THE FUNCTIONAL HEARING INVENTORY:

CRITERION-RELATED VALIDITY AND

INTERRATER RELIABILITY

by

PAMELA M. BROADSTON, B.S., M.A.

A DISSERTATION

IN

SPECIAL EDUCATION

Submitted to the Graduate Faculty of Texas Tech University in Partial Fulfillment of the Requirements for the Degree of

DOCTOR OF EDUCATION

Approved

December, 2003 Copyright 2003, Pamela M. Broadston ACKNOWLEDGEMENTS

First and foremost, I thank my Lord, Jesus Christ for opening the door that provided the opportunity for me to obtain this degree. Without His almighty love and endless grace, I would never have achieved this milestone. This milestone could also never have been achieved without the love and support of my family. I cannot proceed without first acknowledging them: to my parents who provided constant love and support throughout this entire endeavor; to my brother Bob, without his financial support I would probably still be working on my master's degrees one class at a time; to my sister, who allowed me to vent and provided sound advice during trying times; to my baby brother,

Jeff, thanks for believing in me.

I most gratefully thank my dissertation committee for their wisdom, support, and constructive criticism. Their dedication and skilled instruction were vital to the completion of this project. They include: Dr. Carol Layton who provided me with her expertise and guidance in diagnostics and assessment, Dr. Nora Griffm-Shirley who got me hooked on O&M, and Dr. Robert Kennedy who patiently explained and re-explained statistics, time and time again. Last but not least, I want to thank my chair. Dr. Roseanna

Davidson, for providing the resources and opportunities that enhanced my doctoral studies and for her expertise and guidance into the field of deafblindness.

I sincerely thank Gillis Ward, my second rater, who allowed me to totally control her life for four weeks. Without her willingness to drop everything and show up when and where I asked her, I would never have completed the data collection. Thank you

Gillis, you are the best. I also want to thank the many professionals who assisted me at various stages of the FHI development and this dissertation research. Some of these professionals include:

John Macias for his professional input and constant support and encouragement, Marcella

Dalla Rosa for allowing me access to her staff and students (Cheers), Theresa Mays for contacting parents, all of the teachers and staff at the residential school for allowing me free access to your classrooms and school activities, Candace Bums and Jim Vander

Putten for editing my proposal, my colleagues and friends at UALR for their constant words of support and encouragement, Paul Pagliano, Pat Kelley, Jim Durkle, Suzanne

House, Hansel Burley and NTAC for their input when this project was in its infancy.

And a very special thanks to Margaret Robinson, my friend and colleague, for teaching me PowerPoint and table formatting, and for walking around for days with a sound level meter attached to her hip.

A special thanks is extended to the parents and students who participated in this research project. Without you this research could not have been completed.

Ill TABLE OF CONTENTS

ACKNOWLEDGEMENTS ii

ABSTRACT viii

LIST OF TABLES x

CHAPTER

I. OVERVIEW OF THE STUDY 1

Introduction 1

Significance of the Study 7

Statement of the Problem 7

Purpose of the Study 8

Research Questions 8

Null Hypotheses 9

Definition of Terms 9

Delimitations 11

Assumption 12

Organization of the Study 12

H: REVIEW OF THE RELATED LITERATURE 13

Role of Hearing 13

Primitive Level 13

Signal Warning 14

Spoken Communication 14

IV Impact of Hearing Loss 15

In Adult Lives 15

In Infant's and Young Children's Lives 16

Hearing Impairment 18

Age of Onset 18

Severity or Degree of Hearing Loss 19

Types of Hearing Loss 20

Assessment of Hearing in Infants and Children 22

Basic Audiometric Assessments 22

Physiological Tests 25

Limitations of Traditional Audiological Testing 27

Infants and Young Children 27

Children with Multiple Disabilities 28

Functional Hearing Screenings/Assessments with Limitations of Each 29

Infants and Young Children 29

Children with Multiple Disabilities 30

Summary 33 m. METHOD 35

Introduction 35

Setting 36

Participants 36

Participant Selection 36 Purposeful Sample 37

Demographic Data 37

Informed Consent 37

Research Design 3g

Instrument Development 38

Validity 40

Criterion-Related Validity 43

Interrater Reliability 44

Data Collection 46

Data Analysis 46

Materials 49

Summary 49

IV. RESULTS 51

Introduction 51

Research Questions 52

Null Hypotheses 52

Demographics 52

Criterion-Related Validity 57

Interrater Reliability 61

Summary 64

V. SUMMARY, CONCLUSIONS, RECOMMENDATIONS, AND IMPLICATIONS 66

Summary 66

VI Limitations of the Study 67

Conclusions 68

Recommendations 71

Implications 73

BIBLIOGRAPHY 76

APPENDIX

A: PARTICIPATION LETTER, INFORMED CONSENT FORMS, AND INSTITUTIONAL REVIEW BOARD EXEMPTION 83

B: FHI TEACHER QUESTIONNAIRE AND FHI PARENT QUESTIONNAIRE 88

Vll ABSTRACT

The Functional Hearing Inventory (FHI), an observational instrument for functional hearing, provides information about how a deafblind child uses his/her residual hearing within his/her natural environment. This study obtained evidence of the validity and reliability of the FHI.

In particular, criterion-related validity for the FHI was investigated by correlating it with teachers' and parents' ratings of functional hearing, and the traditional measure of

hearing, the audiogram. Interrater reliability for the FHI was studied through correlating

the FHI ratings of deafblind subjects by two trained evaluators using point-by-point and

consensus methods. The two raters included the researcher and one other rater who was

trained by the researcher. The raters observed students in their natural settings and recorded the information on the FHI observation form. The subjects for this study were a purposeful sample of students between the ages of three and twenty-one who were reported on the Federal Deafblind Census.

There were 14 participants for whom there was complete information, comprising

6 females (43%) and 8 males (57%). The demographic section indicated that 57% of the participants were male, and 57% were Caucasian. The majority of the participants are in their teens with 21% being in the 7* grade. Over 42% of the participants had a primary disability of deafblindness and four of the participants had a secondary disability of either hearing or visual impairment.

vui Cohen' s kappa was used to measure agreement for criterion validity as well as to determine interrater reliability. Null hypotheses of no relationship between the FHI and teachers' ratings, and between thd^HI and parents' ratings were rejected, with a moderate relationship in the former case (K = 0.46, p = 0.0043), and with a somewhat weaker relationship in the latter case (K = 0.22, p = 0.01 ). The null hypothesis between the FHI and the audiogram could not be rejected (K = 0.13, p = 0.26).

The null hypothesis for interrater reliability was rejected for environmental conditions/background noise, signal, and response levels. The respective kappas were

0.96 (p < 0.0000001), 0.85 (p < 0.0000001), and 0.81 (p < 0.0000001), all considered to be high levels of association.

IX LIST OF TABLES

1 Levels of Hearing Loss with Implications 20

2 Levels of Response with Descriptions 39

3 Criterion Validity by histrument. Source, Scale, and Technique 48

4 Frequency Distribution by Gender 53

5 Frequency Distribution by Age 54

6 Frequency Distribution by Grade 55

7 Frequency Distribution by Ethnicity 55

8 Frequency Distribution by Primary Disability 56

9 Frequency Distribution by Secondary Disability 56

10 Frequency Distribution of Students wearing Hearing Aids During FHI Observations 57

11 Cohen' s Kappa between FHI Ratings and Teachers' Ratings of Hearing Functioning 58

12 Cohen' s Kappa between FHI Ratings and Parents' Ratings

of Hearing Functioning 59

13 Cohen' s Kappa between FHI Ratings and Audiogram 61

14 Cohen' s Kappa between Trained Evaluators' FHI Environmental Conditions/Background Noise Measurements 62 15 Cohen' s Kappa between Trained Evaluators' FHI Intensity of Signals Measurements 63

16 Cohen' s Kappa between Trained Evaluators' FHI Levels of Response 63 CHAPTER I

OVERVIEW OF THE STUDY

Introduction

Deafblindness is a multifaceted disability that impacts an individual in compound and complex ways. "The deaf-blind child is not a deaf child who cannot see or a blind child who cannot hear. The problem is not an additive one of deafness plus blindness"

(Mclnnes & Treffery, 1982, p. 2). Deafblindness impacts the use of the distance senses of vision and hearing, as well as the development of communication and perception.

Because of the impact that this dual-sensory impairment has on children with deafblindness it is necessary to provide educational instruction in the use of residual hearing and vision for these children, and to provide appropriate access to the environment in which they live. Intervention can significantly expand the learning potential of children who are deafblind (Miles & Riggio, 1999). The development of goals and objectives for intervention should be based on the needs of each individual child as revealed through appropriate educational assessment. Information about access to the environment also needs to be obtained as part of the assessment process for children who are deafblind. (Olson, Miles, & Riggio, 1999, pp. 78-93).

"The primary purpose of assessment is to provide information that can serve as the basis for intervention" (Flexer, 1999, p. 27). Therefore, quality program planning for students with deafblindness must begin with assessment. Eyre (2000) says, "Assessment goes hand in hand with curriculum" (p. 127). "Our assessments will reveal the stages they (children with deafblindness) have reached in each of the areas within curriculum and from there, we can plan next steps to take with them. In most schools, long-term aims or goals and short-term objectives or steps are used to plan this future work with the child"

(p. 138). Assessment provides the baseline from which to begin program planning and assesses the progress made since the previous evaluation. Flexer (1999, p. 189) provided a scenario that explains this process of assessment, program planning, and evaluation for progress as it might pertain to a child with a hearing loss:

...if the child has difficulty listening in a group situation, the listening difficulty and present level of listening function need to be documented, initially, through some evaluative tool. Then, a long term plan for improving listening must be formulated, followed by the short- term steps necessary to reach the long-term goal. Finally, the means of evaluating progress toward the listening goal needs to be specified.

Miles and Riggio (1999) stated, 'In identifying children as deafblind, we are also highlighting the importance of sensory assessment as a crucial piece of the educational assessment process"(p. 27). They go on to stress that "...knowing as precisely as possible how a child receives information, and understanding the possibilities for treatment and intervention, can significantly expand the child's learning possibilities"(p.

27).

Assessing children's hearing has been an issue for decades: When should testing be done, what type of testing yields the best results, at what age should children start using hearing aids or auditory trainers? The fields of pediatric audiology and educational audiology have come to the general consensus on what should be included in a basic assessment of hearing loss. According to Johnson, Benson, and Seaton (1997), a basic assessment should include: • Case history • Pure-tone thresholds • Speech thresholds • Word recognition ability • Otoscopy • Immittance testing.

Pure-tone thresholds, speech thresholds and word recognition ability are all considered behavioral tests because the child must provide a behavioral response to the presentation of sound, whether pure tone or speech. Otoscopy and Immittance testing are objective tests that are used to determine the outer ear and middle ear functioning, respectively (Johnson, Benson, & Seaton, 1997; Ross, Brackett, & Maxon, 1991).

When children are too young or have severe disabilities that preclude their participation in typical behavioral tests, objective tests or electrophysiological tests such as auditory brainstem response (ABR) and evoked otoacoustic emissions (EOAE) are often used. 'However, these methods of assessment can be costly and limited in the information they provide" (Steinberg & Knightly, 1997, p. 255 cited in Batshaw). Flexer,

(1999) explained, "Although objective tests provide some direct indication of auditory function, their results may be open to differing interpretations. Objective test are not tests of hearing" (p. 81). According to Northern and Downs (1991), objective testing "..may yield an index of auditory sensitivity, they are not true measures of hearing and should never be used as a substitute for behavioral audiometry"(p. 135). Therefore the results from objective testing may not provide the information about a child's hearing that is necessary for appropriate educational program planning. It is often difficult to test the hearing of children who are deafblind, or multiply and visually impaired, using typical behavioral audiological procedures. Folsom (1984) explained that accurate results are often difficult to obtain from children with visual and hearing disabilities because of the compounding and complex nature of the multisensory impairments. Franklin (1977) stated that pure tones, which are used in traditional audiometric testing, are often meaningless to children under the age of four, and for all ages of children who are cognitively low functioning. She concluded that it is unsuitable to use these types of testing techniques with children who are hearing impaired, and especially with children who are deafblind.

Often individuals receives audiological assessment that only assesses their sensitivity to pure tones, which are mechanically generated sounds that do not occur naturally in the environment, in a clinical type setting. An audiogram, the graphical results of pure-tone testing, indicates what an individual does not hear, when what is truly important to determine is actually what one does hear and if possible how they hear. "A child may appear to hear well in a soundproof audiologic test room or a quiet one-to-one communicative situation, but not hear equally well in a relatively noisy home or school setting"(Flexer, 1999, p. 27). Traditional audiological evaluations do not reveal how an individual uses his/her hearing in familiar settings such as the classroom or home environment (Goodrich & Kinney, 1985). Also, it is often difficult to use traditional audiological assessment techniques to test the hearing of children who are deafblind or multiply and visually impaired. Crook et al. (1999) explained that clinicians who attempt to test the hearing of deafblind children often find it extremely difficult because they are unfamiliar with the child, spend only a brief amount of time with the child, and the child is unfamiliar with them. Therefore, a children's performance or lack of performance in the clinical setting may not actually predict their performance in the classroom or at home in day-to-day situations (Aitken, Buultjens, Clark, Eyre, & Pease, 2000; McClean,

Bailey, & Woriey, 1996). Crook et al. (1999) emphasized the importance of gaining information about a child's functional hearing from persons who know the child well, from informal assessment, and from observation in non-medical settings.

Even when accurate results can be obtained from pure-tone audiological testing or behavioral testing for a child who is deafblind, the information from the audiogram may be less adequate for a child's programming than is generally assumed. Obtaining functional information about a child's hearing that is classroom oriented and pragmatic for educational planning is important when designing appropriate programs for children with deafblindness. "A funct ional hearing evaluation is an informal, on-going assessment which takes place in the child's natural environment ...to determine how an (individual) responds to and uses sound.. .(It) is a way to learn to recognize the child's 'specific behavioral responses to sound." (Chen, 1997, p 124). Leather (1977) recommended the use of checklists, developmental scales, and narratives to determine the functional hearing of children.

Much of the literature in the early 1980s stated the need for a functional hearing assessment but few instruments were developed as a result of the research. Information from the field indicates that a comprehensive instrument which can be used across ages, and is designed to assess children's responses to naturally occurring sounds within their daily environment is of vital importance. During a Roundtable Discussion session at the

Deafblind Project Director's Meeting in October of 1999, the need for this type of comprehensive functional hearing assessment was discussed by prominent figures in the field of deafblindness in the United States (R. Davidson, personal communication,

January, 2000). Additionally, it was recommended that the interpretation of the results of the use of the instrument be tested for evidence of validity and reliability (V. Baldwin, K.

Stremel, J. Macias, J. McNulty, and R. Davidson, personal communication, October,

2000).

At present, however, there is a gap in instrumentation for hearing assessment, which links to program planning. Broadston and Davidson (2001) developed the

Functional Hearing Inventory (FHI) to provide the type of functional information about a child's hearing that is needed for program planning. The FHI is designed as a diagnostic and prescriptive instrument. It provides a systematic procedure for recording the present level of use of hearing, identifying the functional level of use, and providing a focus for intervention strategies. The FHI is designed to be comprehensive and usable across age levels. The information and results that are obtained from the inventory can be used to plan an appropriate program for the student and will provide information about children's usage of hearing to access their environment. According to Mclean et al. (1996, p. 27),

'When the parameters that facilitate use of hearing are delineated, the child can be encouraged to use his or her hearing optimally to adapt to all environments."The information gleaned from the FHI can be used to help parents and educators manipulate environmental background noise levels in the classroom or at home, to maximize students use of their residual hearing, and to provide a better listening environment for students' learning.

Significance of the Studv

The Functional Hearing Inventory (FHI) was developed because of the need to obtain information about how deafblind children use their residual hearing within their natural environment (Chen et al., 1997). The FHIis an observational instrument for functional hearing that is designed for use across age levels that have been subjected to varied validation activities. Several hearing screenings have been developed for early intervention (birth to three) but there is no documentation that they were validated or tested for reliability (Chen, 1989, 1997,1999; Downs, 1979; Gleason, 1984). Other functional hearing assessment/screening instruments that are available consist of checklists or questionnaires that address some aspects of functional use of hearing, but do not appear to be comprehensive, and only one. Auditory Assessment And Programming

For Severely Handicapped And Deaf-Blind Students (n.d), reports that it was tested for reliability.

Statement of the Problem

To establish utility, the FHI needs additional evidence for validity and reliability.

Preliminary analyses show evidence of content validity using panels of experts to examine information that either should be included or omitted. This particular process of validation will be described in detail in Chapter m. The present study will examine criterion-related validity and interrater reliability of the FHI.

Purpose of the Studv

The purpose of this study is to obtain evidence of the validity and reliability of the

FHI. In particular, criterion-related validity for the FHI will be investigated by correlating it with the teachers' and parenta'atings, and the traditional measure of hearing, the audiogram. Interrater reliability of the FHI will be studied through the correlation of the FHI ratings of deafblind subjects by two trained evaluators.

Research Questions

The study will investigate the following research questions:

1. What is the extent of the relationship between FHI ratings and teachers'

ratings of hearing functioning?

2. What is the extent of the relationship between FHI ratings and parents'

ratings of hearing functioning?

3. What is the extent of the relationship between FHI ratings and the traditional

measure of hearing, the audiogram?

4. What is the extent of the relationship between the FHI ratings of two trained

evaluators? Null Hypotheses

For objectivity, the research questions are framed as null hypotheses. The level of statistical significance is set at the customary level of 0.05, indicating a willingness to accept only a small likelihood of a Type I error.

Hypothesis 1: There is no statistically significant relationship between the FHI

and teachers' ratings.

Hypothesis 2: There is no statistically significant relationship between the FHI

and parents' ratings.

Hypothesis 3: There is no statistically significant relationship between the FHI

and the audiogram.

Hypothesis 4: There is no statistically significant relationship between the FHI

ratings of two trained evaluators.

Definitions of Terms

The following terms are operationally defined below. The definitions come from the cited sources.

Audiogram: a graphical representation of an individual's hearing

thresholds. The graph consists of ".. the signal frequencies (in

Hertz) displayed on the x axis and hearing level (in decibels)

represented on the y axis. The graph is designed in such a manner

that 1 octave on the frequency scale is equal in size to 20 dB on the

hearing level scale" (Bess & Humes, 1990, p. 75). An audiologist records the results of an audiological evaluation on the audiogram

'Using symbols to depict the threshold of each ear as a function of

frequency and intensity (with reference to normal threshold)"

(Martin, 1994, p. 77). Results from the audiogram will be used to

classify the extent of the hearing loss in terms of mild, moderate,

moderately-severe, severe, or profound (Bess & Humes, 1990).

Deafblindness: Concomitant hearing and visual impairments, the

combination of which causes such severe communication and other

developmental and educational needs that they cannot be

accommodated in special education programs solely for children

with deafness or children with blindness [34 CFR §300.7 (C)(2),

2000]

Deafblind census: This census is the means by which states must identify and

report children with deafblindness in accordance with Federal mandates.

On December 1 of each year, school systems must report the census data

to the state's Deafblind Project for every child age three to twenty-one.

The information that is collected by the census includes: age of the child,

degree of hearing and vision loss, etiology and educational placement.

This information is then reported to the Federal government and

influences future funding and grants to improve education for children

with deafblindness (Davidson, 1998;

http://education.gsu.edu/georgiadeafblindproj/census-db.html)

10 Validity: 'In testing, the appropriatenes s, meaningfulness, and usefulness of

specific inferences made from test scores" (Gall, Borg, & Gall, 1996,

p.773).

Criterion-related validity: 'Type of validity that involves an explicit standard

against which claims about a test can be judged" (Gall, Borg, & Gall,

1996, p. 757). 'In establishing criterion -related validity evidence, scores

from a test are correlated with an external criterion" (Kubiszyn & Borich,

2003).

Reliability: The extent to which the scores from a test are consistent and error-free

(Ebel&Frisbie, 1991).

Interrater reliability (inter-observer reliability): 'The extent to which the scores

assigned by one observer of events correlate with the scores assigned by

another observer of the same event" (Gall, Borg, & Gall, 1996, p. 761).

Criterion-related observer reliability: 'The extent to which the scores assigned by

a trained observer agree with those assigned by an expert observer" (Gall,

Borg, & Gall, 1996, p.757).

Delimitations

The number of subjects was delimited to 10-15 because deafblindness is a low incidence disability, affecting less than one percent of the population. All subjects were selected from the State Schools for the Deaf and Blind.

11 Assumption

It is assumed that all participants, including teachers, parents, and raters, responded to any instruments or protocols, truthfully and to the best of their ability. This assumption seemed appropriate given that this population holds in high regard any effort to provide assistance.

Organization of the Study

This dissertation is divided into three chapters. Chapter I consists of an introduction, significance of the study, statement of the problem, purpose of the study, research questions, null hypotheses, definitions of terms, and delimitations.

Chapter n consists of a review of literature which includes the following: role of hearing, impact of hearing loss, hearing impairment, assessment of hearing in infants and children, limitations of traditional audiological testing, functional hearing screening with limitations of each, and a summary.

Chapter HI describes the method of the study. The setting, participants, participant selection, and instrument development were identified at this stage of the study. Validity, reliability, data collection procedures and analysis of data will also be discussed.

Chapter IV comprises the results of the study. The findings relative to criterion- related validity and interrater reliability are discussed.

Chapter V concludes the study. The summary, conclusions, recommendations and implications of the study are discussed.

12 CHAPTER n

REVIEW OF THE RELATED LITERATURE

Role of Hearing

'Hearing plays a vital and often subtle role in our lives, a role that must be

understood to appreciate the impact of hearing impairment..!'(Flexer, 1999, p. 11).

Steinberg and Knightly (1997) explained that 'for most people, the sense of hearing is

integral to one of the most fundamental of human activities: the use of language for

communication" (p. 241). Hearing is often divided into three levels: primitive, signal

warning, and spoken communication (Flexer, 1999; Kaplan, 1992).

Primitive Level

When a person hears, the biological sounds of their own breathing, heartbeat,

swallowing and chewing, they are hearing at the primitive level. The awareness of sound in the auditory background is also considered primitive level hearing. Auditory background is the awareness of sounds that help us identify a location. For example, a playground sounds different from a library. We know of these differences and expect them. Ramsdell (as cited in Kaplan, 1992) stated: "At this level, we react to such sounds as the tick of a clock, the distant roar of traffic, vague echoes of people moving in other rooms of the house, without being aware that we are hearing them. These incidental noises maintain our feeling of being part of the living world and contribute to our own

13 sense of being alive" (p. 137). If the environment starts to sound different from what is expected, one may become uneasy or even depressed (Flexer, 1999; Kaplan, 1992).

Signal Warning

"At the warning level, sounds convey information about objects and events"

(Kaplan, 1992, p. 137). These warning sounds are mostly distance sounds. Since hearing is one of the distance senses it allows us to be aware of the environment around us and allows for incidental learning, it allows us to interpret information about the world around us and provides us with a sense of security about that environment. Miles and Riggio

(1999) stated that the ears provide an " 'antenna -like' function for.. .scannin g the environment on all sides, picking up indications of movements that would tell of danger or pique interest" (p. 31). Hearing also allows for incidental learning. According to Flexer

(1999), 'Much information children learn is not directed to the child, yet this tangential information is important for them to learn. Children learn how to start a conversation, request, problem solve, negotiate, compromise, joke, tease, and use sarcasm by

'listening-in'to the conversations of others" (p. 15).

Spoken Communication

At this symbolic level of hearing, ".. we are dealing with sound as language and a major channel of communication. Nearly all people who are deaf or hard of hearing have difficulty at this level to one degree or another"(Kaplan, 1992, p. 138). Levitt (1989) explained, 'The sense of hearing plays a crucial role not only in the understanding of

14 speech, but also in providing the cues needed for the acquisition of speech and language"

(p. 23). Steinberg and Knightly (1997) stated, 'It is through hearing that the child acquires a linguistic system to both transmit and receive information" (p. 241). Miles and

Riggio (1999) explained, 'Hearing persons receive most of their language input through their ears. Before a child can say his first words, he has heard thousands of words and sentences thousands of times, and has somehow begun to make sense out of them" (p.

31). Flexer (1999) stressed that "..a great deal of listening input does, and indeed must, occur...before verbal output can be expected"(p. 16).

Impact of Hearing Loss

'The sense of hearing is integrally related to communication and interaction among people; to a great extent we relate to others through verbal language. For the vast majority of people who are deaf or hard of hearing, when the sense of hearing is impaired, the ability to relate may be impaired as well" (Kaplan, 1992, p. 135).

In Adult Lives

Hearing loss in adults causes ".. varying degrees of difficulty in receiving the auditory speech and environmental stimuli which allow us to communicate and interact with other humans and with our environment" (Schow & Nerbonne, 1996, p. 9). Schow and Nerbonne (1996) also stated 'The adults with mild to moderate hearing losses experience persistent communication difficulties which vary in degree depending upon a number of variables. Such communication deficiencies can, in turn, lead to problems

15 related to psychosocial adjustment" (p. 239). These psychosocial adjustment difficulties manifest themselves in the manner in which the adult with a hearing loss responds to social and emotional situations.

Social and Emotional. Oftentimes the adult who has a hearing loss ".. may experience strong feelings of frustration and inadequacy stemming from the inability to hear as effectively as before. Withdrawal from situations in which hearing difficulties often occur, such as meetings, church, and social events, is commonplace" (Schow and

Nerbonne, 1996, p. 239). Kaplan (1992) explained:

People who are nonculturally deaf and hard of hearing often feel shut off from the worid, not only because of difficult communication with others, but also because some or all of the subliminal auditory clues which permit one to maintain contact with the 'hearing world' are no longer available. They may react to this depression by withdrawing from social situations and from contact with other people, (p. 136)

In Infant's and Young Children's Lives

According to Schow and Nerbonne (1996), 'the primary and most devastating effect of hearing loss is its impact on verbal communication. Children with severe to profound hearing loss do not generally develop speech and language normally, because they are not exposed to the sounds of language in daily living" (p. 9). Hearing loss not only affects children in the area of language, but it also impacts their social, emotional, and cognitive development. Schlesinger and Meadow (as cited in Miles & Riggio, 1999) stated, 'Profound childhood deafness is more than a medical diagnosis: it is a cultural phenomenon in which social, emotional, linguistic, and intellectual patterns and problems are inextricably bound together" (p. 33). When comparing the effects of deafness and

16 blindness Helen Keller said this about deafness: 'Deafness is a much worse misfortune.

For it means the loss of the most vital stimulus- the sound of the voice that brings language, sets thoughts astir and keeps us in the intellectual company of man..I have found deafness to be a much greater handicap than blindness" (as cited in Miles &

Riggio, 1999, p. 33).

Social and Emotional Development. Estevez (1996) reported that 'the literature suggests that individuals who are deaf are less socially mature than their hearing peers and that the development of personality and social skills in children who are more socially isolated is affected because of limited opportunities to interact socially" (p. 24).

Flexer (1999) stated, 'Because a child with a hearing problem has difficulty overhearing the conversations of others, she or he misses an enormous amount of information and social cues that typical children just 'pick up"'(p. 223). This lack of opportunity to develop appropriate social skills often leads to isolation and social maladjustment.

Intellectual Development. Some significant debate in the field of deaf education existsas to the extent hearing loss has on the intelligence test scores of children. However, experts tend to agree that a hearing loss in infants and young children impacts the phonologic, linguistic, and developmental patterns (Ross, Brackett, & Maxon, 1991;

Hull, 1997; Flexer, 1999). Flexer (1999), for example, stated that auditory deprivation might cause children to exhibit behaviors that are atypical and consistent with developmental delays. A report by Mandell and Fiscus (1981, as cited by Estevez) stated that deaf students tend to developmentally perform several years below their comparable grade levels. Davis, Elfenbein, Schum, and Bentley (as cited in Alpiner & McCarthy,

17 1987) reported that a ".. hearing loss of any degree appears to affect psychoeducational development adversely, leading to the conclusion that even minimal hearing loss places children at risk for language and learning problems" (p. 13). Because of the impact that a hearing loss has on key areas of development in infants and young children, it is important to understand the 'there is no such thing as an insignificant hearing impairment. Consequently, a child's hearing sensitivity must be known and assessed"

(Hexer, 1999, p. 225).

Hearing Impairment

Hearing impairments are generally classified by age of onset, degree of loss, and type of loss. The combination of various aspects of these classifications can have an impact on the development of the individual with a hearing impairment.

Age of Onset

The age of onset is a major factor of consideration for individuals with a hearing impairment. If a severe to profound loss is congenital (at birth) or prelingual (before acquiring language) it can significantly impact the developing child's language, voice and articulation. A congenital or prelingual hearing loss can also affect the child's social and educational development. If the hearing loss occurs later in life, the loss can have a profound influence on the individual socially and emotionally, but the loss does not generally impact the already acquired language or voice quality, although articulation is sometimes affected (Alpiner & McCarthy, 1987; Hull, 1997).

18 Severity or Degree of Hearing Loss

The severity, or degree of hearing loss, can often provide a guideline for the handicapping effects a person might experience as a result of the hearing loss. Table 1 displays how Hull (1997, pp. 20-21) categorized levels of hearing loss with implications, based on the levels in decibels, typical speech understanding, and typical child amplification and educational considerations.

Types of Hearing Loss

Unilateral. A unilateral hearing loss occurs when a person has normal sensitivity in one ear and the other ear has at least a mild permanent hearing impairment. A unilateral loss can cause serious difficulties with the educational experiences of children

(Flexer, 1999; Steinberg and Knightly, 1997). Northern and Downs (1991) explained that a unilateral loss can affect a child's ability to understand classroom instructions and has an adverse effect on a child's ability to pick up on conversational cues which often leads to inappropriate responses from the child. Hull (1997) stated that a unilateral loss impairs a person's ability to understand speech when there is background noise or when there are poor acoustical conditions.

19 Table 1

Levels of Hearing Loss with Implications Mild 25-39 dB; difficulty understanding faint speech; hearing aid may provide mild gain; FM system should be considered; preferential seating should be required. Moderate 40-54 dB; frequent difficulty understanding normal speech; full time use of amplification recommended with supplementation in school with an FM system. Moderately 55-69 dB; constant difficulty understanding even loud speech; behind- severe the-ear amplification recommended and use of FM system in school is essential as well as possible need for special classes and speech therapy. Severe 70-89 dB; severe difficulty understanding even loud or amplified speech; behind-the-ear amplification is recommended but may consider a body- type hearing aid and use of FM system is mandatory. Profound 90+ dB; understanding speech severely limited even with amplification; powerful behind-the-ear amplification may be possible or cochlear implant or vibrotactile devices may be considered and special education programs are usually required.

20 Bilateral. A bilateral hearing loss is a disorder that involves a hearing impairment in both ears.

Conductive. A conductive hearing loss occurs when there is a 'dysfunction of the external or middle ear" (Steinb erg & Knightly, 1997, p. 248). Flexer (1999) stated that this dysfunction ".. interferes with the efficient transmission of sound into the inner ear where sound reception occurs" (p. 271). A conductive loss can often seriously impact the acquisition of language and can adversely affect educational performance (Flexer, 1999;

Hull, 1997).

Sensorineural. A sensorineural hearing impairment occurs when there is a malfunction of the cochlea or auditory nerve (Steinberg & Knightly, 1997). This type of hearing loss is usually permanent. Hearing aids or assistive listening devices are usually prescribed for children who have this type of hearing loss.

Mixed. A mixed loss is a combination of a sensorineural and conductive loss caused by more than one pathology in different parts of the ear at the same time (Flexer,

1999; Schow & Nerbonne, 1996).

Central. A central loss of hearing is often referred to as a central auditory processing disorder (CAPD). Although not an actual impairment of the hearing mechanism, CAPD interferes with the understanding of the meaning of sounds. CAPD can also involve ".. a variety of difficulties either in one or all areas of (a) detection, (b) interpretation, or (c) categorization" of auditory language (Schow & Nerbonne, 1996, p.

345.)

21 Progressive. A hearing impairment, which is not stable and gets worse over time, is considered to be progressive. Rexer (1999) stated that it is imperative that progressive losses be monitored closely by a medical doctor because medical intervention may be able to slow down or completely halt the progression of loss.

Assessment of Hearing in Infants and Children

Basic Audiometric Assessments

Audiometric assessment serves to identify the presence of a hearing loss, quantify its magnitude and determine whether it is conductive or sensorineural loss"(Goetz, Guess, & Stremel-Campbell, 1987, p. 103). 'In general, audiometric tests are known as behavioral if they use voluntary, behavioral responses. They are known as physiological if they monitor some physiological response of the auditory mechanism, (p. 104)

Pure-tone Air-conduction Tests. Pure-tone air conduction testing requires active behavioral responses from the person being tested. The people being tested must be able to indicate when they hear a presented tone even when it is very soft. 'The level at which tones are perceived as barely audible is the threshold of auditory sensitivity. The thresholds at different frequencies form the basis for pure-tone audiometry" (Martin,

1994, p. 72). The results of pure-tone testing is recorded on an audiogram. 'Pure-tone air- conduction thresholds determine if a hearing loss is present and provide a direct indication of the amount of hearing loss at each frequency" (Johnson, Benson, & Seaton,

1997, p. 51). Martin (1994) stated that pure-tone testing does not actually measure hearing, ".. but, rather, the responses to a set of acoustic signals that we interpret as representing hearing" (p. 65).

22 Behavioral Audiometric Tests. Hexer (1999) stated, 'the ultimate and necessary test of hearing is the acquisition and display of behavioral responses to sound" (pp. 81 -

82); therefore, she recommends the use of behavioral testing with infants and young children: 'Behavioral audiometric tests are procedures in which a response to sound is elicited and measured, and the function of the auditory system is subsequently inferred"

(p. 27). Traditionally, all behavioral audiological testing takes place in a sound-proof booth using pure-tones, warbled tones, wide and narrow band noises, or speech stimuli of varying frequencies presented by the use of earphones, if the person will tolerate them, or through the use of soundfield (Bess & Humes, 1990; Martin, 1994; Schow & Nerbonne,

1996).

Behavioral Observation Audiometry (BOA). BOA is a method of audiological assessment developed by audiologists for use with infants, children, and those individuals deemed difficult to test (Auditory Assessment, n.d.). 'BOA provides a quick, simple, and inexpensive means of estimating hearing sensitivity, facilitates decisions regarding which formal test procedures may be most effective and suggests the level and quality of responses that can be expected" (McClean, Bailey, Jr., & Wolery, 1996, p. 130). 'BOA is a procedure that relies on the observation of overt responses (i.e., eye blinks, head turns, cessation of behaviour) to time-locked supra threshold auditory signals without conditioning" (Moore & Connix, 1996, p. 225). Mclnnes and Treffery (1982) explained that BOA consists of the presentation of various acoustic stimuli, such as warbled tones, wide and narrow bands of noise, or speech, which are presented to a child who is sitting in his/her parent's lap in a soundproof room. The audiologist notes the child's behavioral

23 response to periodic acoustic signals of varying intensities and spectra. According to

Flexer (1999), 'BOA is the simplest procedure in terms of the child's task requirements"

(p. 82). However, there are many limitations to the use of BOA. Connix and Moore stated,

the nature of the stimulus affects the probability of obtaining a response since some auditory signals are more alerting than others; habituation to an auditory stimulus may occur rapidly, there can be wide inter-subject variability among individuals tested with BOA, so it is not effective in identifying mild-to-moderate hearing impairments; and responses may not be very obvious depending on the subjects status and attention, (pp. 225- 226)

Visual Reinforcer Audiometry (VRA). 'The VRA procedure utilizes an association between a sound and activation of the visual reinforcer so that a head turn or localization response will occur. Normally, this is done by initially pairing presentation of a sound with activation of the visual reinforcement unit. Most infants will, upon hearing the sound, anticipate the appearance of the lighted and moving toy after a few of these paired presentations" (Guess, Goetz, & Stremel-Campbell, 1987, p. 108). When the child consistently responds to the sound signal in conjunction with the visual reinforcer, the audiologist varies the acoustic signal. One limitation is that "Although it is frequently used procedure, the success of VRA is dependent upon rapid conditioning of the desired response to the paired auditory/light stimulus. If this conditioning does not occur within the test sessions, the procedure is not successful" (Auditory Assessment, n.d.).

Tangible-Reinforcer Operant-Conditioning Audiometry (TROCA). TROCA was designed for use with children and those considered difficult to test. According to

Mclnnes and Treffery (1982), TROCA is a technique that

24 .. utilizes positive reinforcement for appropriate responses and mild punishment for false-positive responses. The reinforcer is edible and/or a tangible reinforcer known to be highly motivating for the child. One limitation is that although it has been shown to be an effective clinical approach with mentally retarded children, there is little supporting evidence for its use with deaf-blind children. It is not usually successful because of their distractability, self-stimulatory activities, and the difficulty in identifying suitable reinforcers. (p. 194)

'Successful shaping of a response using TROCA procedures may involve hundreds of training trials and extensive time on the audiologist's part" (Auditory Assessment, n .d.).

Conditioned Play Audiometry (CPA). CPA is a technique by which children are conditioned to '^lay"in response to pure -tone or speech signals. 'Usually the child is required to put a block in a container, a peg in a board, or a ring on a peg when the auditory stimulus is presented" (Mclnnes and Treffery, 1982, p. 194). Mclnnes and

Treffery stated that a disadvantage to CPA is that '^ome MSD (multi -sensory deprived) children require six months to a year or more of training before such a test can be performed with any degree of reliability" (p. 194).

Physiological Tests

Auditory brainstem response (ABR). According to Steinberg and Knightly

(1997), ABR testing is also referred to as brainstem auditory evoked response (BAER).

This testing does not require the child's cooperation however the child must be sleeping or sedated. Since any movement at all from the child can interfere with the results, sedation is most often administered (Flexer, 1999). The ABR tests the cochlea and the auditory nerve, and ".. y ields information regarding auditory functioning and the identification of lesions in the auditory brain-stem pathways" (McClean, Bailey, Jr., &

25 Wolery, 1996, p. 135). In ABR testing, electrodes are attached to the child's head near each ear. These electrodes determine if there is any activity along the auditory pathway within the brainstem. Steinberg and Knightly (1991) explained, "..a computer averages the responses from the auditory nerve and displays a waveform that reflects activity in the auditory brainstem pathway.. .An absence of waveform at a given intensity suggests a hearing loss"(p. 255). Flexer stated that an "ABR is not a 'hearing test'per se...If the procedure is appropriately performed, information about the sensitivity of each ear can be inferred from the resultant tracing" (p. 87). Flexer cautioned "..that the absence of ABR responses does not mean that there is no residual hearing. Many children who have sensorineural hearing impairments severe enough to show absent ABR responses do have considerable residual hearing that is accessible with amplification technology" (p. 88).

Evoked otoacoustic emissions (EOAE). 'EOAE testing is a rapid, noninvasive, and inexpensive method of assessing cochlear function based on the cochlea's capability of not only transmitting sound to the brain, but also generating low-level sound in response to a stimulus" (Steinberg & Knightly, 1997, p. 254). Steinberg and Knightly

(1997) and Flexer (1999) stated that EOAE has limitations. The major limitation is that in order to perform this type of testing, the middle ear must be functioning normally. Flexer

(1999) explained, 'because middle ear problems are so common in infants and young children, otoacoustic emissions need to be interpreted with caution (p. 86). Another limitation of this testing is that it only assesses the cochlea. It does not assess the outer ear, middle ear, or the auditory nerve (Steinberg & Knightly, 1997).

26 Immittance (Impedence) Testing.

Impedence audiometry is often a component of the battery of audiological assessment, even though it is not a hearing test. Immittance testing measures the functioning of the middle ear. This type of testing is important for determining middle ear pathology (Flexer, 1999). Determination of middle ear functioning is important because it is the middle ear that transmits sound energy to the cochlea (Steinberg & Knightly,

1997).

Limitations of Traditional Audiological Testing

Infants and Young Children

According to McClean, Bailey, Jr. and Wolery (1996), the disadvantages of ABR testing of infants and young children are that the child needs to be sedated during the entire procedure, the ABR is expensive, and ".. an ABR cannot provide information regarding the functional application of existing hearing"(p. 136). ABR testing is also limited to testing the hearing thresholds of a child in the frequencies between 2000 and

4000 Hz, and is therefore unable to detect low-frequency losses (Mclean, Bailey, Jr., &

Wolery, 1996). Northern and Downs (1991) stated that objective audiological testing

(e.g. ABR, EOAE) should be viewed with caution because although ".. they may yield an index of auditory sensitivity, they are not true measures of hearing and should never be used as a substitute for behavioral audiometry" (p. 135).

In reference to young children, McClean, Bailey, Jr. and Wolery (1996) explain that 'the principal disadvantage associated with impedance testing is that the test battery

27 cannot be completed during vocalizations, crying, or yelling, and any movement will influence the accuracy of the acoustic reflex" (p. 135). Therefore accurate results are often difficult to obtain because of the uncomfortable nature of having an earplug type

apparatus placed in the child's ear-canal. The discomfort of the apparatus often makes it

difficult for the child to remain quiet and still. Pure-tone audiometric testing is often

inappropriate for children under the age of 3 years because of their inability to respond to

the auditory stimuli and behavioral audiological testing only infers the functioning of the

auditory system because it does not directly measure the auditory system. Behavioral

testing actually measures the responses of the child to sound and the observers' inferences

about those responses (Flexer, 1999). The various types of behavioral testing also require

that they be performed in a sound-proof room.

Children with Multiple Disabilities

According to Northern and Downs (1991) (as cited in McClean, M., Bailey, D.B.,

Jr., & Woriey, M., 1996), "ABRs may not yield valid data on children with severe

neurological impairments, since such damage interferes with registration of the signal at

the brain level and, consequently, recorded responses may be more a reflection of the

central nervous system impairment that of the perception of sound" (p. 137).

28 Functional Hearinp Screenings/Assessments with Limitations of Each

Infants and Young Children

A meta-analysis of existing instruments was conducted as a part of the systematic review of the literature. The descriptions and limitations of each of the instruments presented herein are a result of that research activity (Broadston, 2000).

Hearing Observation Form. A brief one page chart (Wright, 1995) on which to record observations of a child's response to sound that was developed for use by Texas

School for the Blind and Visually Impaired (TSBVI). It is not detailed enough to provide adequate information for program planning.

Parent Checklist. A brief checklist of developmental auditory skills developed by

TSBVI. The checklist consists of 13 yes/no questions, in developmental sequence to be answered by a parent. It was designed as a preliminary checklist to determine if there are any concerns about hearing. The limitations of this instrument include that it was designed for use from birth to 3 years of age and only as a preliminary screening not for use in program planning.

Assessment of Developmental Skills for Young Multihandicapped

Sensorylmpaired Children: Audition. This is a chart developed by SKI-HI Institute showing the developmental auditory behaviors of children from birth to two years of age.

The limitations include that it is not an actual assessment instrument but rather a developmental scale. There are no validation data or citations for developmental sequence, and it was designed for use with children up to age two.

29 Children with Multiple Disabilities

Functional Auditory Screening. This screening instrument, developed by The Bay

Area Severely Handicapped Project, is a procedure for evaluating a severely handicapped or deafblind child's responses to sound that can be performed in the classroom

(ADAPTIPS, 1985). The procedures for this screening "..involve presenting various auditory stimuli to the student and watching for reliable changes in behavior" (p. 213)

The intended setting for this evaluation is the normal classroom environment; however, it is recommended that a 'tjuiet area" of the classroom be used for the testing. This assessment procedure uses preselected and calibrated sound stimuli that are recorded on an audiocassette. The data sheet is arranged in a chart format on which one adult checks off the child's response to auditory stimuli presented by another adult. This assessment instrument focuses on the awareness/reflexive and attention/alerting levels of auditory functioning. During the development of this instrument inter-rater reliability data was collected while evaluating 17 severely handicapped students. 'The average inter-rater reliability coefficient for two classroom personnel watching one student was .74" (p.

217). Limitations of this instrument include that the sounds presented are not naturally occurring sounds, only one setting is used, and the higher levels of auditory functioning are not assessed.

Informal Auditory Observation Form. This observational tool, developed by

TSBVI, was designed as an informal screening instrument that can be used in various situations. The instrument was designed to help professionals determine if the child is making sense of his/her worid through the use of auditory input and is hearing spoken

30 words. It is also used as a means for gathering information to share with other professionals who might be performing formal auditory evaluations. Suggestions are made on how to focus on the child's auditory abilities. The instrument i s in a chart format. The information on the chart includes various auditory stimuli, including voices

(male and female), television, music, sound toys, musical instruments, and household objects. The chart is divided into different sections that include location of the sound in reference to the child, what the child was doing prior to presentation of the sound signal, and the child's response. The responses focus on the awareness/reflexive and attention/alerting levels of auditory functioning. Limitations include that the instrument is intended to be used only as an informal preliminary screening instrument, the higher levels of auditory functioning are not assessed, there is no validation data, and there are no detailed instructions for using the instrument.

Functional Hearing Evaluation. This evaluation form (Functional Hearing

Evaluation, 1999) is a general questionnaire about an individual's already diagnosed hearing impairment and his/her use of hearing in various acoustic conditions. Limitations include that there are no instructions; it is not an actual evaluation instrument, but rather a questionnaire; and that there is no validation data.

Functional Auditory Assessment for Work with Deaf-blind Persons. This assessment instrument was developed by the Canadian National Institute for the Blind,

Ontario Division, Deaf-Blind Services. The assessment instrument consists of a series of open-ended questions divided into three sections: Basic Assessment, Assessment of

Speech Recognition, and Assessment of Environmental Sounds. The section on Basic

31 Assessment asks questions for determining basic auditory functioning. The 'Speech

Recognition" section is divided into three sub-sections that focus on: unaided speech recognition in isolation, aided speech recognition in isolation, and aided speech recognition in a noisy room. The 'Environmental Sounds" section focuses on the individual's response to auditory stimuli in the person's living situation and in the community. All levels of auditory functioning are scattered throughout the questions.

Limitations are that it was designed for deaf adults, it is very lengthy, the format is not easily utilized for programming, there is no sequential way of determining levels of auditory functioning, there is no detailed instruction manual, there is no validation data, and there is no information on how to use the information for program planning.

A Manual for Assessment of a Deaf-Blind Multiply Handicapped Child: Auditory

Development. This is a developmental scale checklist which ".. reflects the sequence in which most deaf-blind students progress" (p. 1). The checklist does reflect auditory skills at all levels of auditory functioning. Limitations are that it is not detailed enough for program planning (only information is presence or absence of response to stated auditory skill), and that there is no validation data.

Auditory Assessment of the Multihandicapped Deaf-Blind Child. This was a paper presented at the Workshop for Serving the Deaf-blind and Multihandicapped Child:

Identification, Assessment, and Training. The paper was divided into three sections:

Terminology, Grass Roots Evaluation, and Formal Audiological Evaluation. The Grass

Roots Evaluation section is the portion that deals with functional evaluation. Sweitzer

(1979) developed a sample form for the Documentation of Auditory Response Behavior.

32 The setting for this observational evaluation should be a quiet room out of the mainstream traffic of the school. The room should have some acoustical treatment such as carpet, acoustical ceiling tiles and drapes over the windows. Two people are needed to complete this evaluation, one to present the sound signal and one to record the responses of the child. Prior to the testing situation, an audiologist should spectrally analyze all noisemakers and the evaluator's voice. All of the data collected during the observation should be recorded using the coding system developed by Sweitzer. Sweitzer's intent was that the information gathered through observation would be used as preliminary data for a formal audiological evaluation. Limitations are that it only focuses on awareness/reflexive, attention/alerting, and localization and not on the higher levels of response; it is not intended for program planning; there is no validation data; the setting for evaluation is not a natural setting; the sound stimuli are not naturally occurring; and there is a need for access to an audiologist for spectral analysis of sounds.

Summary

The review of the literature shows the critical role that hearing plays in the total development of human beings and the impact a hearing loss has on that development.

The various means of assessing hearing and their limitations for program planning are discussed in detail. Functional hearing screenings/assessments that are currently available for infants and young children, and children with multiple disabilities are described and the limitations of each are discussed.

33 The literature review shows that there is a lack of functional hearing screening/assessment instruments that are comprehensive, can be used across ages, are designed to assess a child's hearing within their natural environment, and have been investigated for evidence of reliability and validity. The literature shows that this type of assessment instrument is necessary for program planning and that there is a need for the development of such an instrument for deafblind children.

34 Chapter m

METHOD

Introduction

The original problem identified in Chapter I was that the Functional Hearing

Inventory (FHI) (Broadston & Davidson, 2001) needed additional evidence for validity and reliability. Specific research questions which addressed this problem included:

1. What is the extent of the relationship between FHI ratings and teachers'

ratings of hearing functioning?

2. What is the extent of the relationship between FHI ratings and parents' ratings

of hearing functioning?

3. What is the extent of the relationship between FHI ratings and the traditional

measure of hearing, the audiogram?

4. What is the extent of the relationship between the FHI ratings of two trained

evaluators?

For objectivity, the research questions have been framed as null hypotheses below. Statistical significance was set at the level of 0.01 which was adjusted from the commonly adopted 0.05 to account for multiple statistical tests.

Hypothesis 1: There is no statistically significant relationship between the FHI

and teachers' ratings.

Hypothesis 2: There is no statistically significant relationship between the FHI

and parents' rings.

35 Hypothesis 3: There is no statistically significant relationship between the FHI

and the audiogram.

Hypothesis 4: There is no statistically significant relationship between the FHI

ratings of two trained evaluators.

Setting

The setting for the observations varied according to the individual subjects' daily routine, since the intent of the FHI is to observe individuals within their natural, daily environments. All of the subjects were observed within a residential school environment.

The settings included a regular education classroom, self-contained special education classroom, cafeteria, gym and pool, playground, hallway, vocational class, outside areas around the school, and a school office.

Participants

Participant Selection

Participants for the research project were limited to subjects who met the following criteria:

• The participant must have been reported as a child with deafblindness on the

Federal Deafblind Census.

• The participant must be between the ages of three and twenty-one.

36 Participants for the project were recommended by Deafblind coordinators from the residential school and the State Deafblind project and by the Student Services coordinator.

Purposeful Sample

The selection of participants for this research project used the method of purposeful sampling. Purposeful sampling is used to select cases that were 'information - rich" relative to the purpose of the study, particularly when only small samples are available (Patton, 1990, as cited in Gall, Borg, & Gall, 1996). Due to the low incidence of the deafblindness in the population and the purpose of this study, the researcher selected a purposeful sample of 15 subjects.

Demographic Data

Data was obtained on all subjects regarding age, grade, gender, ethnicity as well as primary, secondary and tertiary disabilities and hearing aide use.

Informed Consent

Parental/guardian permission was obtained for all students under the age of eighteen or for students who have legal guardians if over the age of eighteen. Permission was obtained from the individual if he/she was over the age of eighteen and was his/her own legal guardian. A second informed consent was also obtained, in accordance with the state Department of Education, in order to conduct a specialized evaluation and to

37 gain access to participants' school records. See Appendix A for a copy of the letter requesting participation, a sample of the research study consent form, a sample of the state Department of Education consent form, and for the letter of exemption from the

Institutional Review Board.

Research Design

Instrument Development

The constructs of the FHI were developed based on the information gleaned from the literature review. The first draft of the protocol for the FHI was developed using information obtained horn Auditory Assessment, (n.d.), Chen (1997), Functional Auditory

(1992), Gleason (1984), Shapiro (1973), and Sweitzer( 1979). Based on information from those sources three main types of sounds were deemed important for evaluation of functional hearing. The sounds included speech sounds, environmental sounds, and sound toys/noisemakers. At the advice of the panel in Denver (Riggio, Osias, & Davidson, personal communication, 2000) the sound toys/noisemakers category was merged with the environmental sounds in order to make the FHI comprehensive across all ages. The literature also revealed that the typical responses to sound were categorized into six categories. Table 2 displays how Gleason (1984) described the six levels of response.

38 Table 2

Levels of Response with Descriptions RESPONSE LEVEL DESCRIPTION Awareness/Reflexive Motoric responses indicating awareness of sound. Attention/Alerting In addition to being aware of sound, paying attention to the sound for a few minutes. Localization Attempt to locate and/or find a sound source. Discrimination The ability to tell the difference between two different sounds. Recognition Responding to sound in a patterned way. Comprehension Responding to novel and routine sounds appropriately.

The FHI is an evaluation instrument on which responses to auditory stimuli that naturally occur within a student's daily environment are observed and recorded. The evaluator will choose three environments that are familiar to the student that have varying levels of background noise. The evaluator will need to use the sound level meter to determine the background noise level in these various environments. The decibel level of the environment is recorded on the protocol using the coding system provided. The evaluator will observe sound stimuli that occur throughout the day. The sound level meter is used to determine the intensity of these sounds. As the sounds occur, the evaluator will watch for a response from the student to the sound, paying close attention to what the student's re sponse is and if it is consistent. The source of the sound signal is written on the protocol form under the column Type of Signal, the code for the decibel level of the signal is recorded under Intensity of Signal, and the code for the Level of Response is recorded. The student's actual response is then written in the last column, What was the child's response?. A minimum of six environmental signals of varying levels of intensity

39 and a minimum of three speech signals within each of the three environments need to be recorded.

Validity

The content of the first prototype of the FHI was based on information obtained from a review of the literature in the fields of deafness, audiology, deafblindness, visual impairment, and special education (Auditory Assessment, n.d.; Chen, 1997; Functional

Auditory, 1992; Gleason, 1984; Shapiro, 1973; Sweitzer, 1979).

Phase 1. Prototype I was submitted to an expert panel in Lubbock, Texas and one in Portales, New Mexico. These panels consisted of professionals in the following fields: deaf education, visual impairment, deafblindness, speech pathology, and communication disorders. These panels participated in a group discussion of both the face validity and content validity of Prototype I. Group consensus methodology was used to determine recommendations and conclusions. The recommendations were that there should be major revisions to the design and format of the instrument, additions and deletions to the explanation of codes, and revisions of the categories.

Phase 2. Based on recommendations from the above mentioned validity activity.

Prototype n was developed. The Parent/Teacher/Paraprofessonal/Specialist Interview

Form was also developed and became step 2 of the FHI. Step 1 is the analysis of the student's Audiological Rep ort; step 2 is the Interview Forms; and step 3 is the administration of the

40 FHI. From this point forward the FHI refers to all 3 steps listed above. Prototype n and the Interview Form were presented to a panel of experts for group discussion of face and content validity. This panel was held in Denver, CO, and consisted of professionals in the fields of deafblindness, deaf education and visual impairment. The consensus method was used to determine recommendations and conclusions. This panel believed the FHI and the Interview Form to be valid but recommended exploring the addition of a component to deal with frequencies of sound and recommended some minor revisions to the format which included combining the sound toys/noisemakers category with the environmental sounds category to make the instrument comprehensive across all age levels.

Phase 3. Prototype HI was developed as a result of the Phase 2 activities.

Prototype HI and the Interview Form were presented individually to two additional experts in the field of deafblindness. One of these experts was a certified audiologist and speech pathologist. The other was a Senior Lecturer in Special Education at James Cook

University in Australia. Both of these individuals believed the instrument and the interview form to have face validity and content validity and recommended only minor changes, to add clarity and specificity to the instrument. As a result of these two interviews. Prototype IV was developed.

Phase 4. A questionnaire was developed for the specific purpose of assessing the content validity of Prototype IV of the Functional Hearing Inventory. A Likert-type scale was used to rank questions that relate to the appropriateness, utility and comprehensiveness. The questionnaire included two questions relating to

41 appropriateness, three questions relating to comprehensiveness, and three questions relating to usability. There were also two open-ended questions asking for elements of the

FHI that were particularly liked and what elements could be improved. The questionnaire and Prototype IV were presented to a select group of individuals at the Deafblind Project

Directors Meeting in Washington, D.C. This group consisted of professionals from the

National Technical Assistance Consortium for DeaflDlindness (NTAC), Helen Keller

National Center, and Hilton/Perkins Foundation. This group recommended further exploration into including frequency and suggested sending the FHI and the questionnaire to fifteen people. This group concurred on face and content validity of the

FHI and the Interview Form, and agreed with this researcher that the quantifiable data that would be gained from the questionnaire would be invaluable.

Phase 5. Eight items on the questionnaire were answered on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Scores on appropriateness, comprehensiveness, and usability of the FHI, provided further information on content validity of the instrument. The mean values of the questions ranged between 3.81 and

4.27 with the highest possible mean of 5.00. Reliability for scores on the questionnaire was assessed using Cronbach's coefficient alpha method (Cohen & Swerdlik, 1999). The reliability coefficient for the 8 items was .78 for the alpha and .80 for the standardized item alpha. These scores exceed the acceptable level of .70 (Nunally, 1978, as cited in

Leong & Austin, 1996).

42 Criterion-Related Validity

The study investigated the relationship between FHI ratings and the teachers' and parents' ratings of hearing functioningand the traditional measure of hearing, the audiogram. Criterion validity ".. involves an explicit standard against which claims about a test can be judged" (Gall, Borg, & Gall, 1996, p. 757). 'In establishing criterion -related validity evidence, scores from a test are correlated with an external criterion" (Kubiszyn

& Borich, 2003). This type of criterion validity is also called concurrent validity, referring to the extent to which the scores of a new instrument correspond to the scores of another test. The other test is called the criterion against which the new test is evaluated

(Gall, Borg, & Gall, 1996). For this study, the new test was the FHI and the criteria was the teachers' and parents' ratings of hearing functioning, and audiogram measures.

The parents' and teachers' ratings of functional hearing were obtained by using the FHI - Parent and Teacher Questionnaires (Broadston, 2003) which consist of a 3 point Likert-type questionnaire with a scale of 0=no response, l=physical response to sound, or 2=discriniination or comprehension of sound. The questionnaire was adapted from the Functional Auditory Assessment for Work with Deaf-Blind Persons (1992) by the researcher. The student's primary teacher completed the Teacher Questionnaire and the Parent Questionnaire was sent home with the student and the parent was asked to complete and return the form to school. Four parents did not return the questionnaire so they were contacted by phone and the questionnaire was conducted over the phone for two of the parents and the other two were never contacted and never responded to the voice messages.

43 The FHI ratings were correlated with each child's audiogram as to response or no response for the ranges of levels of intensity that are listed on the FHI. Only information regarding intensity levels was used from the audiogram. Information regarding frequencies was not utilized. All children reported on the Deafblind Census are required to have an audiological evaluation a minimum of every three years as mandated by

Individuals with Disabilities Education Act; therefore the results of the audiogram were obtained from the student's school records. Parental consent was obtained prior to accessing the records.

The FHI ratings that were used for criterion-related validity included only those signals for which both raters agree on the signal, level of intensity, and level of response.

This included the correlations of the FHI ratings with the Parent and Teacher ratings and the FHI ratings with the audiogram.

Interrater Reliability

The study investigated the relationship between the FHI ratings of two trained evaluators. Interrater reliability is 'the extent to which the scores assigned by one observer of events correlate with the scores assigned by another observer of the same event" (Gall, Borg, & Gall, 1996, p. 761). For this study, two raters observed each student during the same session and met immediately afterwards to discuss and critique the observation. The two raters included the researcher and one other rater who was trained by the researcher. The second rater was trained using the FHI assessment

44 instrument, the Instruction Manual, a videotape and CD that were developed for training

purposes.

The environments were evaluated prior to the actual administration of the FHI.

Informal observations of the student within his or her natural environment, and an

informal interview of the student's teacher are necessary to determine the three different

environments of varying background noise levels that are part of the student's d aily

routine. (The FHI requires that the student be observed in three different environments

with different levels of background noise.) However, not all students' routines involved

three different environments so for some students observations were only done in two

environments with varying background noise levels. A sound level meter was used to

determine the decibel levels of these environments during the pre-observation and the

actual administration of the FHI, to ensure that the environments have varying levels of

background noise. The two raters observed each student within the chosen environments.

The raters observed the students in the first and subsequent environments. The decibel level of the background noise was recorded using the coding system on the protocol. The raters stood near each other to ensure that the decibel level of the signal was not influenced by distance from the sound source. The raters stood eight to ten feet from the subject so as to limit possible visual distraction of the subject by the raters. As sounds occurred naturally during the observation period, the raters individually recorded the type of environmental and speech signals that occurred and the intensity level of each signal. The raters also recorded the student's respon se to the signal and the level of that response was coded. Immediately following each session the two raters met to discuss

45 and critique their observations and they addressed any disagreements of the level of response of the subject by attempting to come to consensus about the child' s response

(Sawada, Pibum, Judson, & Turiey, 2002).

During the discussions by the raters immediately following each observation, the raters identified which sound signals were identified by both raters and only the information relating to those common signals were correlated. It was possible for each rater to independently observe and record various signals that might have occurred simultaneously or might not have beem observed by the other rater. Therefore, only those signals that were common to both raters were analyzed.

Data Collection

Data Analysis

This study used descriptive and inferential statistics. Descriptive techniques included frequency counts and percentages to illustrate the aggregate responses about the participants. The null hypotheses were tested using a significance level of 0.01, rather than the customary 0.05, due to there being several hypotheses, to reduce the likelihood of a Type I error. Cohen' s Kappa was used to measure agreement for criterion validy as well as to determine interrater reliability. For criterion validity, the FHI - Teacher

Questionnaire and the FHI-Parent Questionnaire, the FH/ratings were recoded as 0 to indicate no response; 1 for the lower three levels (awareness/reflexive, attention/alerting, and localization; and 2 for the higher three levels (discrimination, recognition, and comprehension). These three levels were considered to be comparable to the teachers'

46 and parents' ratings indicating a 0 for no response; 1 for a physical response, that is, some motion by the child indicating awareness of the sound; and 2 for a discriminating response, that is, attending to or understanding of the sound by the child. Having equal- metric scales allowed for meaningful agreements or disagreements.

With respect to the audiogram, the FHI has five ranges of signal intensity which could be matched on the audiogram. Within each range, whether the child responded to a sound was noted by the raters. The indications of presence or absence of a response for the five ranges by the evaluators was correlated using Cohen' s Kappa. Since the number of signal intensity ranges was the same, there was no need to recode them to insure equal metrics. The degree of agreement was indicated by the calculation of Cohen' s Kappa.

Table 3 describes the instruments, sources, data scales, and statistical techniques for data analysis.

47 Table 3

Criterion Validity by Instrument, Source. Scale, and Technique Instruments to be Source of information Data scale Statistical technique correlated for for data analysis criterion validity 7 Levels of response Teachers 3-point Likert-type Cohen' s Kappa (recoded as 3) of the FHI with the FHI - Teacher Questionnaire 1 Levels of response Parents 3-point Likert-type Cohen' s Kappa (recoded as 3) of the FHI with the FHI-Parent Questionnaire

5 Ranges of intensity School records Response/No Cohen' s Kappa of the FHI with the response over five Audiogram intensity ranges

For interrater reliability, the raters assessments of the child' response to sound signals was correlated using Cohen' s Kappa. Since the number of ranks for both was the same, there was no need to recode them to insure equal metrics.

Cohen' s Kappa was an appropriate choice because it is specifically designed to measure interrater agreement and is often used to examine the reliability of ratings

(Howell, 1992, p. 148; Liebetrau, 1983, p. 32; Sax, 1989, p. 310). According to Howell

(1992, pp. 148-150) and Rossi, Schuerman, and Budde (1996, pp. 16-171), kappa measures the percent of agreement between the raters, adjusted for chance, with a positive kappa representing agreement beyond chance and a negative kappa indicating that agreement is less than would be expected by chance. A kappa of 0 means that the raters' agreements equal to that expected by chance. Kappas below 0.3 generally

48 indicate weak reliability while a kappa above 0.5 to 0.6 is generally considered to be an acceptable level of agreement (Baird, Wagner, Healy, & Johnson, 1999).

Materials

The Functional Hearing Inventory Protocol and Instruction Manual (Broadston

& Davidson, 2001) were used. The Instruction Manual was used during the training session for the observer training. The FHI protocol was used by the observers for all subjects. A sound level meter was used during training of the observers and during all observations. The sound level meter was utilized to determine the decibel level of the background noise during the observation and the decibel level of the signals that occurred during the observations. A CD-ROM and Videocassette were used during the training of the second rater to show examples of the various categories on the inventory and the various types and levels of response to sound listed on the inventory. The NCSS computer package (Hintze, 2001) was used to evaluate and summarize quantitative data.

Summary

Chapter HI recalled the problem of the study, that the Functional Hearing

Inventory (FHI) needs additional evidence for validity and reliability. The research questions and null hypotheses were listed. The setting for the observations; the participant selection process; the data collection procedure; and the research design, including the five-phase development of the FHI; were described. Establishment of criterion-related validity with respect to the teachers' and parents' ratings of hearing

49 functioning, and the audiogram was proposed; as well as investigating interrater reliability between the FHI ratings of two trained evaluators. Finally, the data collection and data analysis procedures were outlined and needed materials were specified.

50 CHAPTER IV

RESULTS

Introduction

The purpose of this study was to obtain evidence of the validity and reliability of the Functional Hearing Inventory (FHI). In particular, criterion-related validity for the

FHI was investigated by correlating it with the teachers' and parents' ratings, and the traditional measure of hearing, the audiogram. Interrater reliability of the FHI were

studied through the correlation of the FHI ratings of deafblind subjects by two trained evaluators.

The chapter is organized into six parts: The 'Introduction" explained the purpose and actions of the study. The 'Research Questions" will list the research questions developed by the researcher that the study sought to answer. The "Null Hypothesis" will restate the research questions as null hypotheses. The 'Demographics" part will present the demographic information of the participants. The 'Criterion Related Validity" section will describe the results from the correlations between the FHI and the FHI Teacher

Questionnaire, the FHI Parent Questionnaire, and the audiogram. 'Interrater Reliability" part will present the results of the correlations between the two trained evaluators on the

FHI. The final section, the 'Summary," will pro vide an overall analysis of the data collection process and the results of the study.

51 Research Questions

This study investigated the following research questions:

1. What is the extent of the relationship between FHI ratings and teachers'

ratings of hearing functioning?

2. What is the extent of the relationship between FHI ratings and parents' ratings

of hearing functioning?

3. What is the extent of the relationship between FHI ratings and the traditional

measure of hearing, the audiogram?

4. What is the extent of the relationship between the FHI ratings of two trained

evaluators?

Null Hypotheses

For objectivity, the research questions are framed as null hypotheses. The level of statistical significance is set at the level of 0.01 (which was adjusted from the commonly adopted 0.05 to account for multiple statistical tests), indicating a willingness to accept only a small likelihood of a Type I error.

Hypothesis 1: There is no statistically significant relationship between the FHI

and teachers' ratings.

Hypothesis 2: There is no statistically significant relationship between the FHI

and parents' ratings.

Hypothesis 3: There is no statistically significant relationship between the FHI

and the audiogram.

52 Hypothesis 4: There is no statistically significant relationship between the FHI

ratings of two trained evaluators.

Demographics

The results from the Demographics section are presented in Tables 3-9. Originally there were a total of 15 subjects for which demographic, audiogram, teacher questionnaire, and parent questionnaire information was available. One of the female participants was not included in the count because the FHI could not be conducted with her due to her being located in a remote site. The logistics of having both raters and the subject available locally at the same time was not possible.

Table 4

Frequency Distribution by Gender Gender Count Percentage Male 8 57 Female 6 43 Total 14 100

Table 4 displays the subject count by gender. There were a total of fourteen subjects comprising eight males and six females, representing 57 and 43 percent of the sample, respectively.

53 Table 5

Frequency Distribution by Age Age Count Percentage 4 1 7 7 1 7 10 1 7 13 1 7 14 3 21 17 1 7 18 4 29 20 2 14 Total 14 99* Note. *Total does not equal 1(3 0 due to rounding error.

Table 5 displays the subject count by age. The subjects ranged in age from 4 to 20 with the majority in their teens. By count, there was only one subject for ages 4, 7, 10, 13, and 17; two aged 20, three aged 14, and four aged 18. Respective percentages were 7, 14,

21, and 29, rounding included.

54 Table 6

Frequency Distribution by Grade Grade Count Percentage 0 1 7 1 2 14 4 1 7 6 1 7 7 3 21 9 1 7 11 2 14 12 3 21 Total 14 98* Note. *Total does not equal 100 due to rounding error.

Table 6 displays the subject count by grade. The subjects' grade ranged from 0 pre-K (0) to 12th with the majority of the subjects in the 7* and 12"^ grade. By count, there was only one subject for grades pre-K, 4*, 6*, and 9*; two for l" and 11* grades; and three for 7* and 11"' grades. Respective percentages were 7, 14, and 21, rounding included.

Table 7

Frequency Distribution by Ethnicity Ethnic Group Count Percentage Caucasian 8 57 African American 43 Total 14 100

55 Table 7 displays the subject count by ethnicity. As recorded on the FHI the ethnic group 1 represented Caucasian subjects and group 2 represented African American subjects. By count, there was a total of 14 subjects comprising eight Caucasian subjects and six African American subjects, representing 57 and 43 percent of the sample, respectively.

Table 8

Frequency Distribution by Primary Disability Primary Disability Count Percentage Deafblind 6 43 Hearing Impaired 2 14 Multiple Disabilities 4 29 Visually Impaired 2 14 Total 14 100

Table 8 displays the subject count by primary disability. The primary disability was documented from the students Individualized Education Plan (lEP) located in the subjects' school records. By count, there was total of 14 subjects, six whose primary disability was deafblind, two hearing impaired, four multiple disabilities, and two visually impaired. Respective percentages were 43, 14, 29, and 14.

Table 9

Frequency Distribution by Secondary Disability Secondary Disability Count Percentage Hearing Impaired 2 50 Visually Impaired 2 50 Total 4 100

56 Table 9 displays the subject count by secondary disability. The secondary disability was documented from the student' s Individualized Education Plan (lEP) locati in the subjects' school records. By count, there was a total of only four subjects with a documented secondary disabilities: two hearing impaired and two visually impaired with each representing 50 percent of this distribution.

Table 10

Frequency Distribution of Students wearing Hearing Aids During FHI Observations Hearing Aids Worn Count Percentage 0 9 64 1 5 36 Total 14 100

Table 10 displays the subject count by those students who wore a hearing aid or hearing aids during the FHI observations. A 0 represents students who did not wear hearings aides and a 1 represents those who did wear hearing aids. By count, there was a total of 14 subjects, nine of whom did not wear hearing aids and five who did wear a hearing aid or aids, representing 64 and 36 percent of the sample, respectively.

Criterion-Related Validity

The first research question investigated was. What is the extent of the relationship between the FHI ratings and the teachers' ratings of hearing functioning? To answer the question, Cohen' s kappa was calculated from ihi^HI and teachers' ratings. The original

FHI ratings are based on the intensity levels of the environmental conditions/background noise and signal, and then the subject' s level of response to that signal. The background

57 and signal levels range from 1, meaning less than 50 decibels; to 5, meaning 100 or more decibels. The response levels range from 0, meaning no response; to the highest level of

6, meaning comprehension of the signal. These response levels were recoded to 0, 1, and

2, meaning no response, physical response, and discriminating response, respectively.

The recoded 0 corresponds with the response of NR (No Response), the recoded 1 corresponds with the response levels of 1, 2, 3 and the recoded 2 corresponds with the response levels of 4, 5, 6, on the original FHI. The FHI Teacher Questionnaire was coded with 0, 1, and 2, with the same meanings. For signal levels 1, 2, 3, and 4, the only ones for which responses were available in this study for both the FHI and the teacher questionnaire, these 0, 1, and 2 codings were used in the calculation of Cohen' s kappa.

Only items observed for the FHI and also listed on the teachers' questionnaire were included in the correlation. Table 11 illustrates the findings for the FHI ratings and the teachers' ratings of the subjects' hearing functioning.

Table 11

Cohen' s Kappa between FHI Ratings and Teachers' Ratings of Hearing Functioning Kappa Standard Error Probability Level 0.46 0.12 0.0043

The relationship between the FHI ratings and the teachers' ratings is 0.46, statistically significant at the 0.0043 level, indicating that there is a moderate relationship between the two. The standard error of 0.12 is comparatively large, probably due to the relatively small sample. The null hypothesis, that there is no statistically significant relationship between the FHI and teachers' ratings, is rejected.

58 The second research question investigated was. What is the extent of the relationship between the FHI ratings and the parents' ratigs of hearing functioning?

To answer the question, Cohen' s kappa was calculated from ih^HI and parents' ratings.

The original FHI ratings are based on the intensity levels of the environmental conditions/background noise and signal, and then the subject' s level of response to that signal. The background and signal levels range from 1, meaning less than 50 decibels; to

5, meaning 100 or more decibels. The response levels range from 0, meaning no response; to the highest level of 6, meaning comprehension of the signal. These response levels were recoded to 0, 1, and 2, meaning no response, physical response, and discriminating response, respectively. The recoded 0 corresponds with the response of

NR (No Response), the recoded 1 corresponds with the response levels of 1, 2, 3 and the recoded 2 corresponds with the response levels of 4, 5, 6, on the original FHI. The FHI

Parent Questionnaire was coded with 0, 1, and 2, with the same meanings. For signal levels 1, 2, 3, and 4, the only ones for which responses were available in this study for both the FHI and the parent questionnaire, these 0, 1, and 2 codings were used in the calculation of Cohen' s kappa. Only items observed for th#'/// and also listed on the parents' questionnaire were included in the correJtion. Table 12 illustrates the findings for the FHI ratings and the parents' ratings of the subjects' hearing functioning.

Table 12

Cohen' s Kappa between FHI Ratings and Parents' Ratings of Hearing Functioning Kappa Standard Error Probability Level 0.41 0.10 0.000016

59 The relationship between the FHI ratings and the parents' ratings is 0.41,

statistically significant at the 0.000016 level, indicating that there is a moderate relationship between the two. The standard error of 0.10 is relatively large compared to

the value of kappa, probably due to the relatively small sample. The likelihood of this

value of kappa being replicated in another study is not particularly great. The null

hypothesis, that there is no statistically significant relationship between the FHI and parents' ratings, is rejected.

The third research question investigated was. What is the extent of the relationship between the FHI ratings and the traditional measure of hearing, the

audiogram? To answer the question, Cohen' s kappa wasdculated from the FHI and the

audiogram. The original FHI ratings are based on the intensity levels of the environmental conditions/background noise and signal, and the subject' s level of response to that signal within that environment/background noise. The background noise level and signal levels range from 1, meaning less than 50 decibels; through 5, meaning 100 or more decibels. The response levels range from 0, meaning no response; to the highest level of 6, meaning comprehension of the signal. These response levels on the FHI were recoded to 0 and 1 meaning absence or presence of a response, respectively, for each of the five levels for intensity of signal as described on the FHI Explanation of Codes Table.

The audiogram was coded using 0 and 1 meaning absence or presence of a response, respectively, for each of the five levels for intensity of signal as described on the FHI

Explanation of Codes Table. For intensity of signal levels 1, 2, 3, 4, and 5, these 0 and 1

60 codings were used in the calculation of Cohen' s kappa. Table 13 illustrates the findings for the FHI ratings and audiogram.

Table 13

Cohen' s Kappa between FHI Ratings and Audiogram Kappa Standard Error Probability Level 0.13 0.11 0.26

The relationship between the FHI ratings and the audiograms' ratings is 0.13, statistically significant at the 0.26 level, but not at the 0.01 level, indicating that there is no significant relationship between the two. The standard error of 0.11 is comparatively large, probably due to the relatively small sample. The likelihood of this value of kappa being replicated in another study is not particularly great. The null hypothesis, that there is no statistically significant relationship between the FHI and the audiogram, cannot be rejected, indicating a lack of a relationship between the two measures.

Interrater Reliability

The fourth research question investigated was. What is the extent of the relationship between the FH/ratings of two trained evaluators? The relationship was determined separately for environmental conditions/background noise, signal, and response. To answer the question for environmental conditions/background noise intensity levels, Cohen' s kappa was calculated from the evaluatorsF/// background noise measurements. The original measures of the FHI background noise levels are based on the readings from the sound level meters. The decibel levels as recorded on the FHI were

61 converted to the range of 1, meaning less than 50 decibels; through 5, meaning 100 or more decibels, as described in the Explanation of Codes Table on the FHI observation form. Table 14 illustrates the findings for the evaluators' F///background ratings.

Table 14

Cohen' s Kappa between Trained Evaluators' FHI Environmental Conditions/Background Noise Measurements Kappa Standard Error Probability Level 0.96 0.03 < 0.0000001

The relationship between the trained evaluators' FHI environmental conditions/background noise intensity level measurements is 0.96, statistically significant below the 0.0000001 level, indicating that there is a strong relationship between the two.

The standard error of 0.03 is comparatively small. The likelihood of subsequent studies

obtaining the same results is high. The null hypothesis, that there is no statistically

significant relationship between the FHI ratings of two trained evaluators, is rejected for

environmental conditions/background noise measurements.

To answer the question for intensity of signal, Cohen' s kappa was calculated from

the evaluators' FHI intensity level measurements of the sound signals. The original

measures of the FHI intensity of signals are based on the readings from the sound level

meters. The decibel levels as recorded on the FHI were converted to the range of 1,

meaning less than 50 decibels; through 5, meaning 100 or more decibels, as described in

the Explanation of Codes Table on the FHI observation form. Table 15 illustrates the

findings for the evaluators' FHI background ratings.

62 Table 15

Cohen^_sjCappa between Trained Evaluators' FHI Intensity of Signals Memments Kappa Standard Error Probability Level 0.85 0.03 < 0.0000001

The relationship between the trained evaluators' FHI intensity level of signals measurements is 0.85, statistically significant below the 0.0000001 level, indicating that there is a strong relationship between the two. The standard error of 0.03 is comparatively small. The null hypothesis, that there is no statistically significant relationship between the FHI ratings of two trained evaluators, is rejected for intensity level measurements of the sound signals.

To answer the question for response levels, Cohen' s kappa was calculated from the evaluators' FHI levels of response. The original measures of the FHI levels of response are based on the evaluators observation of the participants response to the sound signal as described in the Explanation of Codes Table of the FHI. The levels of response are coded as 1 meaning an Awareness/Reflexive response through 6 meaning

Comprehension, as described in the Explanation of Codes Table on the FHI observation form. Table 16 illustrates the findings for the evaluators' Fi^/levels of response.

Table 16

Cohen' s Kappa between Trained Evaluators' FHI Levels of Response Kappa Standard Error Probability Level 0.84 0.03 < 0.0000001

63 The relationship between the trained evaluators' FHI levels of response is 0.84, statistically significant below the 0.0000001 level, indicating that there is a strong relationship between the two. The standard error of 0.03 is comparatively small. The null hypothesis, that there is no statistically significant relationship between the FHI ratings of two trained evaluators, is rejected for the levels of response.

Summary

Chapter IV dealt with an analysis of the data collected on 14 deafblind students whose functional hearing was evaluated using the FHI, the FHI Parent Questionnaire, the FHI Teacher Questionnaire, and the data collected from the students' school records including demographic information and the students' audiograms. The FHI was administered by two trained evaluators, the questionnaires were completed by the parent or guardian and the primary teacher of the participant, and the demographic data and the audiogram were obtained by the researcher from the participants' school records. The chapter was divided into six parts: an Introduction, Research Questions, Null Hypotheses,

Demographics, Criterion Related Validity, Interrater Reliability, and a Summary.

The demographic section indicated that 57% of the participants were male, and

57% were Caucasian. The majority of the participants are in their teens with 21% being in the 7'*' grade. Over 43% of the participants had a primary disability of deafblind and four of the participants had a secondary disability of either hearing or visual impairment.

Nine of the 14 participants, or 64%, wore a hearing aid during the FHI observations.

64 The criterion related validity section indicated that there is a moderately strong relationship between the FHI ratings and the teachers' ratings, and the results indicated a somewhat weaker relationship between the FHI ratings and the parents' ratings. The results also indicated that there was not a significant relationship between the FHI and the audiogram.

Results of the data analysis indicate that the null hypothesis for interrater reliability could be rejected for environmental conditions/background noise, signal, and response levels. Tables 11-16 displayed these results. The results indicated very strong correlations between the two evaluators in all three areas relative to the FHI.

65 CHAPTER V

SUMMARY, CONCLUSIONS, RECOMMENDATIONS,

AND IMPLICATIONS

Summary

The Functional Hearing Inventory (FHI), an observational instrument for functional hearing, provides information about how a deafblind child uses his/her residual hearing within his/her natural environment. This study obtained evidence of the validity and reliability of the FHI. In particular, criterion-related validity for the FHI was investigated by correlating it with teachers' and parents' ratings of functional hiag, and the traditional measure of hearing, the audiogram. Interrater reliability of the FHI was studied through correlating the FHI ratings of deafblind subjects by two trained evaluators using point-by-point and consensus methods. The two raters included the researcher and one other rater who was trained by the researcher. The raters observed students in their natural settings and recorded the information on the FHI observation form. The subjects for this study were a purposeful sample of students between the ages of three and twenty-one who were reported on the Federal Deafblind Census.

There were 14 participants for whom there was usable information, comprising 6 females (43%) and 8 males (57%). The demographic section indicated that 57% of the participants were male, and 57% were Caucasian. The majority of the participants were in their teens with 21% being in the 7^^ grade. Over 42% of the participants had a primary disability of deafblind and four of the participants had a secondary disability of either hearing or visual impairment.

66 Cohen' s kappa was used to measure agreement for criterion validity as well as to determine interrater reliability. There was a moderate relationship between the FHI ratings and the teachers' ratings^ = 0.46, p = 0.0043), with a slightly weaker yet still a moderate relationship between the FHI ratings and the parents' ratingsi< = 0.41, p =

0.000016 ). There was not a significant relationship between the FHI and the audiogram

(K = 0.13, p = 0.26). The null hypothesis for interrater reliability could be rejected for environmental conditions/background noise, signal, and response levels. The respective kappas were 0.96 (p < 0.0000001), 0.85 (p < 0.0000001), and 0.84 (p < 0.0000001), all considered to be high levels of association.

Chapter five addresses the conclusions and inferences that may be drawn from the study. It is divided into four sections: summary, conclusions, implications, and recommendations.

Limitations of the Study

A limitation of the study is that the small sample size limits the generalizability of the findings. It is recommended that a larger sample be used in subsequent studies.

Because the sample size is limited it would be beneficial to increase the sample size within the same region so that a more representative sample for that region can be developed.

67 Conclusions

The study sought to answer four research questions posed by the researcher. The first research question investigated was. What is the extent of the relationship between the FHI ratings and the teachers' ratings of hearing functioning? To answer the question,

Cohen' s kappa was calculated from ihi^HI and teachers' ratings. There was a moderate

(Hintze, 2001) relationship between the FHI ratings and the teachers' ratingsi< = 0.46, p

= 0.0043).

The second research question investigated was. What is the extent of the relationship between the FHI ratings and the parents' ratings of hearing functioning?

To answer the question, Cohen' s kappa was calculated from ihi^HI and parents' ratings.

The relationship between the FHI ratings and the parents' ratings was 0.41, statistically significant at the 0.000016 level, and considered to be a moderate measure of association

(Hintze, 2001).

The third research question investigated was. What is the extent of the relationship between the FHI ratings and the traditional measure of hearing, the audiogram? To answer the question, Cohen' s kappa was calculated from thi^HI and the audiogram. There was not a significant relationship between the FHI and the audiogram

(K = 0.13, p = 0.26). According to Hintze (2001), this is a low measure of association.

The lack of a relationship is understandable because the audiogram measures the threshold levels of man-made sounds and the FHI measures the student's use of residual hearing within natural environments. The results of this study support the idea that obtaining information about functional hearing is different from the results obtained in a

68 clinical setting from a traditional audiological evaluation. The lack of a relationship between the two suggests that the two assessments are not measuring the same hearing ability (Aitken, Buultjens, Clark, Eyre, & Pease, 2000; Franklin, 1977, 1999; Goodrich &

Kinney, 1985; McClean, Bailey, & Woriey, 1996).

The fourth research question investigated was. What is the extent of the relationship between the FHI ratings of two trained evaluators? The relationship was determined separately for environmental conditions/background noise, signal, and response. To answer the question for environmental conditions/background noise intensity levels, Cohen' s kappa was calculated from the evaluatorsF/// background noise measurements. The relationship between the trained evaluators' FHI environmental conditions/background noise intensity level measurements was 0.96, statistically significant below the 0.0000001 level, indicating that there is a relationship between the two. According to Hintze (2001), this is a high measure of association. A high degree of relationship would be expected because both raters used sound level meters, an objective instrument, to measure the intensity of the environmental conditions/background noise. A possible reason that there are slight variations in the readings is that the two raters were not always standing side by side and the distance could have affected the readings.

To answer the question for intensity of signal, Cohen' s kappa was calculated from the evaluators' FHI intensity level measurements of the sound signals. The original measures of the FHI intensity of signals are based on the readings from the sound level meters. The relationship between the trained evaluators' FHI intensity level of signals measurements is 0.85, statistically significant below the 0.0000001 level, indicating that

69 there is a strong (Hintze, 2001) degree of association between the two. As with the environmental conditions/background noise, the intensity level of the sound signals was also measured by the sound level meter. However, the sound signals occurred spontaneously and often very rapidly so the exact moment that the rater observed the sound level meter could have varied somewhat therefore allowing for a higher variance in the responses. Even though there is more variance than with the environmental conditions/background noise, the level of association is still considered very high.

To answer the question for response levels, Cohen' s kappa was calculated from the evaluators' FHI levels of response. The original measures of the FHI levels of response are based on the evaluators' observaOns of the participant' s response to the sound signal as described in the Explanation of Codes Table of the FHI. The relationship between the trained evaluators' FHI levels of response is 0.84, statistically significant below the 0.0000001 level, indicating that there is a relationship between the two.

According to Hintze (2001), this is a high measure of association. The relationship is considered strong and is comparable to the relationship obtained signal level correlations.

This is noteworthy because of the fact that the levels of response are a subjective measure (based on the raters independent observations) and the signal levels are based on an objective measure (the sound level meter). The extensive training of the second rater prior to the beginning of any observations could have been helpful in enabling the raters to carefully observe and pay attention to the response levels and subtle nuances of the students being observed and might have contributed to the high correlation between the two raters. Also, using the point-by-point and consensus method immediately following

70 each observation could have contributed to the high correlation. The magnitude of the positive correlations suggests that a continued investigation in the psychometric properties of the FHI is warranted.

Recommendations

The results of this study seems to indicate that the ranges for the Environmental conditions/Background noise levels and Intensity of Signal levels on the Explanation of

Codes Table should be modified. The hand held sound level meters that are currently available on the market can only determine the intensity of sound down to 50 dB.

Therefore it is suggested that the ranges of the first level need to be modified. Level one, very quiet to below average, should be changed from >40 to >50; and level two, average noise, should be changed to 50 to 60 dB. In the course of the research it was also noted that there was an overlap of the dB levels among all of the ranges. For example level two was 40-60 dB and level three was 60-80 dB, with 60 dB being in both levels. Therefore the ranges for Environmental Conditions/Background noise should be modified as follows.

Level 1-Very quiet to below average: <50 dB

Level 2-Ayerage noise: 50-60 dB

Level 3-Above average noise: 61-80 dB

Level 4-Very noisy: 81-100 dB

Level 5-Excessively noisy: >100

The ranges for the Intensity of the Signal should be modified as follows.

71 Level 1-Very soft to soft: <50 dB

Level 2-Ayerage: 50-60 dB

Level 3-Loud: 61-80 dB

Level 4-Very loud: 81-100 dB

Level 5-Extremely loud: >100

Another recommended modification in the FHI is to record the actual decibel level of the sound signal on the observation form rather then the code for the range. It appears to be more efficient to record the actual decibel level and it provides more accurate information.

During the assessment process, there was a consistent question between the two raters regarding the difference between the Levels of Response for recognition and comprehension of environmental sounds. A limitation of the FHI is that it is a behavioral/observational instrument and the response levels of the participants are based on the observers' interpretation of the participant's response. In a conversation with the audiologist at Helen Keller National Center, J. Macias (personal communication,

September 26, 2003), it was suggested that the Comprehension level of response implies the use of language and therefore might only apply to environmental sounds if the participant is able to communicate the identification of the sound. As a result of the study and the personal communications, it has been determined that the levels of recognition and comprehension need to be further investigated and information will need to be included in the Explanation of Codes Table and in the FHI Instruction Manual to help clarify the ambiguity that currently exists.

72 In the process of correlating the data, it was found that there needs to be a modification of the FHI Parent and Teacher Questionnaires to include a larger variety of examples of sounds that could potentially occur within both the home and school environments. In fact, a limitation of this study was that there were only a minimal number of sounds that occurred during the observations by the two trained evaluators and that were also listed on the questionnaires. The correlations might have been stronger had there been more sounds to correlate between the FHI and the questionnaires. Further research into the selection of the sounds should be done in order to make appropriate changes. The changes should be made before any further studies are conducted. In addition, it is recommended that a larger study with deafblind children be conducted to affirm the results that have been obtained in this study.

The FHI was originally designed to evaluate students in three different environments with varying background noise levels. As a result of this study, it was found that three environments were not always available for every child. Some students' natural environments throughout the school day, only involved environments with two different levels of intensity. Therefore the instruction manual and observation form should be modified to account for such situations.

Implications

Often individuals receive audiological assessment that assesses only their sensitivity to pure tones, which are mechanically generated sounds that do not occur naturally in the environment, in a clinical type setting. An audiogram, the graphical

73 results of pure-tone testing, indicates what an individual does not hear, when what is truly important to determine is actually what one does hear and if possible how they hear.

Therefore, children's performance or lack of performance in the clinical setting may not actually predict their performance in the classroom or at home. This premise seems to be supported by the results obtained in this study. The data showed that there was no relationship between the evaluators' observations and the audiogram. This result means that the evaluators observed responses to naturally occurring sounds within intensity level ranges that the audiogram did not indicate the children responded to.

This lack of relationship between the audiogram and the two trained raters further supports the idea that obtaining functional information about a child's hearing that is classroom oriented and pragmatic for educational planning is important when designing appropriate programs for children with deafblindness. The use of the FHI is a way to learn to recognize the child's specific behavioral responses to sounds within his or her natural settings.

According to McLean, Bailey, Jr., and Wolery (1996), 'When the parameters that facilitate use of hearing are delineated, the child can be encouraged to use his or her hearing optimally to adapt to all environments" (p.37). The information gleaned from the

FHI can be used to help parents and educators manipulate environmental background noise levels in the classroom or at home, to maximize students' use of their residual hearing, and to provide a better listening environment for students' leaming. Further study in the area of the educational implications of the child' s functional hearing needs to be conducted.

74 The FHI was designed as a diagnostic and prescriptive instrument. It provides a systematic procedure for recording the present level of use of hearing, identifying the functional level of use, and providing a focus for intervention strategies. The FHI was contructed to be comprehensive and usable across age levels. It was created so that the information and results that are obtained from the inventory can be used to plan an appropriate program for the student and can provide information about children's usage of hearing to access their environment.

75 BIBLIOGRAPHY

Works Cited

Aitken, S., Buultjens, M. Clark, C, Eyre, J.T., «& Pease, L. (2000). Teaching children who are deafblind: Contact communication and leaming. London, England: David Fulton Publishers, Ltd.

Alpiner, J.G. & McCarthy, P.A. (1987). Rehabilitative audiology: Children and adults. Baltimore, MD: Williams & Wilkins.

Auditory assessment and programming for severely handicapped and deaf-blind students, (n.d.). San Francisco, CA: The Bay Area Severely handicapped Deaf- Blind Project.

Baird, C, Wagner, D., Healy, T., & Johnson, K. (1999, November/December). Risk assessment in child protective services: Consensus and actuarial model reliability Child Welfare, 78(6), 723-748.

Batshaw, M.L. (Ed.)(1997). Children with disabilities (4"' ed.). Baltimore, MD: Paul H. Brookes Publishing Co.

Bess, F.H. & Humes, L.E. (1990). Audiology: The fundamentals. Baltimore, MD: Williams & Wilkins.

Broadston, P. (2000). An analysis of hearing assessments/screenings. Unpublished manuscript, Texas Tech University, Texas.

Broadston, P. (2003). Functional hearing inventory - Parent questionnaire. Author: Little Rock, AR.

Broadston, P. (2003). Functional hearing inventory - Teacher questionnaire. Author: Little Rock, AR.

Broadston, P. & Davidson, R. (2001). Functional hearing inventory. Unpublished assessment instrument, Texas Tech University, Lubbock,Texas.

Chen, D. (1989). Functional hearing screening. Published in Parents and visually impaired infants. Lewisville, KY: PAVE Project and American Printing House for the Blind.

76 Chen, D. (1999). Understanding hearing loss. In Essential elements in early intervention (pp. 207-245). New York: American Foundation for the Blind.

Chen, D. (Ed.). (1997). Effective practice in early intervention: Infants whose multiple disabilities include both vision & hearing loss. East Lansing, MI: National Center for Research on Teacher Leaming. (ERIC Document Reproduction Service No. ED406795)

Cohen, R.J. & Swerdlick, M.E. (1999). Psychological testing and assessment: An introduction to tests and measurement. Mountain View, CA: Mayfield Publishing Company.

Crook, C, Miles, B., & Riggio, M. (1999). Assessment of communication, hi B. Miles & M. Riggio (Ed.), Remarkable conversations: A guide to developing meaningful communication with children and young adults who are deafblind. Watertown, MA: Perkins School for the Blind.

Davidson, R. (1998). Deafblind Census of Texas. [Brochure]. Lubbock, TX: Author.

Downs, M. (1979). Early evaluation and diagnosis of hearing loss and its management. In Educational methods for deaf-blind and severely handicapped students, volume II. East Lansing, MI: National Center for Research on Teacher Leaming. (ERIC Document Reproduction Service No. ED 176430)

Downs, M. (1979). Screening score card. In How we hear. Monmouth, OR: The National Information Clearinghouse on Children Who Are Deaf-Blind, U.S. Department of Education, Office of Special Education Programs. (DB Link Document No. ASM-96-016)

Ebel, R.L. & Frisbie, D.A. (1991). Essentials of education measure fj"" ed.). Englewood Cliffs, NJ: Prentice-Hall, Inc.

Eyre, J. (2000). Holistic assessment. In S. Aitken, M. Buultjens, C. Clark, J.T. Eyre, & L. Pease. Teaching children who are deafblind: Contact communication and leaming. London, England: David Fulton Publishers, Ltd.

Rexer, C. (1997). Individual and sound-field FM systems: Rationale, description, and use. Volta Review. 99(3), 133-162.

Flexer, C. (1999). Facilitating hearing and listening in young children,( 2" ed.). San Diego, CA: Singular Publishing Group, Inc.

77 Folsom, R.D. (1984, Oct.). An approach to the audiologic assessment of multi­ handicapped deaf-blind children. In A.M. Skylanda (Ed.), Insight in sight: Proceedings of the conference on the visually impaired child. East Lansing, MI: National Center for Research on Teacher Leaming. (ERIC Document Reproduction Service No.ED264699)

Franklin, B. (1977). Audiological assessment of the deaf-blind and multihandicapped child. In C. Rouin, Proceedings: Basic assessment and Intervention techniques of deaf-blind and multihandicapped children (pp. 17-21). East Lansing, MI: National Center for Research on Teacher Learning. (ERIC Document Reproduction Service No.ED 146726)

Functional auditory assessment for work with deaf-blind persons. (1992). Toronto, Ontario, Canada: Canadian National Institute for the Blind, Ontario Division, Deaf-Blind Services.

Functional hearing evaluation. (1999). Adapted from Helmstetter, R.S., Guess, D., Murphy-Herd, M., & MuUigan, M. (1984). Programming for students who are deaf-blind: Vision assessment. Lawrence, KS: University of Kansas

Gall, M.D., Borg, W.R., & Gall, J.P. (1996). Educational research: An introduction, 6"' Edition. White Plains, NY: Longman Publishers USA.

Goetz, L., Guess, D., & Stremel-Campbell, K. (Ed.) (1987). Innovative program design for individuals with dual sensory impairment. Baltimore, MD: Paul H. Brookes Publishing Co.

Gleason, D. (1984). Auditory assessment of visually impaired preschoolers: A team effort. Education of the visually handicapped,(3), 102-113.

Goodrich, J.A. & Kinney, P.G. (1985). ADAPTIPS: Adapting curricula for students who are deaf-blind and who function in the sensorimotor development stage. East Lansing, MI: National Center for Research on Teacher Leaming. (ERIC Document Reproduction Service No. ED276255)

Hintze, J. L. (2001). NCSS 2001: Quick Start & Self Help, User' s guiddandll. Kaysville, UT: Number Cmncher Statistical Systems.

Howell, D. C. (1992). Statistical methods for psychology. (3"* ed). Boston, MA: PWS-Kent Publishing Company, p. 148.

Hull, R. (1997). Aural rehabilitation: Serving children and adults, (3"* ed.) San Diego, CA: Singular Publishing Group, Inc.

78 Johnson, C, Benson, P.V., & Seaton, J.B. (1997). Educational audiology handbook. Washington, DC: Alexander Graham Bell Association for the Deaf

Kubiszyn, T. & Borich, G. (2003). Educational testing and measurement: Classroom application and practice (7* ed.). New York: John Wiley & Sons, Inc.

Leong, F.T. & Austin, J.T. (Eds.) (1996). The psychology research handbook. Thousand Oaks, CA: Sage Publications, Inc.

Liebetrau, A. M. (1983). Measures of association, hi J. L. Sullivan & R. G. Niemi (Series Eds.), Quantitative applications in the social sciences: Vol. 32. (p. 32). Beveriy Hills, CA: Sage Publications, hic.

Martin, F.N. (1994). Introduction to Audiology (5* ed.). Englewood Cliffs, NJ: Prentice- Hall Inc.

McClean, M., Bailey, D.B., Jr., & Woriey, M. (1996). Assessing infants and preschoolers with special needs (2'"^ ed.). Englewood Cliffs, NJ: Prentice-Hall, hic.

Mclnnes, J. M. (Ed.) (1999). A guide to planning and support for individuals who are deafblind. Toronto, Canada: University of Toronto Press.

Mclnnes, J. M. & Treffry, J.A, (1982). Deaf-blind infants and children: A developmental guide. Toronto, Canada: University of Toronto Press, Inc.

Miles, B. & Riggiom M. (Eds.) (1999). Remarkable conversations: A guide to developing meaningful communication with children and young adults who are deafblind. Watertown, MA: Perkins School for the Blind.

Moore, J.M. & Coninx, F. (1996). The audiological assessment of individual with deafblindness utilizing behavioural methods. Proceedings of the Fifth Canadian Conference on Deafblindness, Vancouver, B.C., 225-234.

Northern, J. & Downs, M. (1991). Hearing and Hearing Loss in Children. Baltimore, M.D.: WiUiams & Wilkins.

Nunnally, J. (1978). Psychometric theory. New York, NY: McGraw-Hill.

Olson, K., Miles, B., & Riggio, M. (1999). Environments that encourage communication. In B. Miles & M. Riggio (Ed.), Remarkable conversations: A guide to developing meaningful communication with children and young adults who are deafblind. Watertown, MA: Perkins School for the Blind.

Parent checklist. Austin, TX: Texas School for the Blind and Visually Impaired.

79 atton, M. Q. (1990). Qualitative evaluation and research methods (2"^* ed.). Newbury Park, CA: Sage. In Gall, M. D., Borg, W. R., & Gall, J. P. (1996). Educational Research: An hitroduction (6"^ ed.). White Plains, NY: Longman Publishers USA.

Ross, M., Brackett, D., & Maxon, A.B. (1991). Assessment and management of mamstreamed hearing-impaired children: Principles and practices. Austin, TX: PRO-ED, Inc.

Rossi, R, Schuerman, J., & Budde, S. (1996, June). Understanding child maltreatment decisions and those who make them. Chicago: University of Chicago, Chapin Hall Center for Children. In C. Baird, D. Wagner, T. Healy, & K. Johnson (1999, November/December). Risk assessment in child protective services: Consensus and actuarial model reliability Child Welfare, 78(6), (pp. 723-748).

Sawada, D., Pibum, M. D., Judson, E., & Turiey, J. (2002, October). Measuring reform practices in science and mathematics classrooms: The reformed teaching observation protocol. School Science and Mathematics, 102(6), 245-253.

Sax, G. (1989). Principles of educational and psychological measurement and evaluation. (3,"^ ed.). Belmont, CA: Wadsworth Publishing Company, p. 310..

Schow, R.L. & Nerbonne, M.A. (1996). Introduction to audiologic rehabilitaion (3"* ed.). Needham Heights, Ma: Allen & Bacon.

Shapiro, S.L. (1973). The noise pollution crises: Part I. the problem. The eye, ear, nose, throat monthly, volume 52^ 62-66.

Shapiro, S.L. (1973). The noise pollution crises: Part H. The solution. The eye, ear, nose, throat monthly, 52, 110-114.

Steinberg, A.G. & Knightly, CA. (1997). Hearing sounds and silences. In M.L. Batshaw, Children with disabilities (A^ ed.). Baltimore, MD: Paul H. Brookes.

Sweitzer, R. (1979). Auditory assessment of the multihandicapped deaf-blind child. In Proceedings: Workshop for serving the deaf-blind and multihandicapped child: Identification, assessment, and training. East Lansing, MI: National Center for Research on Teacher Leaming. (ERIC Document Reproduction Service No. ED 179039)

Wright, K. (1995). Hearing observation form. Austin, Texas: Texas School for the Blind and Visually Impaired.

80 Works Consulted

Abdala, C. (1999). Pediatric audiology: Evaluating infants. In Essential elements in early Intervention (pp. 246-284). New York, New York: American Foundation for the Blind.

Allen, T. (1978). Auditory assessment for the deaf-blind and severely/profoundly handicapped children, hi D.H. Clark (Ed.), The deaf-blind/severely-profoundly handicapped: Proceedings from the 1978 Nebraska statewide conference. East Lansing, MI: National Center for Research on Teacher Learning. (ERIC Document Reproduction Service No.ED 177797)

Berg, F. (1993). Acoustics and sound systems in schools. San Diego, CA: Singular Publishing Group, Inc.

Blaha, R. & Shafer, S. (1997). Informal auditory observation form. Austin, Texas: Texas School for the Blind and Visually Impaired, Outreach Department.

Crandell, C, Smaldino, J., & Flexer, C. (1995). Sound-field FM application: Theory and practical applications. San Diego, CA: Singular Publishing Group, Inc.

Feiber, N. (1978). The profoundly handicapped child: Assessing sensorimotor and communication abilities: Working papers in developmental disabilities. East Lansing, MI: National Center for Research on Teacher Leaming. (ERIC Document Reproduction Service No.ED235656)

Franklin, B. (1979). Auditory assessment. In Educational methods for deaf-blind and severely handicapped students, volume II. East Lansing, MI: National Center for Research on Teacher Leaming. (ERIC Document Reproduction Service No.ED 176430)

Gee, K. (1996). Functional auditory assessement. Monmouth, OR: The National Information Clearinghouse on Children Who Are Deaf-Blind, U.S. Department of Education, Office of Special Education Programs. (DB Link Document No. ASM-96-020)

Hearing observation form. Austin, TX: Texas School for the Blind and Visually Impaired Outreach.

81 Isaac, S. & Michael, W.B. (1987). Estimating sample size required for making inferences about magnitudes of population proportions. In Handbook in research and evaluation (pp. 191-193). San Diego, CA: EdITS publishers.

Kukla, D., Connolly, T.T. (1979). Calibrated Toys List. Monmouth, OR: The National hiformation Clearinghouse on Children Who Are Deaf-Blind, U.S. Department of Education, Office of Special Education Programs. (DB Link Document No. 1998- 0225)

Langley, M.B.(1996). Screening and Assessment of Sensory Functions. Li M. McLean., D.B. Bailey, M. Wolery (Eds.), Assessing infants and preschoolers with special needs. Englewood Cliffs, NJ: Merrill, and imprint of Prentice Hall.

Leathers, M. (1977). Essential pretesting information from teachers, hi C. Rouin (Ed.), Proceedings: Basic assessment and intervention techniques for deaf-blind and multihandicapped children. East Lansing, MI: National Center for Research on Teacher Leaming. (ERIC Document Reproduction Service No. ED 146726)

Little, J. hiformal assessment of listening skill. In Assessment KIT: listening. Austin, TX: Texas School for the Blind and Visually Impaired.

Lunden, J. (Ed.). (1990). Program guidelines for individuals who are deaf-blind. East Lansing, MI: National Center for Research on Teacher Leaming. (ERIC Document Reproduction Service No.ED329065)

Lyall, J. & Others. (1972). Manual for the deaf-blind program and ability screening test. East Lansing, MI: National Center for Research on Teacher Leaming. (ERIC Document Reproduction Service No. EDI 13893)

Morgan, E. & Watkins, S. (1989). Assessment of developmental skills for young multihandicapped sensory impaired children: An instruction manual for the INSITE developmental checklist. Logan, Utah: SKI*HI Institute, Department of Communicative Disorders, Utah State University.

Rudolph, J.M., Bjoriing, B.J., & Collins, M.T. Auditory development. In Manual for the assessment of a deaf-blind multiply handicapped child (3*^ ed.), 28-30. Lansing, Michigan: Midwest Regional Center for Services to Deaf-Blind Children.

Sheeley, E. (1979). Audiological assessment. ]n Assessment and education of deaf-blind children: Proceedings of the special study institute. East Lansing, MI: National Center for Research on Teacher Leaming. (ERIC Document Reproduction Service No. ED 179041)

82 larver, P.M. (1999). Functional hearing assessment. Paper presented an inservice presentation for VI teachers at Region 13, Austin, TX.

83 APPENDDC A

PARTICIPATION LETTER, INFORMED CONSENT FORMS,

AND INSTITUTIONAL REVIEW BOARD EXEMPTION

84 Dear Parent or Guardian,

I am conducting research on the functional hearing of students who have both a hearing loss and vision loss. I would like your permission to assess your child using the Functional Hearing Inventory (FHI). The FHI is an observational instrument that looks at how children use what residual hearing they have in the natural environments of school and home.

As part of the research, I would also need access to the student's audiogram and other information such as gender, age, ethnicity, and primary and secondary handicapping conditions as listed on their lEP forms.

I would also like to contact you via phone or mail with a questionnaire about how you think your child responds to sound. The questionnaire should take about 10 minutes to complete.

The information will be kept completely confidential and I will share the results of the FHI with you and the classroom teacher.

All of this was explained to you in the phone conversation with either ...(Statement removed due to confidentiality.)

Please read and sign the two enclosed consent forms and return in the stamped envelope.

Thank you,

Pamela Broadston (Title removed due to confidentiality.)

85 Consent Form

I hereby give my consent for my participation and/or that of my child in the project R" 1 h r ~^^ ^""(^fi^nalHearing Inventory: Criterion-related Validity and hterrater

I understand that the person responsible for this project is: Dr. Roseanna Davidson Telephone number: (806) 742- 2345

Authorized Representative is: Pamela Broadston, M.Ed. Telephone number: (806) 438- 5678

She or her authorized representative has explained that these studies are part of a project that has the following objectives: The purpose of this study is to obtain evidence of the validity and reliability of the FHI. In particular, criterion-related validity for the FHI will be investigated by correlating it with teachers' and parents' ratings, and the traditional measure of hearing, the audiogram. Interrater reliability of the FHI will be studied through the correlation of the FHI ratings of deafblind subjects by two trained evaluators.

She or her authorized representative has (1) explained the procedures to be followed and explained that none are experimental; (2) described that there are no anticipated attendant discomforts and risks; (3) ^described the benefits to be expected; and (4) described appropriate alternative procedures.

Information concerning payment for my participation in this study has been explained to me as follows: Qthe estimated amount of payment for project completion 0 ; nthe method of disbursement N/A ; nthe schedule of payment N/A ; Qthe effect of my withdrawal from participation none_

The risks have been explained to me as follows: The conduct of the above-described research creates no risk of physical or emotional harm, or social or legal embarrassment to any participating human subject.

It has further been explained to me:

86 The total duration of my participation will be approximately 20 minutes and/or the observation of my child will be 3-5 hours; Only the researcher, evaluators, and the dissertation committee members will have access to ine records and/or data collected for this study; All data associated with this study will remain strictly confidential. ur. Roseanna Davidson has agreed to answer any inquiries I may have concerning the procedures and has informed my that I may contact the Texas Tech University Institutional Review Board for the Protection of Human Subjects by writing to them in care of the Office of Research Services, Texas Tech University, Lubbock, Texas 79409, or by calling (806) 742-3884.

If this research project causes any physical injury to participants in this project, treatment is not necessarily available at Texas Tech University or the Student Health Center, nor is there necessarily any insurance carried by the University or its personnel applicable to cover any such injury. Financial compensation for any such injury must be provided through the participant's own insurance program. Further information about these matters may be obtained from Dr. Robert M. Sweazy, Senior Associate Vice President for Research, (806) 742-3884, Room 203 Holden Hall, Texas Tech University, Lubbock, Texas 79409-1035.

I understand that I may not derive therapeutic treatment from participation in this study.

I understand that I may discontinue this study at any time I choose without penalty.

Signature of Subject Date_ Signature of Parent/Guardian or Authorized Representative (if required): Date:_ Signature of Project Director or her Authorized Representative: Date_ Signature of Witness to Oral Presentation: Date

87 TEXAS TECH UNIVERSITY

Office of Research Services

Box 41035, 203 Holden Hall Lubbock, TX 79409-1035 (806) 742-3884 FAX (806) 742-3892

August 22, 2003

Dr. Roseanna C. Davidson Ms. Pamela Broadston V M Sowell Ctr for Res & Ed in VI MS 1071

RE: Project 03191 The Functional Hearing Liventory: Criterion-related Validity and Interrater Reliability

Dear Dr. Davidson:

The Texas Tech University Committee for the Protection of Human Subjects has approved your proposal referenced above. The approval is effective from August 1, 2003 through July 30, 2004. You will be reminded of the pending expiration one month prior to July 30, 2004 so that you may request an extension if you wish.

The best of luck on your project.

Sincerely,

Dr. Richard P. McGlynn, Chair Human Subjects Use Committee

An FFO / Affirmative Action Institution

88 APPENDIX B

FHI TEACHER QUESTIONNAIRE

FHI PARENT QUESTIONNAIRE

89 FUNCTIONAL HEARING INVENTORY Parent Questionnaire

Think about how you have observed your child responding to sound. Read the following situations and determine if your child responds to sound in the following ways and rate your responses accordingly. Circle the rate that best describes your child's response to the following sounds.

" " JNU RESPONSE. You have not observed your child respond to the following sounds in any manner.

1 • PHYSICAL RESPONSE. You have observed your child show an awareness to the following sounds with a physical/motoric response. Some examples of a physical response might be: startling to sound; widening of eyes; eye shift; eye blink; facial expressions including laughing, smiling, or grimacing tensing body; cessation (or an increase) in crying or an activity; or a change in respiration. In addition to being aware of sound, your child might: pay attention to the sound for a few seconds; incline their head toward sound, increase or decrease vocalizations in response to a sound. Your child might make brief attempts to locate and/or find the sound source by turning toward, looking at, or reaching for a sound source but does not focus or attend to it for any length of time.

2 - Discriminating Response. You have observed your child attending to, paying attention to or responding appropriately to different sound sources. Some examples of a discriminating response are: Your child can tell the difference between two different sounds; your child attends to familiar voice or favorite sound toy in presence of background noise; responds differently to primary care-giver's voice than to a stranger's voices; stops, hesitates, or changes sounds when you change vocalizations; or your child may imitate sounds. Your child may respond to sound in a patterned way. For example: he/she responds differently to his/her own name; smiles to praise or sobers to scolding voice; begins to perform gestures associated with a familiar song; stops activity when presented with a prohibitive command; follows simple, routine verbal commands; responds to novel and routine sounds appropriately or reacts appropriately in response to known sounds or verbal instructions.

90 Sound Source N o Respons e Physica l Respons e Discriminatin g Respons e A whispered voice 0 1 2 The rustle of leaves or a paper bag. 0 1 2 A person talking in another room. 0 1 2 A microwave buzzer. 0 1 2 A car driving by outside. 0 1 2 The garage door opening. 0 1 2 A doorbell (buzz or single chime) 0 1 2 A radio or TV at an average loudness level. 0 1 2 A telephone ringing in another room. 0 1 2 A familiar person talking in a normal voice. 0 1 2 An unfamiliar person talking in a normal voice. 0 1 2 A telephone ringing in the same room. 0 1 2 A familiar person talking in a loud voice 0 1 2 An unfamiliar person talking in a loud voice. 0 1 2 A Washing machine or dryer running (if in the 0 1 2 same room). A blowdryer 0 1 2 A vacuum cleaner in another room. 0 1 2 A vacuum cleaner in the same room 0 1 2 A power lawnmower 0 1 2 Any loud, unexpected sound. 0 1 2 Thank you for your responses.

91 FUNCTIONAL HEARING INVENTORY Teacher Questionnaire

Think about how you have observed your student responding to sound. Read the following situations and determine if your student responds to sound in the following ways and rate your responses accordingly. Circle the rate that best describes your student's response to the following sounds.

" • NO RESPONSE. You have not observed your student respond to the following sounds in any manner.

*- ' "" ' ^ICAL RESPONSE. You have observed your student show an awareness to the following sounds with a physical/motoric response. Some examples of a physical response might be: startling to sound; widening of eyes; eye shift; eye blink; facial expressions including laughing, smiling, or grimacing tensing body; cessation (or an increase) in crying or an activity; or a change in respiration. In addition to being aware of sound, your student might: pay attention to the sound for a few seconds; incline their head toward sound, increase or decrease vocalizations in response to a sound. Your student might make brief attempts to locate and/or find the sound source by turning toward, looking at, or reaching for a sound source but does not focus or attend to it for any length of time.

2 - Discriminating Response. You have observed your student attending to, paying attention to, or responding appropriately to different sound sources. Some examples of a discriminating response are: Your student can tell the difference between two different sounds; your student attends to familiar voice or favorite sound toy in presence of background noise; responds differently to a familiar voices than to a unfamiliar voices; stops, hesitates, or changes sounds when you change vocalizations; or your student may imitate sounds. Your student may respond to sound in a patterned way. For example: he/she responds differently to his/her own name; smiles to praise or sobers to scolding voice; begins to perform gestures associated with a familiar song; stops activity when presented with a prohibitive command; follows simple, routine verbal commands; responds to novel and rouUne sounds appropriately or reacts appropriately in response to known sounds or verbal instructions.

92 Sound Source Physica l Respons e Discriminatin g Respons e N o Respons e A whispered voice 0 1 2 The rustle of leaves or a paper bag. 0 1 2 A person talking in the hallway. 0 1 2 A microwave buzzer. 0 1 2 Background music playing at a soft level. 0 1 2 The computer CPU or overhead projector motor 0 1 2 A radio or TV at an average loudness level. 0 1 2 A familiar person talking in a normal voice. 0 1 2 A telephone ringing in the same room. 0 1 2 A bus accelerating. 0 1 2 A familiar person talking in a loud voice 0 1 2 A Washing machine or dryer running (if in the 0 1 2 same room). A loud voice over the intercom. 0 1 2 The bell to signal change in classes. 0 1 2 A loud whistle in a gymnasium. 0 1 2 Any loud, unexpected sound. 0 1 2

Thank you for your responses.

93