As a rehabilitative audiologist, speech-language pathologist, and the mother of a child who is deaf, I expect to get a lot of questions about how to improve listening performance for children in schools. Classroom listening and educational access are complicated issues. We know most children with any degree of hearing loss fall into the category of hard of hearing; children who are in mainstream education settings tend to have more residual hearing; and that about 75 percent of children with hearing loss in public school settings rely on speech for communication and listening to learn (Karchmer and Mitchell, 2006).
We also know that poor signal-to-noise ratio affects learning for children who are deaf, hard of hearing, who are learning English as a second language, or who have learning challenges such as attention deficit hyperactivity disorder (ADHD). Despite this, mainstream unoccupied classroom noise levels often exceed those recommended by the American National Standards Institute (ANSI, 2002) for optimal speech recognition for young children with typical hearing and those with hearing loss (see Crandell and Smaldino, 2000 for a review; Knecht et al, 2002).
Research shows that high levels of classroom noise negatively impact reading comprehension, auditory and visual attention, and short-term memory in typical hearing children, and that children in noisier school settings demonstrate more oppositional behaviors and poorer social skills than children attending quieter schools (Howard et al, 2010; Ferguson, 2013). High background noise levels can reduce acoustic access to and recognition of conversational speech cues by children who are deaf or hard of hearing (Eisenberg et al, 2004; Finitzo-Hieber and Tillman, 1978; Litovsky et al, 2004) and slow, verbal processing speed (common in children who are deaf) further reduces speech recognition in noise.
We know that even when a child who is deaf or hard of hearing (DHH) can hear what is being said, this does not mean that he or she has equal communication access to his or her typically hearing peers or complete access to the curriculum. In school, children need to hear the teacher, their peers, and other adults with whom they interact (e.g., instructional assistants, specials teachers, recess and lunch monitors, and the school nurse). They need to navigate a dynamic linguistic environment all day that often includes variable and unpredictable background noise. That noise can be generated by outside sources such as traffic, children on the playground, children in the gymnasium, children passing in the hallway, music room noise; or it can be generated by inside sources, such as heating and ventilation equipment, desks moving, or other children making noise. Depending on the location of the child who is DHH, background noise can vary across multiple acoustic dimensions such as intensity, frequency, and duration. The child with hearing loss encounters multiple learning and social situations throughout the school day with which noise can significantly interfere.
Recent research suggests that children who are deaf (especially those with delayed language) are at higher risk for auditory memory and auditory attention deficits (Burkholder and Pisoni, 2006; Pisoni et al, 2010). In addition to classroom noise interfering with auditory access, noise and classroom disruptions interrupt auditory attention; this can also have significant effects on learning for a child who is DHH. Children who intermittently lose track of instructional language because they are attending to other distractions will invariably miss critical information.
About 80 percent of students with hearing loss attend schools with only one to two children who also have hearing loss (Karchmer and Mitchell, 2006). Most children who are DHH are being served by school teams that have limited experience with and knowledge of the educational impact of hearing loss. Educational audiologists have an important role not only in assessing and fitting school-aged children with hearing assistive technology (HAT) for the classroom, but also in helping teachers and other professionals understand the complex listening and learning needs of children who are DHH and how to optimize communication access despite the many listening obstacles these children face throughout the day.
Here are some recommendations for optimized learning, communication access, and communication equity for children who are DHH in schools.
Start with a Good Assessment
Every individualized education plan (IEP) must be based on a comprehensive assessment. Per the Individuals with Disabilities Education Act (IDEA) 2004 Section 300.304 (b)(1), the evaluation process must include a variety of assessment tools “to gather relevant functional, developmental, and academic information about the child, including information provided by the parent that may assist in determining the content of the child’s IEP.”
Further, “the public agency must not use any single measure or assessment as the sole criterion for determining whether a child is a child with a disability and for determining an appropriate educational program for the child” [IDEA Sec. 300.304(b)(2)] and the child must be “assessed in all areas related to the suspected disability, including, if appropriate, health, vision, hearing, social and emotional status, general intelligence, academic performance, communicative status, and motor abilities” [IDEA Sec.300.304 (c)(4)].
When eligibility determination, accommodations, and specialized instruction for a child who is DHH are based solely on standardized assessments of expressive and receptive language, this will be insufficient to develop an appropriate and comprehensive school plan.
The educational audiologist should contribute to the assessment process by collaborating with other team members in conducting and recommending appropriate standardized and functional measures of educational impact. This might include conducting unaided and aided audiological testing, measuring speech recognition in quiet and noise, evaluating functional listening, and observing and evaluating the classroom listening environment.
Furthermore, Title II of the Americans with Disabilities Act (ADA) was clarified in 2014, requiring schools to ensure that communication is as effective for students with hearing loss as it is for students without disabilities (Anderson, 2014). Effective communication is provided through auxiliary aids and services for the purpose of “affording an equal opportunity to obtain the same results, to gain the same benefit, or to reach the same level of achievement as that provided to others” (DOJ, 2010) and “to participate in and enjoy the benefits of the district’s services, programs, and activities” (page 14, DOJ-DOE, 2014).
Auxiliary aids can include such things as interpreters, note takers, computer access real-time translation (CART) services, hearing assistive technology, accessible electronic and information technology, and captioning. Services can include training for staff, students and/or parents, or consultation/collaboration among staff, parents, and/or other professionals (Anderson and Price, 2015). The need for “effective communication” support and services can be documented by assessing impact of noise on communication effectiveness, social communication, and self-advocacy through a combination of standardized and functional measures. While some testing may be outside the scope of competence of an educational audiologist, it is well within the scope of practice for an audiologist to make a recommendation to the IEP for such testing.
For more information on this topic, an outstanding and comprehensive guide to assessment of children who are DHH is Steps to Assessment: A Guide to Identifying Educational Needs for Students with Hearing Loss by Karen Anderson and Lynne Price.
Advocate for a Quiet Classroom
A critical step in facilitating auditory access for children who are DHH is advocating for a quiet learning space. In the primary grades, this will often include advocating for smaller class size because as the number of children in a room increases, typically so does the background noise level—young children make a lot of noise. And they make noise at random. This can pose significant speech recognition and attention problems for a child who is DHH. Although it is not always feasible to control how many children are in a given classroom, research on class size and learning outcomes suggests that the “optimal” class size for children with typical hearing in elementary school is around fewer than 20 children (see Finn et al, 2005).
If it is not possible for a child who is DHH to be in a small classroom, advocate for a room in a quiet location, and a teacher with a clear voice. School districts are not always open to specialists choosing specific teachers for individual children, but it is possible for an audiologist to make a case for visiting a school and measuring the signal-to-noise ratio in several classrooms in order to make an educationally appropriate recommendation for placement. Research suggests that the use of “clear speech” facilitates comprehension for children who are DHH (Payton, 1994); choosing a teacher whose natural inclination is to speak clearly makes sense. Auditory access for children who are DHH is critical, and thoughtfully choosing the learning environment is the first step in facilitating auditory access.
Assess Functional Listening
Teachers, support personnel, classroom environment, and classroom demands change annually. In addition, a child’s ability to hear well in noise can improve or decline over time. It can be helpful to complete a functional listening assessment annually, before the start of the school year for every child who is DHH. This should include measures of speech recognition under ideal conditions (conversational distance in quiet) and at various distance and background noise conditions. Sometimes this type of testing is done as part of annual audiological testing, but sometimes it is not. Even if speech recognition in noise testing is completed during an audiological evaluation, it may not be conducted in such a way as to be reflective of classroom listening demands, and the results of such testing may not be described in a way that makes sense to classroom teachers or other school personnel.
There are many excellent, easily accessible procedures for conducting functional listening evaluations. Karen Anderson’s website is a great place to start; the Hands and Voices website describes a similar evaluation.
The most important thing is to try to replicate classroom listening for each individual child as faithfully as possible, and explain to people who do not know anything about hearing loss how the scores reflect a child’s access in the school setting. For instance, it can be helpful to measure a child’s speech recognition when noise is coming from in front of the child and behind the child (like when the child is sitting in the cafeteria, or in the middle of a group of children on the floor). It can be useful when trying to demonstrate the impact of noise on unilateral listeners to conduct speech recognition testing with the noise and speech directed toward the “good” ear versus the “poor” ear. It might even be helpful for a teacher to see the difference between story comprehension in quiet versus comprehension in low to moderate background noise. A functional listening evaluation should be flexible, understandable to the classroom teacher and team, meaningful for the child, and reflective of the actual listening demands in the child’s classroom.
Research has shown that school-aged children with typical hearing understand 95–98 percent of speech presented in quiet, 93–97 percent of speech presented at a +5dB S/N ratio (low to moderate background noise) and 90–92 percent of speech presented at a 0 dB S/N ratio (moderate to high background noise) (Bodkin et al, 1999). For a student who is DHH to have comparable access to teacher instruction as typical hearing peers, he or she would need to demonstrate functional listening scores across listening conditions in the 90–95 percent range.
Measure Noise Levels During Different Activities
Especially in the primary grades, noise levels vary with activity. The Common Core State Standards include not only the skills and knowledge that children need to acquire at each grade level in English language arts and math, but also describe learning standards for group communication and learning in the classroom (National Governors, 2010).
This presents some unique challenges for children who are DHH because, while some of the school day is still spent in structured, teacher-directed activities, there is a lot of semi-structured peer interaction interspersed throughout the day. To make an appropriate recommendation for the type of HAT and how to best use them in school, audiologists need to gather comprehensive information about noise levels and auditory access during instruction and peer interactions across multiple activities.
To that end, audiologists should spend time observing a variety of learning and social activities, measure noise versus speech levels, and monitor auditory comprehension of students who are DHH. This enables the audiologist to make better recommendations to teachers about optimal technology usage throughout the day. For example, in a classroom where a child uses both a personal FM system and a sound field system, it might make sense for the teacher to give the transmitter to a friend and turn off the sound field system during “buddy reading.” This can become a self-advocacy objective for the child who is DHH as he or she gets older. If a child changes seats throughout the day, it would be helpful for the audiologist to determine for each location what the best seat is.
Assess Subjective Impressions of Noise Impact
Children and teachers can also provide useful feedback to the team. Self-reports and teacher observations about perceived auditory access in the classroom can assist the team in making decisions about seating, HAT use (when it is most helpful, when it is being used effectively, when use needs to be modified), what listening situations are challenging for the student, what communication mode is preferable to the student, and when communication is most and least successful. Self-report measures can be used to educate the team generally about the impacts of hearing loss or can be used to make specific changes to a child’s educational program. Commonly used measures are the Listening Inventory for Education-Revised (LIFE-R) Student Appraisal (Anderson et al, 2011), the Children’s Auditory Performance Scale (CHAPS) (Smoski, 1998), and the Listening Inventory for Education-Revised Teacher Appraisal of Listening Difficulty (Anderson, 2011).
Provide Frequent Training Sessions
Appropriate technology usage by teachers and school personnel takes a lot of practice and coaching. It requires more than annual support for most teachers, especially if the district does not have a full-time teacher of the deaf. Instructional assistants, specials teachers, substitutes, speech-language pathologists, special educators, peers, “big buddies,” and even the school nurse may need to use HAT in the classroom. Per IDEA, assistive technology must be checked every day to ensure appropriate function. One beginning of the year in-service with the classroom teacher will likely be insufficient to guarantee that a child who is DHH has working technology and consistent auditory access via HAT in the classroom for 180 school days.
One common accommodation in the classroom is preferential seating. Perhaps a better term is “strategic” seating. Strategic seating should be used to improve the child’s visual and auditory access to both the teacher(s) and peers. This might mean moving a child from the front and center of the classroom, to the left or right and toward the middle or back, so that he or she can more easily auditorily alert and visually orient to peers when they are speaking. Depending on classroom seating arrangements (desks, multiple pods, or “flexible” seating) the child who is DHH may need to be coached in effective self-advocacy strategies around strategically locating him or herself to optimize visual and auditory access. The educational audiologist should advise the team on strategic seating based on the child’s visual access, the location and level of background noise relative to the child, and the teaching goals during instruction.
Whenever feasible, the FM transmitter should be passed to peers so the child with hearing loss can hear what other children in the classroom are saying. This can be challenging in a busy classroom, but it is good to get in the habit of doing this, especially as children’s brains are still developing with respect to auditory signal processing (Ponton et al, 2000).
Many classrooms purchase a second pass-around microphone to facilitate this goal. Some transmitters can be used as conference microphones as well, depending on the number of children in the group and the goals of the group. For example, if all of the children at the table are sharing information, putting a conference microphone in the middle of the table will allow the child who is DHH to hear his or her peers. If the child is working with a partner at a table where other children are seated, the partner should wear the transmitter in directional mode so that the child who is DHH hears the partner.
Guidelines from the American Speech-Language Hearing Association (ASHA) specify that noise levels in an unoccupied learning space should not exceed 35 dBA, and that the SNR at the child’s ear should be at least +15 dB (ASHA, 2005). Some suggestions for improving classroom acoustics for children with hearing loss (per ASHA) include the following:
- Consider acoustic treatment throughout the classroom.
- Consider carpeting—if there is not wall-to-wall, place some area rugs.
- Request acoustically treated hanging ceiling tiles.
- Avoid situations where the class is split and half of the students are listening to teacher instruction and the other half are watching TV or listening to a tape recorder.
- Use window treatments (thick material).
- Replace buzzing lights.
- Hang long pieces of felt on the wall on which children can pin artwork.
- Use “creative” artwork—hang egg crates and strips of carpet from the ceiling.
- Use corkboards whenever possible.
- Place flat surfaces (movable boards) at an angle.
- Place tennis balls or rubber tips on chair feet (keep in mind latex allergies).
- Have soft chairs (small beanbag chairs) in leisure/reading areas.
- Do not have noisy equipment (e.g., computers, projectors) on if you are not using them.
- Try to keep doors and windows closed.
Use of Hearing Assistive Technology
The importance of appropriate remote microphone usage in the classroom for a child who is DHH cannot be overstated. In order for a child who is DHH to have access to education and to acquire new vocabulary and language, they need to have clear and consistent access to the speech signal during all instruction and throughout the day. Appropriate remote microphone use includes (consistently and across multiple settings):
- Maintaining placement of the microphone in the optimal location for signal reception no greater than six inches directly in front of or directly below the speaker’s mouth.
- Activating the microphone when giving classroom instruction, when talking to the child, or when talking to a group in which the child is a member.
- De-activating the microphone when not addressing the child or a group in which he or she is a member.
- Passing the microphone to other adults and children when they are talking to the child.
- Restating into the microphone what other children and/or adults have said so that the child does not miss incidental classroom discussions or interactions.
- Listening to the child’s hearing aids with the remote microphone activated every morning to ensure optimal function of all technology.
- Monitoring the location of the microphone at all times so that other children or adults do not misuse the technology (either inadvertently or intentionally).
- Giving the microphone to a responsible adult during transition times and “specials” such as recess, art, or physical education.
- Determining a secure location for the microphone and components of the child’s assistive technology for times when it is not in use.
- Charging the microphone every night.
- Consulting regularly with the child’s audiological and educational team as well as the child’s parents about technology function and use in the classroom.
A careful assessment and regular monitoring of appropriate accommodations and services can improve auditory access for children who are deaf or hard of hearing in the classroom. This is not simply a matter of providing educational access. This is a matter of educational equity for these children.