information. If we have any compromise of the CNS due to age we would expect difficulty in all aspects.
Aging Changes in the Visual System
Visual processing speed slows with aging
Age related increase in visual persistence- longer existence of mental image, after it is removed
Higher susceptibility to backward masking in the visual domain
Central changes makes it harder for the audio-visual speech perception, and that makes clear speech even more important
Helfer, 1998.

The older the subject, the more compromised their audiovisual speech recognition, and the greater their clear speech benefits
The degree of the hearing loss was not correlated to clear speech benefit



Otocon has “Clear Speech” booklets that could be hand out to clients
Older adults & their issues
Listening Difficulties
Poorer word recognition
Poorer comprehension of connected speech
Gates (1990) shoed a linear decline ins word recognition with age
12% per decade over age 60
Why these problems?
Loss of Audibility
According to Humes, what accounts for nearly all changes in speech perception with age?
What type of processing is a factor in successful hearing aid use?
Auditory Processing Disorders
Cox & Gilmore reported a correlation between what type of testing & HA performance?
Changes in auditory-visual speech perception
Changes in cognitive abilities
Especially in what three areas?
When do these changes set in?
What skills continue to grow well past our 7th decade?
History of AR
Audiology & AR grew out of needs of soldiers returning from WWII with hearing loss.
Initial programs were intensive & effective.
Why did the profession shift away from comprehensive auditory training in the 1990’s?
On what do these programs available now focus?
Sound & Beyond
Seeing & Hearing Speech
Conversation Made Easy
LACE
Dual Sensory Loss
What are some of the causes of vision changes seen in older adults?
What are some factors to consider when evaluating this population for amplification?
Erber
How does high frequency hearing loss impact a person who also has inadequate visual access?
Low frequency hearing loss?
Suggests looking beyond hearing & vision to see conversational fluency
Stages of Change- Babeu et al
Method of looking at the changes in attitude, behaviors, and intentions as an individual cycles through as apart of making the decision to change behavior
5 Stages
Precontemplation
Contemplation
Preparation
Action
Maintenance

Progress through stages is not necessarily linear
Precontemplation
Person has given no thought to change
Why?
Contemplation
Start to consider/have concerns
When do contemplators move on to next stage?
Preparation
Ready to set goals & priorities
How can an audiologist help a person in this stage?
Action
Doing something about the problem
Maintenance
How long does the new behavior have to be in place to be considered maintained?
Facilitation through the Stages
Audiologists can facilitate progression through the stages by using cognitive strategies
Consciousness raising
Increase the level of awareness of the problem
Dramatic relief
Role-playing how person feels about problem
Environmental evaluation
Look at impact on personal & physical state
Self-reevaluation
How a person feels about themselves in regard to problem
Social liberation
Awareness that society is more understanding of the problem
Behavioral Processes
What the individual can do:
Self-liberation
Commitment to change
Counter-conditioning
Using positive experiences to address anxiety
Stimulus Control
Restructuring the environment
Forming helping relationships
Connect with people who understand
Stages of Change applied to Audiology
Describe the 5 stages as they apply to a person with hearing loss who has not yet realized it. What are they doing/experiencing in each stage?
Precontemplation
Contemplation
Preparation
Action
Maintenance

*Overall, puts emphasis on finding out an individuals wants, desires, needs, and fears regarding hearing aids.
• In Lecture AR10 Dr. Kricos reviews the Transtheoretical Model presented in the Babeu, et al (2004) and demonstrates how it can be applied to adults with late/gradual onset hearing impairment. Dr. Kricos feels the model is useful for:
understanding what the individual is experiencing
developing rehabilitation strategies
facilitating changes in institutions, organizations, and service delivery models
• Dr. Kricos reports a 2003 study by Kricos and Smith where they found that older adults, even when willing to acknowledge a hearing loss, are typically not ready to accept a HA or accept the fact that hearing loss may be impacting them or others. Kricos and Smith identified 3 groups based on hearing screening and the HHIE-S:
Group 1: Acknowledge HL, self-report hearing problems recognize impact hearing problems
Group 2: Acknowledge HL, but disregard or unaware of impact of hearing problems
Group 3: Unaware of HL, unaware of impact
• How does Dr. Kricos describe "change"?
a gradual process
start by thinking about change
focusing on non-compliance and motivation emphasizes failure
What does she suggest you focus on rather than noncompliance?
patient readiness
barriers
anticipate and avoid relapse
• Transtheoretical Stages of Change Model developed by Prochaska and DiClemente can be useful in effecting HA acceptance. The Transtheoretical Model relates to intentional behavior (not forced behavior) and offers a method of looking at changes in attitudes, behavior and intentions
What are the 4 components of the Transtheoretical Stages of Change Model? Provide a brief explanation of each
Stages of Change What we do--steps toward intentional change. (Slide 37)

Processes of Change What we think and feel, How we behave (Slides 51, 52, 53)

Decisional Balance Should I or Shouldn't I? (Slides 41, 42)

Self-efficacy How confident I am I can change. (Slides 45, 46)
• There are 5 "Stages of Change
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
• According to MarkeTrak V (2000) survey 16.2% of those who purchase HA never wear them. The top 3 reasons are
1. Poor benefit (29.6%)
2. Poor performance in noise (25.3%)
3. Fit and comfort (18.7%)
Consequences of Hearing ImpairmentAmong Older Adults
cannot be predicted by audiometric results alone as personal and environmental factors have a significant influence on the extent of hearing-related activity limitations and parti• Speech perception, especially in adverse environments with noise, reverberation, high speech rate, accented speech, and/or when the face of the person talking cannot been seen;
• Understanding of broadcast signals such as radio and television;
• Localization of sound sources such as footsteps and cars; and
• Detection of environmental signals including ringing telephones, doorbells, and alarms.
Participation restrictions
Withdrawal from previous involvement in community life; and
• Avoidance of interpersonal interactions.

Communication partners of older adults with hearing impairment (e.g., spouses) also experience the negative consequences of hearing impairment
Rehabilitation Interventions for Older Adults With Hearing Impairment (3 Main Styles)
Hearing Aids
Usually digital these days

Hearing Assistance Technology
Induction loops
Cordless headphones
Frequency modulation (FM) system is a wireless portable hearing assistance technology that provides a direct path between the sound source and the person with hearing impairment

Communication Programs
Speech perception and/or communication management
Group or Individual
Examples of the Rehabilitation Intervention Outcomes Reported in the Literature Table 1.
Hearing-related activity/ limitations Quality of life
and participation restrictions _______________________

Hearing aids Improved as measured by the Improved as concluded by
International Outcome Inventory a systematic review

Hearing Assistance Improved as measured by the Improved as measured by
Technology International Outcome Inventory-Alternative Interventions

Communication Improved as concluded by Improved as measured by
Programs systematic review International Outcome Inventory-
Alternative Interventions
Rehabilitation Intervention Issues Reported in the Literature Table 2
Hearing aids 21% Older Australians own 23% do not use them
35% Older Americans own 22% do not use them

Hearing Assistance 5% of older Americans with Not reported
Technology with hearing disabilities own

Communication 5% of American audiologists provide 44% did not complete
Programs group communication programs and group
<1% provide individual communication 32% did not complete
programs individual
In Order To Improve Current Practices, 2 Changes Must Occur
1) availability of the range of rehabilitation interventions should be improved.

2) older adults with hearing impairment should be invited to be actively involved in the rehabilitation process.
Shift from an acute to a chronic model of care would
better reflect the permanent nature of age-related
hearing impairment.
Clinically Significant Cognitive Impairment
Mild Cognitive Impairment (MCI) subtle but measurable memory disorder characterized by memory impairment, normal general cognitive functioning, intact activities of daily living (ADL), and no dementia

A person with MCI experiences problems greater than normally expected with aging, but typically does not manifest symptoms associated with dementia, such as impaired judgment or reasoning.

Transitional syndrome between normal cognitive function and dementia.

It is estimated that approximately 3% to 19% of adults 65 years and older have some degree of MCI.
Dementia may range from mild to severe and is characterized by severe compromises in independent functioning.

Memory loss, difficulty with multi-dimensional cognitive tasks necessary for independent living, including driving, preparing meals, and managing self-care such as personal finances, health care, and medications.

Other warning signs described by the Alzheimer’s Association (www.alz.org) include word finding difficulties, time and place disorientation, difficulty with abstract thinking, changes in mood,
behavior, and personality, as well as decreased judgment and initiative.
SCREENING FOR COGNITIVE IMPAIRMENT
Mini-Mental State Exam (MMSE). A total score of less than 23 on this 30-item test suggests impairment in cognitive function.

It is of critical importance for professionals to ensure that hearing impairment is not a confounding factor in cognitive test results.

Hearing loss can present symptoms similar to those of dementia.
When an older patient with a hearing loss responds inappropriately
to an item on a cognitive measure, it may be due to hearing loss,
cognitive compromises, or a combination of the two. If hearing loss, test in amplified condition
How prevalent is hearing loss in persons with dementia and mild cognitive impairments?
The majority of individuals with cognitive disorders also have significant hearing losses?

What is the of ability to test?

Rarely
receive treatment for their hearing losses.
TREATMENT OPTIONS
Among the features of the fitting program were
multiple visits to the patient’s home pre- and post-fitting,
Use of the Hearing Handicap Inventory for
the Elderly to determine treatment effectiveness,
Selection of a hearing aid with adaptive compression,
Spousal instruction on care and use of the hearing
aid, and daily tracking by the spouse of hearing aid use and its effects on the user.
Unconventional Measurement Of Outcomes Can Assist In Determining The Success Of Hearing Aid Fitting
Asked the patients’ caregivers
List problem behaviors: (e.g., repetitive questioning, arguments, and disturbance of activities) that they perceived as being related to the patients’ hearing difficulties.
Outcomes:
According to their caregivers, the patients wore their
hearing aids from 5 to 15 hours a day, and one to four problem behaviors were significantly reduced for each of the patients