key: cord-0307978-g72br4qj authors: Stewart, H. J.; Cash, E. K.; Pinkl, J. J.; Nakeva von Mentzer, C.; Audiology, C. D. o.; Hunter, L. L.; Moore, D. R. title: Adaptive hearing aid benefit in children with mild/moderate hearing loss: A registered, double-blind, randomized clinical trial date: 2021-07-20 journal: nan DOI: 10.1101/2021.07.14.21260541 sha: a74639ea554b81d4e8643b102a511622e59946f5 doc_id: 307978 cord_uid: g72br4qj Objectives: We completed a registered double-blind randomized control trial to compare acclimatization to two hearing aid algorithms by experienced pediatric hearing aid users with mild to moderate hearing loss. We hypothesized that extended use (up to 13 months) of the adaptive algorithm with integrated directionality and noise reduction, OpenSound Navigator (OSN), would result in improved performance compared to the control algorithm, omnidirectional (Omni), on auditory, cognitive and academic tasks. Design: We recruited 42 children, aged 6 - 13 years old, through Cincinnati Children's Hospital Medical Center's Division of Audiology. Two children withdrew from the study due to noncompliance or discomfort. The remaining 40 children were paired by age (within one year) and hearing loss (level and configuration). The individuals from each pair were randomly assigned to a group: OSN (experimental) and Omni (control). Each child completed an audiology evaluation, hearing aid fitting, a follow up audiological appointment and two research visits up to 13 months apart. Research visit outcome measures covered speech perception (in quiet and in noise), novel grammar and word learning, cognition, academic ability and caregiver report of listening behaviours. Results: The children with the experimental algorithm did not show improved performance on the outcome measures compared to the control algorithm. There was a significant relationship between age at first hearing aid use and Reading and Mathematical ability across all participants. Data from six children were not included in the analysis due to daily hearing aid usage of less than 6 hours. Conclusions: Use of the experimental algorithm (OSN) neither enhanced nor reduced performance on auditory, cognitive and academic tasks compared to the control algorithm (Omni). About 15% of children aged 6-19 years in the US have pure tone average (PTA) hearing 30 thresholds > 15 dB HL (Niskar et al., 1998; Su & Chan, 2017) , the level at which hearing loss in 31 children is considered functionally significant. Typically, these children have bilateral PTA ≥ 26 32 dB HL, the threshold used in Butcher and colleagues' (2019) meta-analysis to calculate a 1.1 33 per 1000 prevalence of bilateral hearing loss at newborn screening . Both children (Tomblin et 34 al., 2014) and adults (Gatehouse, 1992) have been shown to obtain greater benefit from hearing 35 aid use across time following initial fitting (acclimatization). While such acclimatization is 36 controversial in adults, with several studies finding no greater, long-term benefit (Bender et al., 37 1993; Dawes et al., 2014; Humes et al., 2002; Humes & Wilson, 2003; Taylor, 1993) , the weight 38 of evidence in children favors increased benefit (Moeller & Tomblin, 2015) . This issue is 39 clinically significant because some of the same evidence shows the importance of earliest 40 possible intervention for hearing loss (Moeller & Tomblin, 2015) . The greater improvement in 41 language and academic skills obtained by early hearing aid use presumably reflects improved 42 speech perception through a process of auditory perceptual learning (Walker et al., 2020) . 2019). Children also learn more easily than adults (Lucas et al., 2014) , possibly due to 54 enhanced brain plasticity and/or greater motivation with the task regimen. 55 56 It seems plausible that improving the features of hearing aids that are most useful for children, 57 such as directional microphones (Chung & Zeng, 2009; Gravel et al., 1999) , may further 58 improve acclimatization. For example, children may be more dependent than adults on spatial 59 localization of sound, due to reduced selective attention (Wightman et al., 2006) , and the need 60 to learn in noisy classrooms (Picard & Bradley, 2001 ) and home environments (Erickson & 61 Newman, 2017). In response to these learning and environmental considerations, OpenSound 62 Navigator (OSN) was developed to provide adaptive, integrated directionality and noise 63 reduction. Briefly, OSN utilizes a dual microphone array to phasically analyze the acoustic 64 environment. Subsequent directionality and noise reduction processing attenuate noise sources 65 and diffuse noise respectively. The system updates 500 times/second across 16 independent 66 frequency channels, enabling a rapid, spatial-based adaptive system with high selectivity to 67 speech sounds (Le Goff et al., 2016) . 68 69 In a previous, exploratory study (Pinkl et al., 2021) , we showed that 6-12 year old children fitted 70 with OSN-enabled hearing aids for two months received enhanced caregiver assessments of 71 their speech and sound perception, spatial sound awareness and ability to participate in 72 conversations. However, their measured speech perception, language, cognitive and academic 73 skills were unaffected by using the hearing aids. As there was no control group in that study, it is 74 possible that the enhanced assessments were affected by reporter bias. In addition, the 75 acclimatization period was short and the sample size limited. Finally, it is possible that the range 76 of measures used, although wide, missed other important aspects of listening and learning. 77 78 assessed speech in noise perception in children with OSN or 79 omnidirectional (Omni) programming after no acclimatisation. They found that speech in steady 80 state noise (SSN) thresholds were better for OSN than for Omni programming, regardless of 81 whether the target talker was facing the participant or not. No programming difference was 82 found for a speech in two-talker speech condition. However, they used a within-subject design 83 for hearing aid programming in that the children received both programming options for testing 84 rather than assessing a separate Omni control group. 85 86 To address these gaps in evidence, we designed a new, expanded, registered double-blind 87 randomized control trial that compared extended (up to 13 months) use of the OSN algorithm 88 with a control, Omni algorithm, programmed into the physically identical Oticon OPN hearing 89 aids. We added outcome measures for speech in noise (BKB-SiN), statistical grammar learning 90 and participant fatigue to our previous behavioural testing battery of speech perception, 91 cognition, academic and caregiver report outcomes. We hypothesized that extended use of the 92 OSN algorithm would result in improved performance on the range of skills previously examined 93 and on other skills (statistical learning, and self-report effort measures) newly introduced in this 94 study. 95 96 < Table 1 secure, web-based application providing: 1) an intuitive interface for validated data entry; 2) 110 audit trails for tracking data manipulation and export procedures; 3) automated export 111 procedures for seamless data downloads to common statistical packages; and 4) procedures for 112 importing data from external sources. Participants were assented if they were 11 years of age or 113 older. Inclusion: Forty-two children were enrolled, but two were withdrawn due to noncompliance or 116 discomfort. The 40 remaining were experienced pediatric HA users, ages 6,7 to 13,2 117 (years,months, mean = 9,9, Fig. 1 ). Age of hearing loss diagnosis ranged from birth to 8 years 118 (mean = 3,8; Table 1) , while age at receipt of first hearing aids ranged from 3 months to 9 years 119 (mean = 4,1). Inclusion criteria were a) native English speakers, b) no history of ear surgeries, 120 c) symmetrical sensorineural hearing loss in the mild to moderately-severe range from 500-4000 121 Hz (see "Audiological evaluation" below), d) The study schedule of participant visits is shown in Fig. 2 . Many of the procedures have been 155 described in detail previously (Pinkl et al., 2021) and will be presented only briefly here. All 156 audiological visits followed a checklist of procedures to ensure that all study audiologists 157 followed the same evaluation and fit protocols. 158 159 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2021. The tester was outside the booth and communicated with the participant visually and via 243 intercom. 244 245 Order of testing was randomized in a latin square design across participants. All tests were 246 completed twice: within one week of hearing aid fitting (RV1; Fig. 2 ) and 6-13 months post-fitting 247 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. ; https://doi.org/10.1101/2021.07.14.21260541 doi: medRxiv preprint (RV2). Test sessions of sentence repetition and novel word learning were recorded using 248 Audacity (v. 2.3.2). Recordings were re-scored by a second researcher. If there was agreement 249 between the two researchers, the initial score was used. Disagreements were reconciled by a 250 third researcher. Participants used a chin rest for head and hearing aid microphone positioning to remain in the 263 center of a speaker ring, diameter 2m. They were instructed to remain still, look straight ahead, 264 listen closely for the target word, and repeat it back. If they were unsure what word they heard, 265 they were instructed to guess. Correct/incorrect identification of Target increased/decreased 266 masker level by 4 dB on next trial. After the second reversal, step size was reduced to 2 dB. 267 Speech reception threshold (SRT) was the mean of the last 6 reversals, following 8 total 268 reversals. participant, who was instructed to listen closely to the stimuli, and repeat back the sentence. If 277 the participant forgot or did not hear the sentence, they were encouraged to guess. Each 278 sentence was scored based on the accuracy of word content and order. Sentences were 279 categorized for memory by length (involving use or non-use of adjectives) and for grammar by 280 complexity (use or nonuse of a ditransitive passive sentence structure where subject and object 281 were expressed by two prepositions). Sentences could thus be short with low complexity (e.g. 282 "The mom baked her daughter a pie."), short with high complexity (e.g. "A piano was delivered 283 by the dad to his son."), long with low complexity (e.g. "The kind man ordered the tired woman a 284 hot coffee."), or long with high complexity (e.g. "A purple pencil was offered by a friendly girl to 285 the new boy."). Different sets of sixteen sentences comprised the task list at each research visit. 286 Each set had four sentences from each of the four categories. 287 288 Sentence repetition in noise: The Bamford-Kowal-Bench Sentences in Noise (BKB-SiN) test 289 contains 18 list pairs of recorded sentences in four-talker babble noise (Bench et al., 1979; 290 Etymōtic Research, 2005) . In this study, participants were presented with one list pair (2 x 10 291 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. Novel grammar learning in noise: The children were exposed to a novel grammar (von Koss 311 Torkildsen et al., 2013) in the form of a game where they were teaching an alien a new 312 language. During a single exposure at RV2, children were introduced to an aX and Yb grammar, 313 with a and b components consisting of a single syllable nonword (CV), X representing one-314 syllable nonwords (CVC), and Y representing one-syllable nonwords (CVCCV). Examples of the 315 aX 'poe' grammar are "poe zek" and "poe zug", whereas Yb 'koo' grammar is exemplified by 316 "wagso koo" and "zikvoe koo". After four examples, to introduce the participant to the format of 317 the task, the grammar exposure was split into 12 blocks, each 4 trials long ending with 2 two-318 alternative forced choice trials to assess their learning. This totaled 48 exposures to the 319 grammar with 24 test trials to assess grammar knowledge. Target words were presented at 0° 320 azimuth and speech shaped background noise, created from the spectral envelope of the 321 nonwords used in the task, was presented at 180° azimuth throughout the task. 322 323 Cognition: The NIH Toolbox Cognition Battery assesses the brain's higher-level functions 324 language, perception, planning and execution of behavior, and memory (Weintraub et al., 2013) . 325 Four subtests from this battery, each lasting 5-15 minutes, were administered to participants on 326 an iPad with the tester seated next to them. Individual subtests produced a raw score as well as 327 an age-standardized score. Together the results of each standardized subtest comprise the 328 'Early Childhood Composite' score. 329 330 • The Picture Vocabulary Test assesses receptive vocabulary. Four pictures were 331 presented together on the screen, and a single word was spoken by a female voice in 332 Standard American English. Participants were instructed to select the picture that best 333 matched the meaning of the spoken word. 334 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. was also completed at both RV1 and RV2 (Fig. 4) . 378 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. the accuracies of these grammars to chance (50%). The PROMIS questionnaire was also only 419 administered at RV2. One way ANOVAs were used separately for the self-report and the care-420 giver report scores. A planned paired samples t-test was used to compare if the self-and care-421 giver reports were significantly different from one another. 422 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. Pearson correlations were used to explore the relationship between speech perception, 424 language, cognitive and academic skills with age of first hearing aid fit and daily hearing aid 425 usage. P-values were adjusted for multiple comparisons whereby each test (e.g. word repetition 426 in noise, NIH toolbox) was treated as its own "family". Adjustments were made for the following 427 number of comparisons: three for word repetition in noise (0.017), four for sentence repetition in 428 quiet (0.0125), one for sentence repetition in noise (0.05), one for novel word learning in quiet 429 (0.05), two for novel grammar learning in noise (0.025), four for the NIH toolbox assessing 430 cognition (0.0125) and two for the WJ-IV assessing academic ability (0.025). 431 432 < Figure The two groups (OSN and OMNI) were well matched for age, mean hearing loss and interaural 439 symmetry (Table 1 ; Fig. 2A However, OSN use did not affect performance significantly, and there were no significant 456 interactions between OSN use and sentence length, complexity or duration of hearing aid use. Sentence repetition in noise (Fig. 3C) : SNR loss scores were mostly in the range 3-7 dB, 459 described by the test manual as a "Mild SNR loss", where 0-3 dB is "Normal" and 7-15 dB is 460 "Moderate". Scores did not improve between tests and there was no significant difference 461 between OSN and Omni groups overall or between tests. Novel word learning in quiet (Fig. 3D) : There was no significant change in scaled scores 464 between RV1 and RV2 and no significant difference between OSN and Omni groups overall or 465 between tests. 466 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. ; https://doi.org/10.1101/2021.07.14.21260541 doi: medRxiv preprint 467 Novel grammar learning in noise (Fig. 3E) : This was assessed at RV2 only, as the stimuli and 468 paradigm needed to be novel. The participants learnt the Yb grammar significantly better than 469 the aX grammar (F1,20 = 8.96, p = 0.007, "# ! = 0.31). Further analysis showed that the 470 participants did not learn the aX grammar, i.e. where the grammar key 'poe' was at the start of 471 the word, significantly more than chance (50%) but they did learn the Yb grammar (t22 = 3.03, p 472 = 0.006, d = 0.63), i.e. where the grammar key 'koo' was at the end of the word. There was no 473 significant difference between OSN and Omni groups overall. 474 475 Cognition (Fig. 3F) Fig. 4C ): This was administered at RV2 only and 502 showed no significant difference between OSN and Omni groups on either the participant self-503 report scores or those by their caregivers. There was no significant difference between 504 participants' self-report and their caregiver scores. 505 506 Hearing aid use 507 Given the similarity between OSN and Omni performance, we combined both groups to 508 evaluate the effect of hearing aid fitting and use patterns. Participants' age at first hearing aid fit 509 (Table 1 ) correlated significantly with their WJ-IV Reading (r = -0.42, p = 0.016) and 510 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. ; Mathematics (r = -0.43, p = 0.012) outcomes at RV2, but not at RV1 (Reading: r = -0.36, p = 511 0.037, note that this does not survive family correction of $ = 0.025; Mathematics: r = -0.34, p = 512 0.052; Fig. 5A ). The improvement in the flanker task between RV1 and RV2 correlated 513 significantly with their average daily hearing aid usage (r = 0.47, p = 0.006; Fig. 5B ). These 514 comparisons at RV2 remained significant after family correction and indicated that the overall 515 duration of hearing aid use was associated with better academic and cognitive outcomes. 516 However, no other significant relationships between performance and age at first fit or duration 517 of hearing aid use were found. 518 519 DISCUSSION 520 521 Long term use of a hearing aid processing algorithm (OSN) designed to improve speech 522 hearing in situations of competing speech neither enhanced nor reduced performance on a 523 variety of age-standardized auditory, cognitive, and academic tasks, relative to a control, 524 omnidirectional processor. Some changes in performance, both objective (perceptual, linguistic, 525 cognitive, academic) and subjective (SSQ), were observed between RV1 and RV2 in both 526 treatment groups. These were likely due to practice/reliability (Taylor et al, 2020) or caregiver 527 expectation (SSQ). However, some exceptions to these otherwise unsurprising results were 528 observed. One was the subjective improvement in spatial hearing of trial users only of the Omni 529 processing strategy. Another was the emergence of a significant relationship between age at 530 first hearing aid use and both Reading and Mathematics scores that became significant at RV2. 531 532 Enhanced target word repetition in SSN, compared with a two-talker masker (TTM), has 533 previously been reported in children with mild/moderate hearing loss using OPN hearing aids, 534 regardless of whether the target talker was directly in front of the child (Browning et al., 2019) . 535 Other studies using headphone stimulation have also shown more TTM in younger children, but 536 not in older youth or adults (McCreery et al., 2020). In the study reported here, we confirmed 537 these findings of greater TTM, and extended them by showing improved performance in all test 538 conditions after 7-13 months of OPN hearing aid use. Browning and colleagues (2019) 539 additionally found that performance using the OSN processing algorithm was superior to that of 540 the same children using the Omni algorithm in SSN masking, but not in TTM. Here, different 541 groups of children used OSN and Omni algorithms, and we did not find enhanced benefit of 542 OSN during either SSN masking or TTM. It is possible that the difference between these studies 543 was due to the reduced variance associated with retesting the same participants in two test 544 conditions. 545 546 Previously, we found that word repetition in noise did not improve after 2-3 months of using 547 OSN in a new fitting, but caregiver reports of ability improved over the study period (Pinkl et al., 548 2021) . Here, we report improved word repetition in noise after 7-13 months of continuous use of 549 OSN and Omni. In addition, we found a general improvement in caregiver-reported (SSQ) 550 speech abilities, and improved spatial spatial ability in the Omni group. Together, these results 551 provide evidence for longer-term acclimatization. Acclimatization may reflect enhanced training, 552 motivation and/or expectation, along different timelines. For example, there may be a general 553 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. ; and rapid, positive motivation and caregiver expectation after a new intervention (Gilliver et al., 554 2013), followed by a more gradual perceptual learning. 555 556 There is a growing literature on the effects of complex processing enhancements on speech 557 perception using hearing aids (Cox et showing no significant difference in a highly controlled study of the auditory and related 562 cognitive and academic performance of children using omni or directional microphones with 563 noise reduction processing strategies, the results reported here appear to support Lesica's 564 thesis. However, his optimistic suggestion was that alternative strategies based on recent 565 developments in physiology and artificial intelligence should improve matters in the near future. 566 In particular, an emphasis on the importance of cognitive and environmental factors to 567 determine optimal, individualized processing strategies seems particularly suited to a pediatric 568 population. 569 570 Moeller & Tomblin (2015) and Nakeva von Mentzer et al. (2020) have shown the importance of 571 early and prompt fitting of hearing aids for children with hearing loss. The average age of our 572 participants was 9 years 9 months and the length of hearing aid usage prior to the study was 4 573 years 1 month. We showed that, regardless of processing strategy, the age of hearing aid fit 574 continued to have an effect on academic achievement during development with the relationship 575 between age of first hearing aid use and reading/mathematics scores showing significance at 576 RV2, and trending, but not surviving family correction at RV1. 577 578 The end of our study was conducted during the COVID-19 pandemic with eight of our 579 participants (OSN = 5, omni = 3) completing RV2 during periods of school closures. It is of note 580 that four of these children (OSN = 2, omni = 2) were not included in the final analysis as they 581 stopped wearing their hearing aids consistently with their daily usage below 6 hours. Consistent 582 daily use of HAs has been highlighted as a strong predictor of cognitive and academic scores 583 (Walker et al., 2015b) . We echo this with a positive significant relationship between daily HA use 584 and change in performance on the selective attention (flanker) task. Adding a covariate of 585 whether the participants completed testing during the pandemic did not affect our findings. 586 587 We have provided a broad spectrum of test approaches including auditory sensitivity, several 588 forms of speech listening, learning in noise and in quiet, cognitive and academic performance, 589 and caregiver-and self-report. On none of these tests was any significant performance 590 difference found between the Omni and the OSN processing strategies. However, it remains a 591 possibility that in more realistic test environments differences would be found between these 592 strategies, for example, where distracting sounds were presented simultaneously from several 593 different directions or where visual information is combined with auditory. While a within-subject 594 design reduces individual differences, our study had multiple levels of quality checks built in. 595 These included groups well matched in hearing level, audiogram shape and age, double-596 blinding throughout the study until the last participant completed their RV2, checklists to ensure 597 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. ; all audiologists followed the same rigorous fitting protocols, and study pre-registration. Behrens from Oticon for help with funding, providing hearing aids, and other general support. 616 A preprint of this paper can be found at: medxriv 617 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. ; https://doi.org/10.1101/2021.07.14.21260541 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. ; Figure 5 : (A) Negative correlations between the children's age at first hearing aid fit with WJ-IV 846 Reading and Mathematics outcomes at RV2. (B) Positive correlation between daily hearing aid 847 usage and change in performance on the NIH toolbox attention task (flanker task). 848 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. ; https://doi.org/10.1101/2021.07.14.21260541 doi: medRxiv preprint CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2021. ; https://doi.org/10.1101/2021.07.14.21260541 doi: medRxiv preprint It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 20, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2021. ; https://doi.org/10.1101/2021.07.14.21260541 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 20, 2021. ; Speech Discrimination for Children Prescribing and verifying hearing aids applying the American Academy of Audiology 623 pediatric amplification guideline: Protocols and outcomes from the Ontario infant hearing 624 program The University of Western Ontario pediatric audiological monitoring protocol 627 (UWO PedAMP) The BKB (Bamford-Kowal-Bench) sentence lists for 629 partially-hearing children Longitudinal study of 632 hearing aid effectiveness. I: Objective measures Effects of noise reduction on speech 635 intelligibility, perceived listening effort, and personal preference in hearing-impaired 636 listeners Effects of adaptive Effects of 644 Adaptive Hearing Aid Directionality and Noise Reduction on Masked Speech 645 Recognition for Children Who Are Hard of Hearing Prevalence of permanent 648 childhood hearing loss detected at the universal newborn hearing screen: Systematic 649 review and meta-analysis Using hearing aid adaptive directional microphones to 651 enhance cochlear implant performance Development of open-set word 653 recognition in children: Speech-shaped noise and two-talker speech maskers Impact of advanced hearing aid technology on 656 speech understanding for older listeners with mild to moderate, adult-onset, 657 sensorineural hearing loss Acclimatization to hearing aids. Ear 659 and Hearing Influences of background noise on infants and 661 children Assessing speech intelligibility in children with hearing loss: Toward 663 revitalizing a valuable clinical tool Bamford-Kowal-Bench Speech-in-Noise Test Adaptation of the speech, spatial, and qualities of hearing 666 scale for use with children, parents, and teachers The time course and magnitude of perceptual acclimatization to 669 frequency responses: Evidence from monaural fitting of hearing aids Glasgow hearing aid benefit profile: Derivation and validation of The speech, spatial and qualities of hearing scale (SSQ) Systemwide Implementation of Patient-Reported 677 Outcomes in Routine Clinical Care at a Children's Hospital. The Joint Commission 678 When expectation meets experience Parents' recollections of and experiences with a child diagnosed with hearing loss soon 682 after birth Children's speech recognition in noise 684 using omni-directional and dual-microphone hearing aid technology A 687 metadata-driven methodology and workflow process for providing translational research 688 informatics support Speech Recognition in Noise for Adults With 690 Normal Hearing: Age-Normative Performance for AzBio A Taxonomy of Fatigue Concepts and Their 697 Relation to Hearing Loss Manual for program outline for rehabilitation of 700 aural casualties both military and civilian An examination of changes in hearing-aid performance 703 and benefit in the elderly over a 3-year period of hearing-aid use Changes in hearing-aid benefit 706 following 1 or 2 years of hearing-aid use by older adults Immittance Measures in Children Sampling plan and patient characteristics of the PROMIS 712 pediatrics large-scale survey NEPSY: A developmental neuropsychological 714 assessment The Glasgow Children's Benefit Inventory: A 716 new instrument for assessing health-related benefit after an intervention Development and psychometric properties of the PROMIS® 720 pediatric fatigue item banks An introduction to 722 Why do hearing aids fail to restore normal auditory perception? Trends in 724 When children are better (or at 726 least more open-minded) learners than adults: Developmental differences in learning the 727 forms of causal relationships Speech recognition in 729 noise using bilateral open-fit hearing aids: The limited benefit of directional microphones 730 and noise reduction Contributions to Masked Speech Recognition in Children linguistic factors predict speech recognition in adverse listening conditions 736 for children with hearing loss Behavioral measures of 738 listening effort in school-age children: Examining the effects of signal-to-noise ratio, 739 hearing loss, and amplification An introduction to the outcomes of children with hearing 741 loss study Sentence repetition as a marker of 743 language skills in children with dyslexia Hearing aid use for children with hearing loss: A literature 745 review. Perspectives on Hearing and Hearing Disorders in Childhood & others. (2020). Reading Ability and Working 748 Memory in School-Age Children Who Are Deaf and Hard of Hearing Using Cochlear 749 Implants and/or Hearing Aids: A 3-Year Follow-Up on Computer-Based Phonics Prevalence of hearing loss among children 6 to 19 years of age: The Third National 753 Health and Nutrition Examination Survey Revisiting Speech Interference in Classrooms: Revisando la 755 interferencia en el habla dentro del salón de clases Evaluation of the effects of nonlinear 757 frequency compression on speech recognition and sound quality for adults with mild to 758 moderate hearing loss Acclimatization to Adaptive Hearing Aid Technology The Web-based Sentence Repetition Test to 764 diagnose developmental language disorder (DLD): User manual Johnson IV tests of cognitive abilities Prevalence of hearing loss in US children and adolescents: 769 Findings from NHANES 1988-2010 Self-perceived and audiometric evaluations of hearing aid benefit in the 772 elderly The influence 774 of hearing aids on the speech and language development of children with hearing loss Psychometric properties of the PROMIS® pediatric scales Precision, stability, and comparison of different scoring and administration options Exemplar 781 variability facilitates rapid learning of an otherwise unlearnable grammar by individuals 782 with language-based learning disability The 784 influence of hearing aid use on outcomes of children with mild hearing loss The 787 influence of hearing aid use on outcomes of children with mild hearing loss Language and reading outcomes in fourth-grade children with mild hearing loss 791 compared to age-matched hearing peers. Language, Speech, and Hearing Services Cognition assessment using the NIH Toolbox Informational masking of speech in children