Audacity Issue 14 by Audacity magazine

Audacity ...a British Society of Audiology Publication

issue 14 September 2019

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12 Global Outreach SIG event: And now for something completely different...

14 Development of the British Society of Audiology Practice Guidance...

Audiology in Ghana: Innovations in a developing Postgraduate...

26 Has Newborn Hearing Screening Helped close the Gap int...

audacity@thebsa.org.uk

................................. www.thebsa.org.uk

British Tinnitus Association - Annual Conference 13 September 2019 - Goldsmiths University, London Richard Hoggart Building Goldsmiths University 8:30

Arrival - Registration - Exhibitions

Ian Gulland Lecture Theatre 9:30

Welcome - Shapiro Prize - BTA Update from David Stockdale

9:45

BTA Research - Current and future partnerships from David Stockdale

For any questions, queries or bookings contact: marcus@tinnitus.org.uk

Poster Competition

5 minute comfort break to move to session streams

Practice

Specialist

10:15 - 10:40 Update on priority Cochrane Reviews in tinnitus Magdalena Sereda

Latest

10:15 - 10:40 Tinnitus triage in a busy University hospital Sam Nutt

10:15 - 10:40 Soldiering on: UK Veterans’ experiences of living with tinnitus Georgina Burns-O’Connell

10:45 - 11:10 Tinnitus heterogeneity: methods for tinnitus subtyping Eleni Genitsaridi

10:45 - 11:10 10:45 - 11:10 Tinnitus Case studies: sharing experience, BSA Practice Guidance reflecting on practice Derek Hoare Charlotte Rogers

11:10

Refreshment break + Exhibitors

11:30 - 11:55 CBTi - Tinnitus and Sleep Laurence McKenna

11:30 - 11:55 ‘But what do you actually say?’ Observe patient consultations... Live Sandy Grimes & Beth-Anne Culhane

11:30 - 11:55 EMDR for Tinnitus - Does it work? Sally Erskine

Ian Gulland Lecture Theatre 12:00

Nature versus Nurture: Genetic Considerations in the Development of Tinnitus from Chris Cederroth

12:30

Lunch + Exhibitors

Latest

Practice 13:30 - 13:55 Tinnitus triage in a busy University hospital Sam Nutt

(Repeat)

14:00 - 14:25 Tinnitus heterogeneity: methods for tinnitus subtyping Eleni Genitsaridi

14:00 - 14:25 Tinnitus Case studies: sharing experience, reflecting on practice Charlotte Rogers

(Repeat)

14:30 - 14:55 CBTi - Tinnitus and Sleep Laurence McKenna

14:30 - 14:55 ‘But what do you actually say?’ Observe patient consultations... Live Sandy Grimes & Beth-Anne Culhane

Posters must cover some aspect of tinnitus etiology and management, or a very closely related subject area.

Networking Event Start things off in style with a drinks reception, networking and entertainment; taking place the evening before conference on Thursday 12th Sept at Goldsmiths University. This increasingly popular network event is a great opportunity to meet other delegates, our speakers, BTA staff and invited guests ahead of the Conference in a relaxed social setting.

5 minute comfort break to move from session streams

13:30 - 13:55 Update on priority Cochrane Reviews in tinnitus Magdalena Sereda

We are now taking entries for this year’s poster session. If you would like to showcase your work to a wide and varied audience within the tinnitus community contact Marcus (marcus@tinnitus.org.uk) to find out more.

Specialist 13:30 - 13:55 Introducing the BTA Gold Standard for Tinnitus Support Groups Colette Bunker

14:00 - 14:25 Practical Strategies for supporting a child with hyperacusis Veronica Kennedy and Claire Benton

Sponsored by Neuromod, this is complimentary and included with your conference ticket

Exhibitor space is open to book

The Exhibition is at the heart of the Conference. If you want to be there contact Patrick Cavan (patrickc@tinnitus.org.uk) for all enquiries

Get Social 14:30 - 14:55 Why haven’t we cured tinnitus? Don McFerran

(Repeat)

We will be using #BTAconf2019 in the run up to the day. Keep an eye on our streams for updates and info and let people know you’re coming by tagging us!

(Repeat)

15:00

Refreshment break + Exhibitors

Ian Gulland Lecture Theatre 15:20

Tinnitus distress and thoughts of suicide from Derek Hoare, Carol MacDonald and panelists

16:40

AGM - BTA Members only

17:00

A4 Conference Programme for BSA.indd 1

@BritishTinnitus

#BTAconf2019

19/07/2019 14:15:00

3 Jane Wild Editor-in-Chief On behalf of the editorial team E: jane.wild@wales.nhs.uk

Welcome to the 14th edition of Audacity. Changes are on the horizon as we move towards an online version of Audacity. The opportunities and benefits that an on-line version offers are significant. Not only will we be able to make the publication more dynamic with media clips and links, we can potentially include interactive elements such as surveys or learning. We won’t have the same restrictions on number of pages meaning we can include more of your articles and all without printing and postage costs and the associated impact on the environment. The Audacity team will be working with Council and Pinpoint over the next few months to begin to take this important step. But for now, what do the printed pages of Audacity have in store for you this Autumn? We have two great featured articles. Hannah Cooper and colleagues outline some fascinating work around novel drug treatments for hearing loss and the importance of optimising technologies to improve patient benefit, whilst Magdalena Sereda provides an insight into the development of the BSA Practice Guidance for fitting of combination hearing aids for people with tinnitus. Research Round Up and Clinical Catch Up sections have a range of articles from assessment to outcomes and includes Audacity’s Top Ten Qs by Debi Vickers discussing the changes to UK Cochlear Implantation criteria. This is an exciting but potentially challenging time for CI services as they adapt to meet this growing demand. Take a look at BSA Today section to see what the BSA Special Interest and other groups have been up to and check out Ear to the Ground for what’s been hitting the headlines or causing a storm on social media. This is the fifth edition that the North Wales team have edited. We’re still enjoying the experience but as I mentioned back in March we will be handing over to another team ready for some fresh ideas after March 2021. We hope to be able to identify a new team within the next twelve months so that we can ensure a clear handover and so that they have the opportunity to shadow the process for at least one edition. Taking on the editorial role may seem a bit daunting but it really is a great experience and an opportunity for individuals to develop as well as to bring a team together. If you are interested in taking this on, or just want to know more about the process before you register your interest, please get in touch. As always, a big thank you to the Audacity team for their hard work in putting together another great edition. Happy reading! Editor’s note: In the 10th edition of Audacity, an article celebrating TS Littler as a founding father of UK audiology was published. It is noted that this article was co-authored by Laura Dawes and Kevin J Munro. The primary source of information was the booklet, published by the University of Manchester, called ‘100 years of Deaf Education and Audiology at the University of Manchester, 19192019.’ The booklet was authored by Laura Dawes and funded by the University of Manchester. This note has also been included in the online version of Audacity.

editor in chief welcome

Dr Ted Killan PhD CS (Audiology) Chair Audiological Science and Education (ASE) Group Lead & Deputy Head of Specialist Science Education Department (SSED) LICAMM, Faculty of Medicine & Health University of Leeds

Chair’s Message - September 2019 The BSA is always looking for ways to increase the size and scope of its membership. An impactful BSA is dependent on its members, and the more of us that are engaged with the aims and associated activities of the BSA, the more it will be successful in improving the lives of individuals with hearing and balance problems. To this end, Council are always thinking of ways to create innovative membership benefits that attract and retain active members. At our annual conference in June we soft-launched the new BSA Fellowship Scheme. This is a scheme open to all BSA members, regardless of career level or speciality. It allows members to seek recognition for their contribution to the BSA and its aims, and the discipline of audiology, with members of the scheme able to use post-nominals as markers of esteem. The scheme formally opens in September (about the time you will be reading this issue of Audacity) with our first BSA Fellows being announced in December. I think this will be a great initiative that represents a genuine membership benefit that encourages engagement with the BSA, so wanted to take this opportunity to tell you a little more about the scheme. There are four levels of fellowship – associate, fellow, senior fellow and principal fellow – each with specific criteria that need to be met through written application. Criteria have been developed based on the BSA’s aims and multi-disciplinarity, and are deliberately open and inclusive to encourage applications from junior through to senior members, from all walks of audiology life. Example criteria include having made some contribution to the BSA, being involved in developing the evidence base and contributing to the training or education of others. The scale, impact and reach of these contributions will determine the level of fellowship that is awarded. We are keen to ensure that the application process is straight forward. We have therefore limited the application to a 1000 word personal statement cross referenced with a CV. A one-off charge of £25 will be payable to cover the administration costs. As well as recognising members’ contributions to our discipline by allowing the use of post-nominals, it is hoped that over time the scheme will become a measure by which employers can differentiate between job applicants (e.g. including fellowship within the desirable attributes of a job specification). Our lead for this scheme is Bhavisha Parmar who has been working hard with her team to ensure this initiative is both attractive and inclusive for members whilst providing the necessary rigour required by such a scheme. For further information please contact her at fellowship@ thebsa.org.uk. I strongly encourage you to engage with this exciting initiative that provides clear benefits for individual members, the BSA and ultimately people with hearing and balance problems.

audacity@thebsa.org.uk www.thebsa.org.uk

chair’s message

Contents 3

Editor in Chief’s & Chair’s welcome

BSA Today

Short articles on relevant clinical topics Susan Boon / Emily Dennis / Suzanne Tyson

Research Round-up

Find out about the latest charity and humanitarian work going on within audiology, both in the UK and abroad, with some opportunities for you to get involved. Amber Roughley / Beverly Soden / Sophie Wareham

Clinical Catch-up

Expert writing about topical areas in audiology Joanne Goss

Ear Globe – audiology around the world

Information and updates from all aspects of the work of the BSA Susannah Goggins / Sueann Meyer / King Slowlakowska

featured articles

Development of the British Society of Audiology Practice Guidance for Fitting of Combination Hearing Aids for Subjects with Tinnitus CD

Author and Correspondence Dr Magdalena Sereda Senior Research Fellow in Tinnitus and Hyperacusis / British Tinnitus Association Head of Research NIHR Nottingham Biomedical Research Centre, University of Nottingham Correspondence address: NIHR Nottingham Biomedical Research Centre Ropewalk House, 113 The Ropewalk, Nottingham, NG8 1LB E: Magdalena.Sereda@nottingham.ac.uk

Tinnitus affects around 5 million people in the UK, with over 1/2 million experiencing symptoms that negatively affect quality of life. In most cases tinnitus is accompanied by some degree of hearing loss. Sound therapy is the preferred mode of audiological tinnitus management in the UK and refers to a wearable sound generator or hearing aid. Combination hearing aids combine amplification and sound generation options within one device and provide a further option for those with an aidable hearing loss. Postulated mechanisms through which sound therapy can be beneficial for tinnitus include reversing or reducing the drive responsible for ‘pathological’ changes in the brain, refocussing attention to alternative auditory stimuli, reducing audibility of tinnitus, reducing stress and anxiety, and aiding relaxation (Sereda et al., 2018a). However, the recent Cochrane systematic review concluded that there is the lack of evidence to support the superiority of sound therapy for tinnitus over waiting list control, placebo or education/information with no device (Sereda et al., 2018a). There was also insufficient evidence to support the superiority or inferiority of any of the sound therapy options (hearing aid, sound generator or combination hearing aid) over each other. The review recommended that further high quality research should establish the effectiveness of sound therapy options for tinnitus. In line with the lack of evidence for the effectiveness of sound therapy current tinnitus management guidelines do not make strong recommendations regarding its use in clinical

featured articles

practice (Cima et al., 2019; Tunkel et al., 2014). Patients’ preferences play a significant role in whether to choose or not this management option. Combination hearing aids offer a variety of noise options (Tutaj et al., 2018). Broadband noise (such as white, pink, red or brown) are a standard option on most devices. Additional options can include modulation or filtering of broadband noise, noise shaped according to patients’ audiogram, noise centred either at or away from the tinnitus frequency, or nature sounds (e.g. ocean sound). In addition wireless streaming is available with many combination devices, mainly through purchasing an additional device streamer (Tutaj et al., 2018). Wireless streaming options can include music, environmental sounds, or even individually modified sounds.

Understanding of certain clinical terminology might be very different for subjects and clinicians and potentially lead to false expectations. Combination aids are used as a part of many different management programmes (Tinnitus Retraining Therapy, Tinnitus Masking, Zen Therapy, and Progressive Tinnitus Management) and outside of those. There is a rich literature describing the principles of various management programmes, with many having strict criteria regarding candidacy, fitting and use of combination hearing aids (Tutaj et al., 2018). Marked variability was observed in candidacy and fitting of combination aids between different management programmes and different studies; however it is not clear whether any of these approaches yield superior results. Many UK audiology clinics offer combination aids. However, there is no standard guide to help audiologists decide on who to offer the devices to or how to fit them to best meet the needs of each patient with hearing loss and tinnitus. As a result many audiologists comment that they do not feel they have enough guidance or knowledge to fit combination aids. In response to variability in clinical practice regarding candidacy and fitting of combination hearing aids, and the absence of

featured articles

Figure 1 A multistep process for the developent of practice guidance

standard recommendations about candidature and prescription options, the British Society of Audiology (BSA) Tinnitus and Hyperacusis Special Interest Group (SIG) is currently developing a practice guidance for fitting combination hearing aids for subjects with tinnitus. Development of the guidance was identified as a priority by the BSA members and the BSA SIG. The development of the guidance was a multistep process including key stakeholders (clinicians and combination aid users; Figure 1).The guidance took into consideration current evidence base. Work conducted specifically to support the development of this practice guidance included a service evaluation, and a users’ survey and focus group. The service evaluation involved a UK wide survey of clinical practice (Sereda et al., 2017) and a Delphi survey of UK hearing professionals (Sereda et al., 2018b). The survey gathered the opinions of 90 UK hearing professionals regarding the criteria for candidacy and fitting practices for combined amplification and sound generation for tinnitus. The survey confirmed that the main barrier to fitting combination hearing aids was a lack of expertise and guidelines. The survey highlighted that UK clinical practice was highly variable with no standardised protocols for fitting combination hearing aids (Figure 2). Areas where variability was particularly pronounced were recommended levels of sound/noise, timing of fitting amplification and activating sound, and recommended daily use of the devices and different programmes. While most of respondents considered that combination aids can be an effective management option for some patients with tinnitus they would have welcomed more research looking at effectiveness. Clinicians stated that they would be willing to follow guidelines for candidacy and fitting of combination hearing aids if those were available. The Delphi survey is a systematic methodology that seeks consensus amongst experts through consultation using a series of iterative questionnaires with feedback. The Delphi survey established clinical consensus among a panel of 32 UK hearing professionals, on 319 statements covering: candidacy, fitting

procedures, safety, recommended use, streaming options, information provided, and assessments. In general, the panel agreed that combination aids can be offered to tinnitus subjects with a wide range of hearing losses, including those who do not perceive hearing difficulties and those who suffer from hyperacusis. Experts agreed that the protocol for fitting combination hearing aids should be flexible to allow for individual subjects’ preferences. They identified several aspects of fitting of combination aids where subject’s preferences play an important role including: fitting laterality, programme options, choice of sound/ noise, recommended use, and adjustments to sound/noise. The users’ survey indicated, that in the UK the decision to offer combination aids lies in the hands of hearing professional (Sereda et al., 2018c).The expectations towards combination hearing aids were variable, however the main ones were masking or reduction of tinnitus. Focus group discussions revealed that a reduction in tinnitus loudness was very important to subjects. However, survey respondents reported a range of benefits of combination hearing aids for them including distraction from tinnitus or a reduction of distraction by tinnitus, improvement in hearing and/or communication, control over tinnitus, replacing tinnitus with more bearable sound, helping the process of habituation, reduction in discomfort, reduction of annoyance from tinnitus, reduction of anxiety, better sleep, and reduced awareness of tinnitus.The survey also highlighted that the terminology and language used by clinicians would set certain expectations, however the understanding of certain terms might be very different for subjects and clinicians. Subjects tended to adapt the terminology used by clinicians but it is important to understand what a subject means by specific terms they use and if the understanding of those terms is the same for the subject and clinician. Improvement in hearing and communication seemed as important to users as addressing their tinnitus problem and participants indicated that they would like devices to be optimised for both hearing loss and tinnitus. In summary, the British Society of Audiology Practice Guidance

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Figure 2 Variability in the level of sound clinicians would use when fitting combination hearing aids

for fitting of combination hearing aids for subjects with tinnitus is currently undergoing peer-review and will be published next year. The guideline was developed using a rigorous multistep process involving key stakeholders. Incorporating patientsâ&#x20AC;&#x2122; views into this process equips clinicians to take a more patient centred approach. The practice guidance will not only guide clinical practice but also facilitate high quality research into the effectiveness of combination hearing aids by providing a standardised fitting protocol. References 1. Cima, RFF, Mazurek, B, Haider, H, Kikidis, D, Lapira, A, NoreĂąa, A, Hoare, DJ (2019) A multidisciplinary European guideline for tinnitus: diagnostics, assessment, and treatment. HNO, 67 (Suppl 1): 10-42. 2. Sereda, M, Hoare, DJ, Brady, J on behalf of the BSA Tinnitus & Hyperacusis Special Interest Group (2017) Combined amplification and sound generation for tinnitus: survey of UK clinical practice. Poster, British Society of Audiology Annual Conference, 29th-30th November 2017, Harrogate, UK. 3. Sereda, M, Xia, J, El Refaie, A, Hall, DA, Hoare, DJ (2018a) Sound therapy (using amplification devices and/or sound generators) for tinnitus. Cochrane Database Syst Rev, 12: CD013094. 4. Sereda, M on behalf of the British Society of Audiology Tinnitus & Hyperacusis Special Interest Group. (2018b) Recommended procedure for fitting combination aids: Delphi review, oral presentation, 11th Tinnitus Research Initiative (TRI) Meeting and TINNET conference, 14th - 16th March 2018, Regensburg, Germany. 5. Sereda, M on behalf of the British Society of Audiology Tinnitus & Hyperacusis Special Interest Group (2018c) Combined amplification and sound generation devices for tinnitus: survey of users expectations and experiences, oral

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presentation, 11th Tinnitus Research Initiative (TRI) Meeting and TINNET conference, 14th- 16th March 2018, Regensburg, Germany. 6. Tunkel, DE, Bauer, CA, Sun, GH, Rosenfeld, RM, Chandrasekhar, SS, Cunningham, ER Jr, Archer, SM, Blakley, BW, Carter, JM, Granieri, EC, Henry, JA, Hollingsworth, D, Khan, FA, Mitchell, S, Monfared, A, Newman, CW, Omole, FS, Phillips, CD, Robinson, SK, Taw, MB, Tyler, RS, Waguespack, R, Whamond, EJ (2014) Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg, 151(2 Suppl):S1-S40. 7. Tutaj, L, Hoare, DJ, Sereda, M (2018) Combined Amplification and Sound Generation for Tinnitus: A Scoping Review. Ear Hear, 39: 412-422.

Take Home message: The British Society of Audiology Practice Guidance for fitting of combination hearing aids will guide clinical practice and facilitate high quality research into effectiveness of this management option for tinnitus by providing a standardised fitting protocol. This document was developed in response to variability in clinical practice regarding candidacy and fitting of combination hearing aids, and the absence of standard recommendations about candidature and prescription options.

featured articles

Novel drugs and technological innovations for hearing loss; translational research within the NIHR UCLH Biomedical Research Centre CD

Authors and Correspondence

Hannah Cooper E: hannah.cooper@ucl.ac.uk Liz Arram Tanjinah Ferdous Giorgos Dritsakis Bhavisha Parmar Michelle Craft Anne Schilder Correspondence address The UCL Ear Institute 332 Gray’s Inn Road London WC1X 8EE

There are around 466 million people with a disabling hearing loss globally, estimated to rise to over 900 million by 2050 with an annual cost of US$750 billion (World Health Organization, 2019). Current management options including hearing aids and cochlear implants have been transformative but do not halt progression or restore hearing function. Recognising hearing loss as an area of unmet need, the National Institute for Health Research (NIHR) awarded funding to the University College London Hospital Biomedical Research Centre (BRC) in 2017 to support a programme of translational hearing research, in order to translate hearing discoveries into new treatments for patients with hearing loss. Here is an overview of some of our current work supported by the BRC.

Figure 1 Clinical trial progression stages

Novel drugs for hearing There are currently no drugs on the market to treat hearing loss. However, based upon recent insights into the mechanisms underlying hearing loss, new targets for drug treatment have been identified and new treatments are underway; this means it is an exciting time to be working in the hearing field. Such new drug treatments for hearing loss, developed in animal studies must go through extensive testing in clinical trials to ensure safety and assess efficacy in humans (see figure 1). REGAIN – REgeneration of inner ear hair cells with GAmma-secretase INhibitors An example of such a trial is REGAIN; funded by the European Union’s Horizon 2020 (EU H2020) programme, the REGAIN team set out to develop and test a new drug administered locally to the ear in patients with adult onset sensorineural hearing loss caused by the loss of sensory hair cells in the cochlea. The drug used is a gamma secretase inhibitor which promotes the trans-differ-

entiation of supporting cells in the cochlea into hair cells by blocking the Notch cell-to-cell signaling process. While it was long believed that sensorineural hearing loss is irreversible, studies in mice deafened by noise have shown that this drug partially restored their hearing (Mizutari et al, 2013). The REGAIN trial is led by UCL and has two phases: phase I focusing on safety and tolerability of the drug, and phase II evaluating efficacy. Adult participants with mild to moderate SNHL receive a trans-tympanic injection with the drug LY3056480 once per week in one ear for three weeks followed by close monitoring for 3 months during which any changes in hearing, tinnitus, balance, facial nerve function and taste are measured. The phase I trial was completed at the Royal National Throat, Nose and Ear Hospital (RNTNEH) in 2018 and demonstrated that the use of the new drug is safe and well tolerated. The phase II efficacy study started in

featured articles

18 January 2019 and is well underway. It aims to recruit a total of 40 participants across three European sites – the RNTNEH in London, the National and Kapodistrian University of Athens in Greece and the Tübingen University Hospital in Germany. The study closes in October 2019 and results are expected in 2020.

you come across such a patient who is interested in taking part, please contact:

research in audiology is rapidly expanding and now encompasses drug trials as well as cutting-edge technological evaluation.

Technological innovation Hearing aids are currently the first-line treatment for most people with hearing loss. It is therefore imperative that device technologies continue to be optimised to improve patient benefit and that patients have access to these high quality hearing solutions.

AUDIBLE-S – A potential new emergency treatment for people with sudden onset hearing loss Sudden onset sensorineural hearing loss (SSNHL) is an emergency condition, where there is sudden hearing loss, usually in one ear, either instantly or over the course of up to three days. Current treatments, steroid tablets or injections given as soon as possible after the start of hearing loss, help hearing recover in some patients but not all. There is therefore a need for new and better treatments. AUDIBLE-S is a phase II-III randomised, double-blind placebo-controlled trial of a new oral drug, SENS-401, taken for 28 days, in patients with severe or profound SSNHL (Petremann et al, 2019). Nineteen centres worldwide are currently recruiting, including two in the UK; the RNTNEH in London and the Royal Hallamshire Hospital in Sheffield. The trial’s primary objective is to assess efficacy of the drug regarding hearing at 4 weeks. Secondary objectives include efficacy regarding hearing at 12 weeks as well as SSNHL related tinnitus, to determine a dose-effect of the drug and confirm its safety drug. The UK teams are looking for people aged 18 years and over who have developed SSNHL very recently; that is within the past 3 days of entering the trial. If

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Royal National Throat Nose and Ear Hospital (London) – 0203 108 9344. evident@ucl.ac.uk Royal Hallamshire Hospital (Sheffield) – 0114 226 1294. Jayne.willson@sth.nhs.uk

EVOTION – Big data supporting public hearing health policies The EU- H2020 project EVOTION is using big data from hearing aid users to develop a platform to support public health policy for hearing loss. UCL is the scientific and clinical coordinator of a multidisciplinary consortium of 13 partners across seven countries. Big data collected by smart hearing aids and mobile apps was used to study hearing aid usage and benefit in different acoustic environments. The results will inform hearing health care and public policies for hearing loss. EVOTION includes a clinical study run across 6 sites in the UK, Greece and Denmark which has recruited 1070 adults with mild to severe HL who were fitted with a smart hearing aid and a mobile phone app to study how the body and brain respond to hearing aid usage in different (noise) environments. Data collected in the clinic (audiological, demographic, cognitive and quality of life) and real-time data from the smart hearing aids and phone app ( hearing aid usage, sound environments, location, auditory training scores) were fed into a database to enable the validation of the platform. So far, 50 million data points have been collected from hearing aid logging alone. A front-end dashboard of the EVOTION platform enables the user to choose types of data and statistical methods to run analytics on the data and generate policy

recommendations. The EVOTION tool has the potential to help policy makers, funders, commissioners, clinicians and other stakeholders make decisions about hearing loss by demonstrating real-world outcomes in large scale. In the remaining five months of the project, the tool will be evaluated by professionals and big data analytics will be completed. Assessing hearing devices with a multi speaker test In this project a Spatial Speech test is being developed for hearing aid users to refine their hearing aid fitting and help patients better understand their hearing loss and amplification needs. A survey exploring the opinions of practicing adult audiologists in the UK (n=295) revealed that although many audiologists found speech testing to be beneficial in practice, the majority were not using these test techniques in regular practice. Some reasons for this include lack of clinic time, equipment, training and the current speech testing battery not being sufficiently sensitive to changes in hearing aid programming. The Spatial Speech test involves simultaneous assessment of relative localisation and word identification performance (Bizley et al., 2015). Recently, the test has been amended in order to make it more sensitive to changes in advanced hearing aid programming systems and Oticon have agreed to collaborate with this project to test their Open Sound Navigator processing scheme with the Spatial Speech test. Summary Research in audiology is expanding rapidly and now encompasses drug development, in parallel to technological innovations. It is an exciting and dynamic field with new developments challenging established practice. Research is fundamental to the practice of all audiologists, challenging the boundaries of our field to develop the best treatments for our patients. You can keep up to date with the progress of all of our projects through the evidENT webpage https://www.ucl. ac.uk/ear/evident and our Twitter feed

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19 @evidENT_UCL. For REGAIN see https://www.regainyourhearing.eu/. For EVOTION see http://h2020evotion.eu/. You can find out about audiology research in your area by contacting your local NIHR Hearing/Audiology Champion. References • Bizley JK, Elliott N, Wood KC, Vickers DA. (2015). Simultaneous Assessment of Speech Identification and Spatial Discrimination: A Potential Testing Approach for Bilateral Cochlear Implant Users? Trends Hear. 30;19. • Mizutari K, Fujioka M, Hosoya M, Bramhall N, Okano HJ, Okano H, & Edge AS. (2013). Notch inhibition induces cochlear hair cell regeneration and recovery of hearing after acoustic trauma. Neuron, 77(1), 58–69.

Look at what the BSA has in store for you on www.thebsa.org.uk, its all there at your finger tips.

9 September

• Petremann M, Romanet C, Broussy A, Van Ba CT, Poli S, Dyhrfjeld-Johnsen J. (2019). • SENS-401 Effectively Reduces Severe Acoustic Trauma-Induced Hearing Loss in Male • Rats With Twice Daily Administration Delayed up to 96 hours. Otol Neurotol. 40(2):254-263. • World Health Organisation (2019, March 20). Deafness and Hearing Loss. Retrieved from https://www. who.int/news-room/fact-sheets/detail/deafness-and-hearing-loss

Take home message: the NIHR UCLH BRC undertakes cutting-edge research in order to understand hearing and fight deafness.

www.thebsa.org.uk featured articles

ear globe: audiology around the world

Audiology in Ghana Innovations in a Developing Postgraduate Audiology Department CD

Authors and Correspondence

Dr Neal Boafo (Head of Department, University of Ghana) E: nbeoafo@ug.edu.gh Dr Lucy Handscomb (Senior Lecturer, University College London) E: l.handscomb@ucl.ac.uk Dr Joy Rosenberg (Postgraduate Programme Leader, Mary Hare School with University of Hertfordshire) E: j.rosenberg@maryhare.org.uk Background and History Ghanaâ&#x20AC;&#x2122;s population is close to 30 million. By the mid-2000s the country had 7 audiologists and 2 Speech and Language Therapists (1 in active practise and the other in academia). Ghana is divided into 10 administrative regions and all the Audiologists were concentrated in 3 of the regions. The other 7 regions had no audiology presence. The nationâ&#x20AC;&#x2122;s largest teaching hospital, Korle Bu Teaching Hospital, has a vibrant ENT clinic and a strong demand for audiology services could not be overemphasized. Something had to be done and done quickly. Distress calls for help went out. One group that responded was the charitable wing of the Church of Latter Day Saints in Accra. They put together a team of missionary Audiologists from Utah (USA), donated diagnostic audiology equipment, trained audiometric technicians and in 2005/2006 Korle Bu had a wellequipped and functional Hearing Assessment Centre. To address the huge deficit of professionals in the country, plans were put in place to develop an Audiology and Speech and Language Therapy (SLT) programme at the University of Ghana to train professionals in the locality. The necessary groundwork was done and the Audiology and Speech Language Department of the

School of Biomedical and Allied Health sciences, University of Ghana was born in 2011.The Department started with just one programme, the 2 year MSc in Audiology. Since its inception, five cohorts of Audiology students (average of 6 per year) have graduated and the sixth is in place.The MSc in SLT was included in 2016 with 12 students. They are currently doing their internships and would formally graduate in July 2019. This year, 12 more students were admitted into the programme. By the end of 2020, there should be approximately 30 Audiologists and 24 SLTs in place, all locally trained. This feat could not have been accomplished without the generous support from groups like Aud Med Trust and the Direct Aid Programme (DAP), Department of Foreign Affairs and Trade of the Australian Government who either brought in the International faculty needed or provided funds to source them.

Lecturers, students, interns and practicing professionals in attendance

ear globe: audiology around the world

21 positively impact their own professional and personal development and subsequently those of their students and colleagues in their home universities. Delegates are encouraged to investigate issues such as training models, technologies and serJoy Rosenberg lecturing. Lucy Handscombe and Neal Boafo lecturing. vices most appropriPreparation and Delivery ate in particular lower-resource environments and to consider Interventions in the field of audiology, in lower-resource environimpact and sustainability. ments, often focus on direct input, as well as training in-country Reflecting on our experience workers. McPherson and Brouillette (Audiology in Developing We were greeted each morning by rows of eager students, Countries, 2008) reported a decade ago on the imbalance for keen to learn and keen to contribute. We had planned interlower-resource environments: 66% of the world’s approximately 300 million hearing-impaired, live in less developed countries, active sessions and, after some initial shyness, students became very engaged in the classes and were a real pleasure to teach. where one million of the needed 30 million hearing aids are Once free from that perennial question: “is this going to be in fitted each year by one audiologist per half million people. the exam?” (Because we will have no part in setting the exThis article features an ongoing project in Accra sponsored by ams) we were free to go off-piste and adapt our material to Aud Med Trust who recruited pairs of volunteer lecturers via fit the students’ interests. We were wary of presenting some British Society of Audiology avenues. In addition to Aud Med kind of unattainable Western ideal, so we made it our business Trust sponsorship, lecturers also gratefully acknowledge their to find out from students how audiology works in Ghana. We employers (University College London and Mary Hare School then focused on the parts of our knowledge that seemed most for the Deaf, partnered with University of Hertfordshire) for a applicable and the suggestions that seemed most achievable. It couple days release to supplement their holiday for this project; would have seemed wrong to spend time explaining the adas well as the University of Ghana’s provision of lecturing facilivantages of cochlear implantation in a country without funding ties, in-city transportation and wonderful Ghanaian lunches and for an implant programme, for example, but it felt worthwhile hospitality. focusing on how one might run a tinnitus information session in a hall with a few chairs. The project contributes to the postgraduate training and CPD of Ghanaian audiologists, bridges communities between the As well as differences in wealth, we were made aware of differUniversity of Ghana and UK audiology lecturers and has just ences in culture. For example, most people thought that Ghanacompleted its second season. Topics this year, developed collabians would not have much time for Shared Decision Making and oratively between the Head of Department and guest lecturers, would expect to be told what to do and many patients think ranged from speech and language development to adult tinnievil spirits cause tinnitus. However, similarities between humans tus, diagnostics and rehabilitation. These were delivered over an are always greater than differences. Across both cultures, adults intensive week to 40 delegates including students, interns and want a cure for tinnitus and feel reluctant to disclose hearing practicing professionals from Audiology and Speech Language loss and parents are just desperate for their deaf babies to comTherapy. municate and be happy. The aims of Aud Med Trust and the collaborative training project include sustainability by building links in assessment and development. This is is achieved, in part, by awareness raising, sustainable management of provision and investigation to better ascertain potential sustainable solutions. The aims of professionals in Accra, related to audiology, are to establish audiology assessment centres in each of the ten regions of the country (Oppong A, Fobi D (2019) Deaf Education in Ghana, in Knoors H, Brons M and Marschark M eds Deaf Education Beyond the Western World, Oxford University Press.) The project benefits the visiting delegates as well as the guest lecturers, in coming away with further knowledge and intrinsic reward, which will

I found being in Accra a personally enriching experience and I would recommend it to others. The team at Korle Bu hospital are open to offers from different specialities and it was great spending a whole week just teaching the bits of audiology I know and love the best. From a few chats with students, it seems like balance is another topic students would particularly like to study. We met so many people; students, teachers and clinicians, just working their socks off to enable audiology to really take off in Ghana and I am confident that in due course they won’t need us any more. Meanwhile, as the profession develops, it would be great if we could keep supplementing the excellent teaching that already exists.

ear globe: audiology around the world

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* Powers, L., dos Santos, G.M., & Jons, C. (2016, September). Notch Therapy: A new approach to tinnitus treatment. AudiologyOnline, Article 18365.

18/07/2019 17:24

clinical catch-up

Top Ten Qs: Cochlear Implant Candidacy, the changes and the impact

This article will be of interest to a particularly large number of readers; including all engaged in aural rehabilitative decision making and associated interventions. The long awaited guidance from NICE was released a few months ago and is of course written in the prescribed NICE format. The author provides here a concise comment on the updated guidance, including the context of its development and the anticipated impact. As acknowledged, increased uptake and benefit for individuals will only be realised if all corners of the Audiology community recognise that the criteria have changed and respond with appropriate referrals to the implant programmes. So for readers there is a need to bring awareness of the new criteria into their professional practice – this timely article will help. John Day, Consultant Clinical Scientist (Audiology), BCU Health Board, N.Wales

Author and Correspondence Debi Vickers PhD, Reader of Speech and Hearing Sciences, University College London Speech Hearing and Phonetic Sciences, London, UK.

The National Institute of Health and Care Excellence (NICE) prepare the guidance on ‘Cochlear implants for children and adults with severe to profound deafness’. The guidance was originally published in 2009 (TA166) and after 10 years it has been updated (TA566). This article outlines some of the key information behind the change and the impact that it might have on the cochlear implant field. 1. What were the audiological and speech perception candidacy criteria in the original NICE Guidance (2009)? The TA166 guidance suggested that individuals were appropriate for consideration for a cochlear implant if: 1.) They could only detect sounds that are higher in level than 90 dB HL at frequencies of 2 and 4 kHz without hearing aids 2.) For adults, speech perception scores needed to be less than 50% on Bamford–Kowal–Bench (BKB) sentence testing at a sound intensity of 70 dB SPL in best-aided condition 3.) For children, clinicians determined if speech, language and listening skills were less than average for their age, developmental stage and cognitive ability.

2. What was the source of the original evidence for establishing the criteria in 2009? The criteria for the TA166 were based on data published in 2004 by the UK Cochlear Implant Study Group. The research was a collaborative effort across the UK, coordinated by Professor Quentin Summerfield. Audiometric and speech perception data was collected from all adult patients receiving unilateral cochlear implants between 1997 and 2000. On average the hearing thresholds for the patients in that research were 115 dB HL in the better ear, far poorer than today’s candidates. 3. What has changed since the criteria were established in 2009? Much has changed over the past 10 years since the original NICE guidance was published. Improvements have been made in surgical techniques and implant design so that residual hearing is better preserved enabling more people to benefit from cochlear implants. Audiologists have a better understanding about how to optimise the devices and rehabilitationists have refined their approaches for providing training to enable patients to get the best out of their cochlear implants. There are options available to make use of residual hearing preserved after implantation, such as electro-acoustic stimulation or linking between the cochlear implant and a contralateral hearing aid. In addition to all of this children with cochlear implants are implanted bilaterally so should be expected to do better than they would have done with unilateral implants. 4. What sources of evidence were available to suggest that the criteria should be changed? Over time, it became apparent that the cochlear implant criteria may not be appropriate for today’s candidates. Some research conducted in my research group, by Dr Rosie Lovett,

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24 in collaboration with Professor Quentin Summerfield (York University) showed that the criteria for hearing thresholds were too conservative for children and could be relaxed to 80 dB HL (rather than the 90 dB HL recommended in TA166; Lovett et al., 2015). This is still conservative compared to some countries, however, this level is also supported by evidence from other sources, such as the candidacy consensus which Dr Padraig Kitterick (University of Nottingham Biomedical Research Unit (NBRU)) and I conducted with many stakeholders in the field (https://www.cicandidacy.co.uk/). To gather clinical opinions together the BCIG Working Group on Candidacy collated a series of articles in a Cochlear Implants International supplement on ‘Issues in Cochlear Implant Candidacy’ (https://www.tandfonline.com/toc/ycii20/17/sup1). This supplement highlighted the main areas that clinicians were concerned about. Common concerns related to candidates who had one ear that fitted the criteria and one ear that fell just outside, resulting in the patient not receiving an implant at all. Also some patients, had unusual audiograms, where they fell outside criteria at 2 and 4 kHz but were really struggling because they had extensive hearing loss in the lower frequencies. The supplement also highlighted how conservative the UK criteria were compared to other countries. 5. Who were the stakeholders who were involved in providing evidence to NICE? Much of the success of convincing NICE to update the cochlear implant candidacy criteria in their guidance can be attributed to the collaboration between major stakeholders in the field. The stakeholders were from implant centres (e.g. Nottingham, Southampton and Bradford), professional organisations (British Cochlear Implant Group, British Society of Audiology and British Academy of Audiology), implant manufacturers (Advanced Bionics UK, Cochlear Europe, MED-EL UK, Oticon Medical), patient organisations (e.g. Cochlear Implanted Children’s Society, National Cochlear Implant Users Association), Universities (e.g. University College London, Nottingham University) charities (e.g. Action on Hearing Loss, National Deaf Children’s Society), NHS commissioners and the Adult Cochlear Implant Action Group. In January 2018, the different stakeholders submitted their recommendations on how criteria should be updated for both children and adults. The stakeholder groups worked together and agreed on the key evidence-based changes that were recommended to NICE. 6. What have the audiological and speech perception candidacy criteria been changed to in the new NICE Guidance (2019)? The new TA566 guidance recommends the following: 1) For both adults and children, an individual’s hearing should be considered potentially appropriate for cochlear implantation if the threshold for hearing is equal to or greater than 80dBHL (≥80dBHL) at two or more frequencies (at

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500Hz, 1000Hz, 2000Hz, 3000Hz and 4000Hz) bilaterally without acoustic hearing aids. 2) For adults speech perception should be assessed with a word test and scored by number of speech sounds (phonemes) correct, with a score of less than 50%. 3) For both adults and children, the multidisciplinary clinical team should discuss each case and believe cochlear implants are likely to provide greater benefit than hearing aids. New NICE guidance was released on March 7th 2019 (https:// www.nice.org.uk/guidance/TA566). 7. What is different about the guidance for adults compared to children? For adults there is an additional requirement based on speech perception testing. In the TA166 guidance the BKB sentences were used. The problem with the sentences is that they are highly predictable and many candidates scored at a higher level than was truly representative of their everyday listening skills. The TA566 therefore uses a candidacy criteria cutoff based on the phoneme score for the AB words. For children, the multi-disciplinary team decide if speech and language skills are developing appropriately for the individual child. This can be based on the emergence of babbling, aided speech intelligibility index calculations or speech and language scores on standardised tests if appropriate. Additionally, adults are only implanted unilaterally unless they have an additional sensory impairment, in which case they will receive bilateral implants (children offered bilateral implants as standard). 8. What effect might the new guidance have on potential candidate numbers? It is estimated that in the first year following the introduction of the guidance that the number of potential candidates might increase by 30% and then there will be a steady 20% increase for the next 4 years with numbers expected to have doubled after 5 years. 9. What can cochlear implant teams do to manage the changes? The implant teams across the country are working hard to rationalise service delivery to be able to work with larger numbers of implant candidates. They are reviewing patient pathways to determine ways to streamline the process and are thinking creatively about approaches such as remote fitting and rehabilitation. 10. What should we do going forwards to prepare for any future candidacy reviews? NICE will revisit the guidance in 2022. A National Registry that collates the speech outcome scores and audiological information on each patient would help facilitate rapid analysis of whether the candidacy criteria have been appropriately set. Also, implant teams should monitor if they believe that the appropriate individuals are receiving cochlear implants. In addi-

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25 tion to this, information should be provided to all audiology teams around the country to ensure that they are aware of the change and that they refer appropriate patients to the implant programmes. As candidacy criteria for implants change there will be more individuals with cochlear implants and residual hearing who could benefit from some form of additional acoustic aiding (e.g. bimodal). We move into an era where increased alignment is necessary between audiology and cochlear implant services to ensure that each patient receives the highest quality personalised care. In addition, creative approaches for utilising digital health services and improving the support offered by community services is necessary to reduce the strain for cochlear implant teams. This fits well with the priorities identified in the NHS long-term plan (https://www.england.nhs.uk/long-termplan/). Acknowledgements Thanks go to Marina Salorio-Corbetto for reviewing the text. Debi Vickers is funded by an MRC Senior Fellowship in Hearing (MR/S2002537/1).

References • Lovett RE, Vickers DA, Summerfield AQ. Bilateral cochlear implantation for hearing-impaired children: criterion of candidacy derived from an observational study. Ear and Hearing 36(1):14-23. •

NICE TA166 (2009) https://www.nice.org.uk/guidance/ ta166. NB guidance has been updated and replaced.

•

NICE TA566 (2019) (https://www.nice.org.uk/guidance/ TA566.

•

UK Cochlear Implant Study Group (2004) Criteria of Candidacy for Unilateral Cochlear Implantation in Postlingually Deafened Adults I: Theory and Measures of Effectiveness. Ear & Hearing 25(4): 310-355.

Websites • Candidacy Consensus (https://www.cicandidacy.co.uk •

NHS England Long-term plan https://www.england.nhs.uk/ long-term-plan

•

Open access supplement on ‘issues in candidacy’ (https:// www.tandfonline.com/toc/ycii20/17/sup1

clinical catch-up

Has Newborn Hearing Screening helped close the Gap in Educational Attainment between Hearing and Deaf Children? CD

Authors and Correspondence Karen Taylor, Head Teacher, Virtual School Sensory Support

Cathy Rodd, Lead Teacher Early Years/KS1 Virtual School Sensory Support

John FitzGerald, Consultant Clinical Scientist Norfolk & Norwich University Hospitals NHS Trust

The newborn hearing screening programme (NHSP) has been in place throughout Norfolk since July 2005. Its introduction in England aimed to identify children with a moderate or worse hearing loss early, in order to provide amplification earlier, to facilitate speech development and learning and thereby enable deaf children to reach their full potential (Joint Committee on Infant Hearing, 2000). It is well documented that a child with a hearing loss who is not aided within the first 6 months of life is disadvantaged in being able to establish the neurological connections for sound analysis and speech development (Yoshinaga-Itano et al, 2000,Yoshinaga-Itano et al, 2017 Ching et al, 2013, Tomblin et al, 2014) In the absence of good hearing, speech development is delayed, as we learn to speak from mimicking sounds we hear, from an early age. An inability to communicate affects our social interactions, expression of wishes and feelings and in young children can lead to withdrawal, lack of interaction or disruptive behaviour due to frustration (Bennett et al, 1999, www.ndcs.org.uk/family_support/glue_ear) . Hearing loss per se is not a ‘learning disability’, but without the ability to hear well, learning is delayed (Roberts et al, 1990).

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Evidence from the Department of Education figures from 2017 show that 16 year old deaf children (prior to the introduction of universal newborn hearing screening in England) are 24% behind their hearing peers (Attainment 8 gap*) and achieved a whole grade less at GCSE. 71% of deaf children did not achieve a “good” grade 5 pass in GCSE English and maths compared to 54% of their hearing peers. Whilst it is not currently possible to look at the impact of newborn hearing screening on GCSE results nationally (the oldest children in Norfolk from the introduction of hearing screening are currently 12 years old), it is possible to compare younger age educational assessments between deaf (identified through NHSP) and hearing children as shown in Table 1. This shows that an attainment gap continues to be evident at Key Stage 2 (KS2), Key stage 1 (KS1) and at the Early Years Foundation Stage (EYFS) level for deaf children compared to their hearing peers even after the introduction of newborn hearing screening on a national basis (newborn hearing screening was in place across England for children undergoing KS2, KS1 and EYSFS for all the years shown in Table 1). Table 1 NDCS Relative attainment gap between deaf children and children with no identified SEN on different key measures 2017

2016

2015

2014

GCSEs Attainment 8

24%

20%

21%

N/A

GCSEs Grade 5 or above in both English and Maths

40%

N/A

GCSEs Grade 4/C or above

35%

33%

43%

KS2 Reading, Writing & Mathematics

44%

47%

38%

40%

KS1 Reading

39%

41%

27%

32%

EYFS – Good Level of Development

55%

56%

61%

*Attainment 8 measures the average achievement of pupils in up to 8 qualifications, including English (double weighted if the combined English qualification, or both language and literature are taken), maths (double weighted), three further qualifications that count in the English Baccalaureate (EBacc) and three further qualifications that can be GCSE qualifications (including other EBacc subjects) or any other non-GCSE qualifications on the Department for Education approved list.

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27 NDCS calculates the attainment gap between deaf children and children with no identified special educational needs (SEN) by calculating the difference between the attainment of the two groups and then expressing this as a percentage of the attainment of children with no identified SEN. It is a crude measure but allows for comparisons between different groups and data sets. It indicates the relative likelihood that deaf children will do as well as children with no identified SEN at different stages. AIM The aim of this study was to examine the educational attainments of deaf children identified through the newborn hearing screening programme in Norfolk and compare them to their hearing peers both regionally and nationally to see if the educational gap between hearing and deaf children that previously existed continues to be present or has been closed for Norfolk children. METHODS Assessment Methods Four performance indicators of learning and development were used to examine the impact of newborn hearing screening on educational outcomes; 1. The early years foundation stage profile (EYFSP) data 2. Phonics screening data at end of KS1 3. KS2 national curriculum data 4. The British Picture Vocabulary Scale (BPVS), Clinical Evaluation of Language Fundamentals (CELF) or Reynell Developmental Language Scales (RDLS) The EYFSP is a teacher assessment of children’s development at the end of the EYFS. The EYFSP sets standards for the learning, development and care of a child from birth to 5 years old. Currently, there are 7 areas of learning in the EYFSP, assessed by classroom observation by the reception class teacher at the end of the school year (age 5): • communication and language • physical development • personal, social and emotional development (PSE) • literacy • mathematics • understanding the world • expressive arts and design Children are awarded one of three achievement levels within each area of learning: • Expected: your child is working at the level expected for his age

17 Early Learning Goals covering Personal Social and Emotional Development, Physical development, Communication and Language Development, Literacy and Mathematics. However, there have been changes to the EYFSP over the period of time used for this analysis, so comparisons according to the National Sensory Impairment Partnership (NatSIP) criteria for that year were used. e.g. until 2015 NatSIP looked at a ‘good level of development’ but this changed to solely looking at Communication and Language Development. This is why there are two sets of data for EYFS presented in Table 2 and Figures 3 and 4. The Phonics Screen, undertaken at the end of year 1 (age 6) and year 2, involves the child reading 40 words aloud to the teacher. Half of the words on the Screen are real words and half are non-words, such as “strom”. There is a defined pass mark (e.g. 32 out of 40). Key Stage 2 Assessments are performed at the end of year 6 (aged 10/11) and include assessments in maths, English grammar, punctuation and spelling and reading. These are scored in terms of attainment using a scaled score where 100 represents the expected standard on the test and the raw score is varied each year to ensure the expected standard is met. Pupils scoring at least 100 will have met the expected standard on the test. Educational attainment for NHSP identified deaf children in Norfolk was compared with all deaf children in Norfolk (the latter included both NHSP identified and those identified outside of NHSP) as well as all children nationally (which includes all hearing children) and their deaf peer group nationally as reported by NatSIP. The BPVS is recorded annually for most children from the age of 3. CELF is also recorded for higher need children and the RDLS is also recorded if it’s use was thought to be appropriate. Standardised scores are used. A child is within age appropriate level if a standardised score of 85 or more is achieved. The percentage of deaf children identified through NHSP that met the targets at EYFSP, BPVS and/or CELF or RDLS were calculated and expressed as a percentage for each level of hearing loss. The total number was 116 (instead of 118) as 2 children were too young to be assessed. Study Numbers 188 deaf children have been identified though NHSP, in Norfolk, since 2005. The educational attainment records for 118 cases were examined. Of the 70 cases not examined they included; • Those with complex needs

• Exceeding: your child is working above the expected level

• Those who were discharged from the Virtual School Sensory Support (VSSS) caseload

A child was considered to have ‘a good level of development’ (GLD) if they achieved at least the expected level in 12 of the

NHSP identified deaf children in Norfolk, since 2005, account

• Emerging: your child is working below the expected level

• Those who declined input from VSSS

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28 for 33% of all deaf children in Norfolk.The other 67% are either due to later acquired hearing loss (temporary conductive or permanent hearing loss) or progressive hearing loss. Figure 1 shows the audiological management of the 118 deaf children identified through NHSP between 2005 and 2017. 78 had hearing aids, 24 cochlear implants, 2 were undergoing cochlear implant assessment. The 14 cases without hearing aids had conductive unilateral or mild hearing losses and/or hearing aids were not issued immediately.

Figure 3 Percentage of children who achieved â&#x20AC;&#x2DC;a good level of developmentâ&#x20AC;&#x2122; at end of EYFS

NHSP on the VSSS caseload, reached the expected level of language and communication at the end of EYFS. 61% of deaf children on the VSSS caseload also achieved the expected level in language and communication, showing no difference between deaf children identified through NHSP and those identified later. The national score for this assessment against their hearing peers was 82.1%. Figure 1. Audiological management of 118 Children Identified with Hearing Loss through NHSP

Figure 2 shows the hearing profile of the 118 children.

Figure 4. Children with Communication and Language skills at the level expected for their age

Phonics Screening Figure 5 shows that 90% of the deaf children identified through NHSP passed their Phonics Screen, a similar level to the national score for all children (92%) and better than the national score for deaf children (75%) Figure 2. Degree of Hearing Loss

Some of the 188 NHSP identified children appear in more than one assessment method as they moved through the age appropriate assessments from 2005 to 2017; 41 children were assessed by EYFSP, 31 children were assessed by phonics screening 6 children were assessed in key stage 2 65 children were assessed by BPVS and/or CELF or RDLS RESULTS EYFSP 56% of children, on the VSSS caseload, identified through NHSP achieved the NatSIP criteria for that year in the EYFS assessment when aged 5 (Figure 3). Figure 3 also shows the national score for EYFSP for all children at a national level (69%), Norfolk (68%) and deaf children nationally (32%). 33% of all VSSS the deaf children (those identified via NHSP and those identified at a later date) achieved the NatSIP critiera of a good level of development in the EYFS assessment. EYFS Communication and Language Figure 4 presents the communication and language aspect of the EYFSP. 61% of children identified with a hearing loss through

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Figure 5 The percentage of children passing the phonics screen at end of Year 1.

Key Stage Two Figure 6 shows that 50% of NHSP identified deaf children reached the expected standard at the end of Key Stage 2 compared to 32% of all the deaf children in Norfolk in this cohort which compares to 39% of deaf children nationally and to 61% of all children nationally. Table 2 shows the results for deaf children identified through NHSP at the different assessment levels against the national results for deaf children and national results for all children. The VSSS deaf children identified by NHSP scored better in all the educational assessments than the NatSIP Deaf children and as

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29 through a number of measures at difference ages. 41 children at age 5 by EYFSP and more specifically language and communication as part of the EYFSP • 31 children by phonics screen at age 6 • 6 children at KS2 at age 10/11 • 65 children were assessed by BPVS and/or CELF or RDLS at various ages Figure 6. The percentage of children reaching the expected standard at the end of Key Stage 2 in the National Curriculum Standardised Assessment Tests.

well as or better than other deaf children in Norfolk. In no assessment category did the NHSP identified deaf children score worse than other deaf children either locally or nationally. EYFS

EYFS L&C

Phonics

KS2

VSSS Deaf NHSP

VSSS Deaf

NatSIP Deaf

35.9

44.9

68.8

42.7

National

82.1

Norfolk

68.1

Table 2 Attainment in National Curriculum Measures of Children identified through NHSP in Norfolk in 2017 compared with other cohorts Age Appropriate Levels Figure 7 shows the percentage of deaf children identified through NHSP currently working at age appropriate levels according to the relevant assessment for their age e.g. EYFSP, BPVS and/or CELF or RDLS. Results show a wide variation of attainment related to levels of hearing loss from 100% of children with mild losses reaching the attainment level to 57% of children with severe loss. Overall 76% of the NHSP population were at age appropriate levels and children with unilateral and mild hearing loss were above 84% (87 and 100% respectively).

Figure 7. Percentage of children achieving within the average range on standardised language assessments or at expected level or above on EYFSP

DISCUSSION Of the 118 children identified as deaf through NHSP since 2005 it has been possible to assess their educational attainment

Early Years Foundation Stage 56% of deaf children in Norfolk identified through NHSP achieved the criteria for EYFSP compared to 33% of all the VSSS deaf children and 32% of deaf children nationally, indicating the VSSS NHSP children are performing at a better level than other local deaf children and deaf children nationally (Figure 3). The national deaf children score of 32% reflects all deaf children so this indicates VSSS as a whole is comparable to performance elsewhere in the country. This indicates that NHSP is positively closing the gap at EYFS at the end of Reception between deaf children and their peers nationally. However, they are still performing less well than all children at a national level (56% compared to 69%). When communication and language alone are represented at EYFSP (Figure 4) the NHSP identified deaf children perform equally with all VSSS deaf children (both 61%). This is better than the national deaf score of 44.9% suggesting that the care that all deaf children receive in Norfolk has a greater positive impact on outcomes compared to the rest of the country. It may also suggest that early identification of hearing loss through NHSP helps develop other aspects of development in areas such as personal, social and emotional development, literacy, understanding the world or that acquired hearing loss or progressive hearing losses at a later age inhibit some or all of these areas of development. The 21% gap between Norfolk Deaf children and the National average (including hearing children) of 82.1% shows that identification of deaf children early and the current service provision for them is still not enough to close the gap completely. These results were explored further by looking at consistent use of amplification (defined as ‘worn all waking hours’) and initial findings indicated that only 45% of the hearing aided NHSP identified deaf children demonstrated consistent use of amplification by the age of 2 years.This could be a contributory factor in the remaining gap in outcomes at the end of EYFS, between NHSP identified deaf children and hearing children and is an area for further focus. Phonics Screen Outcomes from Phonics Screen (Figure 5) shows that deaf children identified through NHSP score slightly better than the VSSS deaf children as a whole (90% compared to 85% respectively) and almost match the National score for all children and scored better than deaf children nationally (75%), suggesting

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30 that NHSP, through enabling appropriate early fitting of hearing aids and good early and ongoing educational support from VSSS has benefited these children to access phonic sounds and to vocalise them. The similarity between the NHSP score and National score for all children (90% and 92% respectively) indicates action following identification of hearing loss through NHSP helps children match their hearing peers at a national level for the Phonics screen. This may further support the importance of focusing on hearing aid use as 76% of the hearing aided NHSP identified deaf children demonstrated consistent use of amplification after the age of 2 years, implying that several years of consistent hearing aid use and ongoing educational support to has contributed to the good outcome in phonics at age 6 – 7. Key Stage Two As there are only 6 children at KS2 identified by NHSP and 33 in the VSSS group it is still encouraging that 50% attain the KS2 criteria compared to 61% of all children nationally and 39% of all deaf children nationally, indicating that NHSP is helping to close the gap in educational attainment between deaf and hearing children. However, it is not possible to draw conclusions from this data due to the small cohort. Working at age appropriate level in relevant areas The variation in outcomes by the degree of hearing loss for NHSP identified deaf children working at an age appropriate level (Figure 7) suggested that the level of hearing loss is an important factor for outcomes. It is encouraging that 100% of the children with a mild hearing loss were working at an age appropriate level and suggests that early provision of hearing aids and support from VSSS help enable these children to meet these targets The result for unilateral hearing loss of 87% supports the view that children with only ‘one good ear’ are at a disadvantage within the classroom and raises the question as to whether more encouragement to aid these children and provide additional teaching support is required. Bess et al (1986) reported that children with unilateral hearing loss had a higher failure rate than their normal hearing peers and that 13% of them needed teaching support. It is of interest to note that children with severe loss do not perform as well as those with other hearing losses, even those with profound loss (57% and 69% respectively). The latter may be due to children with profound losses having cochlear implants and receiving focused support in speech and language development following implant surgery and possibly having better access to speech sounds than children with severe losses using hearing aids. This raises the question whether children with severe hearing loss require further support to help improve their outcomes. Given that the new NICE guidelines for cochlear implants for children and adults with severe to profound deafness (ID 1469, 2019) have relaxed the hearing loss criteria for cochlear implants (hearing loss of 80dB HL or worse at any two frequencies at 500Hz, 1000Hz, 2000Hz and 4000Hz instead of a hearing loss of 90dB or worse at 2000Hz and 4000Hz), this

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will include more children with severe hearing losses and it will be interesting to see if this results in better outcomes for this cohort in the future. Overall the outcomes of these educational assessments suggest that the gap in educational attainment for deaf children identified through NHSP has narrowed more when compared with the national deaf peer cohort and the national score for all children (Table 2). It will be interesting to see if this trend continues as more children go through KS2 and as deaf children identified from NHSP move through KS4. In the NDCS Note of Attainment 2017 they state; ‘We are particularly interested in the GCSE attainment gap. We believe that, by 2022, 16 years after the newborn hearing screening programme was fully rolled out, there should be no attainment gap between deaf children and other children’. Given 67% of children identified with a hearing loss in Norfolk in this study group were not identified through newborn hearing screening (due to progressive hearing loss or acquired hearing loss (temporary or permanent) and that there is an attainment gap between NHSP identified deaf children and non NHSP identified deaf children, it may be likely there will still be an attainment gap in 2022 in all deaf children, but it will be of interest to identify if there is improvement in the NHSP cohort and also to analyse reasons why the non NHSP group have not done as well, if that is the case. CONCLUSION Comparison of educational attainment at age 5, 6 and 10/11 suggests that deaf children identified through NHSP have performed better than deaf children nationally and that NHSP is helping close the gap in educational attainment between deaf and all children nationally. The continuation of NHSP, early hearing aid provision, audiological and educational support from diagnosis and throughout a childs’ education will help deaf children reach their potential. The lower attainment levels for children with severe hearing losses and the recognition that the majority of deaf children are not identified through NHSP are factors that may mean expectations and predictions of reducing the attainment gap fully, may not be realised, unless there is further focus on these other areas as well. The age of consistent use of amplification may be a factor in the lower attainment of the deaf children in relation to hearing children. This is considered an important area for multi-agency investigation and improvement for the future, as research shows NHSP per se does not always lead to good early consistent use of amplification (Moeller et al 2009). References • American Academy of Pediatrics, Joint Committee on Infant Hearing 2007 Position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2007;120(4):898–921.

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31 • Bennett, KE, Haggard, MP (1999). Behaviour and cognitive outcomes from middle ear disease. Arch Dis Child; 80; 28-35. • Bess FH,Tharpe AM (1986). Case history data on unilaterally hearing impaired children Ear Hear. 7;(1):14-19. • Ching TY, Dillon H, Marnane V, et al. (2013). Outcomes of early- and late-identified children at 3 years of age: findings from a prospective population-based study. Ear Hear. 34(5):535–552. • Joint Committee on Infant Hearing. (2000). Year 2000 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. American Journal of Audiology, 9, 9-29.

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• Moeller M.P, Hoover B, Peterson B, Stelmachowicz. (2009). Consistency of hearing aid use in infants with early identified hearing loss. American Journal of Audiology Jun 18 (1) 14-23. • NDCS note on Department for Education figures on attainment for deaf children in 2017(England) Updated: 11 April 2018. • NICE (2019) Cochlear implants for children and adults with severe to profound deafness ID1469 • Roberts JE, Schuele C. (1990) Otitis media and later academic performance: the linkage and implications for intervention.Topics. Language Disorder 11:43-62. • Tomblin JB, Oleson JJ, Ambrose, SE, Walker E, Moeller MP. (2014). The Influence of Hearing Aids on the Speech and Language Development of Children With Hearing Loss. JAMA Otolaryngol Head & Neck Surg. May 1; 140(5); 403-409. • Yoshinaga-Itano C, Coulter D, Thomson V. (2000) The Colorado Newborn Hearing Screening Project: Effects on Speech and Language Development for Children With Hearing Loss. J Periatology 20, S132-S137. • Yoshinaga-Itano C, Sedey AL, Wiggin M, Chung W. (2017) Early Hearing Detection and Vocabulary of Children With Hearing Loss. Paediatrics: 140, Issue 2.

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Our Sep/Oct 2019 issue of ENT & Audiology News focus: Women in Leadership ▶▶ Leadership: in conversation with Dr Joyce Aswani Sujana Chandrasekhar

▶▶ The otolaryngologist as hospital director: a view from Thailand Nadtaya Mills

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▶▶ European power women in otolaryngology: a focus on Laura Viani, Ireland’s first female otolaryngologist Elinor Warner

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▶▶ In conversation with Shelly Chadha Alex Griffiths-Brown

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clinical catch-up

Trilogy of papers on the relationship between parental separation and parental mental health in childhood and how people cope with tinnitus and hyperacusis in adulthood CD

Author and Correspondence Dr. Hashir Aazh BSc, MSc, PhD Team-lead, Tinnitus & Hyperacusis Therapy Specialist Clinic, Audiology Department, Royal Surrey County Hospital, Egerton Road, Guildford, GU2 7XX, UK. E: hashir.aazh@nhs.net

Introduction Not everyone who has tinnitus and/or hyperacusis is affected or distressed by them. The effect of tinnitus and hyperacusis on patientâ&#x20AC;&#x2122;s life is typically measured via the use of self-report questionnaires. In a study of 620 patients who sought help concerning their tinnitus or hyperacusis from an audiology clinic in the UK, 41% had no or mild tinnitus handicap and 59% had a moderate or severe tinnitus handicap as measured via the Tinnitus Handicap Inventory (THI) (Aazh and Moore, 2017a). In the same study, it was reported that 56% of patients with hyperacusis, experienced hyperacusis disability as measured via the Hyperacusis Questionnaire (HQ). Recent studies suggest that some of the variance of tinnitus and hyperacusis disability is explained by psychological factors (Aazh et al., 2017). There may be a relationship between adverse childhood experiences and poor mental health among the offspring across their life span (Anda et al., 2006). Parental separation and poor parental mental health are important forms of adverse childhood experiences with prevalence of 23.3% and 19.4%, respectively (Anda et al., 2006). In addition, adverse childhood experiences seem to influence the process in which a health condition leads to development of disability (activity limitations and participation restrictions) (Schussler-Fiorenza Rose et al., 2014). However, no study prior to this trilogy (Aazh et al., 2018a; Aazh et al., 2019; Aazh et al., 2018b) has assessed whether the individuals with a history of parental separation and poor parental mental health in their childhood are at more risk of developing tinnitus and/or hyperacusis disability if they experience symptoms of tinnitus and/or hyperacusis in their adulthood. In a trilogy of studies conducted at the Tinnitus and Hyperacusis

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NHS-based clinical research to equip audiologists who are specialized in tinnitus and hyperacusis rehabilitation with up-to-date knowledge about identifying the need for onward referral to mental health services and deciding the urgency of the referral.

Therapy Specialist Clinic (THTSC) at the Royal Surrey County Hospital, the relationships between parental mental health and parental separation in childhood and the psychological impact of tinnitus/hyperacusis on the individual in their adulthood have been explored. An international network of researchers from different disciplines has collaborated in these studies. The collaborators consisted of: Professor Brian C. J. Moore (Department of Experimental Psychology, University of Cambridge, UK), Professor Ali A. Danesh (Department of Communication Sciences and Disorders, Florida Atlantic University, USA), Dr. Michael Landgrebe (Department of Psychiatry, Psychosomatics and Psychotherapy, kbo Lech-Mangfall-Hospital Agathried, Germany), and Professor Berthold Langguth (Department of Psychiatry and Psychotherapy at the University of Regensburg, Germany).

Figure 1 Dr. Hashir Aazh (UK).

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33 The aim of this article is to review the key outcomes of these studies.

Figure 2 Professor Brian CJ Moore (UK).

Figure 3 Professor Danesh and his students (USA).

What are the relationships between parental separation and parental mental health in childhood with tinnitus and hyperacusis disability in adulthood? In the first study, the data for consecutive patients who attended the THTSC in the UK over a six month period were included (n = 184) (Aazh et al., 2018b). 14.7% of patients reported that while they were growing up, their parents were separated or divorced. There were no significant differences in THI and HQ between patients with and without history of parental separation. About 40.2% reported history of mental health disorders in their parents. Parental mental health illness did not significantly relate to THI, however, it was significantly related to the risk of hyperacusis (odds ratio [OR], after adjusting for age and gender: 2.05, p = .026). The adjusted OR for a subgroup of patients with a diagnosis of hyperacusis was 6.7 (p = .011), indicating a stronger relationship for this subgroup. Diagnosis of hyperacusis was based on average ULL at 0.25, 0.5, 1, 2, 4 and 8 kHz for the ear with the lower average ULL, which is called ULLmin. Hyperacusis was considered as present if ULLmin was ≤77 dB HL (Aazh and Moore, 2017b). What is the relationship between parental mental health in childhood and anxiety and depression for patients experiencing tinnitus and/or hyperacusis? In the second study, 287 consecutive patients who attended the THTSC were included (Aazh et al., 2018a). The associations between anxiety and depression measured via the Generalized Anxiety Disorder questionnaire (GAD-7) and the Patient Health questionnaire (PHQ-9) and responses to the question “While you were growing up during the first 18 years of life did your parent(s) have depression or mental illness?” was explored.

“Among patients seeking help for their tinnitus and hyperacusis, poor parental mental health was associated with increased hyperacusis disability.”

Figure 4 Dr. Michael Landgrebe (Germany).

Figure 5. Professor Berthold Langguth (Germany).

39% of patients (111/287) responded “yes” to the question about their parents’ mental health. Regression analysis showed that parental mental illness significantly increased the risk of anxiety and depression, with unadjusted ORs of 2.7 (95% confidence interval [CI]: 1.5-4.9, p = 0.001) for the PHQ-9 and 2.6 (95% CI: 1.4-4.8, p = 0.002) for the GAD-7. However, when the models were adjusted for the effects of age, gender, THI, HQ, ULLs, GAD-7 scores (for the depression model only), and PHQ-9 scores (for the anxiety model only), parental mental health was only significantly associated with depression, with an OR of 2.7 (95% CI: 1.08-6.7, p = 0.033). What is the relationship between parental mental illness in childhood with suicidal and self-harm ideations in adults seeking help for their tinnitus and/or hyperacusis? In the third study, the data for 292 consecutive patients who attended the THTSC was included (Aazh et al., 2019). 15.75% of patients (46/292) expressed that they have been bothered

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34 by suicidal and self-harm ideations within the last 2 weeks. This is consistent with past studies (Aazh and Moore, 2018b). 38.7% of patients (113/292) reported that while they were growing up during the first 18 years of life, their parent(s) were suffering from a mental illness. Logistic regression analysis showed a significant relationship between suicidal and self-harm ideations and the history of parental mental illness after adjusting the model for (1) THI, (2) HQ, (3) GAD-7, (4) PHQ-9, (5) age and gender. Adjusted OR was 2.5 (95% CI: 1.14, 5.6, p=.022).The only other variable which was significantly related to the risk of suicidal and self-harm ideations was depression, adjusted OR was 7.7 (95% CI: 2.6, 26.3, p=.001).

“Audiologists offering tinnitus and hyperacusis rehabilitation should screen patients for parental mental illness in childhood, especially for those with comorbid depression, and make an onward referral to appropriate mental health services when needed.” Conclusions and clinical implications 1. Poor parental mental health was significantly associated with increased hyperacusis disability especially for patients with low ULLmin. The stronger links between hyperacusis and mental health illness compared to tinnitus could explain the difference observed in the relations of tinnitus and hyperacusis disability with poor parental mental health. 2. Parental mental illness in childhood increased the risk of depression by a factor of 2.7 for patients with tinnitus and/or hyperacusis. 3. Approximately 16% of patients who sought help for their tinnitus and/or hyperacusis reported some level of suicidal or self-harm ideations. Audiologists who are involved in tinnitus and hyperacusis should screen for suicidal and self-harm ideations among patients, especially for those with symptoms of depression and a childhood history of parental mental illness. In the UK, one of the key interventions offered to patients who experience hyperacusis disability is cognitive behavioural therapy (CBT) which typically is delivered by audiologists who specialize in tinnitus and hyperacusis rehabilitation (Aazh and Moore, 2018a). It is important to take these results into consideration in order to decide whether the patients also need to be seen by mental health professionals. To learn about the training course on audiologist-delivered CBT see https://tinnitustherapy. org.uk/

“Clinicians who offer tinnitus and hyperacusis rehabilitation should screen for suicidal and self-harm ideations among patients, especially for those with symptoms of depression and a childhood history of parental mental illness.”

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References • Aazh H, Danesh A & Moore BCJ. 2018a. “Parental Mental Health in Childhood as a Risk Factor for Anxiety and Depression among People Seeking Help for Tinnitus and Hyperacusis.” J Am Acad Audiol, Nov 16. [Epub ahead of print]. • Aazh H, Lammaing K & Moore BCJ. 2017. “Factors Related to Tinnitus and Hyperacusis Handicap in Older People.” Int J Audiol, 56, 677-684. • Aazh H, Landgrebe M & Danesh AA. 2019. “Parental Mental Illness in Childhood as a Risk Factor for Suicidal and SelfHarm Ideations in Adults Seeking Help for Tinnitus and/or Hyperacusis.” Am J Audiol, Jun 11:1-7. [Epub ahead of print]. • Aazh H, Langguth B & Danesh AA. 2018b. “Parental Separation and Parental Mental Health in Childhood and Tinnitus and Hyperacusis Handicap in Adulthood.” Int J Audiol, Dec;57(12):941-946. • Aazh H & Moore BCJ. 2017a. “Factors Associated with Depression in Patients with Tinnitus and Hyperacusis.” Am J Audiol, 26, 562-569. • Aazh H & Moore BCJ. 2017b. “Factors Related to Uncomfortable Loudness Levels for Patients Seen in a Tinnitus and Hyperacusis Clinic.” Int J Audiol, 56, 793-800. • Aazh H & Moore BCJ. 2018a. “Effectiveness of Audiologist-Delivered Cognitive Behavioral Therapy for Tinnitus and Hyperacusis Rehabilitation: Outcomes for Patients Treated in Routine Practice “ Am J Audiol, 27, 547-558. • Aazh H & Moore BCJ. 2018b. “Thoughts About Suicide and Self-Harm in Patients with Tinnitus and Hyperacusis.” J Am Acad Audiol, 29, 255-261. • Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C. et al 2006. “The Enduring Effects of Abuse and Related Adverse Experiences in Childhood. A Convergence of Evidence from Neurobiology and Epidemiology.” Eur Arch Psychiatry Clin Neurosci, 256, 174-86. • Schussler-Fiorenza Rose SM, Xie D & Stineman M. 2014. “Adverse Childhood Experiences and Disability in U.S. Adults.” PM&R, 6, 670-80.

Oticon Opn Play™ redefines child-friendly hearing care

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research round-up

Exploring teleaudiology: Design thinking research at the National Acoustic Laboratories (NAL) CD

Authors and Correspondence

Dr Nicky Chong-White Senior Research Engineer, National Acoustic Laboratories E: nicky.chong-white@nal.gov.au

Laura Button Research Speech Pathologist, National Acoustic Laboratories E: laura.button@nal.gov.au

A brief overview of NAL The National Acoustic Laboratories (NAL), based in Sydney, Australia, is wellknown internationally for its significant contributions to hearing assessment, hearing rehabilitation, and prevention of hearing loss. Building on over 70 years of independent research, NALâ&#x20AC;&#x2122;s mission is to lead the world in hearing research and evidence-based innovation, improve hearing health, and transform the lives of people with hearing difficulties. Two of its most widely used tools are the hearing aid fitting prescriptive formula NAL-NL2, and the Client-Oriented Scale of Improvement (COSI). NAL comprises around 40 researchers, including audiologists, engineers, scientists, psychologists and speech pathol-

research round-up

ogists. The core professional skills are enhanced with continuously growing expertise in the key competency domains of design thinking, connected health, machine learning, human technology interaction, behavioural insights, ecologically valid data collection, and cognition and neural measures. These diverse skillsets are brought together in multidisciplinary project teams to investigate hearing loss and listening difficulties in adult and paediatric populations and advance hearing research across a number of emerging areas. The results are often translated into meaningful hearing health outcomes such as new clinical diagnostic tools, tests and technologies. Opportunities for teleaudiology When many people think of teleaudiology, they often think of the clinic-to-clinic scenario, whereby an audiologist conducts an appointment from a distant location to the client using video conferencing, and possibly also remotely controlling peripheral equipment. The client attends a local clinic and is supported by a trained assistant. This has benefits especially for those who live in regional or rural areas. However, the scope and range of teleaudiology services extends well beyond just the clinical appointment. There are opportunities for teleaudiology along the whole client journey, from when a person might not even be aware they have a hearing loss, through to when they seek advice, are fitted with hearing aids and progress with rehabilitation. Some examples are online hearing assessments, remote fine-tuning adjustment of hearing aids, and counselling via videochat. Teleaudiology, as an alternative delivery model for clinical services, has the potential to improve the accessibility, efficiency, cost and effectiveness of hearing services whilst maintaining quality. With recent ad-

vances in technology and the growth in the distribution of health-related services and information via telecommunications methods, there are many opportunities for advancement. However, to avoid rushing into developing a solution based on our own assumptions of what we think clients and clinicians want or need, we chose to first gain an empathetic understanding of the issues that exist. Design thinking: gathering insights for innovation As healthcare shifts towards a more patient-centred approach, design thinking is well-suited to find out how to achieve the greatest benefit for the client. Design thinking is a methodology that involves reframing the problem in human-centric ways. It encourages building empathy and focusing on what is most important to the people we are developing for. By analysing the insights gained, the core problems and user needs are identified. These become the motivation and basis for stimulating new ideas and innovative solutions that will provide the most needed value. Using design thinking principles, a team of six NAL researchers worked together to engage with users and discover the best opportunities for NAL to contribute and make a positive impact in the area of teleaudiology.The aim was to understand the experiences and problems facing people with hearing loss, audiologists and others in the hearing healthcare industry, in order to identify the unmet needs that could be solved with teleaudiology. We wanted to discover how people with hearing loss manage their hearing health, the issues they face, current applications of teleaudiology and the attitudes towards receiving hearing services by alternative methods. This would guide us to create a solution that fills a gap in currently available services or technology.

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37 Information was gathered by reviewing the literature on telehealth trends and attitudes and researching teleaudiology technologies offered in clinics and available in some hearing devices. We immersed ourselves by observing behaviour in both face-to-face and remote clinical appointments, and listened to people’s stories in phone and videochat interviews. We also gained perspectives from users all around the world by designing and distributing online surveys. Four surveys were implemented that targeted different user groups including people with hearing loss (adults and parents of hearing-impaired children), audiologists, managers of hearing service providers and hearing device manufacturers. The survey link was posted on several online forums (including Reddit, Action on Hearing Loss, Hearing Tracker, Aussie Deaf Kids), as well as in newsletters, emails and social media. Survey questions for audiologists explored how they thought teleaudiology services would affect quality, satisfaction and access-related factors, their willingness to provide different services for various client age groups (either with or without a trained assistant present to help the client), as well as attributes that would indicate whether a client would be suitable to receive services by telecommunications methods. We asked them what they thought were the main benefits of teleaudiology and what were the greatest barriers to uptake. For people with hearing loss, the survey questions covered how they would like hearing services to be improved, what concerns they had about using teleaudiology for different types of services, and if there were any tasks they wished could be done without needing to visit their audiologist. Discovering users’ perspectives One hundred and seventy-five survey responses were received and 39 interviews were conducted.The survey respondents included 59 adults with hearing loss, 17 parents of children with hearing loss, 80 audiologists, 10 managers of hearing service providers and 9 others in the hearing industry. Fifty percent of the audiolo-

gists lived in Australia, 21% in the United States of America, 11% in Denmark, and 9% in the United Kingdom.

18-30 years age group reported they were ‘somewhat willing’ or ‘willing’ to use teleaudiology.

The adults with hearing loss varied in age, duration of hearing loss, audiological management plan, and use of teleaudiology. While teleaudiology experiences included video conferencing, online hearing tests, remote hearing aid adjustment, and remote cochlear implant mapping, only 12% of people with hearing loss who answered the survey had used teleaudiology services before.

Similarly, clinicians were more willing to use teleaudiology to provide counselling and answer questions than perform tests (Figure 1). As expected, having an assistant present with the client increased the clinician’s willingness for most other tasks, especially assessment, hearing aid fitting and device maintenance.

One of the main things we wanted to find out was the willingness of users to use services delivered by teleaudiology, as acceptance and willingness are critical for any successful technology uptake. Fifty percent of adult clients responded they were ‘likely’ or ‘very likely’ to use teleaudiology services, whereas only 30% of parents with a child with hearing loss indicated they were ‘likely’ or ‘very likely’. However, willingness varied depending on the type of task. Clients were more willing to use teleaudiology for receiving counselling, advice about hearing, advice about hearing aids and general information than hearing testing or hearing aid fitting. For all advice and information-related tasks, 100% of respondents in the

The responses indicate that attitudes towards teleaudiology could be significantly improved by educating both clinicians and clients about the many tasks that are being successfully delivered using teleaudiology and increasing awareness of the benefits to assist not only with tasks during the appointment, but also in the preand post-appointment stages. In addition, given the lower proportion of parents of children with hearing loss willing to use teleaudiology and clinicians less willing to provide services to children, it suggests teleaudiology solutions developed primarily for users over 18 years of age may have greater success and uptake. Effect on the client-clinician relationship We considered 12 different aspects that might be affected by teleaudiology,

Figure 1. Willingness of audiologists to provide services using teleaudiology for different client age groups.

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38 including quality of care, access to services, client satisfaction, and number of face-to-face appointments needed. One of the main barriers identified was the perception of the effect of teleaudiology on the client-clinician relationship. A strong theme that recurred in survey responses and interviews with audiologists was that teleaudiology will make it harder to build rapport with the client, and is an impersonal delivery of service. Some comments received were: * It will be the relationships between clinician and client that will impact client confidence and satisfaction. We need to be aware that improvements in technology may make processes faster, but we will still need to ensure that the client doesn’t feel rushed, glossed over or assembly-lined. – Audiologist [S331] * One thing that concerns me is that I try to forge a relationship with my clients that keeps them wanting to stay with us. If they don’t see me as a person they can trust, then what is to stop them leaving and having no special bond with this centre? - Audiologist [S308]

This is supported by some of the highly positive feedback that we received in interviews and follow-up surveys from audiologists and trained tele-assistants at Australian Hearing clinics after they started providing tele-appointments. In many cases, they were pleasantly surprised at how smoothly the appointment went, and how satisfied the client was as well. For adult clients, many thought teleaudiology would have a negative effect and somewhat decrease the quality of their service. This response was fairly consistent across age groups. However, most of the clients who responded to the survey (82%) had not been offered any teleaudiology services before, so this perception is likely influenced by lack of knowledge and also fear of change or new technologies. Some clients were also concerned about increased communication difficulties using video conferencing. It thus seems likely that increasing opportunities for clinicians to gain practical experience with teleaudiology, and also providing more exposure and familiarity to clients, has the potential to improve perceptions of the technology and overcome some barriers.

population affected by the problem, the impact on stakeholders, and the desired outcome. We also considered to what extent existing solutions addressed the need, what were the shortcomings or gaps, and any key criteria that a solution must address. The needs were then prioritised, taking into account the strengths and expertise of researchers at NAL and potential collaborators. One of the main needs selected was to improve client access to hearing services and specialist clinicians, particularly for those in regional or remote areas where services are infrequent, but also for people who have trouble travelling to appointments due to work, or mobility issues. Another need was to improve monitoring of a client’s hearing progress by clinicians and family members. Again, this is especially beneficial for people in remote areas where follow-up soon after a hearing device is fitted is difficult, but for all clients in general, regular follow-up, support and feedback throughout the hearing journey can greatly improve client outcomes. A further need was to provide options for clients to self-manage their hearing health and devices outside of appointments. This would empower clients and possibly increase involvement by family and support networks, as well as increase efficiency for the hearing service provider. Finally, there was a strong need to raise awareness and education about both teleaudiology and the effects of hearing loss in general.

The responses to how clinicians thought teleaudiology would affect quality of care and quality of relationships with Identifying and analysing user needs new and returning clients are shown in Further qualitative and quantitative analyFigure 2. At first there didn’t appear to sis of the data revealed many insights and be any strong positive or negative effect user needs. The next step in the design on quality, but interestingly, when we thinking process was to characterise each separated the responses of audiologists need by defining the core problem, the who had used teleaudiology from those who hadn’t, it showed that audiologists who have used teleaudiology are more likely to believe that quality of care and relationships increase relative to face-to-face services than those who have not used it. In fact, 90% of audiologists who have used teleaudiology said the quality of the relationship with a new client will increase or not be affected with Figure 2. Audiologists’ perception of the effect of delivering services via teleaudiology on quality. teleaudiology.

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39 The top needs were the stimuli for a successful brainstorming ideation workshop. A group of 20 NAL staff, enriched with much deeper insights into the needs of our users, generated 85 different project ideas. Summary Using a design thinking process, NAL researchers were able to view audiological services delivered by various methods

from the perspective of different groups of users. Insights were gained into how adults and children were interacting with their audiologists, the current problems faced, and the willingness to provide or receive services at a distance. Whilst use of teleaudiology is currently low, all user groups could identify a range of benefits of teleaudiology. The results clearly indicated that those who had used teleaudiology were more likely to be positive

about it, and those who hadn’t were less willing and expressed concerns. The plethora of ideas generated to address the top-ranked user needs will be used to guide future research and development of new innovative technologies to support engagement with hearing services using teleaudiology. Watch this space! For information about current projects, see www.nal.gov.au

Aided Cortical Auditory Evoked Potentials in babies with hearing loss CD

Author and Correspondence

Caroline L Hudson Research Associate & Research Audiologist Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, Manchester, UK Manchester University Hospitals NHS Foundation Trust, Manchester, UK

Introduction Newborn hearing screening, early confirmation of hearing loss and rapid hearing aid prescription/fitting has provided significant benefits to thousands of infants. Early intervention has, however, introduced challenges: hearing instrument prescription is often based on limited assessment data from the Auditory Brainstem Response, and there are few procedures available to assess the adequacy of amplification before babies are ready for behavioural assessment from the developmental age of around 9 months.

The research team at the University of Manchester and Manchester University Hospitals NHS Foundation Trust identified the need to answer the following question: Is there a procedure available, which can supplement existing procedures, and be used in clinic to indicate detection of speech before behavioural testing at 9 months of age? Aided Cortical Auditory Evoked Potentials (CAEPs) have the potential to provide early confirmation of physiological detection of aided speech-like stimuli. Many studies have investigated the detection of CAEPs using speech stimuli in infants with hearing loss (Rance et al, 2002; Golding et al, 2007; Carter et al, 2010; Chang et al, 2012; Van Dun et al, 2012; Ching et al, 2016; Gardner-Berry et al, 2016) and without hearing loss (Cone et al. 2013). The studies mentioned generally had small participant numbers and investigated aided CAEPs in infants and children who were, on average, older than the target age range of 3-7 months (i.e. between hearing aid fitting and behavioural assessment). In addition, a proportion of infants (and adults), perhaps around 20%, are reported not to exhibit a CAEP response even when the stimulus is predicted to be audible. If confirmed, this raises some concern about the reliance of the procedure in clinical practice.

The research team’s starting point was to investigate detection rates, test duration, clinical feasibility and parental acceptability in babies who passed their newborn screening and had normal tympanograms. If the results were promising, the next step was to obtain data for babies with hearing loss and hearing aids. Initial study with babies who passed newborn screening The team carried out an initial study measuring CAEPs in young infants (1-7 months) to investigate the feasibility of CAEPs as a supplement to established paediatric clinical test procedures. Babies were recruited for a single test session and CAEPs were performed using three speech stimuli (/m/, /g/ and /t/) presented at 65 dB SPL in the sound field from a loudspeaker. The results (shown below) were promising and provided support for further exploration in to aided CAEPs in babies with hearing loss and hearing aids. • Testing was successfully completed in 95% (n=104) of infants • At least one CAEP response was detected in all infants with normally peaked tympanograms • Detection to the speech stimuli /m/, /g/ and /t/ was found to be 84%, 89% and 96%, respectively • The median test duration was acceptable at 23 minutes

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40 • Positive experiences were reported from the post-study interviews with parents

of cases where a CAEP response is seen will be reported by different sensation levels in the study publication.

Current study – babies with hearing loss Following on from the normal hearing study, the team in Manchester developed a large-scale study performing aided CAEPs on babies with bilateral hearing loss who had been fitted with hearing aid(s). The study’s aim was to answer the following research questions:

Additional information is obtained by means of questionnaires and interviews to determine the acceptability of the procedure to parents. Similarly to the normal-hearing study, post-procedure questionnaires and interviews are completed to measure the acceptability of the procedure to parents.

1. Can aided CAEPs be reliably used in clinic to indicate physiological detection of speech in infants who wear hearing aids?

Recruitment, progress and next steps To date, the study has measured aided CAEP data from 103 babies and is currently following up with VRA data. The team are relying on Paediatric Audiology departments to continue identifying eligible families until March 2020. Every participant identified is invaluable in the quest to bridge the time gap between hearing aid fittings and behavioural assessment for babies with hearing loss. The research team recognise that it can be a challenging time to introduce a research study to families and are grateful for the support from audiologists and families.

2. Are the test procedures acceptable to families? Stimuli, study design and implementation Following consultation and discussion regarding recruitment, a bespoke mobile research unit was designed, purchased and commissioned to permit testing close to families’ homes. NHS Trusts from around UK agreed to act as participant identification centres. These centres have been providing our study information packs to families of infants newly diagnosed with permanent bilateral hearing loss. The research team created three synthetic speech-like stimuli (a low, mid and high frequency). The stimuli were designed to be significantly more frequency specific than other CAEP stimuli (such as used in the normal-hearing study); and to be treated like speech by hearing aids. In the current study, aided CAEPs are measured on infants aged 3-7 months using the mid and high frequency specially designed speech-like stimuli. The researchers return to see the family when the infant is around 9 months of age to perform aided Visual Reinforcement Audiometry, the gold standard behavioural assessment for this age group. Sensation level of the aided CAEP is predicted by using the VRA minimum response level. This allows the team to determine whether a CAEP response was present above aided threshold, i.e. showing a positive sensation level. The percentage

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In March 2019, the research team started using aided Auditory Steady State Response (ASSR) as an alternative electrophysiological method. Results for both the aided CAEP and aided ASSR will be reported in upcoming publications. If you work with infants with hearing loss and could help identify eligible families to take part in the study, please get in contact with the team via email: ladiesinthevan@manchester.ac.uk. Inclusion Criteria • Under 7 months (corrected age) at start of study • Fitted with hearing aids at the start of the study • Diagnosed with permanent bilateral hearing loss of any degree or type • No developmental delay that would likely significantly delay behavioural assessment (Visual Reinforcement Audiometry)

Take home messages The early normally-hearing study provided a positive foundation regarding the potential use of CAEPs to supplement current paediatric clinical practice for babies with normal hearing. Evidence suggests that aided CAEPs have the potential to: 1. Supplement current practice 2. Bridge the time gap between diagnostic Auditory Brainstem Response and Visual Reinforcement Audiometry 3. Provide early indications for Audiologists that alternative strategies may be required; such as the use of frequency lowering, or onward referral for cochlear implantation. Information of this sort at such an early stage has the potential to further benefit the lives of infants with hearing loss The next phase of this research will investigate whether aided ASSR measurements can be reliably used to indicate physiological detection of speech in infants who wear hearing aids and whether the test procedures are acceptable to families. Potential benefits of the ASSR over the CAEP include: (i) greater resilience to baby being asleep or awake during testing, (ii) faster test time due to multiple stimuli being tested simultaneously, and (iii) the sound stimuli being more speech-like in nature, being continuous rather than short duration (speech perception being the ultimate point of interest). One disadvantage is that the ASSR response can originate from widespread neural regions, across both the cortex and brainstem, so does not confirm cortical neural activity in the same way the CAEP does. We are optimistic that the current study will help inform future clinical practice and bridge the time gap between hearing aid fittings and behavioural assessment. Acknowledgements The normal-hearing study was funded by a strategic investment grant from Manchester University Hospitals NHS Foundation Trust, and was facilitated by the Manchester Biomedical Research Centre and Greater Manchester Local Research

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41 Network. The study was supported by the NIHR Welcome Trust Clinical Research facility.

• Chang HW, Dillon H, Carter L, Van Dun B & Young ST. (2012). The relationship between cortical auditory evoked potential (CAEP) detection and estimated audibility in infants with sensorineural hearing loss. International Journal of Audiology, 51, 663-670.

The current study is supported by the National Institute for Health Research, the Marston Family Foundation and the Oticon Foundation. This article presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0214-33009). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social care.

• Ching TYC, Zhang VW, Hou S, Van Byunder P. (2016) Cortical Auditory Evoked Potentials Reveal Changes in Audibility with Nonlinear Frequency Compression in Hearing Aids for Children: Clinical implications. Seminars in Hearing, 37(1), 25-35. • Cone B & Whitaker R. (2013). Dynamics of infant cortical auditory evoked potentials (CAEPs) for tone and speech tokens. International Journal of Pediatric Otorhinolaryngology, 77(7), 1162-1173.

References • Carter L, Golding M, Dillon H, & Seymour J. (2010). The detection of infant cortical auditory evoked potentials (CAEPs) using statistical and visual detection techniques.’ Journal of the American Academy of Audiology, 21, 347-56.

• Gardner-Berry K, Chang H, Ching TYC & Hou S. Detection rates of cortical auditory evoked potentials at different sensation levels in infants with senso-

ry/neural hearing loss and auditory neuropathy spectrum disorder. Seminars in Hearing. 37(01), 53–61. • Golding M, Pearce W, Seymour J, Cooper A, Ching TYC & Dillon H. (2007). The relationship between obligatory cortical auditory evoked potentials (CAEPs) and functional measures in young infants. Journal of the American Academy of Audiology, 18, 117-25. • Roush P, Frymark T, Venediktov R & Wan B. (2011). Audiologic management of auditory neuropathy spectrum dirsoder in children: a systematic review of the literature. American Journal of Audiology: 20, 159-170. • Van Dun B, Carter L, & Dillon H. (2012). Sensitivity of cortical auditory evoked potential detection for hearing-impaired infants in response to short speech sounds. Audiology Research, 2, 65-76.

The contribution of motivation and emotion to effortful listening. CD

Authors and Correspondence Sarah Hughes1,2

1. South Wales Cochlear Implant Programme

Catherine McMahon

2. Swansea University Medical School

Frances Rapport4

3. Macquarie University Centre for Implementation of Hearing Research (CIHR)

Isabelle Boisvert

3,5

Hayley Hutchings

4. Australian Institute of Health Innovation (AIHI), Macquarie University 5. University of Sydney

Full reading list for this article available from our Research Round-Up editorial team

“The Research & Development Group of the BSA (RDG) is delighted to feature an article from a clinical researcher who is a past BSA grant recipient. Sarah Hughes has presented her funded work as an invited speaker to CHSCOM19, Linkoping, Sweden in June 2019 and as part of her doctoral dissertation. We wish her every success with full publication later in the year. We hope that you as readers find her review on the role of motivation and emotion on listening effort of interest. Whilst grants from the BSA are no longer available, the RDG is keen to support clinicians in building their research skills and experience and/or collaborating with primary and translational researchers and teams, and we are scoping mechanisms to do this at present. Should you have any particular ideas or if are able to support us, please do get in touch. Amanda Hall a.hall@aston.ac.uk & Sarah Bent sarah.bent@wales.nhs.uk, Co-leads, Research & Development Group, British Society of Audiology”

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42 “I get mental exhaustion from listening and a deep sense of exasperation as well. Effort is a subjective thing as much as anything else. When it’s rewarded it’s not so effortful. In other words, you could run a marathon and because you achieve it, the effort hasn’t taken as much mentally out of you because you enjoyed the experience.” CI Recipient What determines whether an individual will persist in trying to listen to a conversation in a noisy restaurant? Conversely, what factors lead someone to cease listening and “tune out”? Everyone has experienced moments when listening was effortful; however, for most people, listening is generally perceived as relatively effortless, something they don’t even have to think about. For individuals with hearing loss, the listening situations of everyday life require a sustained investment of mental effort if listening is to be successful. Interest in listening effort has grown markedly in the past decade (Pichora-Fuller et al., 2016; Richter & Wright, 2014; Strauss & Francis, 2017) and these are questions which audiologists, psychologists, and hearing researchers are seeking to address. Listening effort is a relatively new construct. Its theoretical foundations are not yet clear and there is ambiguity around what exactly is meant by the term listening effort. Typically, listening effort has been defined as the attentional and cognitive resources needed to understand an auditory message (McGarrigle et al., 2014). The theoretical foundation for understanding listening effort is based on Daniel Kahneman’s (1973) seminal work, the Capacity Model of Attention. Kahneman’s model proposes that there is a limited capacity of mental resources that can be allocated to performing tasks and that the amount of capacity allocated to tasks increases as tasks become more demanding. In the context of challenging acoustic conditions (e.g., hearing loss, background noise, accented speech), the mental energy needed for successful processing of auditory stimuli depletes available cognitive resources. This leaves insufficient resources to carry out further cognitive processing (i.e., storage in memory) or other concurrent tasks (e.g.,

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driving). The experience in such cases is one of effortful listening. Historically, a presumed correspondence between task demands and cognitive resource allocation has directed research into listening effort. As allocation of cognitive capacity is considered to co-vary with physiological arousal (Pichora-Fuller et al., 2016), indices of physiological arousal (i.e., pupillometry, skin conductance, and EEG) have been used as measures of listening effort (for a review, see Zekveld, Koelewijn, & Kramer, 2018). However, some studies have shown these physiological responses to be invariant despite changes in task difficulty whilst others have found them to vary despite tasks being held constant (Francis & Oliver, 2018). These studies suggest that there may be other factors moderating the relationship between task difficulty and the perception of effort. Motivation is one potential modifier of listening effort (Francis & Oliver, 2018). Undeniably, the relationship between motivation and mental effort has been studied extensively by psychologists over the last century (Richter & Wright, 2018). Motivation, which may be defined as “to be moved to do something” (Ryan & Deci, 2000), has been incorporated into the study of listening effort with the publication of the Framework for Understanding Effortful Listening (FUEL) (Pichora-Fuller et al., 2016). The FUEL is an iteration of Kahneman’s Capacity Model which innovates by proposing motivation to be a modulating influence on the relationship between cognitive resource allocation and task demand (See Figure 1). Acknowledging the role of motivation, the FUEL defines effort as “the deliberate allocation of resources to overcome obstacles in goal pursuit when carrying out a task” with listening effort defined as a “specific form of mental effort when a task involves listening” (p. 11S). Social and psychological factors may affect a listener’s motivation to invest effort by influencing how an individual appraises their own auditory and cognitive capacity to meet task demands (Pichora-Fuller, 2016). Such factors include constructs such as emotional stress, social

connectedness, pleasure, and success importance. In a qualitative study conducted to explore the understanding and experiences of listening effort in adults with severe-profound hearing loss before and after cochlear implantation, we found numerous social and psychological factors, including anxiety, self-esteem, social connectedness, effort-reward balance, pleasure and stigma, that informed participants’ lived experience of listening effort (Hughes, Hutchings, Rapport, McMahon, & Boisvert, 2018). Evidence is emerging in support of the FUEL and the moderating role of social and psychological factors on the allocation of listening effort. For example, social evaluative threat, defined as the fear of negative evaluation by others, is recognised as a source of emotional stress, particularly for individuals with hearing loss (Gagne, Jennings, & Southall, 2009; Hogan, Reynolds, & O’Brien, 2011; Williams, Falkum, & Martinsen, 2015). Zekveld and colleagues (in press) introduced an evaluative threat (i.e., directing participants to “please try harder”) during an adaptive speech reception threshold task (SRT). The presence of social evaluative feedback was found to be associated with increased effort as measured using pupilometry. Mackersie and Kearney (2017) also found effort expenditure to increase significantly with an increase in social evaluative threat for high-demand listening tasks but not when task demands were low. Consistent with the FUEL, these findings suggest listening effort may be modulated by other factors as well as the difficulty of the listening task. Studies of motivation have also shown associations between reward and listening effort investment. Picou and Rickets (2014) found that increasing listeners’ motivation significantly increased their subjective ratings of effort when task conditions were moderately difficult. Using pupilometry, Koelewijn et al. (2018) studied the effect of offering low versus high monetary rewards on effort deployment during a SRT task. When task demands were held constant, they found listening effort to be higher in the high reward condition but not the low reward

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43 condition. With regard to future listening effort, individuals are considered to undertake a cost-benefit analysis when deciding whether to allocate cognitive resources (i.e., effort) to a listening task. Eckert and colleagues (2016) conducted a review of findings from functional neuroimaging studies of speech recognition to provide a neuroeconomic account of listening effort. They proposed that the expected reward or value assigned by an individual to listening (e.g., the expected level of speech understanding), should be taken into account when measuring effort.

creased effort when participants performed those listening tasks associated with high success importance (i.e., higher monetary reward).

Key Reading • Hughes SE, Hutchings HA, Rapport FL, McMahon C & Boisvert I. (2018). Social connectedness and perceived listening effort in adult cochlear implant users: A Grounded Theory to establish content validity for a new patient-reported outcome measure. Ear & Hearing, 39(5), 922–934.

In summary, listening effort is no longer considered to be simply an expression of the relationship between the demands of a listening task and an individual’s auditory and cognitive capacity. • Pichora-Fuller MK. (2016). How social Drawing from rich traditions of inquiry psychological factors may modulate in psychology, theoretical understanding auditory and cognitive functioning of listening effort has evolved to include during listening. Ear and Hearing. 37, the modulation of capacity allocation by 92S-100S. factors such as motivational arousal and emotional state, as reflected in modern theoretical frameworks such as the FUEL. • Pichora-Fuller MK, Kramer SE, Eckert Consistent with notions of cost-benefit MA, Edwards B, Hornsby BWY, Humes Whilst evidence in support of the FUEL analysis, success-importance is another LE, … Wingfield A. (2016). Hearing is emerging, further work is needed to psychological construct that may be conImpairment and Cognitive Energy. Ear understand these constructs and their sidered to influence listening effort. Acand Hearing, 37, 5S-27S. interrelationships more fully. Considercording to Motivational Intensity Theory ation must also be given to the clinical (Brehm & Self, 1989), the deployment of • Strauss DJ & Francis AL. (2017). Toimplications of social and psychological effort is influenced by the importance of ward a taxonomic model of attention factors on listening effort. As these facthe task as appraised by the listener. Irrein effortful listening. Cognitive, Affective tors may be amenable to intervention, spectively of task demands, if success in a and Behavioral Neuroscience, 17(4), they have potential to mitigate the probtask is appraised as important or being of 809–825. lem of high listening effort that individuals high value then effort will be greater than tasks deemed to be of low importance. with hearing loss face daily. However, the • Zekveld AA, van Scheepen JAM, Versdevelopment of effective interventions Richter (2016) studied the influence of feld NJ & Enno CI. (in press). Please success importance on listening effort. to reduce the effects of effortful listening try harder! The influence of hearing BSA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 30/03/2017 12:14 Page 1 will require researchers and clinicians to Success importance was manipulated by status and evaluative feedback during view hearing loss more holistically and the promise of a high versus low monelistening on the pupil dilation response, BSA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 30/03/2017 Page 1 1 30/03/2017 12:14 Page 1 to look beyondBSA_A5_Landscape_Membership_Advert.V1.qxp_Layout audibility and the provitary reward during an auditory12:14 discrimisaliva-cortisol and saliva alpha-amylase sion of devices to consider the broader nation task and cardiovascular reactivity levels. Hearing Research. perspective of what it means to live well was used as a physiological measure of British Society of Audiology with hearing loss.Organisational Membership listening effort. The findings showed in-

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ear to the ground

Ear to the ground

for all things ear-related in the media In this Issue’s Ear to the Ground, we welcome new editor Simon Wierzbicki and say farewell to Sarah Canton. Articles recently have included an app for checking children’s hearing, hearing loss as a barrier to employment, and the benefit of hearing aids in reducing decline of dementia. In Twitterarty we explore the guidelines, books and articles recommended by the audiology community on Twitter.

Auditory Brainstem Implant a Success In April the BBC reported on 7 year old Leia Armitage from Dagenham, one of the first congenitally deaf children in the UK to receive an Auditory Brainstem Implant (ABI). Leia was born without an auditory nerve, making her unsuitable for a Cochlear Implant (CI). An ABI is able to directly stimulate the cochlear nucleus, and consists of an external sound processor, and an implanted electrode array, similar to a CI. Leia’s parents reported she has made much greater progress than they expected. As well as being able to distinguish environmental sound, she is now able to verbalise full sentences, and recognise voices on the phone. She is also progressing well in school. ABI is routinely commissioned in England for patients with neurofibromatosis type 2, being fitted at the same time as tumours are surgically removed. However the use of ABI for congenitally deaf children is an emerging area. In 2016 NHS England published a clinical commissioning policy: “ABI with congenital abnormalities of the auditory nerves of cochleae” targeting children aged 5 and under. The expectation is that 15 children per year will be assessed for an ABI, with 9 going on to have the surgery. Susan Daniels chief executive of the National Deaf Children’s Society said “With the right support, deaf children can achieve just as well as their hearing peers, and this investment is another important step towards a society where no deaf child is left behind” www.bbc.co.uk/news/health-47974844 www.england.nhs.uk/wp-content/uploads/2016/12/clin-comm-pol-16062P.pdf

New research published exploring mechanism of aminoglycoside ototoxicity The New Scientist reported on new research investigating how gentamycin causes ototoxicity. Aminoglycoside antibiotics such as gentamycin are known to have the potential to cause hearing loss as a side effect. Infants in neonatal intensive care units, where aminoglycosides are used, have a rate of hearing loss 6 times higher than otherwise healthy full term babies. Professor Peter Steyger and colleagues tested the effect of gentamycin on mice. They found that a protein TPRV1, found in inner and outer hair cells, was affected by the presence of infection/inflammation, allowing ion channels in hair cells to become more permeable to gentamycin, amplifying the toxic effects. Prof Steyger recommended use of alternative antibiotics where possible, and in cases where aminoglycosides are necessary, the study provides further evidence to highlight the need to monitor these patients for potential hearing loss. www.newscientist.com/article/2210246

ear to the ground

46 Evidence mounting to suggest hearing aids can slow dementia In the previous edition we reported on a recent study by a team at the University of Manchester led by Dr Asri Maharani and Dr Piers Dawes, which has shown a link between uptake of hearing aids and a slower rate of age related cognitive decline. In July, several news sources reported on research by Prof Clive Ballard and colleagues at the University of Exeter Medical School, arising from the large scale PROTECT study, a 25 year longitudinal online study in the UK, run by the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. Prof Ballard’s study was presented as a poster at the Alzheimer’s Association International Convention 2019, and showed that 1557 patients who used hearing aids performed much better than 2815 non hearing aids users when undertaking a cognitive test battery. In particular, individuals using hearing aids performed significantly better in sustained attention, attentional intensity and working memory, and non hearing aid users performed significantly worse in measures of attention, working memory and episodic memory. This research forms another significant piece of the growing body of evidence linking hearing aid use with reduced dementia risk. This work is now gaining national press attention, and should hopefully help to influence health policy in future. www.twitter.com/Clive_Ballard/status/1151908999471566849 www.telegraph.co.uk/science/2019/07/15/wearing-hearing-aid-may-delay-onset-dementia-slowing-brain-ageing/ www.thetimes.co.uk/article/hearing-aids-could-help-to-fight-dementia-8v6hlhk7q

First steps towards mind controlled hearing aid In May, the Guardian reported on research by Prof Nima Mesgarani and colleagues at Columbia University, New York. The study, published in the journal Science Advances, explores the concept of a “brain controlled assistive hearing device”, which can constantly monitor the brainwaves of a listener, and compare them with sound sources in the environment, to determine the most likely speaker that the listener is focusing on.The device can amplify the specific speaker relative to other sounds, facilitating hearing in a noisy environment – a process called auditory attention decoding (AAD). Earlier versions of an AAD system have been developed, however these were limited as the user had to train the device to recognise each speaker, therefore it was only useful for familiar voices, not strangers. The researchers have developed a new version that is able to work for voices the user has not heard before. The study recruited patients with epilepsy who already had electrodes implanted in their brain to monitor seizure activity in preparation for planned brain surgery. They were played audio from different speakers simultaneously while their brain waves were monitored. When the patient focused on one voice, the system was able to automatically amplify it, with a lag of a few seconds. The current version of the system is unsuitable for mainstream use as it requires a connection to electrodes implanted in the brain. However, the team reportedly believe they can develop a non invasive version of the device within 5 years. Jesal Vishnuram, technology manager at Action on Hearing Loss, was quoted as saying “One of the reasons people struggle is they often wait a long time before getting a hearing aid, and in that time the brain forgets how to filter out the noise and focus on the speech. This is really interesting research and I’d love to see the real world impact of it”. www.theguardian.com/society/2019/may/15/scientists-create-mind-controlled-hearing-aid

Don’t forget that any piece that appears on a news website can be commented on or shared via social media, allowing the reader to add their voice to a debate and pass the story to friends and colleagues.

ear to the ground

47 Emoji Update In March 2018, Apple submitted a proposal to the Unicode Consortium (a non-profit organisation which selects the emoji icons used by the world’s smartphones) to request more emojis that would better represent people with disabilities. They proposed a set of emojis designed to be inclusive to a large number of people in 4 main categories: Blind and Low Vision, Deaf and Hard of Hearing, Physical Motor, and Hidden Disabilities. July 17th was World Emoji Day; to celebrate this, the Unicode Consortium announced they had accepted Apple’s proposal and had approved the release of 59 new emojis, due out in Autumn 2019. The release will include a hearing aid emoji and a Deaf signing emoji. Apple released a statement to say “Celebrating diversity in all its many forms is integral to Apple’s values, and these new options help fill a significant gap in the emoji keyboard” Kristina Barrick, a spokesperson for the charity Scope, was quoted as saying the move was a “positive step towards disability being well and truly represented in the world of emoji” https://edition.cnn.com/2019/07/17/tech/apple-disability-emojis-intl-scli/index.html

Twitterarty

Sarah Bent @HearingDementia, updates on and attempts to demystify the audiology Twitter community known as #audpeeps

In this Issue’s Ear to the Ground, we feature recent news on brain implant success, ototoxicity research, a brain controlled hearing aid and new emojis. And again hearing aids and cognition have reached the news with a tweet about a conference poster becoming a mainstream news item. In Twitterarty, we celebrate another successful BSA conference and explore a new hashtag for the audiology community from the BSA Adult Rehabilitation Interest Group (ARIG) #inspiringaudiologists

Firstly, the 2019 BSA Conference was a great success, with #audpeeps posting a multitude of pictures and comments online. BritishSocAudiology @BSAudiology1 ´ 5 Jun THIS YEARS ANNUAL CONFERENCE HAS STARTED!

Marina Salorio @marsalorio 5 Jun Discussion highlighting the importance of supporting #hearing function for people with #cognitive impairment, and how research can help you imporve care. Jenna Littlejohn, Emma Hooper, Brian Crosbie, and an engaged audience #BSAConf @BSAudiology1

We will keep you updated as we translate research into practice throughout the day! #AudPeeps #Audiology #BSAConf

ear to the ground

48 BritishSocAudiology @BSAudiology1 ´ 5 Jun Poster presentations are up at today’s #BSAConf

Laura Turton @LauraAudPeep ´ 5 Jun And so the first #grandround @BSAudiology1 #BSAConf is on! Case study of person with #dementia and #hearingloss how can the researchers work feed in to clinical practice?

Jenna Littlejohn @JennaLittlejohn ´ 5 Jun Delighted to be invited to the BSA annual conference to speak about our work on #hearingloss #dementia @ManCAD_UoM @ManchesterBRC @BSAudiology1 @DSNonline

Bhavisha Parmar @Visha29 5 Jun Derek Hoare speaking about hyperacusis and the James Lind Alliance. Fascinating work involving direct engagement with patients with hyperacusis and clinicians to guide the research framework. #BSAConf #hyperacusis #audpeeps

DMU Audiology @DMUAudiology 5 Jun Derek Hoare presenting research from the James Lind Alliance on hyperacusis with data collected by our very own @Mariiaammmm #DMUAudiology @TheAudiologySoc GeorgieBurnsOConnell @GeorgieBOC ´ 5 Jun Another great Grand Round Session this afternoon at #BSAconf. This session focused on combination #hearingaids, #tinnitus and #hyperacusis. Great to hear how some of the @BritishTinnitus funded research is progressing! #audpeeps

Congratulations to all the prize winners! Emma Hooper @hooper_ek ´ 5 Jun Thank you for inviting us to present at the Grand Round. I hope it was as enjoyable for the delegates as it was for us. Really thought-provoking discussion about managing hearing loss in dementia @JennaLittlejohn @sense_cog #BSAConf

Marina Salorio @marsalorio ´ 5 Jun Prof. Brian Moore has been elected as an Honorary Life Member of @BSAudiology1 #BSAconf #Audiology #Psychoacoustics #rockstar

BritishSocAudiology @BSAudiology1 ´ 5 Jun Thank you to Dr Littlejohn, Emma Hooper & Dr Crosbie for hosting our first Grand Round Session at todays conference! We have been discussing “Hearing functions for People with cognitive impairment” and how currect research can influence our practice #AudPeeps #BSAConf Carolina leal @carolealfono ´ 5 Jun Dr Hannah Cooper at the #BSAconf telling us about some of the exciting work going on at the @UCLEarInstitute

ear to the ground

ENT & Audiology News @ENT_AudsNews ´ 5 Jun Congratulations @garethlsmith on receiving your award at #BSAconf. well deserved. He also makes a remarkable contribution to #ENTAuds Bhavisha Parmar @Visha29 ´ 5 Jun @garethlsmith receiving an award at #BSAconf for his contributions to the society #audpeeps

ear to the ground

49 David from the BTA @DavidfromtheBTA ´ 5 Jun Great to see 2 awards @BSAudiology1 #BSAudiology AGM recognising the fantastic work by @ClaireLBenton1 on paediatric #Tinnitus guidelines and @HelenPryce on shared decision making. Both @BritishTinnitus funded projects

Join us on Twitter @BSAudiology1

And in summary... Ladies in the Van @ladiesinthevan ´ 5 Jun We had a great time at the #BSAConf Some brilliant talks and interactive sessions. It was wonderful seeing some familiar faces and meeting some new ones. We’ll be keeping the pink tee’s so keep an eye out for us at the next event! #audpeeps #audiology #ladiesinthevan

BritishSocAudiology @BSAudiology1 ´ 5 Jun & that’s a wrap for #BSAConf 2019

We’ve had a successful interactive day with experts in the field of #Audiology, looking at how current research ccan influence practice. Thanks to all our speakers, exhibitors and to those who have attended & got involved. #AudPeeps

Stephanie Pearson @Stephanie_UoN ´ 5 Jun In awe of the technology involved with hearing aids at the #BSAudiology1, conference with @Magdalena_UoN Dr Lucy Handscomb @DrHandscomb2´ 5 Jun @BSAConf learning about hearing aids which are also step counters cool idea Jane Wild @JaneWild73 ´ 5 Jun Exciting times ahead for HA technology using AI #audpeeps #inspiringaudiology @BSAudiology1 #BSAudiology1

Follow us on Twitter to keep up to date with BSA courses, meetings and conferences. Find out about relevant events and conferences worldwide; as well as all the latest news from the world of audiology. Get involved by sharing meeting photos and contributing to regular discussion points and surveys.

ear to the ground

50 Secondly, ARIG has come up with a new hashtag #inspiringaudiologists, designed to promote the strengths and achievements in the audiology profession.

Jane Wild @JaneWild73 ´ 15 Nov 2018 Winners!!! #nhswalesawards18 @BCUHB #audpeeps #inspiringaudiologists

Jane Wild @JaneWild73 ´ 15 Nov 2018 Great presentation and representation by Audiology at national primary and community care conference #inspiringaudiologists #bcuhb

Laura Turton @LauraAudPeep ´ 26 Oct 2018 Online #AdultRehab meeting for @BSAudiology1 - love this group and all it stands for @JaneWild73 @JudithCBird @ Mel_Ferguson1 @SarahHughesSLT @aartimakan #inspiringaudiologists @wendytrump31 @nhpbeeston @ElaineClifford4 @lorilew99560657

Sarah Hughes @SarahHughesSLT ´ 31 Jul New article in Ear & Hearing. Thanks to all who supported this research. Relevant in the face of new UK CI candidacy. Clients need info earlier in their CI journey. Non-CI audiologists need to feel empowered to have these conversations. @BCIG_UK #inspiringaudiologists

So far, it has been mostly ARIG members tweeting with this hashtag, but already the number of tweets on awards received this year shows the value in doing this. We are a talented and valued profession, and should be shouting about it more! Lori Lewis @LoriMLewis ´ 16 Mar Equality, diversity and human rights award at the #CAVSRA for work in Audiology with adults with learning disabilities #Audpeeps,#inspiringaudiologists

ear to the ground

Mel Ferguson @Mel_Fergusion1 ´ 23 Nov 2018 Today’s the day! Looking fwd to joining our finalists @rachel_gomez2 & Conor with @ClaireLBenton1 at #NUHonours2018, Go #TeamNottmAud! @hearingnihr @NottmBRC @TeamNUH @UoNHearSci #inspiringaudiologists

Mel Ferguson @Mel_Fergusion1 ´ 16 May Congratulations to my good friends and colleagues @JaneWild73 and @ClaireLBenton1 for their @BSAudiology1 awards!! Denzil Brooks and Ruth Spencer awards - so well deserved!! Excellence in UK audiology delighted for you both #inspiringaudiologists

Aarti Makan @aartimakan´ 12 Apr Congrats @JaneWild73 A finalist at @ahcsuk @AHAwards for the Innovation in Healthcare Science award #inspiringaudiologists @BSA_BIG @BSAudiology1 @LauraAudPeep @JudithCBird @ElaineClifford4 @Mel_Ferguson1 @WeHCScientists @HeadNSHCS @IamPhilippaMay @girlymicro @CSOSue @Mammacoffee

th Annual Conference

14-15 November 2019 ACC Liverpool

Join the British Academy of Audiology for our 16th Annual Conference on the 14th and 15th November 2019 at the ACC in Liverpool. By attending the two-day conference you can expect to receive the latest in Audiology research, education and expertise, with inspiring speakers and informative sessions.

CONFERENCE HIGHLIGHTS • • • • • • • • • • • •

The Adrian Davis lecture to be presented by John Day, Clinical Director of Audiology, Betsi Cadwaladr University Health Board The Bamford lecture to be presented by Professor De Wet Swanepoel, President of the International Society of Audiology Other Keynote speakers include Professor Larry Humes, Indiana University Bloomington and Dr Sally Rosengren, University of Sydney Parallel sessions looking at all aspects of Audiology across all sectors from research to clinical practice, encompassing commercial aspects Thursday to include a walk-through dementia friendly clinic room Friday morning to include an IDA Paediatric Workshop - ticket only! Friday afternoon to include a Clinical Research Workshop Awards programme to acknowledge individuals and teams who have excelled in the Audiology profession The UK’s largest Audiology exhibition Exciting social event and networking opportunities NEW FOR 2019: Pop-up workshops in the Exhibition hall And much more!

If you are a healthcare professional with an interest in any aspect of Audiology then you will beneﬁt from attending this conference.

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For more information visit www.baaudiology.org/conference BAA 2019 A4 Advert.indd 1

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