Books have the power to whisk you and your child away to a magical place and let your imagination run wild.  Books have a way of bringing a pause to busy lives and allow the information you receive to be intentional.  Help foster your child’s language, literacy, and vocabulary development by filling your shelves at home with books and carving out a time to read.

Studies indicate that deaf and hard of hearing children need to hear a word multiple times before they begin to understand and use it correctly.  Therefore, repetition is critical for comprehension.  Often, this requires you to read a favorite book over and over until the spine starts to fall apart.  Consider your child to be a seed and for them to grow, you need to fill them with food (language), water (access to auditory information) and sunlight (repetition).  It’s never too early to begin taking care of your ‘seed’ by making sure reading is a part of your daily routine.

It’s best to find a time in your day when your child will be engaged in a book, and you won’t have many interruptions.  Choose books with topics your child is interested in.  Expand their knowledge by using vocabulary they aren’t familiar with.  Pick books that focus on emotions, to allow for conversations about feeling to take place naturally.  If you can’t seem to fit in reading throughout your day, make it a priority to add reading into your bedtime routine.  Let your child guide you on what they would like to read and bring your patience since it may be the 10^th time you’ve read that book that week!  Encourage your child to talk about what they are reading and how the story relates to your lives.

Lastly, as our deaf and hard of hearing children grow and develop their identity, immerse them in literature featuring deaf or hard of hearing characters.  Knowing that over 90% of our deaf or hard of hearing children are born to hearing parents, they often are the only ones with hearing loss in their families.  Fill your personal library with books where the characters on the page use amplification, hearing technology or visual modes of communication.  You are guaranteed to see your child’s eye light up when they see children on the pages who look just like them! 

Plant the reading seed with your child from a young age, so as they grow, so will their passion for books. 

Author: Teri Urban 

Click here to download this article

The post Plant the Literacy Seed and Read! first appeared on Supporting Success For Children With Hearing Loss.

Most students are hard of hearing, mainstreamed into typical classrooms (U.S.)

It is likely that the majority  of the 80% in schools with less than 3 students with hearing loss are primarily auditory rather than primarily visual learners.

How can we estimate a student’s ability to access verbal instruction ?

CLEARLY UNDERSTAND THE STUDENT’S PERCEPTION OF SPEECH

The Familiar Sounds Audiogram is a tool that is often used to explain the audiogram in terms of what sounds a


person with hearing loss can and cannot hear. Although convenient, this tool lacks accuracy in depicting the different frequency elements that make up the different sounds of speech in the English language.
Speech Perception – Formant representations for Vowels and Consonants provides a one-page chart displaying the frequency spectrum of most vowels and consonants appearing in English. The
Speech Spectrum Audiogram for Consonants plots the formant information in a familiar audiogram form. When considering the impact of a child’s areas of hearing loss (hearing worse than 20 dB) on speech perception it is possible to review these charts to identify the speech sounds that are most likely to be confused by the child.

The handout
Ling Sounds & Formant Spectrum is also available to further understand how a child is perceiving speech sounds. This
information can contribute to ‘diagnosing’ when a speech perception issue is occurring and  the specific frequency range at issue. The information about changes or lack of response at specific frequencies can be shared with the audiologist as a way to explore if amplification in specific frequency regions can be improved.
Another good resource on speech acoustics.
A resource for phonemic inventories across languages can be found here.

CONSIDER AUDIBILITY OF SPEECH

We often consider a child’s audiogram to understand how well they are able to detect sounds across the pitch range. Similar to understanding how well the student is able to perceive speech sounds in the different formant or frequency ranges, it is also helpful to more globally consider how much speech energy they are likely to perceive. Speech energy that is received can be interpreted as audibility, which can be considered as the opportunity a student has to perceive speech. Consider typically hearing students as having almost all of the pieces of a 100-piece picture puzzle. They can easily interpret and understand the picture. Now consider the child with hearing loss as having the same picture puzzle, but missing a number of pieces. Although the picture is the same, they don’t have the same opportunity to understand and interpret the picture because parts are missing. Now think about speech in the classroom as a dynamic puzzle in which pieces are missing due to hearing ability that causes parts of speech to be missed, and is made worse by background noise and excessive reverberation.

The


Speech Audibility Audiogram for Classroom Listening   represents speech audibility for 35 dB HL (soft speech) and 50 dB HL (louder than conversational level speech) inputs and is based on the figure shown right. The Speech Audibility Audiogram for Classroom Listening has
a fillable form that allows you to input student information and your Functional Listening Evaluation results, and comments.  You can also download  a
of the Speech Audibility Audiogram for Classroom Listening rather than the fillable form if you prefer. You still need to  record an individual’s average hearing level (with or without amplification).  Note: Audibility and speech perception (word recognition) are not the same. A child may be able to perform well on single—word speech understanding tasks even if audibility is significantly decreased. Read this article for more information:
Predicting Speech Audibility from the Audiogram to Advocate for Listening and Learning Needs 
Hearing Review, September 2011

ARTICLE:
Speech Perception in Classroom Acoustics by Children with Cochlear Implants. A J Audiol, 25(2) (2016). F. Iglehart.

DETERMINE THE PRECISION OF THE STUDENT’S LISTENING ABILITY

The Ling Sounds and standard word discrimination testing in a sound booth do not provide specific information on how a child perceives each consonant Each consonant is an es
sential element for understanding speech clearly. A child who does not perceive all of the consonant sounds clearly will have increased difficulty comprehending speech.
Children demonstrating consonant perception errors need to have their hearing technology settings changed. 

Ling Sounds are Not Enough! Administer the
Iowa Medial Consonant Test. In a quiet setting with the right, left and both hearing devices, have the child repeat when you say each consonant at 3 feet and 10 feet using a-a (e.g., awpaw) and/or e-e (e.g., eemee). Record the results on the
The Iowa Medial Consonant Test
. This test has been formatted and included for your use. Children with well fit hearing instruments should be able to achieve 100%.

CONSIDER FUNCTIONAL LISTENING ABILITY

The Functional Listening Evaluation (FLE) is a ‘staple’ of audiologists working with school-age children (C.D.


Johnson & P. Von Almen, 1993; Revised 2009 by C.D. Johnson). Age-appropriate speech stimuli are used (words, phrases, nonsense phrases) that the child must repeat back. Lists of words/phrases are presented in different conditions to develop a profile that estimates a student’s ability to access classroom communication.

The pressing question that many educators have when presented with a student’s FLE results is “How does his performance compare to his class peers without hearing loss?” This question can be addressed by research  (
Speech in Noise Norms for Typical Children) that was performed in 1999 (Bodkin, Madell & Rosenfeld) with 126 typically h


earing children ages 3-17 years. These children were presented with age-appropriate lists of single words and asked to repeat the words in both quiet and competing noise 4 talker babble) using soft speech and louder than conversational level speech, which can be compared to listening to a teacher. The results were surprising. In quiet (35 and 50 dB HL), regardless of age, students scored at 95-98%. In a typical level of background noise (+5 dB S/N) with speech loudness comparable to a teacher from a distance (50 dB HL) children ages 3-17 scored just a bit lower – 93-97%. Even in VERY noisy conditions (0 dB S/N) to soft speech (i.e., student answering from across the classroom) these children were able to perform at 90-92% correct. For a student with hearing loss to “compete” with typically hearing peers, he or she would need to be able to have functional listening scores in the 90+% range.

Because the FLE requires a child to respond while only listening and also while watching the speaker’s face, we are also able to provide an estimate of just how beneficial to understanding it is for a student to watch the face of the teacher and class peers. This is especially relevant for students who are expected to take notes during teacher lectures or who have teachers who do not use peer names when calling on them to answer.

Visual Analogies for speech perception challenges when listening in a classroom.


Explaining the effects of reverberation and background noise can be challenging. These visual representations help the teacher or other individual to recognize the challenge posed by poor acoustics and communicates how this issue can result in reduced pace of learning.  Also a puzzle analogy is also included to represent speech audibility and speech perception.

Critical Listening Distance for Self-Advocacy
handout

Performance and the Listening Bubble?
handout

DETERMINE FUNCTIONAL USE OF WHAT IS HEARD – LISTENING COMPREHENSION/LANGUAGE PROCESSING

Refer to information on the
Listening Comprehension Test 2  the
Listening Comprehension Test Adolescent and the
Test of Auditory Processing Skills and the
Phonological Awareness Test for detail on how a student’s precision listening and comprehension of what is heard in the classroom can be compared to age/grade peers.

ESTIMATING ACCESS TO VERBAL INSTRUCTION USING STUDENT INPUT

Estimating how a student is able to perceive speech in a school setting

provides very valuable information about his or her access to verbal instruction and classroom communication. Consider audibility, via the Speech Audibility Audiogram, results of a Functional Listening Evaluation and challenging listening situations identified via the
Listening Instrument For Education – Revised, as all are critical for planning of student accommodation and support needs. Refer to
Providing Audiology Services to School Children – More than Just Preferential Seating  (The Hearing Journal, March 2012) for more information.

Generated report page from the e-version of the Listening Inventory For Education-Revised.

One issue we do not effectively address as we estimate access to classroom communication is the amount of extra effort the student with hearing loss must expend to perceive speech. Each extra millisecond it takes to process speech reduces the cognitive resources available for the student to take what is heard and comprehend the meaning. This requires substantial extra effort that contributes to greater fatigue in the student with hearing loss. These factors underscore the need for extra repetition of new vocabulary and concepts in the classroom and more opportunities to be exposed to this information prior to its introduction to the class. Listening and learning with a hearing loss can be hard work, and challenging to keep pace with the rest of the class.

• Mitchell R., & Karchmer, M. (2006). Demographics of deaf education: More students in more places. American Annals of the Deaf, 151(2), 95-104.
• Anderson, K.L. (2012). Speech Spectrum Audiogram for Consonants.Based on the work of Ross, M., Brackett, D., & Maxon, A.B (1991). Assessment and management of mainstreamed hearing-impaired children: Principles and practices. Pg 190. Austin, TX: Pro-Ed.
• Advanced Bionics (2009). The Sounds of Speech. Adapted from Ling, Daniel (1976) Speech and the Hearing Impaired Child: Theory and Practice
  http://www.advancedbionics.com/content/dam/ab/Global/en_ce/documents/libraries/AssessmentTools/3-01066-B-6_Sounds%20of%20Speech-FNL.pdf
• Anderson, K.L. (2011). Speech Audibility Audiogram for Classroom Listening. From Building Skills for Success in the Fast-Paced Classroom. Page 132, Butte Publications, OR.
• Johnson, C.D. (2011). Functional Listening Evaluation. Based on Functional Listening Evaluation by C.D. Johnson & P. Von Almen, 1993. Educational Audiology Handbook. Singular, San Diego CA.
• Bodkin, K., Madell, J., & Rosenfeld, R. (1999). Word recognition in quiet and noise for normally developing children. Poster Session, American Academy of Audiology Convention, Miami, FL.
• Anderson, K.L., Smaldino, J., & Spangler, C. (2012). Listening Inventory For Education – Revised. E-version of the LIFE-R,
  https://successforkidswithhearingloss.com/tests/life-r . Available June 2012.

These are the views of Karen Anderson, PhD who reserves the right to adapt them as she learns more from the literature and the many DHH professionals and parents who are helping students deal with these issues everyday.

Original post May, 2012 (c) Karen L. Anderson, PhD, revised January 2014, August 2015

The post Speech Perception & Learning first appeared on Supporting Success For Children With Hearing Loss.

Our students who are Deaf and communicate visually will only perceive what is provided via their interpreter and/or captioning, which in combination with language ability may or may not result in complete understanding.

How well a student is able to perceive speech in a classroom will impact educational performance. This Update will review how reduced speech perception is likely to impact learning. These impacts are often overlooked or misunderstood by school staff as they review whether it is necessary to evaluate a student with hearing loss to determine eligibility for specialized supports and services. Hopefully, the information mentioned below will provide the hearing loss professional with the information needed to make the case that this access issue indeed has educational ramifications.

Hard of Hearing Students – comprehension from bits and pieces

Audibility refers to how much sound, especially how much of the speech signal, can be heard. How well language can be used to ‘fill in the blanks’, level of interest and motivation to understand, and level of fatigue from extended listening all contribute to how well a student comprehends what was said.

Audibility

The Speech Audibility Audiogram for Classroom Listening, on the Speech Perception page of the website, shows the difference in audibility for ‘Teacher Speech’ versus ‘Soft Speech.’  Examples of soft speech include comments from peers spoken 6 or more feet away (class discussion) and many of the comments during social situations in school. Group learning when competing conversations are occurring also reduces audibility very significantly. A student with hearing levels in the 25-30 dB range will experience 81% audibility of the teacher’s voice and only 25% audibility of soft speech. This hearing level is not uncommon for children wearing hearing aids. Obviously, hearing aids are not enough to allow these students to fully access class communication, especially class discussions, unless an FM/DM is used and the pass around microphone is used.

Specific Speech Sounds

Decreased audibility looks different from child to child based on their hearing loss and how well their hearing aids are fit. The Speech Perception – Formant Representations for Vowels and Consonants is revealing about the challenges a child with a hearing loss that has ‘peaks and valleys’ that cause islands of hearing. In general, higher pitched consonant sounds (s, f, th, p, k, t, etc.) and brief words and endings are most easily missed, unless speech is presented within 3 feet.

Prereading

A child needs to listen for about 20,000 hours before the brain has developed a clear idea (mental referent) of what each of the discrete speech phonemes sounds like. This requires precision hearing and is a necessary step before children can develop a consistent understanding of sound/letter relationships. It is not a surprise that many students who are deaf or hard of hearing fall behind in their phonological awareness skills. Without these skills students work harder to ‘sound out’ words as they read, which interferes with comprehension. Poor reading fluency will cause even the smartest students to read more slowly and work harder than peers. Students with hearing loss need to have an in depth assessment of their phonological awareness skills.

Reading Comprehension

A recent study* explored reasons why so many students with hearing loss seem to plateau in their reading achievement at the 4th grade level. They found that (1) morphologic awareness was a prerequisite to high reading test scores, (2) speech intelligibility was not correlated with language proficiency (i.e., even if a student has ‘good speech’ this does not predict good language), and (3) language proficiency (measured by the CELF-4) predicted reading achievement. Thus, speech perception has an impact on student’s hearing and learning how to interpret morphological information, such as learning the meanings such as cosmo-, mal-, bio-.

*Nielsen, D. C, Luetke, B., McLean, M., & Stryker, D. (2016). The English-language and reading achievement of a cohort of deaf students speaking and signing Standard English: A preliminary study. American Annals of the Deaf, 161(3), 342-368.

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NOISY CLASSROOMS

A

10 minute Classroom Noise
 file (mpeg) is provided for your use when administering the Functional Listening Evaluation, working with students on listening in noise or when demonstrating listening in noise challenges.

Apps for signaling classroom noise levels: Looking for a phone app that teachers can use to signal when the classroom may be too noisy? There are a number of options! An app highly rated as being most valid is
SPLnFFT (see
YouTube video). Other apps include:
Too Noisy App,
Silent Light – Classroom Timer and Decibel Meter,
MyClassRules (this app overestimates actual noise levels by 20 dB).

Ideas on how to quiet noisy students: Go
here . But noisy students are the easiest problem to handle when it comes to challenging classroom listening environments. How the classroom was built and the sounds surrounding it will define the background noise levels and reverberation times.

Representing classroom listening issues visually: 



Visual Analogies for speech perception challenges when listening in a classroom. Explaining the effects of reverberation and background noise can be challenging. These visual representations help the teacher or other individual to recognize the challenge posed by poor acoustics and communicates how this issue can result in reduced pace of learning.  Also a puzzle analogy is also included to represent speech audibility and speech perception.

Student learning about classroom noise issues: Information for students or schools who want a fun way to learn about these issues can go to
Quiet Classrooms, an alliance of non-profit organizations working to create better learning environments in schools by reducing noise.

Checklist for student to identify acoustic issues: 
Estimating Classroom Noise Effects   This 10—question checklist for students identifies aspects of classroom listening problems that may be related to poor classroom acoustics.
Classroom Acoustical Screening Survey Worksheet  This 10-question checklist is to be completed by classroom teachers or observing teachers or educational audiologists. Any item of the 10 checked NO would raise a concern. Considering items from both of these checklists is a useful means to identify classrooms (or even schools) where poor acoustics is a concern and acoustic measurement may be warranted.

Apps to use to measure background noise in classrooms: Consider these apps to measure background noise in the classroom:
Too Noisy Pro,
Noise Hunter,
NoiSee,
SoundMeter,
SPLnFFT. More info
here. Per the acoustic
standards, the background noise level should not exceed 35 dBA and we know that students with hearing loss need to have a +15 S/N to be able to perceive speech sounds optimally. How close do your student’s classrooms come to this? Even a gross measure of the teacher talking versus when she is not talking (preferably close to the center of the room at student ear height) via a phone app will give an idea as to whether the background noise level and teacher speech level are just a few dB different or are considerably different.

Summary of classroom acoustics research: ARTICLE:
Kids in Noisy Classrooms: What Does the Research Really Say? Over 40 years of research findings have been categorized and summarized in this paper. The synergistic effects of background noise and reverberation on listening and learning result in a serious impediment to learning.

ARTICLE:
Does noise affect learning? A short review on noise effects on cognitive performance in children.

Handout for schools: 
The Insidious Effects of Classroom Acoustics on Student Performance.  A 3-page handout for parents, school administrators, audiologists and teachers that summarizes the research and reality of inappropriate classroom acoustics and learning. Leave a copy in the staff lounge!
Classroom acoustics information and resources from ASHA.

Wind turbines by your school? Wind turbines are becoming increasingly popular as an energy source. The extra low frequency sound emminated from the turbines will have an effect on surrounding neighborhoods, and on learning if there is a school located close to a turbine. Refer to the following articles for more information:
Wind Turbine Noise – What Audiologists Should Know and
Wind Turbine Noise – Recommended Design Goals .

Open Plan Classrooms,
or classrooms without walls, are a hazard to learning for ALL students. Read
here for an article that clearly illustrates the listening issues related to open plan classrooms. The figure to the right illustrates the findings for typically hearing kindergarten students. Any student with auditory or attention issues can be assumed to perform more poorly than typically hearing students.

The
Ted Talks video recording below has been included because it truly is an eloquent description providing vivid examples of how poor classroom acoustics effect learning and the costs to improve.

Because of poor acoustics, students in classrooms miss 50 percent of what their teachers say and patients in hospitals have trouble sleeping because they continually feel stressed. Julian Treasure sounds a call to action for designers to pay attention to the “invisible architecture” of sound.

http://www.ted.com/talks/julian_treasure_why_architects_need_to_use_their_ears.html

MAKING THE CASE FOR CLASSROOM ACOUSTIC CONCERNS

Classroom Acoustics – A First Step Toward Education for All   11/14/08 Slideshow handout

Visual Analogies for speech perception challenges when listening in a classroom. Explaining the effects of reverberation and background noise can be challenging. These visual representations help the teacher or other individual to recognize the challenge posed by poor acoustics and communicates how this issue can result in reduced pace of learning.  Also a puzzle analogy is also included to represent speech audibility and speech perception.

Missing Bits and Pieces of Words  This is a fun exercise that illustrates listening difficulties if classroom acoustics and/or hearing loss causes the higher frequency portions of words to become inaudible. Guess the story based on the ‘words’ presented. Consider how long it took you to figure it out. Those who never heard the story before (imagine new vocabulary in classrooms) may be at a loss to understand the meaning.

ARTICLE: Back to School! 13 Facts Revisited
  (Hearing Review Sept 2004)  Children cannot access classroom instruction unless they can hear the teacher
http://www.hearingreview.com/all-news/15928-back-to-school-13-facts-revisited

SUPPORT FOR USE OF PERSONAL FM TO IMPROVE CLASSROOM LISTENING (not sound field amplification)

Summary of 3 FM Study Comparing Speech Perception in a Typical Classroom for Children with Hearing Aids or Cochlear Implants Information from three


experiments that indicate desktop FM or personal FM use results in better speech perception than using sound field amplification or hearing aids or cochlear implants alone.

From Australian Hearing:

ARTICLE:
Benefit of S/N Enhancing Devices to Speech Perception of Children Listening in a Typical Classroom with Hearing Aids or a Cochlear Implant
Journal of Educational Audiology, 12 (2005)

ARTICLE:
Speech Perception Benefits of FM and Infrared Devices to Children with Hearing Aids in a Typical Classroom
LSHSS, 35 (2004)

Soundfield Classroom Amplification Questionnaires for Teacher, Administrator, Student. Source: original MARRS Project 1978.

Updated January 2016.

The post Classroom Acoustics – Impact on Listening and Learning first appeared on Supporting Success For Children With Hearing Loss.

Classroom Acoustics Standard adopted into the International Building Code. The 2016 edition of these building codes will include
specific requirements for appropriate levels to allow for background noise and reverberation. Once state and local building code agencies adopt the A117.1 code all new school construction projects in those jurisdictions will have to comply with this standard. This code also specifies wheelchair ramps, counter heights and other accessibility requirements.

Classroom Acoustics and ANSI Standard S12.60:

Every day, thousands of students across the country are unable to understand 25


to 30 percent of what is said in their classroom. Excessive noise and reverberation in a classroom interferes with a student’s ability to clearly hear their teacher.

Before reviewing the standards, it’s important to be familiar with the attributes of sound found in the classroom that affect a student’s ability to hear and learn.

The sound of a teacher’s voice traveling directly from the teacher to the student is direct sound. It is always beneficial in terms of speech intelligibility because it is not affected by anything in the room, making it clear and distinct.

The Classroom Acoustic Standard (US): ANSI Standard S12.60 for Classroom Acoustics (Part 1: Permanent Schools) addresses the issues of both reverberation time and background noise and their effect on speech intelligibility by placing maximum permissible levels on each.

Under the new standard, the maximum reverberation time in an unoccupied, furnished classroom with a volume under 10,000 cubic feet is
0.6 seconds, and 0.7 seconds for a classroom between 10,000 and 20,000 cubic feet.  The maximum level of
background noise allowed in the same classrooms is 35 decibels (dBA). There are also specific criteria for portable classrooms.

The standard’s acoustical performance criteria and design requirements apply during the design and construction of all new classrooms or learning spaces of small-to-moderate size, and, as far as is practical, to the design and reconstruction of renovated spaces. At the present time, the new ANSI standard is voluntary unless referenced by a code, ordinance or regulation. However, school systems may require compliance with the standard as partof their construction documents for new schools. A number of school districts are already putting the standard into action.

The following publications are free from the Acoustical Society of America. 

They can be obtained at https://acousticalsociety.org/about_acoustics/acoustics_of_classrooms  These wonderful resources provide powerful information about the acoustic criteria necessary for students to be able to learn without struggling to listen.

1. ANSI STANDARD : Design Requirements, and Guidelines for Schools, Part 1: Permanent Schools (ANSI/ASA S12.60-2010/Part 1;
American National Standard Acoustical Performance Criteria)

2. ANSI STANDARD: Design Requirements, and Guidelines for Schools, Part 2: Relocatable Classroom Factors. (ANSI/ASA S12.60-2009/Part 2;
American National Standard Acoustical Performance Criteria)

3.
Classroom Acoustics I – A resource for creating learning environments with desirable listening conditions. 

4.
Classroom Acoustics II – Acoustical barriers to learning. 

5.
Classroom Acoustics for Architects- A companion booklet for ANSI/ASA S12.60.

Summary on what to do to meet the acoustical standards

Articles with examples:
1,
2,
3. Note: introduction of sound field amplification (CADS) systems as a measure to improve classroom listening will increase the synergistic interaction of noise and reverberation in the classroom. If the reverberation is above the recommended level in the standard, student speech perception clarity can/will decrease as compared to listening without the amplification of the teacher’s voice. Furthermore, peer-to-peer communication as required by small groups or learning pairs will only be improved by overall classroom acoustic improvements. In classrooms with good acoustic ceiling tile (especially those with acoustic panels on the top of adjacent walls) the angle of the reflective white board surfaces in the classroom can be tilted by placing blocks under the edges closest to the floor so that the sound is reflected into the upper portion of the walls and the ceiling. Another tactic used in schools is to insert the legs of all chairs, desks and tables into discarded tennis balls. These balls are known to cause reactions in students with allergies to latex, which are relatively common. A latex-free option would be
Hush-ups.

Does the Classroom Assist or Impede the Learning Process?

By John S. Bradley, (John.Bradley@nrc.ca) Institute for Research in Construction, National Research Council, Montreal Rd., Ottawa

What is reverberation?  A reverberation is the overall effect of reflected sound a
nd the time required for reflected sound to become inaudible.  Short reverberation times are good for speech intelligibility in learning spaces.
Visual analogies for effects of background noise and reverberation on listening

Why is it important?

Teachers and students will do their best in an environment that is conducive to learning.  A poor acoustical environment will often increase stress and decrease concentration, especially with younger children, students for whom English is a second language, students with learning disabilities and the hearing impaired.  It can also contribute to teacher “burnout” caused by the stress of talking “over” the noise.

How can reverberation be measured?

Use this
reverberation time calculation method. This page also provides reverberation time examples that you can experience. If you have a ‘smart phone’ there are also numerous, inexpense applications that allow you to measure the actual reverberation time in an unoccupied classroom.

Resource on soundproofing materials to improve reverberation time in classrooms.

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The post Classroom Acoustics – Impact on Listening and Learning first appeared on Supporting Success For Children With Hearing Loss.

Speechreading as used here means using the visual clues of the speaker’s lip and facial movements, gestures, posture and body language, along with residual hearing to make use of the speaker’s verbal communication, intonation and context to infer meaning (formerly known as lip reading). Speechreading is used by persons with typical hearing and those with hearing loss, especially when there are communication challenges such as background noise, and is an integral part of speech processing.

Speechreading conversation: On average, an English-speaking person will create about 13 to 15 specific speech movements per second in a comfortably paced conversation, but even the best-trained professional speechreaders can only register about 8 or 9 movements per second at most. Even modern day speechreaders trained with conventional techniques (E.G.: extended training procedures that include video recordings that can be paused, slowed-down, rewound, enlarged and have in depth analysis to accompany) can only ascertain a maximum of about 30% to 35% of spoken English in real time conversations, even under optimal conditions. Thus, it is very difficult to capture all of the necessary information to decode meaningful sentences, and building the message from the sum of its parts. Often, the processing time required to visually recognize and interpret recognizable speech movements, arrange them into words, and then arrange the words into sentences outlasts the speakers rate of speech and the sentence the speechreader was trying to follow would have long since passed. For more information go to this review of the literature.

Video examples illustrating the challenges of speechreading use alone for communication: The first YouTube clip is a funny example of speechreading during football.  Clip   Not so funny is The Lost Joke clip that shows a student with hearing loss amongst a group of secondary school age peers when an amusing anecdote is being described. The clips are also powerful examples of why the sentiment, “He may not hear everything but he is a great lipreader and gets it all!” are very concerning. Test your lipreading skills on Can Your Read My Lips and also on the Speechreading Challenge at the bottom of this webpage. 

Assessing speechreading ability:

Functional use of speechreading can be identified via the Functional Listening Evaluation. Alternately you can use the Utley Test of Lipreading Ability.

Methods to teach speechreading:

The first inclination in education is to improve speechreading in order to improve outcomes. Therefore teaching methods are mentioned below:

• The Analytic approach focuses on the smallest units of speech to understand spoken communication. It is a bottom-up approach that concentrates on the details of the sounds – learning to recognize how they look on the lips and practicing their recognition in isolation and in single words. As mentioned above, it is very difficult to build the message from the sum of its parts and the use of this approach exclusively can be a frustrating and cumbersome experience for persons with hearing loss, with lower chances for success in everyday situations.
• The Synthetic approach is a top-down approach, where the perception of the the overall meaning of the message is emphasized more than concentrating on smaller parts. Common exercises focus on giving the speechreader some clues such as key words or a topic that will be discussed, presenting the message and having the speechreader respond to what he thought was said. The goal is to use context and any known information to allow for educated guessing, when parts of spoken information are missed. Limitations include situations when a speechreader is unable to determine the context of the message or unknowingly misinterprets the information, leading to misunderstanding.

Although these approaches may be a limited way to teach ‘lipreading’ or use of context, they have little evidence to support extensive instruction. Individuals naturally vary in how much speechreading benefits their understanding of speech in everyday situations. A bottom-up approach does not really improve this natural ability and a top-down approach may improve understanding in predictable situations with known vocabulary and topics, but is certainly not enough to improve performance in a dynamic educational environment teaching new concepts using previously unheard vocabulary.

Methods to improve speech understanding:

As mentioned, the analytic and synthetic instruction methods to teach ‘lipreading’ lack a strong evidence base. Although they can be used as brief teaching strategies, goals developed around improving these specific skills are not really warranted. The Pragmatic approach below is often included in discussions of speechreading training, yet it is more commonly recognized today as ‘hearing tactics’ or ‘communication repair strategies’.

• The Pragmatic approach focuses primarily on employing communication strategies to ensure that residual hearing is maximized to increase comprehension of the speaker (hearing tactics). The aim of this approach is for the individual to concentrate on interaction more than the reception of specific cues or sounds, to ask for modification of the speakers message, the context in which dialogue takes place, and develop specific strategies that they can employ in particular situations that are found to be most difficult to communicate. The focus of this approach is based on how language is used in social situations and how the use of language can affect those communicating; as a result, most of the exercises are framed from the perspective of interaction. Specific training of communication repair strategies also occurs to ensure they are fully engaged as a responsible communicator and can respond when misunderstandings occur. Exercises can include narratives, question/answer, discussion, and role-playing. Cues such as word order and sequencing, tense and word endings, matching language to the situation and context, among others are considerations when using this approach.

The Holistic approach combines the teaching strategies of the analytic and synthetic approaches combined with hearing tactics and communication repair strategies. Training programs encompassing all of these features have been found to have some evidence base.

• The Holistic approach incorporates aspects from the Analytic, Synthetic and Pragmatic approaches. The main objectives include improvement of overall communication skills, the psychosocial aspects of hearing loss, the education of significant others (e.g. parents, siblings and close friends), hearing aid orientation, an emphasis on improving conversational and interactive skills, and the use of assistive listening devices. Training goals include: increasing the child’s knowledge of the speechreading process, their ability to generalize strategies to facilitate more successful communication, their tolerance for difficult/frustrating communicative situations, their role in generating personal goals, and their motivation to improve their speechreading abilities.

Summary on Teaching Speechreading

As mentioned previously, learning goals specific to the top down or bottom up focus of the first two approaches are not warranted. Rather, it is recommended that the teacher develop goals related to improving speech understanding via communication repair strategies, auditory skill development (focus on the visual aspects of speech sounds can be incorporated into auditory discrimination training), and use of hearing tactics to improve communication in situations in which the student has identified as being challenging for listening.

The Negative Impacts of Speechreading

If a student has challenges hearing everything in class then encouraging him or her to speechread will help understanding, right? Not necessarily.

One study had typically hearing students answer comprehension questions about a story that was presented in a lecture format or when parts of the story were presented from locations around the student, to simulate listening to classroom discussion. The first finding was that accuracy when repeating sentences in quiet or noise (like on a Functional Listening Evaluation) does not predict the true impact of classroom acoustics on listening comprehension for lecture or discussion. In all cases, listening to lecture yielded higher comprehension than listening to discussion. For example, children who achieved a 95% accuracy repeating sentences in a typical classroom listening environment (+7 S/N noise, 0.6s reverberation) had poorer comprehension under more typical classroom lecture or discussion activities. Average results for 11-year olds when listening to lecture was 80% accuracy and 75% for discussion, whereas for 8-year-olds it was 40% and 33% respectively. If the noise level was improved (from +7 S/N to +10 S/N) the scores for understanding class discussion improved from 33%/75% to 60%/90% for 8/11 year-olds respectively.

This study further found that the younger participants (age 8) looked around more to aid their understanding during discussion. Most often these students were unable to visually keep up as the discussion moved from student to student. Furthermore, it appeared as though the act of trying to visually track class discussions could actually use up more cognitive resources, resulting in reduced comprehension, especially for younger students.

Additional research studies on persons with typical hearing  found that considerable listening effort is required when listening at noise levels typical of the school classroom. In low noise, being able to watch the speaker improves speech understanding and reduces listening effort. Listening in high noise while watching the speaker results in greater effort to understand speech. Listeners who are better speechreaders benefit more from visual cues than those that are naturally poorer speechreaders.

Implications of this research

In a relatively quiet classroom listening environment, if a student has good speechreading ability (i.e., 15%+ improvement over auditory alone) he or she should be encouraged to watch the teacher while she is speaking and during classroom discussion. However, the very effort expended to try to view students’ faces during discussion will diminish understanding of what has been heard. It remains critical for the teacher to summarize or repeat key points during discussion, regardless of how well a student speechreads. Indeed, with comprehension lower while trying to visually track discussion, this summarization is important for many students with normal hearing as well.

Take the Speechreading Challenge!

Our thanks to ProCare Therapy for allowing us to share this fun challenge with you. 

Information on speechreading training from here. For more information on the impact of speechreading refer to the article: Access is the Issue Not Hearing Loss: New Policy Clarification Requires Schools to Ensure Effective Communication Access by Karen Anderson from ASHA Perspectives on Hearing and Hearing Disorders in Childhood, Volume 25, pg 24-36. Published April 2015.

Original post of this material in January 2016. Written by Karen L. Anderson, PhD, Director, Supporting Success for Children with Hearing Loss. Updated July 2016.

The post Speechreading first appeared on Supporting Success For Children With Hearing Loss.

In the single-sided handouts below, nine different hearing losses are described, accompanied by information on the possible impact of hearing loss. The handouts address the possible impact on speech and language, social interactions, and educational accommodations/service needs specific to each hearing loss. These handouts may be useful in understanding the impact of a hearing loss as well as for advocating for services with school or medical staff. Select the handout that represents the average range of hearing loss for your student or child.

The dB levels of hearing loss are used rather than terms (i.e., minimal, mild, moderate), because these terms in no way match the seriousness of the impact that these hearing losses may have on child development, listening and learning. Any degree of hearing loss is educationally significant. 

• 16 — 25 dB Hearing Loss
• 26 — 40 dB Hearing Loss
• 41 — 55 dB Hearing Loss
• 56 — 70 dB Hearing Loss
• 71 — 90+ dB Hearing Loss
• Unilateral Hearing Loss

Fluctuating Hearing Loss

• High Frequency Hearing Loss
• Reverse Slope or Mid—Frequency Hearing Loss

• Relationship of Hearing Loss to Listening and Learning Needs — 1 hearing loss per page (parent/teacher version)

• Relationship of Hearing Loss to Listening and Learning Needs — 2 hearing losses per page (professional training)

• Relationship of Hearing Loss to Listening and Learning Needs —

Spanish version of Relationship of Hearing Loss to Listening and Learning Needs, all handouts together

French version of Relationship of Hearing Loss to Listening and Learning Needs, all handouts together

Japanese version 決定版 of Relationship of Hearing Loss to Listening and Learning Needs, all handouts together

ARABIC VERSIONS
Arabic 16-25 dB  ;  Arabic 26-40 dB  ;  Arabic 41-55 dB  ;  Arabic 56-70 dB ; Arabic 71-90+ dB  ;

Arabic Unilateral  ;  Arabic Fluctuating  ;  Arabic High Frequency  ;  Arabic Mid-Frequency or Reverse Slope

Relationship of Hearing Loss to Listening and Learning Needs – all handouts together

Example Impact Statement for Present Levels of Performance

As part of identifying a student’s present level of performance and for IEP development it is necessary to provide a statement that summarizes the impact of the hearing loss on educational performance. The following is an impact statement for an example student that has been developed by Krista Yukow, educational audiologist, and included here with her generous permission:

It is absolutely critical to understand that hearing aids do NOT fix a hearing loss. Even with his hearing aids Tyler will continue to experience gaps in his hearing and understanding. This was observed this in a quiet, close environment and will occur even more often during: communication containing new vocabulary, fast-paced speech, speech from a distance of greater than 3 feet, when there is any amount of background noise, group discussions and communication that includes figurative language.  

It is important to understand that Tyler perceives himself as comprehending all that is said, as he hears more than he misses. He can actually “hear” without his FM/DM device and even without his hearing aids. As a result he perceives himself as “understanding” the entire auditory message. He does not know what he can’t hear, since he can’t hear it.

The complication is that the speech sounds and syntax structures that he doesn’t hear are the THE MOST important ones for speech understanding.  It is the minute details of speech that Tyler will not be able to access without his hearing aids and FM/DM system (e.g. the cats drink vs. the cat drinks). Continued use of both pieces of amplification technology are critical in ensuring Tyler’s access to the verbal instruction and to class discussion.

Being the Only Student with a Hearing Loss

The article below was written by a 14-year-old student with a mild-to-moderate hearing loss in one ear and a moderate loss in the other, who uses bilateral hearing aids to access sound. He has always been the only student in his school with a hearing loss, first in pre-school, then elementary school and now junior high school. He is active in sports, has good friends and does well in school. He was the first student with hearing loss in memory to be accepted into the gifted and talented program in his local area while in elementary school. When this was written in 2010 he attended junior high and hoped to be a marine biologist or veterinarian someday. He gets good grades, but has to work hard to do things that his friends who have typical hearing take for granted. The stress and frustration can be overwhelming. With each new school year, he faces the challenges of unfamiliar teachers who probably have never worked with a student who is deaf or hard of hearing before, and classmates who have never had a peer with a hearing loss. Classroom amplification systems have helped, but haven’t always worked.  Most of his teachers have been supportive and have gone above and beyond to accommodate his hearing loss. But every year, new problems pop up and he has to learn to cope. And, as been true his whole life, he starts each year as the only kid in school with a hearing loss.  – See more at: http://www.listeningandspokenlanguage.org/Document.aspx?id=192#sthash.avoyRMkQ.dpuf

The Lone Sounds of Life

My life as the only student who is hard of hearing in my school can sometimes feel like a bottomless pit of confusion. It is not always that bad, but it is a struggle. I miss a lot of sounds. I often don’t even know if I have missed a sound, sometimes at my own expense. My life at school is defined by what I hear, what I don’t hear and how I learn to cope with the differences.

When I meet new people, they do not always notice my hearing aids. They often do not understand why I do things in a different way, and it may seem weird to them. They will shout at me because they think I am doing something wrong, even though it is just the way I do things. Sometimes, even when they do notice my hearing aids, they will still shout at me. They think I am just being “difficult” or I am lying about my hearing loss. They think I am dumb or don’t have any “feelings” because I can’t hear well.

In school, I struggle with how some teachers act. They cannot seem to adjust to having a student who is hard of hearing. For example, even though my parents and I have asked them not to, they will do things like speak facing the board and not toward the class. The sound just bounces off the board and away from me. I can only hear a bit of what they say. I can’t understand those lone bits of sound if they don’t talk to me.

Teachers will also sometimes change assignments orally and I will miss what they say. Then, when I turn in the assignment, I get marked down or get an “incompletion” grade, even if I have everything else correct. This makes me feel sad and confused because I try so hard, but I don’t seem to meet their standards. It is not that I cannot do the work, but I need to do it my way. It takes a lot of extra energy to do simple things, like listen to a lecture or take notes on a video that is not closed-captioned. If I cannot see the notes or the information the teachers are trying to pass on to me, I find it harder to understand.

I have learned how to cope with the frustrations of being hard of hearing. I spend time with family and friends who understand me. I am also active in sports, like basketball, soccer and tennis, and that helps, but it is not without problems. Occasionally while playing basketball, I will receive a technical foul because I can not hear the referee, and once a soccer coach threatened to kick me off the team because I couldn’t hear him.

Surprisingly, there are some advantages to being hard of hearing. When I sleep without my hearing aids, noises don’t wake me up. I sleep well and have lots of energy when I wake up. The only bad part, of course, is actually having to get up. In school, I find it easy to focus when I take my hearing aids out. Also, I can turn my hearing aids off if my parents are nagging me. Of course that just makes them mad but, after all, I am a little bit of a teenager (but not too much of one).

There are advantages and disadvantages to being the only student who is hard of hearing in my school. Once I explain my hearing loss, most people understand and treat me fairly. Good teachers, good coaches and other school officials have helped me thrive. I have challenges to overcome, but so does everyone else, each in their own way. I may be the only kid who is hard of hearing in my school, but as I listen to the lone sounds of my life, they tell me I am not alone.

Source: Volta Voices, May/June 2010

See more at:
http://www.listeningandspokenlanguage.org/Document.aspx?id=192#sthash.avoyRMkQ.dpuf

 Updated May 2017. Sincere thanks to Krista Yukow for review and revision of this web page.

The post Relationship of Hearing Loss to Listening and Learning first appeared on Supporting Success For Children With Hearing Loss.

The ears are just a way for sound to get in for processing by the brain (Carol Flexer).

Print Version

Hearing is a first-order event for spoken language, reading, and learning which is all based on early development of the auditory centers of the brain.

As of June, 2013, statewide data from North Carolina indicated that 92% of families wanted their child to listen and speak, whereas only 6% chose simultaneous communication, 2% chose ASL, and 1% chose Cued Speech. It is clear that parent choices have changed dramatically over time as 40% chose spoken language in 1995, which increased to 85% in 2005.  The success of developing age-appropriate speech and language skills is built on early, consistent auditory stimulation which is the foundation of development within the auditory cortex of the brain.

Brain Development and Hearing Loss handouts:
Written Format
Graphic Summary

The auditory cortex is the most highly organized processing unit of sound in the brain. This cortex area is the neural center of hearing, language and music, identifying the fundamental elements of pitch and loudness. The right auditory cortex is more sensitive to tonality, while the left auditory cortex is more sensitive to minute sequential differences in sound, such as in speech. The ability of the auditory cortex to function is highly dependent on the sounds encountered early in life. Importantly, the development of brain structures in the auditory cortex to process the minute and rapid changes in pitch and loudness necessary for speech and language development is secondary to consistent stimulation starting prior to birth (4 months gestation) and continuing throughout early infancy and early childhood. These changes to the auditory cortex last throughout the individual’s life. The same exposure to auditory stimulation outside of that period causes no lasting change in the development of brain structures to process pitch and loudness.

Thus, there is a critical window for auditory neural development. Studies in brain development show that sensory stimulation of the auditory centers of the brain is critically important and influences the actual organization of auditory brain pathways. The critical language learning window is secondary to the development of sensory input processing centers in the brain. This, this critical period extends from birth to approximately 3 years of age when brain neuroplasticity is the greatest.

Evidence indicates central auditory pathways do not develop normally in the absence of sound stimulation. This means that the historically poor speech and language skills in children with hearing loss have been due to underlying neurophysiologic deficits in central auditory development caused by the absence of early acoustic stimulation during optimum periods of central auditory system plasticity. Thus, hearing-impaired infants are at risk for abnormal maturation of central auditory pathways if they do not receive adequate sensory stimulation through amplification and, consequently, they will be at risk for delayed or abnormal speech and language development. Given that the central auditory pathways are maximally plastic only in the early years of development, there is a limited time frame for determining whether conventional amplification is providing the stimulation needed for auditory development. For example, it has been shown that congenitally deaf children who are fitted with cochlear implants late in childhood (after age seven years) show delayed central auditory maturation. On the other hand, children who are fitted with cochlear implants within a sensitive period during early childhood (by age 3.5 years) show normal central auditory maturation within six months of implant use.

As we look further into brain development, the foundation of the development of auditory cortex structures to process minute sequential differences in sound, such as in speech, occurs significantly earlier than 3.5 years. Early structures within the brain develop based on consistent sensory stimuli. When born, infants with typical hearing have brains with approximately 2500 synapses, or connections, per neuron. As a result of constant stimulation, the number of synapses grows to 15,000 per neuron by the time a child is 2-3 years old. At age 2-3 years “synaptic pruning” starts to happen. The weaker synaptic connections are eliminated while the stronger connections are kept and strengthened. Thus, if the synapses within the auditory cortex have not been constantly stimulated via amplification and frequent, effective communication with the young child by the age of about 2 years, the majority are likely to be pruned away in the next year or so in favor of the stronger visual processing structures.

To summarize, hearing is a first-order event for spoken language, reading, and learning. Consistent listening experiences in early infancy (birth through age 3) are critical for the development of speech and language in young children and sets the foundation of a strong spoken language base that is essential for reading.

For more information on research related to auditory maturation and the impact of hearing loss review the recent research, especially that by Anu Sharma

• http://pediatrics.aappublications.org/content/60/6/831.short
• http://www.sciencedirect.com/science/article/pii/S0031395505700778
• http://www.sciencedirect.com/science/article/pii/S0378595504004150
• http://www.karger.com/Article/Abstract/94646
• http://spot.colorado.edu/~gilley/pubs_pdf/Sharma_et_al_2005_JAAA.pdf,
• http://fitchlab.com/FitchLabBin/NeuroDev%20Downloads/17.Harrison.etal.2005.PDF
• http://journals.lww.com/neuroreport/Abstract/1996/12200/Auditory_system_plasticity_in_children_after_long.13.aspx

Posted by Karen L. Anderson, PhD, Supporting Success for Children with Hearing Loss, February 17, 2012.

The post Brain Development & Hearing Loss first appeared on Supporting Success For Children With Hearing Loss.

Teachers


and other professionals working with a student with hearing loss must be able to accurately answer the question, “How well can this child hear with hearing aids?”

Setting appropriate speech, language and learning goals, monitoring progress over time, and helping others (such as classroom teachers) work with the student requires an understanding of how the student can hear with his or her hearing aids under a variety of listening conditions. Given the sophistication of today’s hearing aids and the complexity of the testing used to fit hearing aids it is not always clear where this information can be found.

Prescribing and fitting hearing aids is never an exact science. There are three steps involved, each of which adds important pieces of information to the child’s hearing puzzle. This article will describe the three stage process for fitting hearing aids – choosing which hearing aids to order for the child, assessing whether the new hearing aids are working the way we want them to in the clinic (verification), and most importantly, evaluating whether the child is receiving the best possible hearing benefit from his/her new hearing aids in his/her everyday life (validation). The verification and validation stages of the process should provide the answers to the question, “How well can he hear?”

Selecting the hearing aid

A recent Google search for hearing aid manufacturers yielded 3 million results; how do


audiologists even start in choosing the most appropriate hearing aids? They start by gathering information from three sources.

i)  First, audiologists need to gather as much information about both the child’s hearing and auditory function and the physical characteristics of the child’s ear (size, shape, etc.). This is done by using hearing test results and results from a test known as
real ear measurement (sometimes also called probe tube or probe mic measurement), which helps the audiologist tailor the hearing aid fitting for each individual ear.

ii) Second, they need to consider the needs of the child and parents in terms of circuits, features and accessories (e.g., What kind of microphone? should there be a volume control or not? What about noise reduction circuits? etc.). When parents are considering new hearing aids for children who are already amplification users, it is very helpful for teachers and other professionals working with the student to know this in advance. If a student is using an FM system, knowing that new hearing aids may be purchased is necessary to ensure that any needed changes to the school FM system (such as ordering new a


udio shoes) can be done in advance. Teachers and other professionals may also have valuable information about features that work particularly well, or are particularly problematic, with the current aids (for example, multiple programs that the child uses incorrectly).

iii)  Third, audiologists need to generate basic targets for how much volume (or gain) is needed at each frequency, what the maximum allowable sound levels should be (ceiling loudness), etc. Years ago, these targets tended to be “guesstimates” on the part of the audiologist. Today, targets are typically generated by a software program known as the Desired Sensation Level Approach (DSL), pioneered by Dr. Richard Seewald and colleagues at Western University in London, Ontario1,2.
^1,2.

Before we had DSL and other similar software programs, audiologists tended to rely on aided audiograms, standard hearing tests done with the child wearing his/her hearing aids in a sound booth. Parents and teachers grew accustomed to receiving aided audiograms, and used them as assessment, counseling and programming tools. For audiologists, though, the aided audiogram takes a long time (during which the child needs to be paying close attention), does not provide as accurate a measurement of the hearing aid’s characteristics, and therefore is often not performed these days. The DSL approach, on the other hand, provides much more detailed information quickly and easily.

The DSL program needs two pieces of information to generate hearing aid targets (although more detailed measurements can also be incorporated). The first piece of information is the hearing thresholds. It is important that parents know that hearing aid fitting does not need to wait until a child is old enough to provide a full audiogram as the DSL program allows audiologists to start with the information they have and add more information as they get it. It is also important for parents to understand that hearing aid fitting is an ongoing process that can require many “tweaks” to the hearing aid settings as more information becomes known about their child’s hearing.

The second piece of information is the real ear (or probe tube/mic) measurement obtained by putting a small rubber tube into the child’s ear canal and measuring the ear’s size and shape. Our ear canals actually shape sound as it passes through them to the


eardrum. Something called “resonance” causes certain frequencies in sound to be enhanced or amplified by the ear canal.

The amount of enhancement and the frequency range at which it occurs varies from child to adult, and even as a child gets older
^3,4. This real ear measurement shows what happens to sound in an individual’s ear canal without a hearing aid. Knowing all about how each individual’s ear shapes sound provides a better and more individualized hearing aid fitting.  This measurement provides a kind of “virtual ear” for the DSL software, which then uses all of the information entered into it to generate targets for new hearing aids.

Real ear measurement is crucial because the performance of the same hearing aid will differ for different sized ears. For example, we might measure a particular hearing aid on an adult and find that the maximum sound output of the hearing aid is 120 dB. When the same hearing aid at the same settings is placed on a child’s ear, the maximum output of that same hearing aid might be closer to a potentially harmful 130 dB because the child’s ear canal is much smaller than the adult.

The DSL program allows the audiologist to evaluate many different hearing aids and hearing aid settings, either virtually or by doing actual measurements with a hearing aid. Based on all of the information gathered, and hearing aid information provided by the manufacturers, the audiologist can choose what he/she thinks will be the best possible hearing aid for that child. At this point, of course, the selection is a “best guess” that is based on a great deal of information and research. There is a huge choice of different hearing aids these days, so there is no one perfect hearing aid for each child. The best hearing aid for a child is one which has been carefully fit, and is worn consistently every day. An expensive hearing aid with all the bells and whistles that sits unworn in its box most of the day is not the best hearing aid for any child.

Verification

Once the new hearing aids and new earmolds have been received, the audiologist needs to make sure they are programmed properly, and that they meet all of the targets first provided by the DSL program.  Years ago, audiologists relied on putting the new hearing aids on the child and doing a standard hearing test (the aided audiogram). While it seems to make sense to put a child’s unaided and aided thresholds on the same audiogram so that the difference can be seen clearly, aided audiograms are misleading and not accurate enough to reflect how today’s hearing aids amplify sound. The “SPLogram” generated by the DSL program can give us the same information, however, if we know where to look for it.

The most striking thing about an SPLogram is that it looks like an upside down audiogram. The DSL program converts the child’s hearing threshold information a different kind of decibel, dB sound pressure level (or SPL). All hearing aid data is measured in this different kind of decibel and therefore comparing hearing testing information to hearing aid data compares apples to oranges. Frequency is still read from left to right along the bottom; however, loudness values are now reversed – very soft sounds are at the bottom of the graph and loud sounds are at the top. This shows the SPLogram for an audiogram with a 50 dB hearing loss at all frequencies.

The DSL program calculates targets for both average conversational speech and loud sounds for children. Our SPLogram shows a child’s hearing thresholds (as circles), targets for conversational speech (as +’s) and targets for the maximum output of the hearing aid (as *’s). The key to understanding the DSL printouts is to realize that the hearing aid targets have been calculated to ensure audibility of the speech sounds within that frequency range. If an audiologist’s report says “a good match to all DSL targets was obtained”, this implies that all of the speech frequencies (and therefore all of the speech sounds at those frequencies) can be heard (at least in quiet, which is all anyone can predict). We always have to keep in mind that being able to hear a sound doesn’t necessarily mean being able to understand and make sense of it, but hearing is the first step.

This second graph shows a test from a new hearing aid. The hearing aid response is the solid line; this example shows an excellent match to DSL targets since the hearing aid line touches all of the conversational speech targets (the +’s) without going over or under them. This means that speech has been amplified to a level louder than the child’s hearing thresholds (which it must be in order for the child to hear) without making it so loud that it is uncomfortable for the child, and that the child should be able to hear all English speech sounds with these hearing aids.

The SPLogram shows what actually happens – that speech and other sounds are being made loud enough to be heard, not that we are improving the child’s hearing levels. It is a subtle distinction, but one worth making. The traditional aided audiogram implied that we are changing the child’s hearing levels, but the child’s hearing levels cannot be changed. What we have changed is the child’s access to the speech banana. As we know, the speech banana typically falls at a level of 50-60 dB HL; if this is too soft for the child to hear clearly, we must make the speech banana louder to fall within the child’s range of hearing. The SPLogram shows how well the hearing aid is doing its job.

It also demonstrates another audiological truth – that sometimes this “range of hearing” can be very small. With sensorineural hearing loss, the individual’s uncomfortable level for sounds (UCL) may be the same or lower than an individual with typical hearing, producing a small “dynamic range” of hearing. The SPLogram format provides a truer picture of audibility across the frequency range since it indicates predicted or measured
uncomfortable levels as well as thresholds. Allowing a hearing aid to produce uncomfortably loud sounds is a recipe for hearing aid rejection and potential harm to hearing, so audiologists must keep this “ceiling” in mind.

This third graph shows a poor hearing aid response. The hearing aid matches DSL targets up to 1000 Hz, but then the hearing aid response line falls below targets. When this happens (the hearing aid amplifying below targets) sounds in frequency range falling below the targets will not be audible at all with the hearing aid.

If these are the child’s new hearing aids, clearly either this particular hearing aid is a poor choice for this child’s hearing loss or (more likely), it is simply not programmed properly and needs to be adjusted.

In “real life,” these results indicate that the child should be able to detect all speech


sounds at 1000 Hz or lower, but probably cannot detect speech information above 1000 Hz. The frequencies for the different sounds of the
Ling 6 sound speech test (oo, ah, ee, sh, s, m), as well as more comprehensive information about speech perception, can be found
here.

We can predict, then, that this child should be able to hear m, oo, ee and ah, but not sh or s, and would confuse /u/ and /i/. Using
more information about speech acoustics , we could also predict that this child would confuse the words “cat” and “caught,” would not hear the plural marker on most nouns (ie, bib vs bibs), would not hear the f, or th sounds, and would not be able to hear the difference between m and n. Remember that this is a prediction, as is the aided audiogram – it shows what sounds of a generic speech banana we think the child should be able to hear. However, there is no universal speech banana, everyone’s voice and their speech bananas are different, changing dynamically from second to second as distance, noise, reverberation and speaker characteristics change. Therefore any predictions we make based on an aided audiogram or SPLogram apply only to ideal listening conditions. So how, then, can we tell how the child hears in the real world with his or her hearing aids.  We have to go find out; there is no software program for this.

Validation

Validating a hearing aid fitting (making sure the child is hearing and learning with the hearing aids) relies entirely on the eyes and ears of the people in the child’s environment. Before leaving the clinic, parents and families should ask the audiologist to summarize the verification testing in terms of how well the child is predicted to be able to hear all of the sounds of English in a quiet environment. For more severe hearing losses, it might not be possible to make certain sounds (such as s) audible even with today’s technology, and this information is important for parents and teachers to know. At the end of the appointment, the audiologist can easily do a quick Ling 6 Sound test to verify


this, either in the sound room using the audiometer, or informally in the testing room. This is especially important because some hearing aids (e.g. those with frequency transposing circuits) will give misleading results on real ear measurement, but will prove that they are doing their job with a Ling 6 sound test.

There are many ways that parents, teachers and others can find out how well a child hears in a variety of situations. The Ling 6 sound test can be done in different environments, with different noise levels, with different speakers, at different distances, to get a sense of how well the child is able to detect speech sounds.
The Early Listening Function (ELF) from this website is an excellent way for parents and teachers to explore a child’s ability to hear in different situations. Assessments such as the
Functional Listening Evaluation or the
Functional Auditory Performance Indicators might be done by the child’s teacher of the deaf and hard of hearing, speech-language pathologist, auditory verbal therapist or early interventionist to gather more information about how the child is able to use auditory information. Many more examples of assessment tools can be found in the
Tests section of this website. It is important for parents and teachers to have a good sense of how a child hears under different circumstances both to set goals and expectations, and to know when a problem (like a malfunctioning hearing aid) arises.

The unaided audiogram with its speech banana is still a powerful tool to demonstrate the impact of hearing loss for classroom teachers and others. If SPLograms are included with audiological reports, we may still use them as a visual. However, having a classroom teacher see for him/herself that the student cannot hear an /s/ at all from 8 feet away in the classroom, but hears it reliably and consistently with the FM system, is a powerful lesson. Teaching classroom teachers how to be astute and vigilant observers of auditory performance in a classroom, to recognize where listening challenges might be expected to arise, and to be able to implement effective communication and learning strategies, should be our most important goal.

References

¹Bagatto, M., Scollie, S., Hyde, M., & Seewald, R. (2010). Protocol for the provision of amplification within the Ontario Infant Hearing Program.
International Journal of Audiology, 49(1), 70-79.

²Seewald, R., Cornelisse, L., Ramji, K., Sinclair, S., Moodie, K., & Jamieson, D. (1997). DSL v4.1 for Windows: A software implementation of the Desired Sensation Level (DSLi/o) method for fitting linear gain and wide-dynamic range compression hearing instruments.

³Kruger, B. (1987). An update on the external ear resonances in infants and young children.
Ear and Hearing, 8(6), 333-336.

⁴Seewald, R.C. & Scollie, S.D. (1999). Infants are not average adults: Implications for audiometrie testing.
The Hearing Journal, 52(10), 64-72.

I read some of Pam’s writings on this topic and thought she did a great job of breaking down this new way of considering a child’s hearing ability with hearing aids. I’m so happy Pam agreed to share this important information with
Supporting Success for Children with Hearing Loss

-Karen L. Anderson, PhD, Director
Published August, 2012

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