Topic areas

1. Topic areas Speech Perception/recognition Auditory Training Auditory-visual performance Speechreading

2. Speech recognition: listening and lip/speech reading Purposes: Need for intervention Compare tx vs. no tx Compare diff technologies Demonstrate to pt diminished capacity Demonstrate benefit of visual cues Determine speech in noise or other degraded condition Assess long term performance/benefit of tx Determine need for intensive training

3. Patient variables in testing Hearing ability (acuity levels) Cognitive function Linguistic capabilities (native language) Familiarity with test procedures

4. Speech stimuli � Table 6-2 pages 195-198 Phonemes Subjective and statistical analyses Feature analysis Nasality - freqs around 300Hz Duration � temporal cues Place � spectral or freq changes over time Envelope � time-intensity variations in the signal

5. Words Frequently used Phonetically balanced Occur in proportion to real conversation Lexical neighborhoods (from class 1) Similar freq of occurrence and acoustic characteristics � dense and sparse Higher face validity than phonemes Easy to score Disadvantages: People speak/listen in sentences � 140-180 wpm Perform well on word tests and bomb in everyday conversation

6. Phrases and sentences Contextually unrelated or common theme High face validity � this is how we converse Prosodic cues Intonation, rate, duration (gives rough picture) Contextual information Redundancy, deduction Coarticulation Blends � can be good and bad

7. Test conditions Auditory only Presented in quiet Multiple levels (soft, avg and loud speech) Presented in noise Babble (2-6 talkers) Non-speech noise Signal to noise (SNR) Which is best? Depends on what is being tested

8. Test conditions Auditory/visual Used to show benefit of visual addition (mild to moderate losses) Used if auditory is so poor that visual input is main avenue of �hearing� Presented auditory only then with visual cues in quiet Multiple levels (soft, avg and loud speech) Provides difference score Presented in noise (aud only then AV)

9. Test conditions Recorded Calibrated Significantly reduced variability USE Live Don�t need playback equipment Use with children and some adults for more �hands-on� presentation of materials Don�t use

10. Recorded stimuli Learning effects (using the same thing over and over) performance better because of memory of items How to fix this? Equivalent lists Test�retest reliability (consistency) Can control with recorded materials Same room Clinically significant improvement vs. statistically significant Multicultural issues � need tests which are sensitive to language and cultural differences

11. Auditory training Determine capacity and maximize ability Used in conjunction with technologic treatment choices Used intensively with children

12. The components of auditory perception � a continuum� Detection � awareness Discrimination � ability to distinguish Identification � labeling Attention � focus ability Memory � retention/storage to derive meaning Closure/comprehension � aggregate of above to higher level processing centers

13. Auditory Training - Adults Assessment of skills (formal/informal testing) Maximize use of auditory and related cues Adjustment to comprehensive treatment plan (HAs, ALDs and AR) Much more structured for children than adults

14. Auditory Training - Adults Consonant recognition � (Walden, et.al., 1977) analytic approach to improve speech perception � with added AV approach Research showed efficacy after intensive training (same-different judgments) Improvements in consonant rec. applied to sentences as well, esp. with use of visual cues

15. Auditory Training - Adults Communication Training � focuses on �gestalt� rather than drilling on perception Makes sense � patients don�t focus on consonants or even individual sentences but in the overall patterning of speech Usually small groups but can be individual

16. Hearing and Listening Training Topics: Hearing loss and speech perception (why the patient is missing what they are missing) Effective use of amplification ALDs in everyday living Multi-modality learning Psychosocial impact Speech tracking Assertiveness training (other professionals)

17. Speaker Factors Listener Factors Environmental Factors

18. Speaker Factors Voice loudness Rate of speech Clarity of speech Facing away from listener Objects near/in mouth Lack of or conflicting facial expression Lack of or conflicting body language Foreign accents and dialects Distracting mannerisms

19. Listener Factors Amount of hearing loss Type of hearing loss Improper or lack of use of hearing aids Failure to pay attention Distracting thoughts Poor or underused speechreading skills Unrealistic expectations

20. When someone speaks, sound radiates throughout the air.� The intensity of sound that is received is reduced as a function of distance. A clinician engaged an older person in face-to-face conversation under three different conditions of amplification (portable amplifier/ALD, personal hearing aids, no amplification) and six different distances from 0.5 to 3.0 meters.� Conversational fluency was rated under all conditions on a 4-point scale (1 = low; 4 = high).

21. The use of a portable amplifier with the microphone held close to the partner's mouth resulted in high conversational fluency throughout this range of distances.� Personal hearing aids were superior to unaided hearing, but conversational fluency diminished with distance for both of these conditions.� The benefits of near distance and amplification are evident.

22. Environmental Factors Background noise Poor lighting conditions Poor acoustics Interfering objects Visual distractions Distance from sound source Poor angle of vision Lack of use of visual cues

23. Hearing/Listening strategies Facilitative Forward preparation Instructional � helps talker deliver message Message-tailoring � how message is delivered Constructive � design environment (more favorable) Attending � focus by patient Anticipatory � preparation based on prior experiences

24. Repair Receptive � incoming not received Expressive � outgoing not received Specific � repetition, rephrasing, elaboration Simplification Topic indication Confirm receipt of message Manual form (written, hand gestures, signs, etc.)

25. Conversational styles Passive Withdraws Pretends to understand Avoidance of hearing and listening situations Non-interactive behaviors

26. Aggressive Hostile Belligerent Blames others Dominates conversation

27. Assertive Respectful of others Openly expresses needs Takes responsibility Interactive

28. Training Models Formal Introduce various types of strategies Brainstorming � directed group discussion Use of activities Guided Learning Teach individual in a structured setting Role-playing Videotapes Drilling Real-World Practice Skills in everyday life Report on success/failures Training Frequent Comm. Partners Foster empathy Use of appropriate speaking behaviors Tailor messages Repair breakdowns

29. "Instant Therapy": Effects of situation and environment (real-world model) "Instant Therapy" is any therapeutic action that results in immediate improvement of a person's ability to participate in conversation.� To provide instant therapy, simply modify the conditions while conversing with the person, and rate the fluency of conversation under each condition - by assigning a number from 1 (low) to 4 (high). Can compare effects of amplification, voice level, distance, rate of speech, communication partner, the surrounding environment, etc.

30. "Instant Therapy": Effects of situation and environment The results of modifying the situation (including the amount of noise, reverberation, illumination, and glare) are shown below for one older person who resides in a nursing home

31. As a result of training: The person with hearing loss can learn to: control the environment attend to visible cues manage conversations request appropriate clarification The partner can learn to: produce clear speech and language respond to requests for clarification ensure positive outcomes

32. Both can learn to: Avoid communication difficulty Manage situations Use amplification systems Develop confidence

33. Visual Stimuli and cues Speechreading

34. Visual stimuli in hearing training Lipreading Visual hearing Visual communication Visual listening Speechreading Facereading

36. Research has shown lipreaders scan different regions of the face� Primarily to eyes, nose and mouth When asked to judge prosodic info � will look at eyes and above When asked to judge phonetic � lower face, the lips and jaw

38. Visibility of sounds 60% of speech not visible on the mouth Bilabials (p,b) and labiodentals (t,l) most recognizable Voicing not identifiable Vowels difficult to see but provide longer duration, are intense and result in jaw movement

39. Rapidity of speech 4-7 syllables/second: 15 phonemes/sec Visually can recognize 9-10 movements/sec Can�t do it all�..need to fill in the gaps Coarticulation and stress effects Sounds are affected by the surrounding influences � where they fall in the word as well as where in the sentence and with varying emphasis

40. Visemes: shape of the mouth and place of articulation � visual analogy to speech sound Groups of sounds which look alike on the face (table 9-2) Homophemes: speech sounds that look the same � confusing to the listener for semantics (table 9-3) 40-60% of words Grammar, situational cues help

41. McGurk Effect � 1976 Parts don�t always equal the whole (hear �ba�, see �da�, report �ga�)!! Recognition of speech automatically forces a integration of auditory and visual cues

42. Benefit from visual cues Walden , et.al., 1993 � visual cues in AV recognition in middle and older age adults Used syllables (pa, ta, ka, etc.) and CID sentences (maximum length � 8 words � key words scored in each sentence) Bilateral HL � moderate to severe in mid to high frequencies � reduced word recognition in quiet (auditory only � Audibility Index)

44. Benefit from visual cues, cont. Question: Are there differences between age groups in benefit derived from visual cues? Looked at the change in speech recognition with addition of visual cues Comparable benefit found between groups for added visual input Significantly different performance, however, within groups for speech material � greater improvement from auditory only to AV on sentences than compared to syllables (syllables were �closed set� and subjects were familiarized with them)

45. Benefit from visual cues, cont. Largest differences observed in older group with greater visual confusions � however no difference between age groups in the types of mistakes made Conclusions: Older patients can benefit equally well from visual cues (and can integrate with auditory input to improve recognition) Older patients tend to be more conservative with reduced input and therefore should be encouraged to �take more chances/guesses�

46. People with impaired vision may experience one or more of the following difficulties: reduced ability to see small objects reduced clarity of objects reduced contrast sensitivity limited visual field reduced ability to distinguish colors increased interference from glare

47. Several types of vision impairment are common in older people: cataract, glaucoma, macular degeneration, diabetic retinopathy. These disease processes will have a significant impact on �visual hearing� � making the AV blending much less effective

50. SpeechReader Innate ability: visual word decoding, ID ability, speed Hearing status: more severe losses; better � more reliance Emotional and physical state Age � older worse, on average Intelligence � average or better, no effect � still goes to overall cognitive ability and familiarity with spoken language Personality Traits � no hard evidence of effect Visual skills � acuity (distance) and perception (figure/ground and closure)

51. Amplification and speechreading Walden, et.al., (2001) � assessed adults with bilateral HL in four conditions: unaided listening/no visuals; aided listening/no visuals; unaided listening w/ visuals; aided listening w/ visuals Why? Little attention in the HA literature as to influence of visual cues; hearing loss is treated with hearing aids with no thought as to effect of visual cues on capability

52. Amplification and speechreading With today�s HA technology, can set multiple prescriptions within 1 aid for various listening conditions (a la multiple prescription eyeglasses) Strong evidence in the literature that auditory and visual input must complement each other So � could different but complementary cues optimize AV speech recognition?

53. Amplification and speechreading Results: Significant differences among all 4 conditions (unaided vs. aided, visual vs. no visual) Greater improvement from unaided (no visuals) to unaided (w/ visuals) than from unaided (no visuals) to aided (no visuals) Speechreading did not provide the same cues as did amplification � visuals provided place of artic (what you see) and HA�s provided some place info but more manner of artic and some voicing (what you hear � more low to mid frequency information)