1. Fitting Amplification by 6 months of age: Best Practices Susan Scollie, Ph.D. & Marlene Bagatto, M.Cl.Sc. National Centre for Audiology The University of Western Ontario Susan Scollie, Ph.D. & Marlene Bagatto, M.Cl.Sc. National Centre for Audiology The University of Western Ontario

2. Is Amplification Important? Hearing aid use carries a substantial risk of harm, if excessive amplification is provided. Hearing aids confer substantial benefit, if fitted appropriately. Hearing aid use carries a substantial risk of harm, if excessive amplification is provided. Hearing aids confer substantial benefit, if fitted appropriately.

3. EHDI Program Guidance Manual We “cannot solely rely on technology … Comprehensive programs and systems must be in place to ensure infants transition smoothly through other key EHDI components, including rescreening, audiologic and medical evaluation, intervention, and family to family support services.”

4. EHDI Program Guidance Manual “Goal 2: –All infants who screen positive will have a diagnostic audiologic evaluation before 3 months of age. Goal 3: –All infants identified with a hearing loss will begin receiving appropriate early intervention services before 6 months of age.” “Goal 2: –All infants who screen positive will have a diagnostic audiologic evaluation before 3 months of age. Goal 3: –All infants identified with a hearing loss will begin receiving appropriate early intervention services before 6 months of age.” Do we have a smooth transition between Goal 2 and Goal 3? What protocols ensure success in Goal 3? Do we have a smooth transition between Goal 2 and Goal 3? What protocols ensure success in Goal 3?

5. EHDI Program Guidance Manual: Program Objectives: Audiologic services. All infants identified with hearing loss will receive appropriate audiologic services before 6 months of age. Program Objectives: Audiologic services. All infants identified with hearing loss will receive appropriate audiologic services before 6 months of age.

6. 3 areas that need specific protocol: Using diagnostic information (from ABR) for the first hearing aid fitting. Specific procedures for prescribing, fitting, and verifying hearing aids for infants. Appropriate use of advanced technologies with infant hearing aid fittings. Using diagnostic information (from ABR) for the first hearing aid fitting. Specific procedures for prescribing, fitting, and verifying hearing aids for infants. Appropriate use of advanced technologies with infant hearing aid fittings.

7. Commonly-cited sources for consensus-based protocols Pediatric Working Group (1996) American Journal of Audiology, 5(1): 53-68 American Academy of Audiology Pediatric Amplification Guidelines October, 2003 http://www.audiology.org/professional/positions/pedamp.pdf Pediatric Working Group (1996) American Journal of Audiology, 5(1): 53-68 American Academy of Audiology Pediatric Amplification Guidelines October, 2003 http://www.audiology.org/professional/positions/pedamp.pdf

8. Commonly-cited sources for consensus-based protocols Shared features: –Consistent use of terminology to describe the stages of hearing aid prescription and fitting. –Consistent recommendations, such as: Minimum assessment data required Use of nonlinear technology Procedures for real-ear verification (with updates) Important physical features Shared features: –Consistent use of terminology to describe the stages of hearing aid prescription and fitting. –Consistent recommendations, such as: Minimum assessment data required Use of nonlinear technology Procedures for real-ear verification (with updates) Important physical features

9. What does current practice in infant amplification look like? Bamford, Beresford, Mencher, DeVoe, Owen, & Davis (2001). Provision and Fitting of new Technology Hearing Aids: Implications from a Survey fo some “Good Practice Services” in UK and USA. In: Seewald & Gravel, eds., A Sound Foundation through Early Amplification: Proceedings of the second international conference. Surveyed 27 “good practice” clinics in the United States, regarding their amplification practices. Bamford, Beresford, Mencher, DeVoe, Owen, & Davis (2001). Provision and Fitting of new Technology Hearing Aids: Implications from a Survey fo some “Good Practice Services” in UK and USA. In: Seewald & Gravel, eds., A Sound Foundation through Early Amplification: Proceedings of the second international conference. Surveyed 27 “good practice” clinics in the United States, regarding their amplification practices.

10. Did the surveyed clinics fit hearing aids in infancy?

11. What does this tell us? For most levels of hearing loss, hearing aid fitting precedes audiologic certainty by several months. How is this dealt with across programs, clinics, and clinicians? –A hearing aid fitting based on uncertain thresholds should err on the side of caution (i.e., low gain). How is this being done? For most levels of hearing loss, hearing aid fitting precedes audiologic certainty by several months. How is this dealt with across programs, clinics, and clinicians? –A hearing aid fitting based on uncertain thresholds should err on the side of caution (i.e., low gain). How is this being done?

12. Amplification Procedures

13. Training Priorities Priority (USA clinics only)Rank New hearing aids1 Latest research findings2 Non-linear fitting3 Software skills4 Social/cultural5 Later agency working6 Working with families7 Handling young babies8 Assessment skills9

14. Level of comfort with higher technology hearing aids…

15. Factors contributing to positive outcomes…

16. Barriers to improvement in amplification services Top Two Barriers (USA clinics only) Limited resources Lack of evidence on cost effectiveness of new hearing aid technology

17. Summary of this survey Even in “best-practice” clinics, significant procedural variation was present, in the area of hearing aid fitting. Specific training needs related to amplification were among the highest-priority needs identified. Even in “best-practice” clinics, significant procedural variation was present, in the area of hearing aid fitting. Specific training needs related to amplification were among the highest-priority needs identified.

18. What are these clinicians trying to say? “I’ve spent the last few years learning a lot about infant hearing screening & assessment. In the mean time, hearing aids have changed a lot. I know that appropriate hearing aid fitting is important for good outcomes, but I’m not always sure how to handle specific devices or cases. I think I need some update training and/or newer protocols.”

19. Do our current protocols provide the necessary guidance? Several state-level amplification protocols were reviewed, to assess: –Is there a protocol publicly available? –Are the protocols consistent? With one another? With current state-of-the-science? –Is the level of detail specific enough to ensure consistent implementation? Several state-level amplification protocols were reviewed, to assess: –Is there a protocol publicly available? –Are the protocols consistent? With one another? With current state-of-the-science? –Is the level of detail specific enough to ensure consistent implementation?

20. Strengths Most publicly-available protocols tend to follow the 1996 Pediatric Working Group consensus statement. Like the EHDI guidelines and JCIH position statements, they endorse the importance of appropriate hearing aid fitting as a component of intervention programs. Most publicly-available protocols tend to follow the 1996 Pediatric Working Group consensus statement. Like the EHDI guidelines and JCIH position statements, they endorse the importance of appropriate hearing aid fitting as a component of intervention programs.

21. Some possible limitations Protocols that are less than entirely specific leave us open to practice variation due to interpretation. –Is that what we want? (sometimes) –The devil is in the details. What may seem like a very specific protocol on the surface may actually produce very different hearing aid fittings when applied in the clinic. Protocols that are less than entirely specific leave us open to practice variation due to interpretation. –Is that what we want? (sometimes) –The devil is in the details. What may seem like a very specific protocol on the surface may actually produce very different hearing aid fittings when applied in the clinic.

22. Some possible limitations Pediatric amplification practice has changed a lot in recent years. New information is available and needs to be reflected in our protocols. Witness: the differences between the 1996 and 2003 (AAA) position statements. –Role of higher technologies –Greater consensus on infant-friendly procedures Pediatric amplification practice has changed a lot in recent years. New information is available and needs to be reflected in our protocols. Witness: the differences between the 1996 and 2003 (AAA) position statements. –Role of higher technologies –Greater consensus on infant-friendly procedures

23. In particular: Most prescriptive formulae now offer specific targets for compression hearing aids. –These targets differ significantly from the older, linear versions of the same formulae. –They are not interchangeable. –Some higher technologies are very appropriate for the infant population. Others are not. Infant-friendly real-ear measurement procedures are available. Adult-friendly procedures are not likely to be successful with the 6 month old population. Most prescriptive formulae now offer specific targets for compression hearing aids. –These targets differ significantly from the older, linear versions of the same formulae. –They are not interchangeable. –Some higher technologies are very appropriate for the infant population. Others are not. Infant-friendly real-ear measurement procedures are available. Adult-friendly procedures are not likely to be successful with the 6 month old population.

24. In particular: Most older protocols have few specifics on higher-technology hearing aids, e.g.: –Level-dependent processing –Noise reduction processing –Feedback reduction –Directional microphones Yet: this is what most audiologists have questions about… we need to provide some guidance. Most older protocols have few specifics on higher-technology hearing aids, e.g.: –Level-dependent processing –Noise reduction processing –Feedback reduction –Directional microphones Yet: this is what most audiologists have questions about… we need to provide some guidance.

25. Summary & Next Steps: We have witnessed tremendous growth in knowledge & practice regarding screening, assessment, and diagnosis of hearing status in infancy. One of our current challenges is to improve the level of consistency, documentation, and data tracking in the area of amplification in EHDI programs. Two examples… We have witnessed tremendous growth in knowledge & practice regarding screening, assessment, and diagnosis of hearing status in infancy. One of our current challenges is to improve the level of consistency, documentation, and data tracking in the area of amplification in EHDI programs. Two examples…

26. Example One Without specific protocols, how do we ensure accurate data transfer from electrophysiological assessment to hearing aid fitting?

27. Example Two Hearing aid fitting in infancy requires appropriate accounting for the effects of: –The small, variable, and growing infant ear –The signal processing characteristics of modern hearing aids Hearing aid fitting in infancy requires appropriate accounting for the effects of: –The small, variable, and growing infant ear –The signal processing characteristics of modern hearing aids

28. Using ABR Thresholds for Hearing Aid Fitting in Infants

29. Infant Hearing Assessment Estimates of hearing sensitivity are derived from FS-ABR measurements in infants under 6 months Hearing aid selection and fitting proceeds using ABR threshold estimates –Do not postpone intervention for behavioural data Estimates of hearing sensitivity are derived from FS-ABR measurements in infants under 6 months Hearing aid selection and fitting proceeds using ABR threshold estimates –Do not postpone intervention for behavioural data

30. Some issues …… ABR threshold values (nHL) are not equivalent to behavioural thresholds (HL) A correction is applied to ABR thresholds to obtain the Estimated Hearing Level (eHL) ABR threshold values (nHL) are not equivalent to behavioural thresholds (HL) A correction is applied to ABR thresholds to obtain the Estimated Hearing Level (eHL)

31. Correction to ABR Thresholds Protocols must be in place to ensure that the ABR (nHL) thresholds are only corrected once Protocol must indicate specific correction values to be used –Based on equipment type and parameter settings Protocols must be in place to ensure that the ABR (nHL) thresholds are only corrected once Protocol must indicate specific correction values to be used –Based on equipment type and parameter settings

32. Gap in the Procedure…. ABR Thresholds (nHL) Threshold Estimates for Hearing Aid fitting(eHL)

33. Fitting Hearing Aids From HL Data Many programs use DSL for prescribing hearing aids for infants DSL, like other prescriptive formulae, takes in threshold information in HL Therefore, corrections from nHL to eHL are needed before the hearing aid prescription can be calculated Many programs use DSL for prescribing hearing aids for infants DSL, like other prescriptive formulae, takes in threshold information in HL Therefore, corrections from nHL to eHL are needed before the hearing aid prescription can be calculated

34. Converting nHL to eHL: If more than one audiologist is involved, how do we ensure that this is done correctly, and only once? Anything else risks over- or under- amplification If more than one audiologist is involved, how do we ensure that this is done correctly, and only once? Anything else risks over- or under- amplification nHL - correction eHL Prescription

35. Challenges in fitting Hearing Aids From eHL Data ABR (eHL) corrections –do not have ANSI standardized calibration –vary with stimulus and test parameters Click corrections: up to 15 dB Tone pip corrections: up to 30 dB –are largely based on older children, with significant maturation between the nHL and HL test sessions We have an ongoing research project to determine feasibility of using eHL in prescriptive software ABR (eHL) corrections –do not have ANSI standardized calibration –vary with stimulus and test parameters Click corrections: up to 15 dB Tone pip corrections: up to 30 dB –are largely based on older children, with significant maturation between the nHL and HL test sessions We have an ongoing research project to determine feasibility of using eHL in prescriptive software

36. We can use protocols to bridge this gap Ontario Protocol Safeguards: –Audiologist who performs the ABR is responsible for converting to eHL. Corrections are standardized across the program. –This is reinforced by the database: Only eHL data may be entered All candidacy & referral guidelines are stated in eHL units –Amplification audiologists are trained in nHL to eHL, so that they know it has been done and what type of data to expect. Ontario Protocol Safeguards: –Audiologist who performs the ABR is responsible for converting to eHL. Corrections are standardized across the program. –This is reinforced by the database: Only eHL data may be entered All candidacy & referral guidelines are stated in eHL units –Amplification audiologists are trained in nHL to eHL, so that they know it has been done and what type of data to expect.

37. Amplification Services All service providers: Attend training sessions Use same equipment Follow same procedures All service providers: Attend training sessions Use same equipment Follow same procedures

38. Amplification Services Amplification Training: 6 hours; small groups –73 prescribing; 48 dispensing Lecture and hands-on Follow-up consultation available Repeat training as requested or needed Amplification Training: 6 hours; small groups –73 prescribing; 48 dispensing Lecture and hands-on Follow-up consultation available Repeat training as requested or needed

39. Amplification Services Prescription Process: Define hearing levels and ear canal acoustics of the infant Select hearing aid(s) and features Verify that specified targets have been achieved Validation of device effectiveness Prescription Process: Define hearing levels and ear canal acoustics of the infant Select hearing aid(s) and features Verify that specified targets have been achieved Validation of device effectiveness

40. Amplification Services Prescription Shall Include: Specification of type of aid(s) and earmold(s) to be fitted Appropriate settings Must be conducted by a registered audiologist Prescription Shall Include: Specification of type of aid(s) and earmold(s) to be fitted Appropriate settings Must be conducted by a registered audiologist

41. Amplification Services Do: –Measure each infant’s RECD –Use DSL [i/o] prescriptive targets –Use RECD-corrected coupler targets Don’t: –Use the Aided Audiogram for verifying hearing aid fitting – only as an outcome measure –Use Insertion Gain measures Do: –Measure each infant’s RECD –Use DSL [i/o] prescriptive targets –Use RECD-corrected coupler targets Don’t: –Use the Aided Audiogram for verifying hearing aid fitting – only as an outcome measure –Use Insertion Gain measures

42. Amplification Services Use newly developed RECD predictions if necessary –Bagatto, et al, 2001 Advanced Technologies –Directional microphones –Noise reduction –Multi-memory –Feedback management/cancellation Use newly developed RECD predictions if necessary –Bagatto, et al, 2001 Advanced Technologies –Directional microphones –Noise reduction –Multi-memory –Feedback management/cancellation

43. Amplification Services We use an electroacoustic test system that can: –Evaluate all hearing aids accurately, regardless of signal processing abilities –This ability is dependent on the test signals used by the equipment We use an electroacoustic test system that can: –Evaluate all hearing aids accurately, regardless of signal processing abilities –This ability is dependent on the test signals used by the equipment

44. Amplification Is Important Hearing aid use carries a substantial risk of harm, if excessive amplification is provided. Hearing aids confer substantial benefit, if fitted appropriately. www.dslio.com, or: dsl@nca.uwo.ca www.audiology.org/professional/positions/pedamp.pdf Hearing aid use carries a substantial risk of harm, if excessive amplification is provided. Hearing aids confer substantial benefit, if fitted appropriately. www.dslio.com, or: dsl@nca.uwo.ca www.audiology.org/professional/positions/pedamp.pdf