1. Technology Audiologic Rehabilitation for Children & Educational Audiology SPA 6581 – Spring 2015

2. Technology  Rationale for personal hearing instruments and hearing assistive technology  Recent trends and regulatory considerations  Assessment of the personal hearing instrument and hearing assistance technology needs of children and youth  Personal hearing instruments and hearing assistance technology options  Implementation and Management of hearing technology  Other Assistive Technologies

3. Technology: Rationale  Well researcher and documented:  Negative effects of noise, distance, and reverberation  The above can impact any child, but are particularly deleterious to children with deficiencies in:  Hearing  Auditory processing  Language  Attention  Learning  Non-native English speakers

4. Recent trends and regulatory considerations  Regulations  IDEA  No Child Left Behind Act of 2001  Section 504 of the Rehabilitation Ac of 1973  The Americans with Disabilities Act of 1990  HAT is not classified as durable medical equipment  Little regulation of performance with regards to the companies  Widespread commercial availability!  May mean that audiologists are not involved in their selection, purchase, and fitting  Need to be well versed in Professional Practice Standards and Scope of Practice  HAT fitting issues should ALWAYS be addressed as part of the IFSP or IEP so that all members of the planning team understand and are informed of the necessity for a qualified person to perform this service.  REVIEW The AAA Clinical Practice Guidelines for HAT

5. Technology: Assessment of HAT needs  Candidacy and Candidacy Considerations  Every child and youth with HL should be considered a candidate for personal hearing instruments*  Personal choice  Regardless of the decision to fit personal hearing instruments, the next consideration is for HAT. Should be considered for the following populations (AAA, 2008):  Hearing loss  Auditory processing deficits  Auditory neuropathy spectrum disorder  Learning disabilities  Language deficits  Attention deficits  English language learners  The decision to proceed with HAT should be based on evidence that links the deficit to hearing, listening or learning problems whether in or out of school.

6. Technology: Assessment of HAT needs  Candidacy and Candidacy Considerations  The decision to proceed with HAT should be based on evidence that links the deficit to hearing, listening or learning problems whether in or out of school.

7. Technology: Assessment of HAT needs  Next step is to consider the social emotional, functional, and support implications for use of HAT  Social-emotional  Motivation (student, teachers, child and family members)  Attention and fatigue (listening and looking)  Self-image  Self-advocacy  Social acceptance  Classroom culture  Family support  Functional  Age  Chronological and developmental  Academic  Communication skills  Home communication environment  Support  Awareness  External acceptance  Ability to use and manage technology  Financial resources  ADA obligations

8. Technology: Assessment of HAT needs  Device Selection Considerations for HAT  Developmental considerations  Age, academic performance, and additional learning problems  The listening Environment  Extends beyond school to the home and community activities and is one of the most critical areas affecting communication access  Technology  See next slide  Funding  Although it should not dictate the recommendation for HAT or the type of HAT selected, it can be a deterrent  Device Determination  The decision is made after all of these considerations have been discussed

9. Technology: Assessment of HAT needs  Device Selection Considerations for HAT  Technology Considerations  Convenience  Wearability  Reliability  Maintenance  Ease of monitoring  Manufacturer or dealer support  Compatibility with existing amplification  Compatibility with computers, phones, and other devices  Signal interference  Multiple FM frequencies  Bluetooth capability  Electromagnetic capability

10. Technology: HAT technology options  Type: Air conduction, Bone conduction, Cochlear implant, Implantable bone conduction device (FDA approved for children 5 years and older)  Style: BTE, BTE open fit, BTE RITE, All in the ear  Receiver type options: ear level personal FM system, induction, targeted area audio distribution system (ADS), classroom audio distribution system (ADS)  Wireless transmitters:  Location: lapel mic connected to body-worn transmitter, head or cheek boom mic connected to body-worn transmitter, lavalier – mic and transmitter in one unit, conference – mic and transmitter in one unit that sits on a table top  Type: omni-directional, directional  Other Features:  Adaptive FM  Single-fixed FM channel  Multichannel selectable  Accessories  Audio input jack  Bluetooth

11. Technology: HAT technology options  Goals:  Speech recognition that is commensurate with performance in ideal listening conditions  Full audibility of self and others  Consistent signal from the talker regardless of head movement  Technology that will be worn consistently by the individual, parent, or teacher  Technology that will provide full audibility according to the listening group  Group 1 = children and youth with hearing loss who are actual or potential hearing aid uses. (default recommended arrangement: bilateral ear-level wireless technology and fewest equipment adjustments)  Group 2 = children and youth with cochlear implants (default recommended arrangement: bilateral wireless technology)  Group 3 = children and youth with normal hearing sensitivity who have special listening requirements (no default arrangement)  Reduced effects of distance, noise, and reverberation

12. Personal FM System  Page 302 Table 7-9  Page 304 Table 7-10

13. Technology: Implementation and Management  Fitting and Verification  Orientation and Training  The Usage Plan  Validation  Monitoring and Equipment Management

14. Fitting and Verification  AAA Pediatric Amplification Guidelines (2004)  Addresses fitting and verification for hearing aids  AAA HAT Guidelines, Supplement A (2008)  Addresses fitting and verification for ear-level FM

15. Fitting and Verification  Basic premise for HAT?  All verification measures of the relationship between the FM and the HA microphones are based on the assumption that the hearing aid portion of the system has been adjusted to provide appropriate audibility and output for the individual child!  Personal FM system should increase the level of the perceived speech in the listener’s ear by at least 10 dB relative to reception by hearing aid only.  If simultaneous use of the personal FM and hearing aid is normal for the child, the assessment of the FM And hearing aid should be performed in that condition  Assess performance electroacoustically with a speech-weighted input  True estimates of the maximum output of the system are obtained from the HA microphone, not the personal FM system microphone, because of the presence of input automatic gain control in the FM system

16. Fitting and Verification  Electroacoustic verification and Real-ear measurements  Necessary to verify that the instrument is functioning according to the manufacturer’s specifications  Crucial to check before fitting  Determine that there is “transparency” between devices  When the same input is given to the hearing aid microphone and to the personal FM system transmitter, the hearing aid with the FM receiver attached should perform in an identical manner  Difference? Adjustments before continuing with the verification process  Real Ear measures verify optimal audibility and maximum output for the individual user and are routinely performed  Measurements for FM verification rely mostly on the 2cc coupler

17. Fitting and Verification  Behavioral verification  Purpose is to determine that what has been selected and fitted functions as expected for the child or youth  Performance with the FM in an ideal listening condition should be as good as the hearing aid alone in that same condition  Testing in noise to compare the performance with a hearing aid alone to performance with the FM microphone engaged is also necessary to determine the benefit provided by the FM

18. Orientation and Training  As a service required under IDEA (2004), orientation and training activities for assistive devices should be included in the IEP for each child and should be provided as part of the audiologist’s consultation time  Including caregivers if devices are used at home  Should be face-to-face in addition to written information

19. Orientation and Training Topics for children and youth  Implications of hearing loss  Basic function of device(s)  Appropriate use of device and features  Expectations: benefits and limitations, when to use and when not to use  Care and maintenance  Basic troubleshooting  Self-monitoring of function  Self-advocacy Topics for teachers, parents, and others  Basic implications of hearing loss  Basic function of the device  Appropriate use of device and features  Expectations  Listening check and basic troubleshooting

20. The Usage Plan  With leadership from the audiologist and input from the student (when age appropriate), the IFSP or IEP team needs to determine a usage plan that identifies when the HAT will be used.  Out of school events such as: therapy, education classes, organized activities should also be considered  School-owned HAT would only be used if the IEP team determined it was necessary for FAPE

21. Validation  Purpose?  To determine that the hearing instruments audiologists have fit, prepared children or youth to use, and trained the teachers and staff to support actually result in the intended outcomes in classrooms, homes, and other settings  Should identify strengths and limitations of HAT, and be ongoing in its evaluation  LIFE  ELF  CHILD  SIFTER  IT-MAIS  etc

22. Monitoring and Equipment Management  Monitoring – not an option  IDEA 34CFR300.113 specifies that monitoring must occur, it does not state the frequency or procedure with which the monitoring should occur  Daily checks  Monitoring plan  Need battery testing, listening stethoscope, extra batteries, cleaning brush, wax loop, earmold puffer, diagram of hearing aids with parts labeled, directions for physical and listening checks, who to call when a problem is identified

23.  Strategies to Implement the American Academy of Audiology Hearing Assistance Technology Guidelines

24. Classroom Acoustics Audiologic Rehabilitation for Children & Educational Audiology SPA 6581 Spring 2015

25. Acoustical Parameters in Classrooms  They change as a function of:  Time  Specific learning activity  Other factors

26. Measuring Classroom Acoustics  Classroom Observation  Instrumentation and Software Programs  Classroom Noise Measurements  Classroom Reverberation Measurements  Estimating Critical Distance

27. ANSI/ASA Standard (2010) and ASHA Guidelines for Addressing Acoustics in Educational Settings (2005)  Specific procedures should be used:  1) Measure background noise levels in dBA  2) Measure or estimate reverberation time  3) Measure or estimate SNR  Also – estimation of critical distance should be included as part of the classroom survey and acoustical measurements

28. Classroom Observation  Before measuring classroom acoustics, the educational audiologist should conduct an observation of the specific learning space(s).  Subjective appraisal of noise and reverberation characteristics and information about teaching style and physical room characteristics  Observe both OCCUPIED AND UNOCCUPIED space before measuring noise and reverberation

29. Classroom Observation: Referrals  1) General concern about noise and reverberation levels  2) Student-specific concern related to hearing loss, auditory processing, or the effects of noise and reverberation on academic achievement  3) concern expressed by a teacher experiencing excessive vocal stress or fatigue

30. Classroom Observation: Data  Useful in making follow-up recommendations for acoustical modifications in the teaching and learning enviroment

31. Instrumentation and Software Programs  Sound Level Meters  Type 1: integrating-averaging type capable of measuring time-average sound levels  Type 2: conventional sound level meter capable of measuring slow time-weighted sound levels  Most educational audiology facilities supported by local education agencies?  Type 2  Capable of measuring both A and C weighted filter networks is adequate for conducting classroom noise measurements  Some Sound Level Meter manufacturers offer software that allows for transfer of data for analysis.  Calculation of reverberation time, etc.

32. Classroom Noise Measurements  See pdf

33. Classroom Reverberation Measurements  The average Reverberation Time of a classroom is calculated by averaging the RTs at 500, 1000, and 2000 Hz.  All classrooms with the same RT are not the same acoustically.  May differ with respect to the predominant type of reverberation or the frequency characteristics of the reverberation  What is the equipment is not available to the educational audiologist?  The use of estimating software or manual calculation is a good alternative  Applications are available on smart phones, etc.  Classroom Acoustical Screening Survey Worksheet – see pdf

34. Estimating Critical Distance  It is important to know what the critical distance is for a given classroom and for different learning activities.  Learners who are seated beyond the critical distance in the learning environment may experience difficulty comprehending instruction, and as a result, learning opportunities may be missed.  Critical Distance is dependent upon…  The dimensions of the learning space and the Reverberation Time (RT), and the directionality of the auditory signal.  Including critical distance information in the classroom acoustic measurements may provide convincing support when recommending:  acoustical modifications  room arrangement  seating options  other strategies to enhance the listening and learning environment for students AND teachers.