Hearing aids in children and adults with “functional” hearing losses - PowerPoint Presentation

1. Hearing aids in children and adults with “functional” hearing losses Gail M. Whitelaw, Ph.D.The ohio state UniversitySpeech and hearing association of alabama conventionVirtual track 2023

2. At the end of this presentation, you will be able to:Describe functional hearing loss and how to assess itList populations that may benefit from use of hearing aid technologyDiscuss criteria for hearing aid fitting in patients with “normal” audiogramsPresent considerations and address potential controversies with this population

3. Who are these patients…a patient walks into an audiology officeI can’t hear in background noiseI’ve had hearing tests before and “they” always tell me my hearing is “perfect”I avoid situations—social (e.g. bars, restaurants, etc.), work relatedI am anxious about hearing/listening/communicatingA child who says “huh” “what”, has had multiple hearing screenings due to concerns about hearing

4. Framing the presentation: Who are the patients we are talking about?Will label this as “functional” hearing lossThese are people who are seeking our help, who want what we have to offerSome of this information may be “contentious”: Setting a stage for working with this populationEvidence: History with auditory neuropathyEvidence: Pharmaceutical treatment of depression4

5. Pseudohypacusis, malingering, “faking”, psychogenic, non-organic hearing loss (NOHL)This is NOT the patient population that is the focus of this presentationHowever, the focus of the presentation is related to those who are thought to be malingerers or exaggerating their situation“Your hearing is just fine”“This is all in your head”Maybe your kid is just….lazy, not so smart, ADHD…The “happy talk” (Beck & Danhauer, 2018)5Not the historical or “old school” definition of functional hearing loss

6. Research suggests:Prevalence estimated as low as 1.35% to as high as 9.5% (Qui, et al, 1998; Hussain and Hohman, 2022, Mathai, 2021)May demonstrate “intent” (monetary gain or compensation claim, attention needs) based on the Austen-Lynch model (Austen & Lynch, 2004)May demonstrate conscious response (malevolent, malingering) or unconscious (conversion disorder, dissociative disorder) (Fatih Topuz, Erdem Ozel, & Onen, 2021)6Not the historical or “old school” definition of functional hearing loss

7. As with everything else we do:Listening carefully to the patientIndustrial, vocational, or motivationCareful case history: Is there an “organic” explanationNot as easy as in the pastConcepts like hidden hearing loss, subclinical hearing loss were not recognized in the pastListening carefully to your “gut” and intuitionSuspicion of malingeringUsing tools beyond the audiogramAuthentic assessment (questionnaires, etc.)Speech in noise testing7

8. Describing Our Patient’s HearingThe typical relationship where all three aspects agree.

9. Describing Our Patient’s HearingWhat Happens when there is a disconnect?What happens when there is a disconnect?

10. Functional hearing loss, in the context of this presentation, may also be referred to as:Central auditory processing disorder/auditory processing disorder, HD (hearing difficulty), Suprathreshold auditory disorders (SAD), subclinical hearing loss, hidden hearing loss, Obscure auditory dysfunction (OAD), King-Kopetsky syndrome (some of these introduced in the 1980s and 1990s)The definitions of hearing loss are changingWorld Health Organization challenges us to see hearing as “functional” communicationThe role of audiology: hearing is much broader than the “audiogram”, the “graph of hearing”It is an important measure, it is NOT the important measure10

11. What is “functional” hearing lossHewitt (2018)The pure tone audiometer was developed in 1879Pure tone audiometer considered today to be the “gold standard”Although pure tone results will likely be a “gold standard” it will not be THE “gold standard” in the futureNeed to look at binaural/dichotic listening issuesHow do the two ears work together as a team?

12. Current researchSanchez et al (2016)Cochlear synaptic loss that can lead to neural changes in the auditory pathwayMay have a normal audiogram; can actually have about 50% of outer hair cells die and still have ”normal hearing” on an audiogramBack to the example: People with sensorineural hearing loss have difficulty listening in background noise but it is not restricted to those individuals (and they may have “loss” that doesn’t show up on the audiogram)May also have tinnitus (ringing in the ear) or sound tolerance issues and these may be an early indicators of vulnerability to hidden synaptic injuryLearning more about this as a science and profession12

13. A few thoughts about “functional” hearing lossBroadening considerations on an audiogramReconsidering grades of hearing loss based on the Global Expert Group on Hearing Loss (Olusanya, Davis, & Hoffman, 2019): 20 dB or better is normalHistorically, people with hearing between 15-25 dB HL reported difficulty listening in noiseNormal hearing at 25 dB or less is an arbitrary measure; the definition of “normal” hearing and recommendations for hearing aid candidacy are not evidence-based (Golub, et al, 2020)13

14. A few thoughts about “functional” hearing lossBroadening considerations on an audiogramGolub and colleagues (2020) introduced the term of “subclinical hearing loss” (15-25 dB HL)Higher incidence of cognitive issues and depressive symptoms reported in this population then for those who demonstrated “normal” hearingAlso cited that Over the Counter hearing aids may greatly improve accessibility of hearing loss treatment?This is the topic for today—what is our role with this population?14

15. Suprathreshold complaintsPeople with “normal” hearing on an audiogram and standard audiologic testing performed in quiet but report considerable difficulty listening in less than optimal listening environmentsEstimated to be 26 million Americans (Beck and Danhauer, 2019).Report experiencing more difficulty than would be anticipated based on standard audiometric results Suggested to be between 15-30% of younger adults (e.g. less than 40 years of age) (Pang et al, 2019)15

16. What might we learn from psychoacoustic approachesBardi, Siegel, & Wright (2011)Impaired frequency resolution is a factor in this populationHow precise listening is in those “bins” or “channels”Impacted by sensorineural hearing loss—the ”bins” become wider and let in more “noise”In this study, subjects with normal audiograms who had no difficulty listening in noise were compared to subjects with normal audiograms who reported difficulty in noise on frequency resolution skillsThe “impaired” group had significantly wider filters when compared to those with normal hearing and no hearing complaints, specifically in the higher frequencies; no distinguishable differences in absolute thresholdsAuthors suggest that this population have hearing deficits that are not identified by “standard” audiometryMay support the use of hearing technology, for the same reasons that we aid those with sensorineural hearing loss (it’s more than a loss of volume)

17. Is this an auditory processing disorder (APD)?Does a rose by any other name smell as sweet?How do we, as audiologists, practice at the top of our scope?Why do we continue to perpetuate that this is “controversial?” So many controversies, so little time: ANSD, Autism, balance, tinnitus, Cochlear implants—even our beloved hearing aids

18. As a profession, we must challenge some long held myths and beliefsAPD/Functional hearing loss doesn’t existThe “happy talk” described by Beck and Danhauer doesn’t stop patients from continuing to seek answersTeaching only about the audiogram in clinical education programs: must educate future audiologists to be critical thinkers/problem solversThe vast majority of patients don’t malingerUsing a “shared decision making model” of patient careMust move away from a paternalistic/maternalistic modelOur ethical responsibilities: The beneficence of our profession

19. Erber’s Hierarchy (1992. 1996)

20. “Unpacking” Erber’s hierarchyDetection is the ability to respond to the presence or absence of sound. It is the essential first step listening and represents pure tone audiometryDiscrimination is the ability to perceive similarities and differences between two or more speech stimuliIdentification is the ability to label by repeating, pointing to or writing the speech stimulus heard Identification involves the suprasegmental & segmental of speechComprehension is the ability to understand the meaning of speech by answering questions, following directions, paraphrasing, or participating in a conversation. Comprehension is demonstrated by the listener when his/her response is qualitatively different than the stimuli presented.20

21. Patients that are the focus of this presentationSpeech in noise as the “low hanging fruit”Crandell and colleagues (1991) pointed out that pure tone audiometry was unable to reliably predict the issue that many patients present with—difficulty hearing in typical environments where competition is presentWilson (2011) recommended speech in noise testing in every diagnostic evaluationSpeech in noise testing should be a standard of care (however only 15 % of audiologists do this routinely) (Clark, Huff, & Earl, 2017)21

22. Prevalence Normal pure tone audiogram but self-reported hearing difficulties: 12% of adults ages 21-67normal pure tone audiograms & SHD measured by the HHIA Newman et al., 19903-10% of older adults ages 48-92 yearsnormal pure tone audiograms & SHD measured by the HHIA Ventry and Weinstein, 1983; Wiley et al., 2000; Roup et al., 200710% of Veterans that sought help for auditory complaints from the VA between 1995-2015 had normal hearing thresholds Billings et al., 2018

23. Prevalence Normal pure tone audiogram but self-reported hearing difficulties:16% of Veterans with mild TBI Oleksiak et al., 201258% of adults with a history of closed head injury ages 25-59Bergemalm & Lyxell, 2005

24. Prevalence Chia et al. (2007): “Do you feel you have a hearing loss?”51% of respondents self-reported HD Only half had HL on the audiogram Hannula et al (2011)Found that more than half of the subjects who self-reported HD did not have HL Most common complaint was difficulty following a conversation in noiseSelf-reported HD do not have good predictability for HL for 500-4000Hz, but do have good predictability for high-frequency HL

25. Why should you care? Perceived hearing difficulty is found to have a relationship with: Reduced QOL Fatigue Reduced physical health Symptoms of depression Self-perceived hearing handicap was a strong predictor of declining QOL in older adults in a 10 year longitudinal study, more than measured uncorrected HL (Gopinath, 2012)

26. Case historyCareful case historyMany patients may have had lifelong issuesThe importance of addressing functional hearing loss in childrenSome may have new symptoms with a possible known etiology (mild traumatic brain injury)Some may have new symptoms with unknown etiology (Neuro-audiology, our contribution to understanding the case, practicing at the top of our scope)26

27. Authentic AssessmentQuestionnairesAdult Auditory Processing Scale (AAPS) (Roup)Auditory Processing Questionnaire (APQ)Vanderbilt Fatigue Questionnaire (https://www.vumc.org/vfs/scales-and-user-guide)Hearing Handicap Inventory for Adults (HHIA) (cut off of 34 suggested by Roup, Post, & Lewis, 2018)Speech, Spatial, and Qualities of Hearing Scale (SSQ)Personal Assessment of Communication Ability (PACA)Beck Anxiety or Beck Depression Inventory (looking at the “whole” person—analogous to cognitive screening)Cognitive screening (MOCA, etc.)27

28. A test battery approachComprehensive audio (OAEs, ARTs)Speech in noise testingAPD batteryThe key is to tax the auditory system, not to get caught up in a test battery approach; What do you feel comfortable with? There isn’t a “gold standard” at this time and not likely to be one in the foreseeable futureBehavioral optionsSCAN-3 A or CMAPAWARRM (Auditory working memory)LISN-SGINP.E.R.T. (Gallum app)Buffalo model

29. A test battery approachRefer to clinical practice guidelines from AAA, ASHA, BSA, European AssociationNote that additional testing (e.g. electrophysiology, etc.) may be needed as one learns more about the patient

30. Speech in Noise testingTax the auditory systemThese tests are the minimal that should be considered with this population (and the argument may be made that they should be part of every diagnostic audiometric battery)OptionsHINTWINQSINRSPIN OthersSelect what you have, what you like, just do it!30

31. The future of assessmentSome places to keep an eye on!Walter Reed National Medical CenterNational Center for Rehabilitative Auditory Research (NCRAR) (Erick Gallum and his colleagues)Speech Recognition and Aging Lab at The Ohio State University (Christina Roup)Have not even focused on aging in this presentation; aging issues go beyond a loss of volume

32. Identification/diagnosis is the first stepPartnership with healthcare providers: Hearing care is healthcareEducating otolaryngologists and otologists: The payoffIs there a medically treatable aspect of impaired hearing

33. ManagementStenfelt, S & Ronnberg, J. (2009)

34. Top DownThe CANS helps to process information lower in the peripheryHow to train the brain: capitalize on neural plasticityManagement techniques aim to:Improve auditory function via neural plasticityTarget auditory skills or cognitive processing or both Examples: Auditory training programs such as AngelSound, Amptify, Zoo Caper Sky Scraper (Acoustic Pioneer), Insane Airplane (Acoustic Pioneer), Word SuccessAuditory training performed by a speech/language pathologist (e.g. auditory verbal therapist)

35. Bottom UpDriven by the sensesAims to ensure best possible acoustic signal to assist with higher level processingImprove audibility of soft speechImprove SNRManage competing soundsHow?Hearing AidsDigital Modulation TechnologyEnvironmental management & communication strategiesStenfelt, S & Ronnberg, J. (2009)

36. Technology Options

37. Evidence for mild gain amplification Kuk et al (2008) 14 children with APD fit with bilateral mild gain open fit hearing aidsFitting Procedures: 2 programs: P1: omni directional without noise reduction P2: fixed directional microphone with maximum noise reduction (12 dB gain reduction) ~ 15 dB of REIG provided between 700-2000Hz for 50 dB SPL input ~ 10 dB of REIG for 60 dB SPL input Below 100 dB SPL MPO

38. Evidence for mild gain amplification Kuk et al (2008) results: Speech recognition in noise did not improve in the omni directional program Speech recognition in noise improved with directional mics + NR program All parents reported positive comments about HA trial including: better hearing in BG noise child was more focused child was more responsive after being called from a distance improved grades 3 families purchased hearing aids at the completion of the study

39. Evidence for mild gain amplification Roup et al. 39 participants, all with NH Group 1: 20 young adults with no self report of hearing difficulties HHIA score of less than 18 Group 2: 19 adults with report of hearing difficulties HHIA score of greater than or equal to 20 All participants completed a series of test to assess auditory processing abilities and speech in noise abilities Group 2 went through a 4 week hearing aid trial and completed aided testing and questionnaires

40. Evidence for mild gain amplification Roup et al. (contd.) Fitting procedures: Widex Dream 440 RIC hearing aids with open domes Default DM, NR, and Speech Enhancer settings enabled 5-10 dB of insertion gain prescribed for 1000-4000Hz for soft and conversational inputs MPO verified not to exceed 100 dB SPLAsked to wear for a minimum of 4 hours per day

41. Evidence for mild gain amplification Roup et al. Results – Speech in Noise 94% of participants in the self reported HD group scored abnormally on at least one of the auditory processing test batteriesHD Group performed more poorly than control group on SPIN tasksHD participants performed significantly better with hearing aids for SPIN task

42. Evidence for mild gain amplification Roup et al. RESULTS Strong positive and significant correlation between unaided HHIA score & avg # of hours hearing aid was used Statistically significant reduction in HHIA and Auditory Processing Questionnaire (APQ) scores in aided compared to unaided condition Participants reported the hearing aids helped the majority of the time (67-71%) in both quiet and noise 3 of 17 purchased hearing aids at a reduced cost after the study due to perceived benefit

43. Evidence for mild gain amplification Roup et al. Conclusions: Findings suggest that patients with SPIN deficits may benefit from mild gain, open fitting, hearing aids with adaptive, multi-band directionality and NR featuresRecommended an HHIA score of 34 to be used as a consideration for trial with amplification with this population

44. Evidence for mild gain amplification Singh and Doherty (2020)Demonstrated improvements in hearing handicap scores ONLY for the NH participants with SHDOnly a small percentage were willing to purchase hearing aids Conclusions:Mild gain hearing aids can improve hearing handicap levels for SHDMay be more interested in learning about hearing problems vs taking action to purchase a hearing aid

45. Koerner et al. (2020)A Questionnaire Survey of Current Rehabilitation Practices for Adults With Normal Hearing Sensitivity Who Experience Auditory Difficulties

46. Koerner et al. (2020)A Questionnaire Survey of Current Rehabilitation Practices for Adults With Normal Hearing Sensitivity Who Experience Auditory Difficulties Almost ½ of the respondents reported seeing 1-3 patients per month ¼ reported seeing more than 4 per month who fit this description Many respondents stated that their patients are dissatisfied after finding out that they have “clinically normal” hearing and are interested in rehabilitation options

47. Koerner et al. (2020)A Questionnaire Survey of Current Rehabilitation Practices for Adults With Normal Hearing Sensitivity Who Experience Auditory Difficulties What is being offered to these patients? Communication counselingHearing AidsRefer to a clinic that specializes in APD

48. Koerner et al. (2020)A Questionnaire Survey of Current Rehabilitation Practices for Adults With Normal Hearing Sensitivity Who Experience Auditory Difficulties What do we offer them in terms of amplification?99% of those fitting reported fitting bilateral, open fit RIC hearing aidsTop 3 preferred brands: Phonak, Resound, and Oticon89.8% fit high end devices How are they being fit?Gain settings set by prescriptive formula5-10 dB prescribed insertion gain in the mid-high frequencies and incorporating patient preferenceMinimize MPO for these patientsActivated DM and NR features

49. Koerner et al. (2020)A Questionnaire Survey of Current Rehabilitation Practices for Adults With Normal Hearing Sensitivity Who Experience Auditory Difficulties What are the outcomes?

50. Fitting of amplificationThe concept of “mild gain” hearing aidsDrop the term “mild gain”: Focus on appropriately fit with verification and validationHistorically, remote mic/FM systemDM System ◦ Greatest improvement in SNR ◦ Convenience of use in everyday life ◦ Most adults discontinue use despite reporting significant benefitNot a new conceptWinchester (1975) raised this idea in the Maico Audiological Library SeriesHowever, the technology today has opened this door50

51. Fitting of amplificationCurrent technology: SophisticatedDirectional technologyBeam-forming directionalityMulti-speaker-access-technology (MSAT)Beck and Danhauer (2019)Mild Gain Hearing Aids (Roup, Whitelaw, & Baxter, 2018) ◦ Enhance soft consonants of speech ◦ Improve SNR with use of multiband directional microphones ◦ Background noise algorithms may improve comfort and reduce distractions51

52. Fitting of amplificationEvidence from studies in this populationReduced listening effort (Ohlenforst et al, 2018)Improvement of speech in noise and signal to noise ratio (average of 6 dB) (Beck & LeGoff, 2018)Improvement of listening in quiet and noise for the majority of subjects fit (Roup, Post, & Lewis, 2018)Better word recall in noise, reduced fatigue/listening effort, and improved SNR (Beck, Ng, & Jensen, 2019)Perception of soft soundsRestoring some frequency selectivity? (Bardi et al, 2011)52

53. Fitting Recommendations (Roup, Whitelaw, & Baxter, 2022)Open as possible 5-15 dB gain for soft and conversational speech Little to no gain for loud sounds MPO not to exceed patient’s LDL Verification using real ear unaided and aided responses for soft and moderate sounds and MPOUse of directional microphones and noise reduction technologyAdvanced signal processing: level of technology?Q553

54. Fitting Recommendations (Roup, Whitelaw, & Baxter, 2022)VerificationReal ear measuresValidationAuthentic Assessment toolHHIALIFE-RQ554

55. Outcome Measures What is an outcome?“Something that has changed in the life of the patient as a consequence of the services and devices provided to that patient by the clinician” (Dillion, 2012) Verification Objective, device centered ValidationPatient-centeredDetermine how effective your treatment is and how much benefit the patient is receiving in their daily life

56. Practical considerationsObtain medical clearance (educate, help with accessing funding, “shared decision making”)Trial period contributes to successDemo hearing aids on loan for a monthVerification and validationAbility to provide telehealth adjustments if neededTechnologyRemote micBluetooth to devicesProgram such as “live listen”Digitally modulated (DM) systemPayor optionsQ356

57. cases

58. jim33 year old FirefighterReported speech in noise issues that are lifelongRecent exacerbations of hearing and listening difficultiesNoise exposure? Normal hearing thru 12.5Hz bilaterally, normal DPOAEs bilaterallySignificant deficits in speech in noise performance, abnormal “auditory processing” skillsChemical exposures impacting hearing/listening skills (we are looking at this in a study at OSU at the moment)Hearing aids and aural habilitation

59. Ashley34 year old attorneyTBI from a serious car accidentSpeech in noise issues/fatigue/listening anxietySound tolerance issues (music in grocery stores, etc.)Hearing aids recommendedSlow go at firstTwo months of trial: RemarkableCan go into group situations, converse more easily without fatigue, hear and listen to her toddler son’s voiceAural rehabilitation using Amptify app (https://amptify.com/)59

60. Andi37 year old womanDrives 8 hours to come to our clinicLifelong listening issuesFit with hearing aids 5 years agoChanged her family dynamics and her familyHer husband and her batteriesLost her hearing aids at the beginning of summer, 2022What motivated her to get new hearing aids?Fit new technology in July60

61. John10 year oldAuditory processing disorderDyslexia6 months of using hearing aidsRemarkable—uses them all the timeHis blue hearing aids and the difference in his quality of life

62. ConclusionsQuality of Life issues in this patient populationOur role can be significantWaiting until we have all the answers is a mistakeAddressed by use of amplificationPatients who areInterested in options (they don’t stop looking when they are told they have “normal hearing”Willing to use amplification and prioritize obtaining hearing aidsWilling to pursue other treatment options62

63. ReferencesAusten, S. & Lynch, C. (2004) Non-organic hearing loss redefined: Understanding, categorizing, and managing non-organic behavior. International Journal of Audiology, 43 (8) 449-457.Bardi, R., Siegel, J.H., & Wright, B.A. (2011). Auditory filter shapes and high frequency hearing in adults who have impaired speech in noise performance despite clinically normal audiograms. Journal of the Acoustical Society of America, 129 (2), 852-863.Beck, D.L. & Danhauer, J.K. (2019) Amplification for adults with hearing difficulty, speech in noise problems-and normal thresholds. Journal of Otolaryngology-ENT Research, 11(1), 84-88.Beck, D.L. & LeGoff, N. (2018). Contemporary hearing aid amplification: Issues and outcomes in 2018. Journal of Otolaryngology ENT Research. 7(3), 18.Beck, D.L., Ng, E., & Jensen, J.J. (2019) A scoping review. 2019. OpenSound Navigator. Hearing Review, 26 (2); 28-31.Clark, J.G., Huff, C. & Earl, B. (2017). Clinical practice report card—Are we meeting best practice standards for Adult Hearing Rehabilitation. Audiology Today, Nov-Dec. 15-25.63

64. ReferencesCrandell, C. (1991). Individual differences in speech recognition ability: Implications for hearing aid selection. Ear & Hearing, 5 , 100–107. Erber, N. (1996) Communication Therapy for Hearing-Impaired Adults. Melbourne, Australia: Clavis Publishing.Fatih Topuz, M., Erdem Ozel, H., & Onen, S. (2021). A simple supportive evaluation way for the diagnosis of psychogenic hearing loss. Annuals of Medical Research, 27 (4) 1008-1012.Golub, J.S., Brewster, K.K., Brickman, A.M., Ciarleglio, A.J., Kim, A.H., Luschsinger, J.A., & Rutherford, B.R. (2020) Subclinical Hearing Loss and Depressive Symptoms. American Journal of Geriatric Psychiatry. 28, 545-556.Hewett, D. (2018) Audiometry and Its Discontents. Hearing Review 25(1), 20-23.64

65. ReferencesHussain, SAS & Hohman, M.H. (2022). Nonorganic Functional Hearing Loss. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing: 2022 Jan-Available from https://www.ncbi.nlm.nih.gov/books/NBK580555/Mathai, J.P., Aravinda, H.R., Appu, S. & Urs, H.R. (2021) Prevalence and audiology findings of functional hearing loss: A retrospective study. Journal of Indian Speech Language Hearing Association, 35(1), 33-38.Olenforst, B., et al (2018). Impact of SNR, masker type, and noise reduction processing on sentence recognition performance and listening effort as indicated by pupil dilation response. Hearing Review 26 (2), 90-99/65

66. ReferencesOlusanya, B.O., Davis, A.C., & Hoffman, H.J. (2019). Hearing loss grades and the International classification of functioning, disability, and health. Bulletin of the World Health Organization, 97 (10), 725-728.Pang, J., Beach, E.F., Gilliver, M., & Yeend, I. (2019). Adults who report difficulty hearing speech in noise: An exploration of experiences, impact, and coping strategies. International Journal of Audiology, 58 (12), 851-860.Winchester, R. A. (1975) When is a hearing aid needed? Maico Audiological Library Series, 1(12), 36-39.66

67. ReferencesHornsby, B. and Kipp, A. (2016). Subjective Ratings of Fatigue and Vigor in Adults With Hearing Loss Are Driven by Perceived Hearing Difficulties Not Degree of Hearing Loss. Ear and Hearing, 37(1), e1-10.Jayaram, M et al. (1992). Speech in noise: a practical test procedure. J Laryngol and Otol, 106(2):105-110.Jerger, J et al. (1990). Impact of central auditory processing disorder and cognitive deficit on self-assessment of hearing handicap in the elderly. J Am Acad Audiol, 1:75-80.Keith RW. (2009) SCAN-3:A tests for auditory processing disorders in adolescents and adults. San Antonio, TX: The Psychological Corporation. Killion, MC, et al. (2004). Development of a quick speech-in-noise test for measuring signal-to-noise ration loss in normal-hearing and hearing-impaired listeners. J Acoust Soc Am, 116(4):2395-2405.Kockin, s. (2011, June). MarkeTrak VIII: Reducing Patient Visits Through Verification & Validation. Retrived from: http://www.hearingreview.com/2011/06/marketrak-viii-reducing-patient-visits-through-verification-amp-validation/Koerner, T.K, Papesh, M.A., Gallun, F.J. (2020). A Questionnaire Survey of Current Rehabilitation Practices for Adults With Normal Hearing Sensitivity Who Experience Auditory Difficulties. American Journal of Audiology, 29, 738-761,Kuk, F., Jackson, A., Keenan, D., Lau, C. (2008). Personal amplification for school-age children with auditory processing disorders. J Am Acad Audiol, 19(6):465-80Musiek, FE. (1983). Assessment of central auditory dysfunction: the dichotic digit test revisited. Ear Hear, 4(2):79-83.Musiek, FE, et al. (2005). GIN (gaps-in-noise) test performance in subjects with confirmed central auditory nervous system involvement. Ear Hear, 26:608-618.

68. References (cont.)Newman, CW, et al. (1990). The hearing handicap inventory for adults: psychometric adequacy and audiometric correlates. Ear Hear, 11(6):430-433.Nilsson, M, et al. (1994). Development of the Hearing in Noise Test for the measurement of speech reception threshold in quiet and in noise. J Acoust Soc Am, 95(2):1085-1095.Palmer, C.V. Solodar, H.S. Hurley, W.R. Byrne, D.C. Williams, K.O. (2009). Self-Perception of Hearing Ability as a Strong Predictor of Hearing Aid Purchase. Journal of the American Academy of Audiology, 20, 341-347.Rappaport, JM et al. (1993). Disturbed speech intelligibility in noise despite a normal audiogram: a defect in temporal resolution? J Otolaryngol, 22(6):447-453.Roup C.M. (2016). The impact of minimal to mild sensorineural hearing loss in adults. Perspectives of the ASHA Special Interest Groups, 6(1 Part 2), 55-64.Roup C.M., Post E, Lewis, J. (2017). Mild-gain hearing aids as a treatment for adults with self-reported hearing difficulties. Journal of the American Academy of Audiology, 29(6), 477-494 QuickSIN Version 1.3. Elk Grove Village, IL: Etymotic Research, Inc.Saunders, GH, & Haggard, MP. (1989). The clinical assessment of obscure auditory dysfunction-1. Auditory and psychological factors. Ear Hear, 10:200-208.Schaette, R, & McAlpine, D. (2011). Tinnitus with a normal audiogram: physiological evidence for hidden hearing loss and computational model. J Neurosci, 31:13452-13457.Sing, J., and Dohert, K.A. (2020). Use of a Mild-Gain Hearing Aid by MiddleAge Normal-Hearing Adults Who Do and Do Not Self-Report Trouble Hearing in Background Noise. American Journal of Audiology, 29, 419-428.Stenfelt, S. and Ronnberg, J. (2009). The Signal-Cognition interface: Interactions between degraded auditory signals and cognitive processes. Scandinavian Journal of Psychology, 50, 385-393.Strouse, A, & Wilson, RH. (1999). Recognition of one-, two-, and three-pair dichotic digits under free and directed recall. J Am Acad Audiol, 10:557-571.

69. References (cont.)Tremblay, K et al. (2015). Self-reported hearing difficulties among adults with normal audiograms: The Beaver Dam Offspring Study. Ear Hear, 36(6):e290-e299.Ward, L., Robinson, C., Paradis, M., Tucker, K., Shirley, B. R2Spin: Re-recording the Revised Speech Perception in Noise Test. Paper presented at Interspeech 2019, Graz, Austria. Retrieved from: https://pdfs.semanticscholar.org/0654/326cbb5e74e4c94ce23a6184991312bc6006.pdfWeihing, J, Chermack, G., and Musiek, F. (2015). Auditory training for auditory processing disorders. Seminars In Hearing, 36(4), 199-25.Weinstein, B. (2017). Sensory and Cognitive Connections [Powerpoint Slides]. Retrieved from A.T. Still University Blackboard.Welsh, LW et al. (1985). Central presbycusis. Laryngoscope, 95:128-136.Wiley, TL et al. (2000). Self-reported hearing handicap and audiometric measures in older adults. J Am Acad Audiol, 11:67-75.Wilson, RH, et al. (2003). A word-recognition task in multitalker babble using a descending presentation mode from 24 dB to 0 dB signal to babble. J Rehabil Res Dev, 40(4):321-328.Wilson, RH, et al. (2003). Development of a 500-Hz masking-level difference protocol for clinic use. J Am Acad Audiol, 14:1-8.

70. ReferencesHornsby, B. and Kipp, A. (2016). Subjective Ratings of Fatigue and Vigor in Adults With Hearing Loss Are Driven by Perceived Hearing Difficulties Not Degree of Hearing Loss. Ear and Hearing, 37(1), e1-10.Jayaram, M et al. (1992). Speech in noise: a practical test procedure. J Laryngol and Otol, 106(2):105-110.Jerger, J et al. (1990). Impact of central auditory processing disorder and cognitive deficit on self-assessment of hearing handicap in the elderly. J Am Acad Audiol, 1:75-80.Keith RW. (2009) SCAN-3:A tests for auditory processing disorders in adolescents and adults. San Antonio, TX: The Psychological Corporation. Killion, MC, et al. (2004). Development of a quick speech-in-noise test for measuring signal-to-noise ration loss in normal-hearing and hearing-impaired listeners. J Acoust Soc Am, 116(4):2395-2405.Kockin, s. (2011, June). MarkeTrak VIII: Reducing Patient Visits Through Verification & Validation. Retrived from: http://www.hearingreview.com/2011/06/marketrak-viii-reducing-patient-visits-through-verification-amp-validation/Koerner, T.K, Papesh, M.A., Gallun, F.J. (2020). A Questionnaire Survey of Current Rehabilitation Practices for Adults With Normal Hearing Sensitivity Who Experience Auditory Difficulties. American Journal of Audiology, 29, 738-761,Kuk, F., Jackson, A., Keenan, D., Lau, C. (2008). Personal amplification for school-age children with auditory processing disorders. J Am Acad Audiol, 19(6):465-80Musiek, FE. (1983). Assessment of central auditory dysfunction: the dichotic digit test revisited. Ear Hear, 4(2):79-83.Musiek, FE, et al. (2005). GIN (gaps-in-noise) test performance in subjects with confirmed central auditory nervous system involvement. Ear Hear, 26:608-618.

71. References (cont.)Newman, CW, et al. (1990). The hearing handicap inventory for adults: psychometric adequacy and audiometric correlates. Ear Hear, 11(6):430-433.Nilsson, M, et al. (1994). Development of the Hearing in Noise Test for the measurement of speech reception threshold in quiet and in noise. J Acoust Soc Am, 95(2):1085-1095.Palmer, C.V. Solodar, H.S. Hurley, W.R. Byrne, D.C. Williams, K.O. (2009). Self-Perception of Hearing Ability as a Strong Predictor of Hearing Aid Purchase. Journal of the American Academy of Audiology, 20, 341-347.Rappaport, JM et al. (1993). Disturbed speech intelligibility in noise despite a normal audiogram: a defect in temporal resolution? J Otolaryngol, 22(6):447-453.Roup C.M. (2016). The impact of minimal to mild sensorineural hearing loss in adults. Perspectives of the ASHA Special Interest Groups, 6(1 Part 2), 55-64.Roup C.M., Post E, Lewis, J. (2017). Mild-gain hearing aids as a treatment for adults with self-reported hearing difficulties. Journal of the American Academy of Audiology, 29(6), 477-494 QuickSIN Version 1.3. Elk Grove Village, IL: Etymotic Research, Inc.Saunders, GH, & Haggard, MP. (1989). The clinical assessment of obscure auditory dysfunction-1. Auditory and psychological factors. Ear Hear, 10:200-208.Schaette, R, & McAlpine, D. (2011). Tinnitus with a normal audiogram: physiological evidence for hidden hearing loss and computational model. J Neurosci, 31:13452-13457.Sing, J., and Dohert, K.A. (2020). Use of a Mild-Gain Hearing Aid by MiddleAge Normal-Hearing Adults Who Do and Do Not Self-Report Trouble Hearing in Background Noise. American Journal of Audiology, 29, 419-428.Stenfelt, S. and Ronnberg, J. (2009). The Signal-Cognition interface: Interactions between degraded auditory signals and cognitive processes. Scandinavian Journal of Psychology, 50, 385-393.Strouse, A, & Wilson, RH. (1999). Recognition of one-, two-, and three-pair dichotic digits under free and directed recall. J Am Acad Audiol, 10:557-571.

72. References (cont.)Tremblay, K et al. (2015). Self-reported hearing difficulties among adults with normal audiograms: The Beaver Dam Offspring Study. Ear Hear, 36(6):e290-e299.Ward, L., Robinson, C., Paradis, M., Tucker, K., Shirley, B. R2Spin: Re-recording the Revised Speech Perception in Noise Test. Paper presented at Interspeech 2019, Graz, Austria. Retrieved from: https://pdfs.semanticscholar.org/0654/326cbb5e74e4c94ce23a6184991312bc6006.pdfWeihing, J, Chermack, G., and Musiek, F. (2015). Auditory training for auditory processing disorders. Seminars In Hearing, 36(4), 199-25.Weinstein, B. (2017). Sensory and Cognitive Connections [Powerpoint Slides]. Retrieved from A.T. Still University Blackboard.Welsh, LW et al. (1985). Central presbycusis. Laryngoscope, 95:128-136.Wiley, TL et al. (2000). Self-reported hearing handicap and audiometric measures in older adults. J Am Acad Audiol, 11:67-75.Wilson, RH, et al. (2003). A word-recognition task in multitalker babble using a descending presentation mode from 24 dB to 0 dB signal to babble. J Rehabil Res Dev, 40(4):321-328.Wilson, RH, et al. (2003). Development of a 500-Hz masking-level difference protocol for clinic use. J Am Acad Audiol, 14:1-8.