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

3. 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

4. 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

5. 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.

6. …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

7. 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)

8. 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.

9. 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.

10. LISN-S

11. 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.

12. 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

13. 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)

14. 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

15. 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

16. 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)

17. iSense

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

19. 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

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

21. 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

22. 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

23. 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

24. 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

25. 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

26. iSense products Receivers
iSense Micro
iSense Classic

27. 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.

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

29. 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.

30. 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.

31. Dynamic FM Transmitters
inspiro
iLapel
iBoom

32. 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

33. 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.