Audiology and Speech Pathology - Theses
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ItemPsychologically Informed Practice in Hearing Healthcare: Perspectives and Needs of Clients and Audiologists( 2022)For many people, the sense of hearing provides a connection with others and the world around them. Losing one’s hearing can have a deleterious impact on many psychological and social aspects of life. Hearing loss can compromise psychological wellbeing, resulting in an increase in loneliness or reduced self-esteem, and it can also increase the odds of experiencing psychological symptoms, such as depression and anxiety. Given this association, audiologists are likely to encounter clients with psychological concerns on a regular basis. Understanding how these clients experience audiological rehabilitation may be an important way for audiologists to provide relevant and optimal services. Psychological factors, including mental health and illness, can also significantly influence the initiation, adherence, and success of audiological rehabilitation. Despite this, psychological factors are not adequately considered within hearing healthcare, so the recommended approach of person-centred care may need to be further extended to better address these factors. Psychologically informed practice (PIP) may provide a suitable framework that can be used to extend upon person-centred care, especially for clients with comorbid psychological symptoms. A PIP framework recognises the role of psychological factors in chronic health conditions and addresses these using psychological theories and frameworks. PIP has shown success in other rehabilitation settings and may therefore provide benefits within hearing healthcare. The aim of this thesis was therefore to explore the nature of mental illness, mental health, and psychological symptoms within audiological rehabilitation, from the perspective of clients and audiologists, and to provide a foundation of support for the implementation of PIP into hearing healthcare. Four studies were conducted to achieve the aims of this thesis. The first study included in-depth, semi-structured qualitative interviews to understand the experience of hearing loss and audiological rehabilitation for older adults with comorbid psychological symptoms. A novel theme found in this study was the bi-directional and cumulative relationship between hearing loss and psychological symptoms. Given the relationship between hearing loss and psychological symptoms, the second study included a systematic review and meta-analysis to determine the effect of interventions targeted at hearing loss on psychological symptom outcomes in adult clients. The meta-analysis showed that hearing aids, cochlear implants, and communication and education programs resulted in a small decrease in depression and anxiety symptoms. A mixed-method survey of audiologists working in adult audiological rehabilitation in Australia was then conducted to understand the nature of client-audiologist discussions about client mental health within audiological rehabilitation. This study found that audiologists occasionally discuss mental health, and clients are more likely than clinicians to initiate these conversations. The final study aimed to determine the barriers and facilitators to audiologists discussing and addressing client mental health, and to determine audiologists’ preparedness and willingness to implement aspects of PIP in audiological rehabilitation. Audiologists were generally motivated to incorporate PIP into audiological rehabilitation; however, a lack of knowledge about mental health and organisational barriers, such as time and resources, would need to be overcome. Overall, the studies in this thesis provide an understanding of how psychological symptoms are experienced, recognised, discussed, and addressed within audiological rehabilitation and suggested that the current way of delivering audiological rehabilitation is insufficient to achieve optimal outcomes for clients with psychological symptoms. These studies form an evidence-based foundation and rationale for the implementation of PIP within hearing healthcare.
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ItemStudent engagement of children who are deaf or hard of hearing attending mainstream schools( 2021)Student engagement in classroom learning is recognized as being important for a child’s school success. It is a major focus in the education literature, with a range of intervention programs being designed to increase engagement levels in the classroom as a way of increasing school completion rates, and improving school outcomes for the student. Students who are deaf or hard of hearing (DHH) and attend mainstream schools may experience additional difficulties engaging in their learning compared to their peers with typical hearing. Despite this, research investigating the student engagement of children who are DHH remains sparse. To address this gap, the overarching aim of this thesis was to explore the student engagement of DHH students attending mainstream schools. This thesis consisted of two studies. The first study compared the observed and the self-reported engagement of 16 DHH students (aged 9 – 12 years) who attended mainstream schools to that of matched controls with typical hearing. Observed engagement was measured through observations in the classroom setting using the Mainstream Version of the Code for Instructional Structure and Student Academic Reponses (study 1a), and self-reports of engagement were obtained using the Classroom Participation Questionnaire (study 1b). The main finding of this study was that there were no significant differences for either observed or self-reported engagement for the group of DHH students compared to that for the group of matched controls. When looking at individual results, three individual DHH participants had lower levels of observed engagement compared to their matched control. Adverse noise levels for one student, and low vocabulary scores for another student are possible causes for these poor results. The second study was a qualitative study that used individual interviews to explore the self-perceived barriers and facilitators to engagement for DHH students attending mainstream schools. Interviews consisted of a series of question and a card-sorting activity. The same 16 DHH students who participated in study 1, participated in study 2. Thematic analysis of the interview transcripts resulted in the generation of four themes. These were: challenges to engagement, student strategies, supports to students, and teacher actions. These themes demonstrate the complex range of factors that contribute to or impede engagement of students who are DHH in mainstream classrooms.T he work undertaken for this research demonstrated that, for the participating students, there were no differences between the groups on either observed or self-reported engagement. One notable characteristic which is likely to have contributed to this positive finding was that all but one of the participants attended a mainstream school with a deaf facility. As such, it is possible that factors related to this school setting, such as having high levels of support available and having a DHH peer group within the school, may have contributed to the positive finding. Although there were no differences in engagement levels between groups, three individual DHH participants had lower levels of observed engagement compared to their matched controls. As such, some DHH students may benefit from receiving support with a specific focus on engagement. The factors identified in the second study may be used to inform professionals about the engagement of students who are DHH attending mainstream schools, and provide strategies towards reducing the barriers and increasing the facilitators to engagement for these students.
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ItemGoing digital: enabling caregivers to optimise the linguistic environment for children with significant hearing loss( 2019)Early auditory exposure and linguistic interactions are fundamental in shaping the trajectory of typical language development in hearing children. These early linguistic experiences occur within the context of adult-child exchanges, through daily experiences, care routines and play. For children with prelingual hearing loss, early access to sound through hearing devices enables them to participate in these early linguistic experiences and can mitigate the potential negative effects resulting from hearing loss. In addition to early device fitting, research has demonstrated a strong association between the manner, content and amount of spoken language which infants and toddlers are exposed to at home, to enhance their learning, and their later language outcomes. While there is growing research awareness with regard to measuring the amount of talk directed to children, establishing how best to provide feedback to caregivers on their language contributions to their children in the context of everyday life, has been a challenge in traditional service delivery models. To this end, automated speech and language processing technology, also known as the Language ENvironment Analysis (LENA) system, offers clinicians the possibility of measuring and imparting quantified information to parents about their child’s auditory-language environment. Additionally, the use of mobile applications has been gaining traction as an accessible method of promoting health. The Daily Vroom App (DVA) for example, was created as an outreach initiative to communicate developmental research evidence to parents, presented as practical and implementable content. The DVA content takes the form of daily tips aimed at turning everyday moments for parents and their young children into opportunities for shared interaction. This study evaluated these two technology-driven interventions, using LENA technology and the Daily Vroom App, as ways to increase the amount of conversational turns and words spoken by adults to children. The present study firstly investigated relationships between family, maternal and child characteristics and language counts (measured using the LENA system) recorded in the children’s natural home environments. Secondly, changes in the participants’ adult word count and adult-child conversational turn count from baseline were examined after mothers received feedback based on LENA generated language estimates and/or, after mothers had used the Daily Vroom App. Thirdly, survey findings regarding the use of LENA technology and the DVA from the perspective of clinicians and mothers were explored. There were 10 mother-child dyads (six hearing children and four children with bilateral severe-to-profound hearing loss) who participated in a prospective intervention trial. After establishing each dyad’s baseline LENA-generated language counts (adult words and adult-child conversational turns), mean percentage changes in their language counts were analysed for three study conditions: LENA-Only recordings of adult-child verbal interactions in the child’s natural environments (Condition LO); adult-child verbal interactions following specific, individualised feedback from a clinician regarding the quantity of talk (LENA Feedback- Condition LF); and DVA use which provided tips for shared parent-child interactions in addition to Condition LF (LENA Feedback and App- Condition LFA). Maternal and child measures were administered at the beginning of the study. Demographic information and responses to a survey on the use of LENA and mobile technology were collected from participating clinicians and mothers. Key group findings suggested that the mean percentage increases in adult word and conversational turn counts from baseline were significant after the interventions (i.e. providing participants with LENA feedback and mother’s use of the mobile app), compared to Condition LO where only LENA recordings were completed. Significant correlations were found between mothers’ occupational skill level, maternal receptive vocabulary and their ratings of eHealth literacy. Participants assigned the DVA an overall mean quality rating of 3.85 out of 5. Significant positive relationships were found between objective app quality indicators (engagement, aesthetics, information) and participants’ perceived impact (on help-seeking, intention to change and behaviour change) of using the DVA. These two contemporary technologies (LENA and DVA) were demonstrated to support adult language input and conversational turns in the home environments for mothers of children with normal hearing, and children with bilateral significant hearing loss. This study addressed the question of whether providing structured information and feedback to mothers would be associated with a change in maternal language behaviours. This study also contributed to current knowledge regarding the practical applications of the LENA system and the Daily Vroom App as a complement to current service models, extending intervention practices beyond the therapy room.
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ItemMild and moderate congenital hearing loss in childhood: trends and associations with language outcomes( 2018)Background: Children born with mild and moderate bilateral hearing loss experience poorer language outcomes than peers without hearing loss. Following implementation of universal newborn hearing screening (UNHS) in the early 2000s, most children are now fitted with hearing aids very early, even without firm evidence of efficacy. Filling this knowledge gap would support clinicians and families to make appropriate decisions for affected children. Aims: In population-based samples of children born with mild and moderate bilateral hearing loss in two age groups, I aimed to describe the: 1) language and child wellbeing outcomes at 5-8 years of age examined both by system of hearing loss detection and age at detection; 2) relationship between measures of hearing ability (aided and unaided) and speech/language outcomes at 5-7 years of age; and 3) expressive vocabulary of children at age 1-3 years, with comparison to same-aged children without hearing loss. Methods: All participants were drawn from population-based studies or databanks with comparable measures and demographic composition in Victoria and New South Wales. In Aim 1, 21 directly assessed children (5-7 years) were analysed with 125 children (5-8 years) from historical hearing loss cohorts and 1217 children (7 years) without known hearing loss. For Aim 2, hearing aid data were obtained for 19 directly assessed children. In Aim 3, questionnaire data were compared between 20 children (1-3 years) with and 1711 children (2 years) without known hearing loss. Language was assessed or parent-reported, with additional data collected by parent questionnaire. Aim 1 was analysed using unadjusted and adjusted regression models, with potential confounders identified a priori. For Aims 2 and 3, analyses were descriptive and exploratory. Results: Outcomes for 5-7 year olds with moderate loss improved across detection systems spanning opportunistic through to UNHS (mean expressive language p for trend .05, receptive vocabulary p for trend .06) and were better when diagnosed before age 6 months. Children with mild loss did not show similar benefit, despite trends toward earlier diagnosis and hearing aid fitting. Children with mild-moderate loss had poorer expressive language than children without loss (adjusted mean difference -8.9 points, 95% CI -14.7 to -3.1). Audibility measures correlated with unaided hearing (r=-.60 to -.79, p=.02 to <.001) and speech recognition ability (r=-.63 to -.73, p=.04 to .01). Unaided and aided hearing measures did not show associations with speech and language. On average 1-3 year olds with, versus without, hearing loss had lower expressive vocabulary raw scores even though older at assessment. Language of children with mild loss was on average 9 months behind expectations (SD 5.6 months), moderate loss on average 6.6 months behind (SD 6.7 months). Conclusions: Children with mild and moderate hearing loss show early language delays that persist into primary school. Children with moderate loss showed some benefit from earlier detection and fitting with hearing aids. Children with mild loss did not, which is concerning given the current practice of earlier hearing aid fitting. A population-based trial of hearing aids for mild losses would clarify the benefits versus costs of this approach.
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ItemA study of electrical stimulation levels over 10 years for adults using Nucleus cochlear implants( 2017)Cochlear implants have improved sound perception for thousands of people with severe and profound sensorineural hearing loss. To ensure a good quality sound signal, the implant must be individually programmed throughout the user’s lifetime. Programming determines the electrical stimulation level requirements for each electrode of the implant. The frequency with which programming occurs has so far been based primarily on clinical experience and resources available to the clinic for programming purposes. To develop an evidence-based schedule for the frequency of programming, a comprehensive investigation of the change in electrical stimulation level requirements over time for a large group of adults is necessary. The overall purpose of this retrospective study was therefore to investigate the change in electrical stimulation levels up to 10 years postimplantation for a large group of adults using Nucleus cochlear implants. In addition, this study also aimed to investigate whether demographic characteristics and electrode array segments were predictive of the change in electrical stimulation levels. The Cochlear Implant Clinic of the Royal Victorian Eye and Ear Hospital, Victoria, Australia, has been providing programming services for cochlear implant users for over 25 years. The electrical stimulation data obtained at the programming sessions were extracted for 680 participants who used a Nucleus® cochlear implant over the course of 10 years. For each implant user, programming data for the following time points were extracted from Cochlear Limited’s TM Custom Sound 3.2® fitting software: 2, 3, 6, 9 months postimplantation and biennial time points from 1 year up to 10 years postimplantation. For each time point, the mean T level, C level, and dynamic range (DR) were calculated separately for four electrode array segments: apical (mean of electrodes 22, 20, 18), medial (16, 14, and 10) upper-basal (7, 6), and lower-basal (4, 3). The degree of change (DC) in levels between consecutive time points was also calculated. Long-term changes in electrical stimulation levels were also investigated for 128 participants from the same group who had adequate programming data up to 10 years postimplantation. The trends and amount of change in programming levels were investigated separately for the four electrode array segments using regression analyses. The effects of several demographic characteristics (e.g., aetiology and onset of hearing loss) were also investigated. For the 680 participants, the average T levels and C levels were consistent from 3 months and 6 months postimplantation, respectively. In terms of the degree of change between time points, the majority of participants showed an average of ≤ 20% change in levels as a function of DR after the 3- to 6-month time point comparison postimplantation. Long-term patterns of change for 128 individual participants showed that, for 42% of these participants, the electrical stimulation levels remained relatively stable without any significant trends for either the T levels or C levels, from 6 months up to 10 years postimplantation. Some significant changes in levels were evident up to 10 years postimplantation; however, changes were small, equating to less than 6% per year as a function of DR for 75% of the participants and a maximum of 10% change in levels for the remaining 25% of participants. Additional noteworthy findings include the following: 1. For the participants who showed more change in levels in the first 3 to 6 months postimplantation, approximately 70% of these participants showed a non-significant long-term trend in levels up to 10 years postimplantation, 2. The mean T levels and C levels were found to differ significantly for the four electrode array segments in the first 2 years postimplantation, but were relatively consistent in the long-term, and 3. The mean degree of change in levels as a function of DR was significantly greater for the Otosclerosis pathological group (n = 72) compared to all other groups, and for the prelingual onset of deafness group compared to the postlingual group. This thesis provided strong evidence that electrical stimulation levels change in the first 6 months but expected to remain relatively stable up to 10 years postimplantation for the majority of adults using Nucleus cochlear implants. Based on this evidence, a programming protocol for 10 years postimplantation has been proposed. The proposed protocol recommends more frequent programming sessions in the first 6 months compared to the number of sessions thereafter. The reduced number of sessions over an implant user’s lifetime will assist in managing the increasing caseload with the amount of resources currently available for programming. Given that the levels differed across the segments in the first 2 years postimplantation, but not in the long-term, the proposed protocol recommends measuring levels separately for the four segments in the early postimplantation period. This can then be limited to one or two segments beyond 2 years postimplantation. The protocol also suggests that more programming sessions may be required in the first two years for implant users with Otosclerosis and those with a prelingual onset of hearing loss.
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ItemCommunication outcomes for children who receive a cochlear implant before 2 1/2 years of age( 2015)Background and aims: This study examined the long-term benefits of cochlear implantation for children who received their first cochlear implant before 2.5 years of age. Using a comprehensive battery of speech perception, speech production and language measures over six years, the study compared communication outcomes for children using cochlear implants and children with normal hearing. The relative influence of age at cochlear implantation and other covariates on outcome measures was examined. Method: The study design involved the prospective longitudinal evaluation of 32 children with no additional disabilities, who received their first cochlear implant before 2.5 years. Speech perception skills were quantified using the CAP pre-operatively and at one, two and three years’ post-implantation. When the children entered primary/elementary school (five years of age), open-set word testing (CNC) was completed. Speech production was evaluated using the DEAP at school entry. Language was evaluated pre-implantation, at one, two and three years post-implantation, and at school entry using the RI-TLS, PPVT and the CELF or PLS when relevant. Results: All children in the study developed significant open-set speech perception skills with a group mean monosyllabic word score of 56% and phoneme score of 81%. Speech production skills were delayed compared to normally hearing peers at school entry. Rate of language development for the children (M 1.04) and standard scores (M 86) at school entry were equivalent to hearing peers. Younger age at implantation was found to significantly reduce language delay and was associated with optimum speech production at school entry. There was no significant relationship between age at implantation and language growth, language standard score at school entry or speech perception. Measures of family participation and child non-verbal IQ were significantly associated with speech perception, speech production and language. Conclusion: Children with cognitive development within the typical range who receive a cochlear implant before 2.5 years of age, can demonstrate speech perception skills sufficient to communicate using audition alone. This level of speech understanding however, does not lead to age appropriate speech production in all cases. In the present study, speech production was delayed compared to hearing peers. Children who receive their first cochlear implant before 2.5 years can demonstrate rates of language acquisition equal to their hearing peers, but may retain a language delay approximately equal to their age at implantation. This data supports the provision of cochlear implants as early as possible to minimise any language delay resulting from an initial period of auditory deprivation.
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ItemPatient-practitioner interactions: older adults and their audiologists( 2014)Hearing impairment increases in prevalence with ageing. If left untreated, hearing impairment can be a barrier to successful ageing and can cause a variety of negative consequences. Recent investigations of factors associated with hearing aid uptake and use by older adults revealed a paucity of research examining the value and influence of patient-audiologist interactions. Within the health professions, there is a growing interest in patient-practitioner interactions and in particular the quality of professional exchanges termed “patient-centred”. Philosophical and clinical definitions of the term are reported throughout literature where decades of research illustrate relationships between patient-centred care and improved patient outcomes. Before such relationships can be examined in audiological rehabilitation for older adults, the term needed first be defined and the existence of patient-centred interactions explored. This research utilised a mixed-methods design to triangulate patient-centred care in audiological rehabilitation as defined by older adults with hearing impairment with observed patient/companion-audiologist communication in audiology consultations. A sequential exploratory design was used across two studies. Firstly, a qualitative descriptive study was conducted with a purposively sampled group of older adults who owned hearing aids. This study explored participants’ experiences with audiologists and their definition of patient-centred audiological rehabilitation. The findings of this study are represented visually in two models. The first model describes the people, behaviours and processes required to provide patient-centred audiological rehabilitation: a therapeutic relationship was seen as central to patient-centred audiology interactions; the audiologist and patient were seen as key players; and the way two processes occurred (information exchange and decision-making) was considered instrumental in whether audiological rehabilitation was patient-centred. The second model provided an operationalised description of how patient-centred care can be clinically implemented. In this model, there were four dimensions: 1) therapeutic relationship, 2) informed patients, 3) involved patients and 4) individualised care. Results from Study 1 provided a rationale and focus for the examination of patient-audiologist communication in initial consultations and thus informed the second study. In Study 2, 63 initial consultations between audiologists and older adults (and companions in 17 cases) were filmed and analysed using the Roter Interaction Analysis System (RIAS). This method was used to examine the presence and nature of patient-centred communication. Analyses were conducted in two phases: Study 2a focussed on the history-taking phase of initial consultations and Study 2b focussed on the counselling phase. Taken together, the results revealed a dearth of patient-centred communication in initial consultations. That is, little communication was invested in developing a therapeutic relationship; patients were primarily informed only about hearing aids and audiologists asked closed-ended, biomedical questions thus limiting information received about patients’ needs. Little patient and companion involvement was observed. Audiologists rarely sought input from those accompanying the client and, in the presence of a companion, asked fewer psychosocial and lifestyle questions and offered less psychosocial and lifestyle education than when a companion was not present. Limited individualisation of information and options was observed. At the conclusion of this thesis, the results of Study 2 were juxtaposed with the results of Study 1. The overall findings present an imperative to value and promote the quality of patient-audiologist interactions, beyond technical skills, in the provision of “patient-centred” audiological rehabilitation for older adults and in the education of students of audiology.