Hearing problems in school – causes and solutions Harvey Dillon With thanks to: Sharon Cameron Robyn Massie Helen Glyde

Presentation Overview Causes of not hearing clearly in class Solutions Sound field amplification Auditory training for Spatial Processing Disorder (SPD)

Why don’t some children seem to hear and understand easily in class?

Children may not understand speech easily in the classroom because of: Hearing loss Sensorineural hearing loss – permanent Conductive hearing loss Language impairment (including ESL) Cognitive deficit Attention Verbal working memory IQ Auditory processing disorder Spatial processing disorder Other types Poor classroom acoustics

Differentiating these problems based on symptoms Acts (inappropriately) based on what was heard Asks for repetition of instruction Does nothing Misbehaves Response by child Interpretation by observer Daydreams Badly behaved Can’t follow instructions Is not very smart Poor concentration Child fails to understand an instruction Event Cognition Language Auditory processing Hearing loss

What solutions exist?

Solutions to help hear more clearly: Language intervention Hearing aids Wireless remote microphones Sound field amplification Auditory training Memory training

Matching treatment to condition Language intervention Hearing aids Wireless remote microphone Sound-field amplification Auditory training Memory training Attention disorder Language impairment √ Sensorineural hearing loss Conductive hearing loss (√ ) CAPD - general CAPD – spatial processing disorder Working memory deficit

THE IMPACT OF SOUND-FIELD AMPLIFICATION IN MAINSTREAM CLASSROOMs Robyn Massie Harvey Dillon

FACTORS AFFECTING CLASSROOM COMMUNICATION

Direct and reverberant fields in a room Total Noise Reverberant Direct

SOUND-FIELD AMPLIFICATION

PREVIOUS STUDY FINDINGS INCREASED: verbal communication children’s response to teacher verbal instruction child proactiveness in classroom discussion children’s confidence DECREASED: disruptive behaviours teacher voice fatigue

Aim of our study To investigate the effects of sound field amplification intervention on specific educational goals

METHOD Eight Grade 2 classes, in Queensland 242 children 43% Vietnamese, Samoan, Spanish, Aboriginal Dual-channel sound-field amplification Four classes started with amplification, four without. Change-over at mid year. Educational attainment rated by teacher at year start, mid-year, and start of next year (Diagnostic Net)

PROCEDURE Teacher in-service training Audiological assessment Classroom acoustic measurements

Hearing and acoustic results Mean Hearing level Overall effect Mean noise Mean Reverberation Mean Signal-to-noise 15 dB + 7 dB Actual Recommended 50 dB 35 dB 1.5 secs 0.6 secs - 3 dB + 15 dB

Overall “ON” / “OFF” Bars show 95% confidence intervals

Results by skill area and language at home On Off

SUMMARY Positive effect on literacy and numeracy Urgent need to improve classroom and acoustic environment

Spatial Processing Disorder: Overview Diagnosis, cause, remediation

The Australian Broadcasting Commission Catalyst The Australian Broadcasting Commission

Link between SPD and Chronic Otitis Media (middle ear infections)

SPD and chronic otitis media (COM) 50% of children (24/49) diagnosed with SPD at NAL reported a history of COM. (Dillon et al., 2012). 30% of children (15/50) previously diagnosed with COM at University of Melbourne were diagnosed with SPD. (Graydon & Rance, ongoing). Spatial processing deficit worse for early onset age and longer duration of COM (n=35; Tomlin & Rance, under review). 6 yo children with history of COM have below average spatial advantage (n=17; z= -1.0) (Kapadia et al, 2012). 13-17 yo adolescents with history of COM have below average spatial advantage (n=20; z= -0.75) (Kapadia et al, 2014). 10% of a population sample (9/90) of Aboriginal children from remote Australia diagnosed with SPD. (Unpublished data). 7% of a population sample (10/144) of Aboriginal children from regional Australia diagnosed with SPD. (Cameron et al., in review). Indigenous Australian children experience, on average, 2.6 years of conductive hearing loss (vs. 3 months for non-Indigenous children).

Interpretation Based on These and Other Studies Chronic otitis media Fluctuating access to binaural cues reduced effectiveness in better-ear glimpsing

Remediation of SPD: The LiSN & Learn Auditory Training Software

Target: The horse kicked six wet shoes

LiSN-S Results - Pre- vs. Post-Training LC SRT p = 0.158 Talker Advantage p = 0.981 HC SRT p = 0.0002 Spatial Advantage p = 0.0002 Total Advantage p = 0.001 Vertical bars denote 0.95 confidence intervals F(8, 64)=5.3847, p=.00003 Cameron & Dillon (2011)

LiSN & Learn – Preliminary Study 9 children with SPD (6 to 11 years) LiSN & Learn – 2 games/day, 5 days/week, 12 weeks 10 dB Better Average SRT First vs Last 30 Days p = 0.000052 LiSN & Learn SRT (dB) Game Number Cameron & Dillon (2011)

Self-Report Questionnaire - Pre- vs. Post-Training Very Hard Hard OK Easy Very Easy SSQ – Listening in Noise: Pre vs Post - p = 0.0002 * Post vs 3MP - p = 0.397 SSQ – Listening in Quiet: Pre vs Post - p = 0.103 Post vs 3MP - p = 0.529 Cameron & Dillon (2011)

Blinded Randomized Control Study 10 children (aged 6 yrs 0 mths to 9 yrs, 9 mths) diagnosed with LiSN-S as having SPD: 5 x LiSN & Learn (experimental group) 5 x Earobics (control group) Questionnaires Participant (LIFE) Parent (Fishers) Teacher (LIFE) LiSN & Learn or Earobics training – 15 minutes daily x 60 sessions Re-evaluate LiSN-S and questionnaires post-training SSQ = Speech, Spatial and Qualities of Hearing Scale LISN-S one-sided critical difference was calculated as (Mean Test-Retest Difference) - (1.64 x SD of Mean Test-Retest Difference). This represents the decrease in dB needed to infer that there has been a genuine improvement in auditory performance on retest, taking into account mean practice effects and day-to-day fluctuations in performance. Mean difference between test and retest was 0.5 dB for Low-cue SRT, 1.1 dB for High-cue SRT, 0.9 dB for talker advantage, 0.1 dB for spatial advantage, and 0.7 for total advantage. A critical difference on the spatial advantage measure is 2.8 dB, and on the Low-cue SRT it is 2.5 dB 31 31

LiSN-S Results – Pre vs. Post Training Earobics (n = 5) Lisn & Learn (n = 5) p = 0.03 to 0.0008 p = 0.5 to 0.7 Cameron, Glyde & Dillon (2012)

Questionnaires – Post Training Improvements L&L = 16 pts; Earobics = 7 pts; where 0 pts = “no improvement” Teachers Parents Children p = 0.028 L&L = 31%; Earobics = 9% L&L = 22%; Earobics = 9%

Spatial Processing Disorder: Prevalence in a clinical population

Australian Hearing’s CAPD Service Operating in 42 Australian Hearing centers around Australia since May 2012. Diagnosis, assessment and management of specific aspects of CAPD. Recruitment targets children experiencing difficulty hearing in background noise. Tests are chosen which: Have been shown to be associated with difficulties in real life. Are reliable, repeatable and relatively quick to administer. Lead to remediation that is backed by research evidence.

Test structure LiSN-S Auditory memory (digits forward and reverse) Remediate (L&L) LiSN-S Auditory memory (digits forward and reverse) Remediate (Memory booster) Remediate (wireless remote microphone) Dichotic digits

Age Distribution N=618

Minimal Sensorineural Passes and Fails 666 23 4 Mild Conductive Hearing screening Minimal Sensorineural 3 Pass 636 Unknown Z < -1 329 Fail 120 LiSN - HC LiSN SPD 19% Z ≥ -1 307 Auditory memory Fail 167 Pass (not SPD) 209 Memory 26% Pass 349 < 7 years 76 Age Testing discontinued ≥ 7 yrs 273 Dichotic deficit DDT Fail 100 20% Pass 173 27%

National CAPD service results: LiSN & Learn effects

LiSN & Learn training: COSI results

Effect of Memory Booster training

COSI scores for Memory Booster training

Take-home messages Children need to hear their teacher easily Many deficits in children prevent this Many classroom prevent this Acoustics can be improved Classroom amplification helps everyone Spatial Processing Disorder (SPD) is common but can be diagnosed and cured

Disclosure The National Acoustic Laboratories, is an Australian government laboratory NAL licences the LiSN-S test to Phonak, and is paid a royalty on sales. NAL directly sells the LiSN & Learn training package through its web site.

CAPD.NAL.gov.au - TV news story Thanks for listening The support of the Commonwealth Department of Health is greatly appreciated CAPD.NAL.gov.au - TV news story - science TV show 45