Advances in FM Technology Improving Performance in APD Miranda Weidle, MS Pediatric and FM Specialist

The ear will pick it up, the brain will process it. Other Sensory Processing SLI ADHD Memory Language Attention For hearing, ear and brain work together closely. For us to be able to understand and comprehend the message we are presented with, various areas of the brain will work together. When we process speech, various brain areas / skills are activated and work together so that we are able to understand what is being said. SPEECH PERCEPTION (C) APD LD CAP Learning Cognition Intelligence

Hearing is an important sense for Learning Parents and teachers capitalize on this – using the auditory-oral communication mode as the primary approach in the majority of learning situations In our communication we engage in small talk, fiery discussions, romantic discourse, philosophy & politics,… This emphasis on listening can pose difficulties for those who cannot use this information successfully Information carried from the ear to the brain must be of high fidelity or the information available to the listener will be faulty

Auditory Processing Disorder Attention Deficit/Hyperactivity Disorder Sometimes people lose high-fidelity listening – despite normal hearing thresholds… Auditory Processing Disorder Attention Deficit/Hyperactivity Disorder Specific Learning Disability Multiple Sclerosis Non-native speakers Sensory Processing Difficulties, e.g. Asperger‘s syndrome, Autism Spectrum Disorder, Sensory Integration Disorder Speech-Language Disorder Cerebral Palsy Traumatic Brain Injury There are many situations where people lose high fidelity listening. This can happen even to normal hearing people.

…or near-to-normal hearing thresholds… Unilateral Hearing Loss Slight Hearing Loss Permanent Conductive Hearing Loss Fluctuating Conductive Hearing Loss High-frequency Hearing Loss Auditory Neuropathy/Dys-synchrony

Background noise masks speech and reduces speech quality Children are more at risk than adults in the presence of background noise Children bring a different listening to a learning or communicative situation Background noise masks speech and reduces speech quality Understanding speech means that we combine what we hear with what we know The auditory system doesn’t mature until the age of 16 Children don’t have the language and life experiences adults use to fill in gaps Because understanding speech means that we combine what we hear (acoustical information) with what we know already (language & life experiences) children are more at risk to lose the information presented--- Morgenstund hat Gold im Mund Background noise masks speech and reduces speech quality – this makes some sounds less audible than others or no longer audible at all. A child does not have a completely developed auditory system until the age of 16 Children also do not have the years of language and life experience that enable adults to fill in the gaps of missed information (sounds, syllables, words)

An Auditory Processing Disorder Affects the efficiency & precision with which we handle auditory system, primarily in the central auditory system 3-5 % of all children (Musiek, 1997) 2 times more boys than girls Many different possible causes Auditory processing is a term used to describe wheat happens when your brain recognizes and interprets the sounds around you. When there is a issue with processing or interpreting information it can be refered to as an auditory processing disorder. Children with APD often do not recognise the difference between sound and have poor discrimination especially in the presence of background noise. Children with APD typically have normal hearing but may have trouble with paying attention, remembering info presented orally,may have difficulty with directions, poor listening skills, language delays, reading comprehension, spelling and vocab.

Identification Process Electrophysiologic Tests Behavioral Test Monaural Low-Redundancy Speech Tests Dichotic Speech Tests Dichotic digit test Temporal Patterning Tests Frequency pattern sequences test Binaural Interaction Tests Rapidly Alternating Speech Perception (Schminky & Baran, 1999) To diagnose APD, a series of test are ad ministered. Most test rewuire the child to be atleast 7 or 8 due to the normative data provided. Mignon M. Schminky and Jane A. Baran Department of Communication Disorders University of Massachusetts, Amherst, Massachusetts Reprinted from Fall 1999 Deaf-Blind Perspectives, Published by Teaching Research Division of Western Oregon University for DB-LINK Electrophys tests are measures of the brain's response to sounds. For these tests, electrodes are placed on the earlobes and head of the child for the purpose of measuring electrical potentials that arise from the central nervous system in response to an auditory stimulus. An auditory stimulus, often a clicking sound, is delivered to the child's ear and the electrical responses are recorded. Some electrophysiologic tests are used to evaluate processing lower in the brain (auditory brainstem response audiometry), whereas others assess functioning higher in the brain (middle latency responses, late auditory evoked responses, auditory cognitive or P300 responses). The results obtained on these tests are compared to age-appropriate norms to determine if any abnormalities exist. Electrophysiologic tests are measures of the brain's response to sounds. For these tests, electrodes are placed on the earlobes and head of the child for the purpose of measuring electrical potentials that arise from the central nervous system in response to an auditory stimulus. An auditory stimulus, often a clicking sound, is delivered to the child's ear and the electrical responses are recorded. Some electrophysiologic tests are used to evaluate processing lower in the brain (auditory brainstem response audiometry), whereas others assess functioning higher in the brain (middle latency responses, late auditory evoked responses, auditory cognitive or P300 responses). The results obtained on these tests are compared to age-appropriate norms to determine if any abnormalities exist. Monaural Low-Redundancy Speech Tests: Due to the richness of the neural pathways in our auditory system and the redundancy of acoustic information in spoken language, a normal listener is able to recognize speech even when parts of the signal are missing. However, this ability is often compromised in the individual with CAPD. Monaural low-redundancy speech tests represent a group of tests designed to test an individual's ability to achieve auditory closure when information is missing. The speech stimuli used in these tests have been modified by changing one or more of the following characteristics of the speech signal: frequency, temporal, or intensity characteristics. An example of a test in this category is the Compressed Speech test (Beasley, Schwimmer, & Rintelmann, 1972). This is a test in which the speech signals have been altered electronically by removing portions of the original speech signal. The test items are presented to each ear individually and the child is asked to repeat the words that have been presented. A percent correct score is derived for each ear and these are compared to age-appropriate norms. Dichotic Speech Tests In these tests different speech items are presented to both ears either simultaneously or in an overlapping manner and the child is asked to repeat everything that is heard (divided attention) or repeat whatever is heard in one specified ear (directed attention). The more similar and closely acoustically aligned the test items, the more difficult the task. One of the more commonly used tests in this category is the Dichotic Digits test (Musiek, 1983). The child is asked to listen to four numbers presented to the two ears at comfortable listening levels. In each test item two numbers are presented to one ear and two numbers are presented to the other ear. For example, in figure one, 5 is presented to the right ear at the same time 1 is presented to the left ear. Then the numbers 9 and 6 are presented simultaneously to the right and left ears. The child is asked to repeat all numbers heard and a percent correct score is determined for each ear and compared to age-appropriate norms. Dichotic Digits 5, 9  1, 6 (For text only readers: Figure 1 shows numbers 1,6 entering the left ear and numbers 5,9 entering the right ear Temporal Patterning Tests These tests are designed to test the child's ability to process nonverbal auditory signals and to recognize the order or pattern of presentation of these stimuli. A child can be asked to simply "hum" the patterns. In this case, the processing of the stimuli would occur largely in the right half of the brain. If on the other hand, the child is asked to describe the patterns using words; then the left side of the brain is also involved, as well as the major auditory fibers that connect the auditory portions of both sides of the brain. The Frequency Pattern Sequences test (Musiek & Pinheiro, 1987) is one of the temporal patterning tests used frequently with children. The test items are sequences of three tone bursts that are presented to one or both ears. In each of the sequences two tone bursts are of the same frequency, while the third tone is of a different frequency. There are just two different frequencies used in this test: one is a high-frequency sound and the other a low-frequency sound. The child therefore hears patterns, such as high-high-low or low-high-low, and is asked to either hum or describe the patterns heard. As with other central tests, the test items are presented at levels that are comfortable for the child and percent correct scores are obtained and compared to norms. Binaural Interaction Tests: Binaural interaction tests are sometimes referred to as binaural integration tests. These tests tap the ability of structures low in the brain (brainstem) to take incomplete information presented to the two ears and fuse or integrate this information in some manner. Most of the tests in this category present different parts of a speech signal to each ear separately. If only one part of the signal is presented, the child usually cannot recognize the test item. However, if the two different parts of the stimuli are presented simultaneously, with one portion going to one ear and the other portion to the other ear, the child with normal processing abilities has no difficulty recognizing the test item. This is because the two parts (which are unrecognizable if presented in isolation) are integrated into a single identifiable stimulus by the auditory nervous system. An example of a test in this category is the Rapidly Alternating Speech Perception test (Willeford, 1976). For this test, sentence materials are divided into brief segments which are alternated rapidly between the two ears. The example below is a rough approximation of what happens to a sentence when it is segmented in this manner. In this example, the first sound in the sentence "Put a dozen apples in the sack" (represented by pu) is presented to the right ear, then the t sound is presented to the left ear, and so forth and so on. If the child hears only the segments presented to the right ear or left ear, he or she is unlikely to be able to recognize the sentence. However, if the right ear and left ear segments are presented in a cohesive fashion to the child, sentence recognition improves dramatically as long as this particular function of the brain is intact.

LISN-S

Audiologists can offer Direct remediation therapy Compensatory strategies Environmental modifications Depending on the disorder and the challenges the client faces, either a monodisciplinary approach or a multidisciplinary approach will be necessary. Several authors describe APD management as a tripod consisting of the following three “legs”: Direct therapeutic remediation Compensatory strategies Environmental modifications Below we have listed background information on all three aspects. However, the following slides will only address environmental modifications further since this is where EduLink comes in. More information on APD management can also be found in the “Building the Link between Hearing, Understanding and Learning” background story. Direct remediation techniques The purpose of direct remediation activities is to maximize neuroplasticity and improve auditory performance by changing the way the brain processes auditory information. The techniques used are meant to remediate the disorder. Such remediation activities may consist of techniques designed to enhance (phonemic) discrimination, localization/lateralization training, and intonational aspects of speech. Recently there has been renewed interest in auditory therapy (AT) due to the substantial body of literature demonstrating the plasticity in the auditory system. Compensatory strategies training is not designed to remediate the underlying disorder, but rather to strengthen higher-order top-down skills. The more difficult task of auditory processing can then be given greater effort. It will also render any bottom-up activities more effective by enhancing children’s active participation in such activities. Compensatory strategies will include the strengthening of active listening techniques, and linguistic, metalinguistic and metacognitive abilities. Environmental modifications are designed to improve acoustic clarity and enhance learning/listening. It is universally accepted that all listeners perform better in an environment with acoustic clarity and desirable signal-to-noise rations. However, for some children this may be of an even higher importance. Managing classroom acoustics plus the use of a personal FM system, both a part of managing the listening environment, should be approached in a systematic manner: Evaluating the child’s auditory processing strenghts and weaknesses Evaluating the acoustical classroom environment and recommending appropriate modifications Selecting and fitting the FM system Ensuring that the child and the teacher receive inservice training and that efficacy measures are taken A multidisciplinary team approach is critical to fully assess and understand the cluster of problems exhibited by children with APD. Thus, a teacher or educational diagnostician may shed light on academic difficulties; a psychologist may evaluate cognitive functioning in a variety of different areas; a speech-language pathologist may investigate written and oral language, speech, and related capabilities; and so forth. Some of these professionals may actually use test tools that incorporate the terms "auditory processing" or "auditory perception" in their evaluation, and may even suggest that a child exhibits an "auditory processing disorder." Yet it is important to know that, however valuable the information from the multidisciplinary team is in understanding the child's overall areas of strength and weakness, none of the test tools used by these professionals are diagnostic tools for APD, and the actual diagnosis of APD must be made by an audiologist. To diagnose APD, the audiologist will administer a series of tests in a sound-treated room. These tests require listeners to attend to a variety of signals and to respond to them via repetition, pushing a button, or in some other way. Other tests that measure the auditory system's physiologic responses to sound may also be administered. Most of the tests of APD require that a child be at least 7 or 8 years of age because the variability in brain function is so marked in younger children that test interpretation may not be possible. Once a diagnosis of APD is made, the nature of the disorder is determined. There are many types of auditory processing deficits and, because each child is an individual, APD may manifest itself in a variety of ways. Therefore, it is necessary to determine the type of auditory deficit a given child exhibits so that individualized management and treatment activities may be recommended that address his or her specific areas of difficulty.

Use of an FM system Considered a corner-stone intervention It gives the listener an upfront & high-quality access to the speaker‘s voice Listeners can focus on content

Optimal spoken language understanding Higher academic achievement Evidence shows a clear FM benefit for children with learning difficulties Increased attention Optimal spoken language understanding Higher academic achievement More consistent on-task behavior Maximum speech understanding in noise Improvement in classroom behavior Important for long-term benefits: having children tune in again (Blake et al., 1991; Musiek & Chermak, 1997 ; Stach et al., 1987; Crandell et al., 2002)

Massive improvement of speech understanding in noisy situations Speech understanding in noise (Basler): Improvement 30 Not a whole lot of research has been done on FM with APD students, but we are going to review what has been published. 25 20 Improvement (dB SNR) 15 10 5 typical value for directional microphones FM 27 dB SNR improvement with FM system St.Gallen Study, 2004

FM increases auditory memory skills "Telephone game" (Audiolog): Improvement after 4 months % 16 14 12 Improvement (procent points) 10 8 6 4 2 Experimental group (with FM) Control group (without FM) Improvement in auditory memory is significant better for the FM users compared to the controls St.Gallen Study, 2004

AERP results show brain change/maturation FM Group Matched Control Group onset ½ year Auditory Event Related Potential - There are several studies that showed APD kids have P300 evoked potentials with longer latency and smaller amplitudes compared to controls -18 -16 -14 -12 -10 -8 -6 -4 -2 2 4 6 8 10 12 14 16 18 [µV] -100 100 200 300 400 500 600 700 [ms] N1 P2 P3 Pz P4 1 year (Friedrichs 2004)

iSense

The NEW Dynamic FM system for those with normal or near-to-normal hearing iSense Micro & iSense Classic with inspiro ) ) ) )

iSense with Dynamic FM – inside Dynamic FM features: Dynamic Speech Extractor DataLogging FM Monitoring with Earwax detection ChannelFinder SoundCheck MultiTalker Network Specific for the iSense receivers

Dynamic Speech Extractor Automatic brilliance Comprises several sub-features: AFMA Adaptive FM Advantage VAD Voice Activity Detection EAFMA Easy Adjustment of FM Advantage

Dynamic Speech Extractor Adaptive FM volume iSense adapts volume automatically - based on the level of background noise iSense’s output stays within safe limits – at all times How does it work? Ambient noise levels are monitored continuously by the FM transmitter Estimate of the ambient noise level are made in speech pauses If the ambient noise level exceeds 57 dB SPL, the transmitter sends a command to the Dynamic FM receivers to increase the FM Advantage beyond the default or programmed setting The command comprises a digital code, sent with the FM signal at a different, inaudible audio frequency If the noise level drops again, the FM Advantage decreases also

Dynamic Speech Extractor Voice Activity Detector VAD in the transmitter mutes the receiver when the speaker stops talking Benefit 1: ambient noise is not amplified during speech pauses Benefit 2: FM channel noise is not audible when the receivers are silent Voice Activity Detector – VAD a new algorithm detects whether a speech signal is present or not if speech is not detected, the speaker is not talking which means that the FM signal will not include useful information for the listener the transmitter will then inform the receiver(s), via the sub audio wireless data link, that there is no need for amplification the receivers turn silent as soon as the speaker is talking again, the receiver(s) are informed immediately and virtually instantaneously start passing on the FM signal again Benefits: 1. Without VAD: if a teacher is not talking, the input level at the FM microphone is low. That means without the VAD, the gain is relatively high and there may be ambient noise audible in the FM signal; VAD prevents ambient noise from being amplified when the speaker is not talking 2. Without VAD: at a larger distance between talker and listener channel noise (which arises between transmitter and receiver) may become audible. This is especially so if the speaker doesn’t talk. Otherwise, the speaker’s voice will mask the channel noise VAD prevents FM channel noise from being audible, when the receivers are silent

Dynamic Speech Extractor Easy Adjustment of FM Advantage allows for quick and easy adjustment to individual needs and preferences in real conditions separate adjustment of left/right receivers in case of binaural fitting remote volume control for the iSense Micro receiver via the wireless sub audio data link ± 8 dB range, 2 dB step size talk into the microphone and ask the listener for feedback

Monitoring for daily reassurance Monitored parameters: Receiver channel FM receiver settings FM gain Battery status User name / serial number Earwax detection results (iSense Micro only!) The iSense wearer hears beeps confirming finalization of monitoring

Datalogging FM Providing comprehensive insight DataLogging FM data is accessible from FM SuccessWare 4.0 onwards, so only to the audiologist/FM fitter DataLogging FM enables the fitter to give excellent support to FM users and their environment (parents, teachers, partner, friends) DataLogging FM saves teachers to take notes when something happens DataLogging FM provides detailed insight in the FM system‘s performance and use over time

iSense products Receivers iSense Micro iSense Classic

Lightweight and stylish Ergonomic, beautiful design iSense Micro Lightweight and stylish Ergonomic, beautiful design Flexible and secure Small in size 6 colors 312 battery Because it is clear that children with learning difficulties have much poorer speech understanding in noise compared to their peers, it is absolutely necessary that attention is given to the implementation of environmental modifications. One way to address environmental modifications is to change the acoustic design of a classroom. However, evidence shows that this is not sufficient on its own and that the use of an FM system is able to overcome the remaining hindering problems. Therefore, the use of an FM system is considered a corner-stone intervention for most children with learning difficulties.

iSense Micro – different parts Cerustop Pin battery door on/off One-size Flex, left/right compatible, no bending tool necessary iSense housing Retention

iSense Micro – client preferences micro-style for lightweight wearing fully automatic choice of colors to suit personal preferences virtually invisible resembling a Bluetooth headset remote volume control via inspiro earwax detection Because it is clear that children with learning difficulties have much poorer speech understanding in noise compared to their peers, it is absolutely necessary that attention is given to the implementation of environmental modifications. One way to address environmental modifications is to change the acoustic design of a classroom. However, evidence shows that this is not sufficient on its own and that the use of an FM system is able to overcome the remaining hindering problems. Therefore, the use of an FM system is considered a corner-stone intervention for most children with learning difficulties.

iSense Classic – client preferences affordable solution for binaural fitting a directly accessible volume control easy-to-operate receiver with clear LED indication robust body-worn housing contemporary MP3-player like design Because it is clear that children with learning difficulties have much poorer speech understanding in noise compared to their peers, it is absolutely necessary that attention is given to the implementation of environmental modifications. One way to address environmental modifications is to change the acoustic design of a classroom. However, evidence shows that this is not sufficient on its own and that the use of an FM system is able to overcome the remaining hindering problems. Therefore, the use of an FM system is considered a corner-stone intervention for most children with learning difficulties.

Dynamic FM Transmitters inspiro iLapel iBoom

iSense – with “Dynamic FM” transmitter options Because it is clear that children with learning difficulties have much poorer speech understanding in noise compared to their peers, it is absolutely necessary that attention is given to the implementation of environmental modifications. One way to address environmental modifications is to change the acoustic design of a classroom. However, evidence shows that this is not sufficient on its own and that the use of an FM system is able to overcome the remaining hindering problems. Therefore, the use of an FM system is considered a corner-stone intervention for most children with learning difficulties. inspiro used with iSense Micro inspiro used with iSense Classic Basic FM features n Dynamic Speech Extractor Earwax detection at start up Monitoring without Earwax detection Monitoring with Earwax detection DataLogging FM ChannelFinder SoundCheck MultiTalker Network

iSense Micro and iSense Classic - two NEW trendy FM receivers Conclusions FM systems prove beneficial for those challenged understanding and/or concentrating in background noise – despite normal or near-to-normal hearing thresholds Lisn-S Dynamic FM is a revolutionary new platform and has set the bar for FM in the classroom. iSense Micro and iSense Classic - two NEW trendy FM receivers The transmitter of choice for educational environments is inspiro Because it is clear that children with learning difficulties have much poorer speech understanding in noise compared to their peers, it is absolutely necessary that attention is given to the implementation of environmental modifications. One way to address environmental modifications is to change the acoustic design of a classroom. However, evidence shows that this is not sufficient on its own and that the use of an FM system is able to overcome the remaining hindering problems. Therefore, the use of an FM system is considered a corner-stone intervention for most children with learning difficulties.