The current study was intended to look at the effectiveness of using TSI: Focused Attention with adults whose main complaint was difficulty hearing and understanding when there is background noise.

Method

Fifteen participants completed the study. NACD client families were contacted about the study, so participants were either parents or grandparents of children involved with NACD. Criteria for inclusion into the study included:

• Age 40 or older
• Complaint of figure-ground processing problems, with or without a documented hearing loss

Figure-ground processing problems were explained to potential candidates as concerns related to processing, hearing or listening when there is background noise.

Participants were provided with a TSI: Focused Attention program and headphones. They were instructed to listen twice per day, 5 days/week, for a total of 24 weeks. Pre- and post-testing included a speech-in-noise test and rating scales.

Participants were divided into two groups:

• Hearing loss—either documented or suspected but never tested (N=9)
• No hearing loss (N=6)

Regardless of grouping, all participants used the program the same way and received the same instruction and testing.  The speech-in-noise test administered was an informal assessment created by NACD. It consisted of a CD of 20 words spoken in quiet (to serve as a comparison), randomly alternated with 20 words spoken in noise. Listeners were asked to repeat each word they heard.  In addition, participants were asked to rate eight listening/processing skills 0-10, with 0 meaning they had no difficulty with that task and 10 meaning they had the greatest difficulty. Skills on the rating scale are listed in Table 1.

Results

Results are reported in Tables 2 and 3 and are reported separately for the Hearing Loss group and No Hearing Loss group. Results are shown as percentages correct for the speech-in-noise test. For the rating scales, results are shown as the mean score for each question.

On the speech-in-noise test, percentage of accuracy increased after the program, although the increase was much greater for the No Hearing Loss group than the Hearing Loss group. On the functional rating questionnaire, most ratings by the listeners in the Hearing Loss group decreased after the program, indicating a perceived improvement in function. For the few questions that showed a higher post-rating (implying worse function), some possible factors can be found in the Discussion section.

As part of the post-program interview, participants were asked about if they felt they benefited from the program, their enjoyment of the program, and whether they’d recommend it to someone else. Results are reported in Table 4.

Discussion

Results suggest that the normal hearing adults who experience difficulty with figure-ground processing may benefit from auditory training using TSI: Focused Attention. Adults who have issues with figure-ground processing due to hearing loss may be less likely candidates for the program.

One factor that the scores of the speech-in-noise noise test do not reflect is the accuracy—or, more aptly, the degree of inaccuracy—of incorrect responses. In many cases, some responses on the post-test were incorrect, yet closer to the correct answer than they were on the pre-test. If scores could reflect improvement in the accuracy of incorrect responses, the results would have reflected more change than they did only looking at correct vs. incorrect.
Although the numerical values in the tables in the Results section are interesting, perhaps even more significant are the comments made by the listeners about their perception of functional change with use of the program (see Appendix 1). Even listeners with hearing loss commented on how they felt their listening skills had improved. So test scores should be interpreted with caution, as the scores on the tests could be influenced by a number of factors. Some participants admitted that on the functional rating questionnaire they may have been thinking about the questions differently on the post-test compared to the pre-test. Others felt certain that for both the speech-in-noise test and the post functional questionnaire, they were more aware of their own skills and efforts and may have tried harder. A complete list of quotes and comments can be found in Appendix 1.

Besides the scores and listeners’ comments about change, other outcomes were also worth mentioning. Two of the participants reported that family members wanted to do the program because of the change they noticed in the listener. In addition, because of their positive experience with TSI: Focused Attention, 14 of the 15 participants wanted to go on to participate in the second research study, which looked at the effectiveness of TSI: FA2 for adults, a language-based figure-ground program. The one participant who declined participation in the second study said she only did so due to the logistics of her current schedule. Additionally, 100% of participants who responded to the question said they enjoyed doing the program; most felt they benefited from doing it; and most would recommend it to someone else.

Conclusion

It is often the case that efficacy studies such as this raise more questions than they answer. For this reason, almost all “conclusion” sections include the statement, “More research is needed…” And we concur with that thought, especially in light of the small number tested in the current trial. At the same time, understanding the limitations of the current study, we suggest that the results imply that TSI: Focused Attention can benefit adults who experience difficulties with auditory figure-ground processing, and that adults with normal hearing are better candidates for the program than those with hearing loss.

Appendix 1

54 y.o. male with hearing loss: “[It] helped me concentrate on what I was listening to, even though it didn’t help my hearing. I learned to focus, although my hearing problem still seems to be getting worse.”
52 y.o. female: “…I feel like I’m better able to focus.”
71 y.o. female: “As to whether or not it will help in everyday life, I’m not sure yet. But I definitely felt it was worth doing.”
61 y.o. female with hearing loss: “I get nervous going places with friends where I think there will be background nose. The last time I went, it was better than I thought it would be [post-program].” “[The program] helped me work harder at paying attention in conversations.”
41 y.o. female with suspected hearing loss: She reported that after the program she no longer became agitated and frustrated when all of her kids were talking. “It’s been great! My husband wants to do it.”
41 y.o. female who had some rating scores increase on the post-test: “It’s not worse; I’m just paying attention to it more.”
42 y.o. female: In regard to ratings that increased, she felt it was due to being more tuned in and aware of what she’s hearing and what she’s missing. Other comments: “I can turn the volume on things down now.” “I have my kids repeat less.” “I’m still distracted by other people’s conversations, but it’s a little better.”
42 y.o. female: “[After the program] I find it easier to listen in public when someone’s talking to me and there’s others around. I think I’m more focused on who I’m with.”
63 y.o. male with hearing loss: In regard to a functional skill he rated as higher (i.e. worse) after the program: “I don’t think I’m actually any worse than before. I may be doing better; I may be more aware now.”
68 y.o. female: Reported she was able to concentrate better and had less frustration with background sounds after the program. “My focusing has improved.”
64 y.o. female with hearing loss: “[My] awareness has changed. I’m more aware of what I’m missing now.”

Reprinted from the Journal of The NACD Foundation (formerly The National Academy for Child Development)

Reprinted by permission of The NACD Foundation, Volume 27 No. 3, 2014 ©NACD

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At first glance an audiogram may look simple and straightforward. Delving into interpretation and implications of the audiogram, however, leads to a whole different picture: the mysterious world of audiology. As many more parents have been sending me their child’s audiological reports to try to make sense of them, I have become acutely aware of how little parents are being educated by their audiologists regarding what they are testing, what the results mean, and why their audiologists make the recommendations that they do. It’s not a simple matter of reading over the report that the audiologist writes. This is the reason I frequently pass along your reports for interpretation to my “audiology guru,” a university professor of audiology. As a speech/language pathologist, there are many finer points to hearing tests that I do not understand nor am able to identify. As an expert in the field, my audiology colleague looks at all of the pieces, reads between the lines, and gives me valuable insight to pass along to you. Ideally, this is information that you should expect your audiologist to be providing to you. However, as it seems that this is not often happening, it becomes more important that you press your audiologist to answer your questions. Being able to ask questions requires that you have an idea of what you are asking about.

Because hearing tests seem to be such an area of misunderstanding, yet are often a vital piece of information when trying to understand our children’s issues, I thought it would be useful to provide you a few basic definitions and explanations of the different hearing tests that you are most likely to encounter. For the purposes of this article, I will not get into the realm of interpretation of results. I will simply explain what the tests are.

Audiogram

The audiogram is likely the most familiar hearing test to you. The audiogram is a graph representing at what loudness levels (measured in decibels, dB) a person hears tones of different pitches (measured in Hertz, Hz). Typically, the audiologist plays the tones from an audiometer to headphones so that the right and left ears can be assessed separately. However, for very young children or children who are not readily cooperative with headphones, audiologists often test them in the sound field. This means that the audiologist presents the tones to the child through a loudspeaker in a sound booth and then watches for a visible response from the child suggesting she heard the sound. If the audiologist notes responses, she will write them on the audiogram; however, she will not be able to determine if the child heard the sounds with only one ear or both.

Audiometry often includes testing with bone conduction, masking, and speech recognition. These tests give the audiologist more information about the severity and types of hearing loss. For the sake of the present article, I will not elaborate on the specifics of these aspects.

The human ears of most children can hear frequencies up to 20,000 Hz. Although our speech sounds fall within a rather limited range within these 20,000 frequencies, hearing the intricacies of language and adequately perceiving the world around us depends, in part, upon properly hearing the full range of sound. Even so, a typical audiologist tests about four to six different frequencies in each ear (covering about the pitch range of a piano); though some audiologists test a few more. So, how comprehensive can a test be that gives us a snapshot of how we hear only a handful out of 20,000 frequencies? This sample of frequencies does leave some gaps; especially if the audiologist does not also test how well a child can detect and understand speech.

A potentially greater limitation of the audiogram lies with the audiologist’s training and skill in performing behavioral hearing testing of children who are very young or who have developmental disabilities. My impression, as well as that of my audiology colleague, is that some audiologists give up too quickly when a child is labeled as “difficult to test:” the child may cry or will not initially volunteer a response to sound. A skilled audiologist will be patient, work more creatively with the child, or try testing the audiogram again within the next week. Some audiologists, however, recommend the child be retested a few months later when he is more mature. Other audiologists may recommend the child have a different hearing test, like auditory brainstem response testing (abbreviated ABR or BERA). As discussed later, these tests usually are more expensive than getting an audiogram and often require that the child be asleep or sedated. Patience, perseverance, and a little imagination will often yield valid audiograms on most so-called difficult-to-test children and make other, more expensive tests unnecessary.

Tympanograms

Tympanometry is a quick, easy way to assess the status of the middle ear behind the eardrum. An audiologist obtains a tympanogram by placing a probe in the ear canal for a second or two. It takes measurements such as the volume of the middle ear and the movement of the eardrum. A tympanogram does not tell you directly how well your child hears soft sounds or understands speech. However, it is an important test because the results indicate whether or not the middle ear is functioning normally. Certain results suggest fluid is in a child’s middle ear. That is why many of you have had your evaluator recommend that you take your child for a series of these simple tests.

An important point to keep in mind is that a tympanogram provides you with information about your child’s middle ear at the moment the test was performed. If you wish to rule out the possibility of chronic fluid that may have gone undetected, you need to have several tympanograms done at specified intervals (for example, every two weeks for 2-3 months). This will give you a better idea of what is happening with your child’s middle ear over time.

Otoacoustic Emissions (OAEs)

Another commonly and easily used measure of hearing are OAEs. OAEs are sounds produced by the cochlea (also called the inner ear) in response to a sound. Sounds are presented through a microphone in a probe in the ear canal. The sound passes through the middle ear, and into the cochlea (also called the inner ear). Tiny hairs in the cochlea produce a sound echo in response. The audiologist measures this echo from a microphone also in the probe in the ear canal.

Normal OAEs imply normal function of the outer hair cells of the cochlea. However, because the sound has to travel through the middle ear before it is measured in the ear canal of the outer ear, absent OAEs may or may not indicate a problem with the cochlea. If there is a problem with the middle ear, this can reduce or remove the echo. This is a good example of why audiological test results must be looked at as a big picture, not simply in individual pieces. Assessing the tympanogram in conjunction with the OAE makes the results of OAE testing more clear and meaningful.

Acoustic Reflexes

Acoustic reflexes are contractions of tiny muscles in the middle ear: the stapedius and the tensor tympani muscles. Acoustic reflexes normally occur in the presence of loud sounds. That is, the ear has these protective reflexes to dampen loud sounds and thus protect the cochlea from damage. Audiologists typically test acoustic reflexes immediately after obtaining tympanograms. As with tympanograms and OAEs, acoustic reflexes are measured through a probe in the ear canal. They are easily and quickly measured when a child is quiet. The absence of acoustic reflexes often during testing suggests a problem with the middle ear, the inner ear, or the auditory nerve.

Auditory Brainstem Response (ABR)

ABR is a hearing test mainly used for screening hearing of newborns. ABR is used with older children when the audiologist is unable to obtain valid information by an audiogram. As suggested earlier, a complete ABR test of “difficult-to-test” children is relatively expensive and too often over-used. A child must not move much when administering the ABR; accordingly, the child usually must sleep naturally or be mildly sedated during the test. A series of clicks is presented to each ear through earpieces inserted into the ear canals. Brain wave activity is then measured in response to the clicks. Because ABR requires no visible response to sound on the part of the child, it is not considered to be a behavioral hearing test like an audiogram. That is, ABR provides an indirect estimate of the individual’s hearing level and usually yields less information about a child’s hearing than a valid audiogram.

Audiology is complex field that requires the ability to look at different diagnostic tests together in order to adequately assess a child’s hearing. You cannot expect to understand all there is to know about interpreting your child’s hearing test results; I certainly do not. If your audiologist does not provide you with adequate education, you must take the initiative and ask as many questions as you need to understand the meaning of your child’s hearing tests. You must also ask about the rationale when your audiologist makes recommendations for additional testing. The more informed you are, the better equipped you are to make decisions regarding what your child really needs.

Before seeing an audiologist, think through the questions that you might want to ask him/her. What do you want to know? Write your questions down and take them with you. I am including some possible questions here that you may want to include; but be sure you get the information that you want to know.

1. What type of tympanogram does my child have?
2. What does the tympanogram suggest?
3. What is my child’s hearing threshold in the right ear? Left ear?
4. If he/she has a hearing loss, what are the best options? (ex. FM system at school; FM system at home; hearing aids; preferential seating; other suggestions)
5. Are additional tests being recommended? If so, what do they test? How would this additional information be helpful?

Reprinted by permission of The NACD Foundation, Volume 21 No. 10, 2008 ©NACD

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Luke was diagnosed as hearing impaired at the age of 11 months. At 2 years of age an Auditory Brain Stem Evoked Response (ABR) showed him to have a severe loss in the right ear and a profound loss in the left ear. We went the conventional route with homebound therapy until age 3, then public school early education program. Along with that he attended speech therapy and until age 3 he attended a special pre-school program at the speech center. During this time it was our decision, based on what we saw as Luke strengths, to raise him as an oral child. Luke was most happy in the oral environment and that was that. The public school route was not working. Luke finished 1st grade unable to read. This greatly disturbed me because before starting 1st grade he was reading and had finished reading the first primer book required. I’m not even going to mention all the trouble we had in the public school system. We were not happy with their expectations for Luke. Most of all Luke was not happy. It was at this time we began home schooling Luke. He progressed very well the first year home and began reading. Midway through the second year we hit a wall and could seem to make no progress and were very distraught. At this time we sent Luke away to oral residential school for the deaf some 150 miles from home. He was 9 1/2 years old and my heart was breaking. During this time I was still looking for a way to help Luke and keep him at home. I discovered NACD and asked to be placed on the waiting list.

I walked into my first evaluation with varied emotions. From uncertainty and doubt to down right fear. I’d listened to the tapes “The Miracles of Child Development,” but I was so scared and nervous that I couldn’t remember anything. NACD and Bob Doman believe that the parent is the greatest expert on the child and the most motivated to help. We’d been to so many “evaluations.” These other “evaluations” were more of me than Luke and I was told things like I was the one with the problem because I couldn’t accept my child’s handicap. I was worried, would he see the same child I see or would he see the one most evaluators saw? Luke is a master at giving you what you want to see. If you expect him to be the poor little deaf boy he will play that roll very well. I have to add that I was there alone. My husband saw our trip to NACD as another evaluation” and most likely a waste of time and money. Was I surprised when the first thing Bob said to me was that his learning disability was more of a problem to him than his hearing impairment. His auditory and visual digit spans were only 4. I became so excited finally someone who saw what I saw! I’d been trying for years to convince people that he had a problem other than being hearing impaired. He also told me I had a very bright child which I was convinced of although some had tried to convince me otherwise. I left the evaluation excited and ready to start to work. I knew that now I had a plan and the support I needed. When we came to that cross road where one road lead to school and the other to home, Luke and I together chose home. Much like the poem, I felt we had chosen the road less traveled.

The results were almost immediate. He loved doing the program and so did I. Finally something concrete to do that will help him. His reading began to improve and he was great in math. He began to ask questions and was interested in what we read. His vocabulary and articulation improved. Everything was going so well. His Auditory Digit Span is now 6 and his Visual Digit Span is 7.

Nine months later at his 4th evaluation, Bob suggested Auditory Enhancement Training. This was the turning point in our lives. It was not a new concept to me. I had done some investigating into it but was always told that they hadn’t worked with any hearing impaired children. He needed new hearing aids at the time so we simply put it out of our minds. Bob’s suggesting it simply reinforced our feeling that it might help and it couldn’t hurt. Luke began Auditory Enhancement Training in February 1995. We noticed a change the first day. He loves to whistle like his brothers do. Everyone else hated it because it was a very flat and annoying sound. Suddenly I began looking around for his brothers because Luke didn’t whistle like that. His voice began to change and we noticed more tonality in his voice. For some reason he began talking about he was the 5th child and Will as the 1st. I’d given up teaching him ordinary numbers two years before. The real acid test, as I say, was what his siblings saw. Luke has two brothers and three sisters none of whom have ever given him a break. They have always treated him like everyone else, not giving him an inch because he couldn’t hear. Shortly after finishing Auditory Enhancement Training he was sitting with his 16 year old sister as she listened to the stereo. He was dancing and swinging to the music with no hearing aids on. His sister looked at me with tears in her eyes, and said “he hears that.” Shortly after that, his brother (14), came downstairs to tell me “Boy! He sure is hearing better.” When I inquired as to why he felt that, he told me that he was talking behind his back and called him a name (something that he use to be able to get away with), and Luke turned around and hit him. Other people started commenting on how well he was talking and asking us what we were doing different. He was going through his speech cards so fast that his therapist couldn’t keep up and ended up working on conversational speech with him because she didn’t have new words for him to work. She also informed me that at a recent annual review of clients, the Ear, Nose and Throat Doctor on the board tossed his speech report back to her telling her that she had the wrong speech report with the wrong audiogram. He claimed no child with that amount of hearing loss could have a speech report like that. She passed it back to him telling him that Luke was a very unique child and that he had parents willing to work with him.

When Bob suggested we try Auditory Enhancement Training again and see if we could gain anymore we jumped at the chance. This time did not go as smoothly as the first as he became highly emotional during training, his articulation dropped off, his speech was unintelligible, his behavior was at its worst and he began wetting the bed again, something that he’d stopped doing after the first round of training. He continued to wet every night throughout the training. You can’t imagine the panic we felt with the deterioration of his speech. Bad behavior, emotions and bedwetting were nothing in comparison. A call to Utah reassured me that it was normal and temporary.

I can’t tell you exactly when it changed but suddenly he was calling home on the telephone from his friend house down the street, and even leaving messages on the answering machine. One evening he called to see what time he had to come home. I told him 7:00 and his answer was “But it’s 6:30 now!” He was not only talking to me on the phone but understanding what I said. His vocabulary increases daily as he is beginning to talk more like a normal 11 year old, slang and all. As his vocabulary and speech improved his social life has soared. Recently he and two of his friends met three little girls at the movies. He was asked by his friend to attend the Cowboy vs. Green Bay playoff game. He often stays the night with one of his friends. He has begun to serve as altar boy at church with his brothers. He’s independent and sure of himself. Recently he began Karate and attended his first tournament where he placed 1st in sparring. This was exciting but not the high point for me. It was when he was directed to the tournament table, after receive his trophy, ALONE, and was able to answer their questions and give them his name and phone number with NO hearing aids in. I was more than proud. Our local Superintendent of schools attends church with us and recently Luke walked up to him, stuck out his hand and announced “I saw you on T.V.” A very astounded superintendent answered “Yes, you did,” and they continued to talk for a few more minutes. It’s been almost 6 months since our last Auditory Enhancement Training Session and we’ve recently seen another change in his speech with many new words, excellent sentence structure, and mature conversations.

All of these things may seem normal to you but for us they are miracles. Long ago we had begun to believe that our child would never have a normal life, never read better than a 3rd grade level and be trapped in a world by himself, and only able to communicate with a few people. This is no longer true. He’s out going, sure of himself, well liked and fun to be with. He has an incredible sense of humor, and most importantly can laugh at himself. Before NACD and Auditory Enhancement Training he was lovingly called “Wild Man.” We now jokingly call him the “Question Man” because he has a question for every thing you say. His personality has grown and matured. We’re looking forward to Luke future now with excitement. Each day brings new accomplishments and new goals. We can’t wait to see what else he can accomplish. We now know that he can do whatever he sets his heart on.

Reprinted by permission of The NACD Foundation, Volume 10 No. 18, 1996 ©NACD

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