Effects of Remote Microphone Hearing Aids (Rmhas) on Listening-In-Noise, Attention and Memory in School-Aged Children with Auditory Processing Disorder (APD)
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Effects of Remote Microphone Hearing Aids (RMHAs) on Listening-in-Noise, Attention and Memory in School-Aged Children with Auditory Processing Disorder (APD) ----- Georgios Stavrinos ----- A thesis submitted for the degree of Doctor of Philosophy ----- University College London Faculty of Brain Sciences Ear Institute ----- University College London September 2018 1 DECLARATION I, Georgios Stavrinos, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. 2 ACKNOWLEDGMENTS This has been one of the most challenging long-term projects I ever took on and it would not have been completed without the contribution, help, guidance, discussions and support from all the wonderful people mentioned here. I would first like to give warm thanks to the children, their parents and teachers who took part in my study. They were all very willing to contribute to the study and their patience and dedication is much appreciated. Of course, this project would not have been realised without the contribution from the funders of the project, GN ReSound and Action Medical Research. I am therefore grateful for their support. His support was constant for thirty-something years and without him I would not have been in the position to even start this PhD project. A lot of gratitude and love goes out to my father, Panagiotis Stavrinos, whom I had the misfortune to lose before he saw me complete this journey of which he was so supportive. The supervision and guidance of my supervisor, Professor Doris Bamiou, throughout this project have been nothing short of excellent. Her style of supervision fit exactly my style of work and this meant I was working in an environment where I felt motivated and confident. She has always been there to give the right advice, answer questions, listen, support and guide me whenever required. I have developed as a professional and as a person through her mentorship. I thank her for everything and feel extremely happy to be submitting this work having her name on it as my supervisor. The help of Professor Maria Chait, who served as my secondary supervisor, was invaluable and it shaped a large part of this work and my way of thinking, as well. She is scientist I look up to and her approach to research has taught me to be a better researcher myself and has definitely improved the quality of work in this thesis. I am grateful for her input and I thank her for everything I have learned from her. There are a number of people who practically contributed in various ways and varying degrees to the PhD project. They either discussed ideas, addressed concerns, gave me practical advice, read 3 parts of my work or offered tips on where to find answers. Debi Vickers, Ulrich Pomper, Ed Sohoglou, Vivian Iliadou, Irini Symeonidou, Orestis Georgiou, Nehzat Koohi, Hannah Cooper, Lindsey Edwards, Rajeev Mathew, Theo Petsas, Anahita Mehta, and Deborah Ridout, a thousand thanks! I also wish to give special thanks to Zelia Gregoriou who inspired me through her lectures during my undergraduate and played a big part in my love and interest for research and academia. And of course, last but not least, I am giving love and thanks to friends and relatives for the immense support and love who provided unconditionally to me throughout this PhD adventure. This PhD has taken me to many peaks and many valleys, but I am grateful to have had the following group of beautiful people be with me to help me up or cheer with me in all these moments, sometimes from distance (thank you skype, too!); Orestis, the other Orestis, Ianthi and Rallou, Giannis, Christiana and Teddy, my sister Constantia, Alexis, my nephews Nikolas and Ifigenia, huge thanks to Claudia who helped me immensely, Silvia, Andreas and Alexia, Irini and Christos (and Donald), Panos, Xenios and Eugenia, Giulia, Gyorgyi and Melinda, George and Maggie, Steph and Tom, Agata, Marta, Marios and Stella and Yiannakis Heracleous, and the rest of my family in London, Cyprus or Canada who have loved me, fed me and worried about me throughout this journey. 4 ABSTRACT Auditory Processing Disorder (APD) is characterised by poor Auditory Processing (AP) in the presence of normal hearing. Children with APD have poorer Speech-in-Noise (SIN) skills than their peers and are often reported to have poor attention and Auditory Working Memory (AWM). Management approaches include auditory training and Remote Microphone Hearing Aids (RMHAs). Research on the effects of RMHAs on children with APD is scarce. Some studies claim improvements in SIN performance following RMHA intervention, others suggest that AWM might not be assisted, while the system’s effect on attention remains unexplored. Also, the relationship between types of attention and AP skills has not been adequately explored and APD diagnostic criteria do not routinely include attention measures despite evidence linking the two. This thesis aims to address these gaps in the field through three studies. The first two studies examine the effects of RMHAs on measures of SIN and AWM but also on the novel measures of attention and spatial listening in children with APD using randomised controlled trials. The third study is the first to use correlation analyses to examine the relationship between AP skills and attention in a sample of only APD-diagnosed children. Furthermore, this study looked at a newly proposed APD diagnostic process which included measures of attention with the aim to better inform APD management. Overall, findings from the clinical trials did not find improvements in any of the attention tests following RMHA use for 6 months, while spatial listening was not negatively affected. In the final study, a strong relationship between divided attention and the dichotic digits test (an AP test) was revealed. Finally, the proposed diagnostic procedure provides useful information to the clinician in terms of management, which may potentially better address children’s needs. All findings are discussed in the context of the studies’ limitations. 5 IMPACT STATEMENT The results of the two clinical trials showed improved listening when using the Remote Microphone Hearing Aids (RMHAs) in some challenging acoustic situations in the classroom. We did not find any significant long-term improvement in attention, working memory, or listening-in-noise tests, and no adverse effect on spatial listening skills as documented on the listening-in-spatialised-noise test (for up to 6 months of use). These findings can inform clinical management of Auditory Processing Disorder (APD). For example, families who are recommended to use RMHAs with their child should be informed that while the RMHAs will make listening easier for the child, they will not have a direct impact on children’s attention, working memory, and listening-in-noise ability when not wearing the hearing aids. Therefore, additional interventions should be implemented to address such skills. At the same time, children who are diagnosed with Spatial Processing Disorder may use the RMHAs for at least up to 6 months (if the other auditory processing tests warrant a use of the device), as it will not negatively influence their spatial listening skills. The findings from the correlational study showed that divided auditory attention has a partial correlation with the dichotic digits test (a test already used to diagnose APD) in a sample of only APD-diagnosed children. This is a novel finding and it may have a direct impact on the APD diagnostic procedure. It is suggested that the two tests should be administered in combination with each other during APD assessments. This will help clinicians have a more complete profile of the patient’s dichotic listening skills and abilities in divided attention tasks. Furthermore, both the findings from the two clinical trials and the correlational study provide with a basis for future studies to build on. Firstly, future clinical trials should test RMHAs under longer intervention periods (of at least up to 12 months) to test long-term (unaided) benefits in attention, working memory, and listening-in-noise. Additionally, aided conditions (i.e. when RMHAs are used) should also be included in the research design to test whether they provide with an improvement in these outcome measures, compared to the unaided conditions. Based on limitations that were identified in the two clinical trials, it is proposed that future work using 6 RMHAs with APD-diagnosed children should follow these guidelines: not using other interventions alongside RMHAs unless part of the research protocol, verifying functionality of RMHAs, monitoring and reporting the total time the system was used during the study period, and administering a children’s questionnaire on levels of satisfaction in using the RMHA to be used as a control factor in the analysis. These guidelines aim to minimise bias, control confounding factors, while they also ensure uniformity across RMHAs trials on APD studies. Finally, based on the findings from the correlational study research should further explore the relationship between divided attention and the dichotic digits test in children with APD. 7 PUBLICATIONS AND PRESENTATIONS Published article resulting from this work 1. Original research article: Stavrinos, G., Iliadou, V.-M., Edwards, L., Sirimanna, T., & Bamiou, D.-E. (2018). The Relationship Between Types of Attention and Auditory Processing Skills: Reconsidering Auditory Processing Disorder Diagnosis. Frontiers in Psychology, 9(January), 1–13. doi:10.3389/fpsyg.2018.00034. Platform presentations resulting from this work 1. FM systems for APD, Auditory Processing Disorder Masterclass at the Ear Institute, UCL, London, 10th February 2016. 2. The effects of Personal Remote Microphone Hearing Aids on listening skills and auditory attention in children, aged 7-12, with Auditory Processing Disorder, GN ReSound Complex Needs Educational Events, a.