20Q: Understanding and Supporting Reluctant Users of Remote Microphone Technology

From the Desk of Gus Mueller

If you’ve ever had dinner with Mead Killion, or even observed him at a dinner table from afar, you know that he always has one or more different hearing–aid related devices with him, that he wants to talk about or demonstrate.  On more than one instance, I’ve been with a group at a noisy restaurant when Mead has handed out some new type of remote microphone technology for all of us to try.  It’s always pretty amazing how using this technology, even when you have normal hearing, makes understanding the others at the table so much easier.  And, not surprisingly, I’ve also noticed that using this technology usually draws stares from the people at the tables around us.  More or less, this month’s 20Q relates to these two issues.  

Gus Mueller

Understanding speech is mostly related to good audibility and a favorable signal-to-noise ratio (SNR).  We know that hearing aids are more beneficial when the user is close to the talker, and the background noise level is low.  But being close to the talker is not always possible.  What is possible, however, is to have the talker use a remote microphone, and this signal then is delivered to the listener via FM or some type of digital streaming, which significantly improves audibility and the SNR.  While there is no question that using such an amplification strategy is beneficial, there is the issue that in some cases, it is noticeable to others, which can reduce the willingness to use such a device.  Paradoxically, one specific group where hearing assistive technologies such as this are extremely beneficial—school age children—is also a group that is not too keen about drawing attention to themselves.  Our 20Q author this month is going to tell us what we can do to improve this situation.

Cheryl DeConde Johnson, EdD, has a consulting practice,  ADEvantage, through which she provides services regarding educational audiology and deaf education focusing on state service delivery and accountability systems.  She also holds faculty appointments at the University of Colorado, University of Northern Colorado and University of Arizona.  Over the years, Dr. Johnson has held many leadership positions in professional organizations including President, Educational Audiology Association, President, Hands & Voices Board of Directors, and Chair, American Board of Audiology. You are no doubt familiar with many of her publications, such as the books Educational Audiology Handbook and Educational Advocacy for Student who are Deaf or Hard of Hearing. 

Cheryl began her career as a school-based audiologist, and for over 30 years, she was the face of educational audiology in Colorado.  She still lives in Colorado much of the time, but finds Arizona winters more to her liking.  Regardless of her geographical location, she always has been a persistent advocate for effective communication access in the classroom and the use of hearing assistance technologies. We’re fortunate to have her pass along some of her insights in this month’s 20Q.

Gus Mueller, PhD

Contributing Editor
March, 2015

To browse the complete collection of 20Q with Gus Mueller CEU articles, please visit www.audiologyonline.com/20Q

20Q: Understanding and Supporting Reluctant Users of Remote Microphone Technology

Cheryl DeConde Johnson

1.   Exactly what kind of technology are we talking about?

The remote microphone technology I’m referring to is that which is personally worn, and can be either frequency–modulated (FM) or digitally-modulated (DM) audio systems. The signal may be speech or non-speech sources typically from classroom talkers (e.g., teacher, peers), or media (e.g., television, computers). The FM/DM microphone/transmitters are worn by the talker or connected to the sound source to deliver the desired signal to the receiver worn by the student. Receiver options may be integrated or booted with personal hearing instruments (hearing aids, cochlear implants, bone anchored devices), or the signal may be delivered to the hearing instrument’s telecoil via a neckloop. These systems are often referred to by their broader category name, hearing assistance technology, or simply HAT.

2.  This technology can offer significant improvement in the speech-to-noise ratio, right?

Significant is putting it mildly, and this has been widely known for some time.  You maybe recall the work of Hawkins, dating back to the 1980s (Hawkins, 1984).  In this research, he conducted testing with children with mild-to-moderate hearing loss in a school classroom.  Word recognition scores were obtained for three amplification arrangements at two different SNRs (+6 and +15 dB). He found that the average FM advantage over a personal hearing aid was equivalent to a 15 dB improvement in SNR.

Similar findings using today’s technology recently were reported by Thibodeau (2014).  She compared the benefits of three different types of remote microphone hearing assistance technology: adaptive digital broadband, adaptive frequency modulation (FM), and fixed FM.  The participants were 11 adults, ages 16 to 78 years, with primarily moderate-to-severe bilateral hearing impairment, who wore binaural behind-the-ear hearing aids.  Word recognition and subjective ratings were obtained in three conditions of wireless signal processing.  She found that the new wireless technology was quite effective, especially in high background noise (75-80 dBA).  At noise levels of 65 dBA and higher, people with hearing loss using remote wireless technology performed better in the speech recognition test than those with normal hearing. At a noise level of 75 dBA, those with hearing loss achieved 69% accurate word recognition compared with only 7% by people with normal hearing.

3.  You’re right, that is impressive.  In your title you say “reluctant.”  For technology that works so well, is this a real problem?

It most certainly is. Reluctant users for the purpose of this discussion are students, generally teens, with whom FM/DM has been recommended but who fall into one of these categories: non-use, refusal, sabotage, inconsistent use, forced use because it is in their IEP, compliance because they are told it is needed.  It also includes former users and prospective users who may have tried the technology but decided it was not for them at this time. 

4.  Isn’t “reluctance” typical of teen behavior - they want to be in control and to be like their peers?

Yes, these are characteristics of teens that we certainly need to understand and respect as well as to recognize behavior that is considered “teen” from other reticent behavior. As audiologists, however, we have a responsibility to inform students of their options for communication access. In this case, we need to inform them regarding the purpose of FM/DM, how it functions, and the benefits and limitations.  And, we must provide opportunities for meaningful experiences with it so that teens can make an informed choice regarding usage.

5. You pointed out the benefits of FM/DM. Why do teens reject it?

First, not all teens reject using FM/DM. Factors that have been found to impact acceptance or rejection include:

• The teen’s acceptance of his/her hearing status and personal self-esteem
• The teen’s degree of motivation to perform well in school and actively participate in classroom discourse
• The priority of the teen to be treated the same and to be the same as his/her peers
• The age at which the FM/DM was initiated
• The teacher or other school staff member’s motivation to use the device and whether they believe it is necessary for the student’s communication access (e.g., a teacher who believes his/her voice is loud enough for the student to hear)
• The "hassle factor” for using the system
• The teen not wanting to impose on teachers for the extra work
• How well the technology is working and the consistency which with the device function is monitored
• The support for the classroom teacher regarding the purpose and intended benefits of the technology, how to use it, and how to troubleshoot potential problems
• The student’s knowledge about the technology, its purpose and intended benefits, what the technology can and cannot do, and the recommended uses
• The information that was provided to the parents to engage their support

6.  Wow – that’s a lot of variables to consider.  You didn’t specifically mention bullying.  Is that also a concern among teens that are deaf and hard of hearing?

Yes, teens are vulnerable. Add hearing loss and the associated challenges to the usual teen insecurities and they can easily be targets for bullying. The September/October 2013 Audiology Today (AT) cover story featured an article about the pediatric audiologist’s role with teen bullying (Squires, Spangler, Johnson, & English, 2013). The article reviews current statistics, including the fact that children with disabilities are up to two to three times more likely to be bullied than their peers without disabilities. Since bullying is not the current topic of this discussion, I won’t go into details here. I will, however, take this opportunity to refer interested individuals to the AT article where you will find a list of screening questions and dialogue prompts to guide your discussion with teens. 

7.  Given the obvious benefits, why not recommend FM/DM for all students with hearing and listening auditory deficits?

In theory that sounds like a good plan but there are individual differences in audibility and intelligibility as well as other variables that must be considered prior to recommending an FM/DM. The AAA clinical practice guidelines: Remote microphone hearing assistance technologies for children and youth from birth to 21 years (American Academy of Audiology, 2008) describes a comprehensive candidacy, fitting and verification, validation, and management protocol. Included in the protocol are considerations that must be addressed before proceeding with fitting (HAT) devices.  These include the acoustical environment, social/emotional status, functional performance and support considerations. For example, when considering the acoustical environment we need to know the ambient noise levels (unoccupied classroom with lights and ventilation systems on), reverberation time, and speech-to-noise ratios as evidence to implement HAT and inform the type of HAT to achieve the desired SNR. Social-emotional considerations address the students’ motivation to use HAT, self-image and social acceptance. Communication effectiveness and academic status are components of functional performance, and the teacher’s desire to embrace the technology, use and manage it on a consistent basis is part of the support system that is necessary for HAT implementation. If there are contraindications in any of these areas, the recommendation should be put on hold until further review and counseling address the concerns.

8.  Why do some students accept and use FM/DM and others do not?

Good question. Jennifer Franks conducted a survey of deaf and hard of hearing students, their parents, and educational professionals regarding FM use for her MA thesis (Franks, 2008). Of those solicited, 68 people participated (45.3%) including nine students, five parents, fifteen special education teachers, seven teachers of speech and language, eleven general education teachers, eight educational audiologists, and twelve other school personnel. All participants completed the same survey.

Her findings highlight the array of issues that impact acceptance and use of FM systems. She found that on average, 53% of all respondents indicated that the primary reason for non-use of FM was social (compared to 56% of the students as a group themselves). The interesting data however, are the reasons that make up the other 47%. Just considering the student responses, lack of benefit was the next highest reason reported by 44% of the students.  Mechanical, convenience, and comfort problems were each reported by 22% of the students, followed by support issues by 11%.

9.  What can we learn from this study and other similar surveys of students?

That nearly half of the reasons why teens reject FM/DM are issues that audiologists can manage!

10. That’s good news. What specifically can we do to address FM/DM use with teens?

First, address the benefit issue. Make sure students understand the purpose of SNR enhancement devices, what they do and do not do, and that students are able to experience and describe the benefits provided. Work with the students to identify classes and situations where the devices will provide benefit, and together develop a usage plan. Then, make sure the devices are comfortable to wear, convenient to use, and implement a monitoring and management plan to ensure they function consistently and that teachers implement their use correctly.

11.  Earlier you mentioned the IEP?  I have never worked with the school system, and I have to admit I don’t really understand IEPs.  A quick review?

Sure.  IEP stands for Individual Educational Program, which is a requirement for all public school students who receive special education services under the Individual with Disabilities Education Act (IDEA). This federal program is administered through the U.S. Department of Education, Office of Special Education Programs. State and local schools must provide services that are in compliance with IDEA regulations. The IEP is a legal document, like a contract, between the school and the student and his/her parents that outlines a service plan including goals, objectives, timelines and providers. The IEP also specifies accommodations and other support services that are necessary for a student to access his or her educational program. These accommodations include assistive technology (e.g., HAT) and services that are necessary to properly implement HAT use. To be eligible to receive special education services there is a two part requirement. First, there must be a diagnosed disability, e.g., hearing impairment, and second, there must be evidence of an adverse impact on educational performance as a result of the disability. The IEP is developed by a team that includes the student’s parents, teachers, special education providers and audiologist. Students should participate in their own IEP meetings as early as possible; participation is required beginning at age 16.

12.  Thanks. So then, can’t you just write FM/DM into the IEP?

I am sure it is done but I would not recommend it until completing the steps outlined in the AAA HAT Guidelines. Though we understand the SNR consequences, the IEP is for the student’s benefit, not ours. Students must be part of the selection and fitting decision process. Therefore, the IEP may indicate “explore benefit, selection and use of an FM/DM system” until the decision has been determined. In addition to providing the device, the IEP must also address the required assistive technology services, e.g., assessment in the student’s customary environment to demonstrate the need and validate the benefit; orientation and training for the student, teachers, and parents; and coordinating use for classes and therapies.

13.  If FM/DM is written into the IEP, don’t the students have to use it?

Technically yes because the IEP is a contract between the school, student, and the student’s parents. Although we hear students say they wear their FM because their teacher makes them, we do want our students to take personal responsibility for their personal hearing instruments and HAT, and to be able to advocate for their use.

Early in my audiology career, I tried improving usage by paying teens when they wore their FMs. It worked well while they received the payment but it did not have any long term effects. Once the experiment was over, FM use reverted to previous levels. Let’s not write the FM/DM into the IEP until the student is ready.  The same process applies to the 504 Plan.

14.  What is a 504 Plan?

A 504 Plan is part of Section 504 of the Rehabilitation Act of 1973. The 504 Plan is administered through the office of Civil Rights. It is different from the IEP because the only requirement for services is evidence of a disability (e.g., hearing impairment). The 504 Plan is used for students who have disabilities but who are not eligible for special education services under IDEA. The primary focus is on the accommodations that are necessary for a student to access their educational program. For students who are deaf or hard of hearing, these include accommodations may include HAT, special seating in the classroom, captioning, a sign language interpreter, and a quiet place to take a test. There seems to be a growing number of students who are not eligible for special education under IDEA because they do not have sufficient academic needs. Consequently, there is an increasing number of students who receive support through a 504 Plan.

Getting back to remote microphone technology, if the 504 plan stipulates an FM system as an accommodation, then the school would be in violation of a student’s right to their education program if not provided. A middle school in Massachusetts was found in violation of 504 for not using an FM with a student that had FM use written into the plan. Again, we must do our homework with the student first, then add to the 504 Plan or IEP.

15.  Is there a protocol for audiologists that guide the fitting process for FM/DM?

Yes, the AAA HAT guidelines mentioned previously provide fitting goals and step-by-step procedures for selecting, fitting, validation, and management. Available evidence is provided that supports HAT use as well as for all practices that are recommended.  It’s important that we involve the student in the fitting process from the time they begin using the devices – this can start at kindergarten with basic information that is built upon as the student is ready.  Students should understand the purpose and function of HAT, experience the benefit, and have had an early positive record of use. Then, we should be understanding of their teenage social concerns and support them with counseling and exploring other options to achieve communication access, even though it may be compromised.

16.  What else can we do to support FM/DM use?

Once the fitting has been satisfactorily completed, focus on implementation. Work with the student to guide the teacher in using the device properly and consistently. Be sure the assistive technology services required in IDEA are conducted including support to the teacher regarding the purpose of the HAT, and what it does and does not do to improve communication access.

17.  Sounds like teacher education is important?

Most certainly.  Help them learn about the challenges caused by noise, distance, and reverberation for classroom listening. Encourage them to create an open and positive relationship with the student to consistently provide the accommodations that enable the student to participate fully in all instructional activities.  This includes minimizing the “hassle” factor when using FM/DM.

18. What about the parents? Surely they are important for use of HAT?

Oh yes. We should not overlook the need to counsel the parents, and encourage them to talk to their child about the importance of communication access for learning and class participation. Just as for teachers, parents must understand the challenges associated with reduced hearing ability and reinforce the accommodations that are recommended for school. They need to know to make use of the FM/DM important by periodically asking questions of their child about the type of device used, how often it is used and for what classes and activities, and how well it is working. Reinforce the IEP goals.

19.  And of course, we need to counsel the students, too.

Absolutely.  We need to emphasize that they take responsibility for their devices and the operation and use. They need to create a contract with their teachers that describe what they will do to support FM/DM use and what they would like the teachers to do for you.  They need to talk with their teachers about their hearing status, the communication challenges they face and the communication strategies and accommodations that work best for them.

20.  Any final advice that might help impact FM/DM use?

Actually, yes.  In November 2014, the Department of Justice (DOJ) and the Office of Special Education Programs (OSEP) published a joint document of frequently asked questions regarding ADA Title II (DOJ/OSEP, November 12, 2014). The focus was on effective communication for deaf and hard of hearing students, as well as students with vision impairments or blindness, and children with communication disorders. The clarification reiterated the ADA requirement that defines effective communication as “affording an equal opportunity to obtain the same result, to gain the same benefit, or to reach the same level of achievement as that provided to others”. Students with hearing impairments are disabled under ADA. They may also be eligible for services under IDEA if their hearing impairment or deafness adversely affects their educational performance.  What is most interesting is that the ADA standard is actually higher than the IDEA requirement. Therefore, audiologists need to be able to evaluate for effective communication including use of HAT devices.  The goal is that these students are afforded communication that is as effective as it is for non-disabled peers. This policy clarification has the potential to be a game changer for our students (Johnson, 2014).

References

American Academy of Audiology. (2008). American Academy of Audiology clinical practice guidelines: remote microphone hearing assistance technologies for children and youth from birth to 21 years. Available at www.audiology.org.

DOJ/OSEP. (November 12, 2014). Frequently asked questions on effective communication for students with hearing, vision, or speech disabilities in public elementary and secondary schools. Available at: https://www2.ed.gov/about/offices/list/ocr/docs/dcl-faqs-effective-communication-201411.pdf

Franks, J. L. (2008). Why do students with hearing impairment resist wearing FM amplification? Masters Thesis and Doctoral Dissertations. Paper 205. Available from https://commons.emich.edu/these/205

Hawkins, D.B. (1984). Comparisons of speech recognition in noise by mildly-to-moderately hearing-impaired children using hearing aids and FM systems. Journal of Speech & Hearing Disorders, 49(4),409-18.

Johnson, C.D. (2014). Important ADA Policy Guidance on Effective Communication. Educational Audiology Review, www.edaud.org

Squires, M., Spangler, C., Johnson, C.D., & English, K. (2013). Bullying is a health and safety issues: How audiologists can help. Audiology Today, Sept/Oct, 18-26.

Thibodeau, L. (2014). Comparison of speech recognition with adaptive digital and FM remote microphone hearing assistance technology by listeners who use hearing aids. American Journal of Audiology, 23(2), 201-10.