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Paper on evaluation for MCHAS website: for discussion/comment. Evaluation of children’s hearing aids Summary Evaluation is the process of gathering information and reaching a judgement about the experience of amplification in both clinical and real world situations. This paper outlines the purposes of evaluation, the reasons for doing it, and the main techniques that can be employed. At the end is an appendix with a list of questionnaires etc suitable for use with children. a list of references for readers who wish to follow up the published literature. a list of abbreviations used in the text. What is evaluation? The process of hearing aid fitting comprises a number of stages. 1. the generation of amplification targets for the hearing aid wearer. It is recommended that this is done using prescriptive formulae that have been published in peer reviewed journals rather than proprietary software supplied by hearing aid manufacturers. 2. the selection and fitting of a hearing aid that has the necessary gain output and other required features. 3. verification, which involves measuring the hearing aid performance to ensure that it meets the amplification targets. This should be done using Real Ear Measures (either in situ REAR or in the 2cc coupler with measured RECD accounted for). 1 4. evaluation, which involves gathering relevant information about the effectiveness of the amplification provided. An important aspect of this is subjective “real world” evaluation (e.g. questionnaires) which is increasingly becoming a part of the evaluation process in modernised hearing aid services. “Real world” evaluation is desirable because even if a hearing aid is producing the gain required by the prescriptive targets, this may not be translated into optimal speech recognition (as indicated by speech tests or predicted audibility measures) and/or it may not be providing a listening experience in everyday contexts that is helpful or pleasant for the user. Therefore, evaluation is now recognised to be an essential element in ensuring that hearing aid wearers are receiving the intended benefit of amplification. How can it be done? Methods of hearing aid evaluation include: Measuring functional gain (eg aided threshold measurement). Real Ear Measurements (REMs). These are more correctly placed in the verification stage of the fitting process, but are sometimes referred to in the context of evaluating hearing aid performance. Sound and/or speech recognition tests (eg Ling, Parrot, CCT, Manchester picture, AB word lists, BKB sentences, FAAF tests.) Observation/video recording/checklists/measures of speech/spoken language/communication development. Calculation of predicted audibility indices (eg SII, AAI). Questionnaires about matters such as the extent to which hearing aids are used, the benefit experienced by the user, residual disability (or limitation 2 to hearing in everyday contexts), residual handicap (or impact of hearing loss on lifestyle) and overall satisfaction. They may also seek information about the effect of hearing aids on significant others and on the user’s quality of life. In the case of children, such questionnaires may involve proxy reporting, in which an appropriate adult (such as a parent or ToD) provides information additional to or on behalf of the child. Psychoacoustic (listening) and electroacoustic checks. These are more commonly perceived as part of essential ongoing management and are important in maintaining hearing aids’ optimal performance over time, but do not help in evaluating aspects such as use, benefit or satisfaction. Assessing the ergonomic aspects of hearing aids can be important as these influence satisfaction – reliability, robustness, comfort (including earmoulds) and cosmetic features. The evaluation process seeks a comprehensive picture of how effective hearing aids are in real world situations. This can then prompt further enquiry as to factors that hinder or enhance the hearing aids’ effectiveness for an individual. All of these methods listed above have strengths and weaknesses. The more “objective” measures that involve tests in a clinic or classroom are believed to produce “hard” data free from the bias that may affect “subjective” self-reports. However they usually produce data about artificial situations (e.g. performance on a speech test) and test instruments tend to require calibrated equipment and can be time-consuming. Subjective measures (e.g. 3 questionnaires) have the advantage that they can produce data about real world listening contexts that are relevant to the hearing aid user and they are relatively quick and easy to administer. However, in the case of children in particular, there is little evidence about the extent to which they align with more “objectively” gathered information. Despite this, they can still be useful in giving an informative, and systematically obtained account of the respondents’ views (eg child, parent , ToD). What questionnaires are available? The appendix to this paper contains a list of twenty different questionnaires that have been developed for use with children. Many of these have been developed in the USA and few have any published data about their reliability, validity or sensitivity. None have published norms for either normal hearing or hearing-impaired populations. Hence it can be seen that there is a pressing need for further research to establish this sort of benchmark information. In the meantime, the MCHAS team recommend that in addition to whatever evaluation is currently carried out, services should begin to use routinely two questionnaires which have been modified or developed for use in the UK. These are: The Listening Inventory For Education – Individual Hearing Profile (LIFEIHP). The Listening Situations Questionnaire (LSQ), Parent and Child versions. Data are being gathered about the validity, reliability and sensitivity of these measures. Both have had recent modifications: check www.mchas.man.ac.uk for the latest versions. 4 These questionnaires are most appropriate for children aged seven years or more. Therefore the MCHAS team currently recommends the Parent Evaluation of Aural/oral performance in Children (PEACH) questionnaire, which was developed in Australia for use with infants onwards. However, a recent development in the UK which should help hearing aid evaluation greatly at the younger end of this age range is the launch of the Early Support Project and specifically the Common Monitoring Protocol (CMP) for deaf babies. This has been designed to meet the need for standardisation in monitoring all aspects of early development in deaf babies and children: see www.earlysupport.org.uk . Monitoring the hearing aids in a systematic way is built into this process within the “attending, listening and vocalisation” section of the CMP and also to some extent within the “communication” section. The Level Two materials also address attending/listening skill/vocalisation (specifically, detailed recording of phoneme development) which are directly relevant to assessing the benefit from hearing aids. Relevant information about the development of listening skills and babies’ and toddlers’ responses to amplification is being systematically collected where these protocols are in use. Further development of the actual practice of extracting and sharing relevant information for the specific purpose of a hearing aid review is necessary. Why should we use questionnaires? The main advantages of using questionnaires can be summarised as follows: They help to promote better understanding about children’s needs and priorities in relation to the use, benefit from and satisfaction with their 5 amplification equipment (hearing aids, fm systems, other assistive listening devices). They can enhance education and hearing aid service quality by identifying needs which can then be more closely examined. Ways of meeting these needs are varied and may be innovative and personalised. For example, there may be a need for a change in hearing aid settings or activation of features (second listening program, directional microphone); provision of additional equipment such as fm systems or sound field systems; provision of practical help and emotional support or counselling in relation to amplification; provision of guidance to mainstream teachers and Learning Support Assistants. Collecting information in a common format creates a record of the child’s experience with hearing aids which is more easily shared between the family and service providers and across different areas if the family moves (subject to data protection requirements). Collecting “standard” information facilitates research into the hearing aid evaluation process. Local data could be fed back to researchers or into a national database, and with other information also being recorded on patient management systems (such as type of hearing aid, features, fitting parameters etc) these and other variables (staffing ratios, provision of support etc) could be statistically analysed to provide insight into the factors which promote effective services and successful outcomes. Use of questionnaires intensifies awareness of the use of audition in the user and managers of the amplification systems. 6 When should we use them? Before a hearing aid review, to facilitate the exchange of information between families, education and health professionals. At times of transition (eg into new class, school) to assess the new situation. At regular reviews of progress (according to the individual child’s level of support). To evaluate a particular change in amplification provision or support (eg switch to DSP, ITE, CI provision, introduction of personal or Sound Field fm systems). Conclusion At present, our knowledge of how best to evaluate children’s hearing aids is much less advanced than other stages of the fitting process. We need more research into the following areas: the content of questionnaires (which is related to the purpose of using them). the reliability, validity and sensitivity of different questionnaires and norms for hearing and hearing-impaired populations. the timing and frequency of evaluation measures. the administration of questionnaires : interview/self report/observations; use of pictures/computers. the different perspectives of parents, ToDs and peers in relation to both their own and the children’s experiences with hearing aids; how these perspectives mesh together. 7 The value to parents, children, education, health and other services of using questionnaires as well as other methods of evaluation. Despite the lack of definitive information on these topics, there are strong reasons to introduce a more systematic evaluation process which includes children’s real world experiences, and there are adequate if not yet ideal tools for doing so. List of abbreviations used in the text REAR – Real Ear Aided Response RECD – Real Ear to Coupler Difference REMs- Real Ear Measures Ling – Ling 6 sounds test Parrot/Phoenix – recorded automated version of the McCormick Toy Test * CCT – Consonant Cluster Test (available from J.Marriage, CHEAR) AB – Arthur Boothroyd word lists* BKB – Bamford-Kowal-Bench sentence tests* FAAF – Four Alternative Auditory Feature test* SII – Speech Intelligibility Index AAI – Aided Audibility Index ToD Teacher of the Deaf MCHAS – Modernisation of Children’s Hearing Aid Services LIFE-IHP _ Listening Inventory For Education – Individual Hearing Profile LSQ – Listening Situations Questionnaire PEACH – Parent Evaluation of the Aural/oral performance of Children 8 ESP – Early Support Project CMP – Common Monitoring Protocol DSP – Digital Signal Processing ITE – In The Ear CI – Cochlear Implant * Available from the Medical Research Council Institute of Hearing Research, Nottingham. 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