The effectiveness of Otto’s World of Sound computer-

based auditory training for improving auditory

discrimination and auditory attention skills in children
who have a hearing impairment

Anna Carey

Master of Speech Language Therapy Practice

(MSLTPrac)

Research Project

Speech Science
Department of Psychology
The University of Auckland

2006

Formatted for submission to The Australian and New Zealand Journal of Audiology
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Abstract

This study investigated the effects of computer-based auditory training software (Otto’s World of

Sound) on auditory discrimination, speech perception and auditory attention skills in New

Zealand children who have a hearing impairment. Four school-age participants with moderate to

profound hearing loss participated in the study. A pre versus post test case study series design

was employed to obtain pilot information on effectiveness of the intervention. The results for

speech perception and auditory attention skills were promising. Hence further research is

warranted using Otto’s World of Sound computer-based auditory training to demonstrate efficacy

of the training, using a larger group of participants in a randomised controlled trial.

Key Words: hearing impairment, hearing loss, deaf, hard of hearing, children, school-age,

auditory training, auditory rehabilitation, computer, computer-based intervention, speech

language therapy, speech perception, auditory attention, auditory discrimination

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INTRODUCTION

The ultimate goal of an auditory rehabilitation programme for a child with a hearing impairment

is to develop age appropriate language and communication skills. Traditional auditory training is

usually a crucial part of an auditory rehabilitation programme. It can be very time consuming, for

both the child and the therapist, and can be relatively boring and drill-based. However, research

has proven auditory training to be effective for improving auditory skills. Speech Language

Therapists (SLT) working in New Zealand are under pressure to develop interventions that

provide maximum benefits. Research conducted by Tallal, Miller, Bedi, Byma, Wang and

Nagarajan et al. (1996) with children who had language difficulties showed that the use of

computers and computer software could be an effective intervention tool for providing language

rehabilitation to young children. Is it possible that using computers and computer software as an

auditory training tool would be effective and beneficial for children who have a hearing

impairment?

Auditory Training

Auditory training aims to increase auditory skills to enhance the individual’s ability to pick up the

acoustic cues required for acquisition of speech. Erber (1982) defined auditory training as the

process of training a person's residual hearing ability and suggested that an auditory training

intervention programme should consist of four stages. These stages are detection, discrimination,

identification, and comprehension of sounds and speech. In the process of auditory training, the

intervention firstly introduces fundamental processes (detection of sounds), as the child practises

and gains experience, the programme progresses to the development of more advanced abilities

(comprehension of speech) (Erber, 1982). According to Erber (1982), many suitable approaches

can be implemented at each stage.

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Auditory Training History

More than 50 years ago, Fry and Whetnall (1954) reported that the aim of auditory training was

to enable a deaf child to develop hearing and speech, in order to use these modalities as their

main way to access learning. Fry and Whetnall reported that auditory training was not a new

technique. They cited Ernaud (1761), who demonstrated that deaf-mute children with residual

hearing could be trained to hear words. Ernaud (1761) also reported that the children who were

able to hear the largest number of words were those with the most residual hearing.

In 1802, Itard (cited in Fry & Whetnall, 1954) was the first person to show, that through

methodical listening practise, congenitally deaf children acquired increased power of auditory

perception. Based on the findings of Ernaud (1761) and Itard (1802), Fry and Whetnall (1954)

believed that in order to develop speech and hearing through auditory training, the training must

be provided during the period when speech normally develops. Fry and Whetnall (1954) reported

that the auditory training method sought to enable a deaf child to develop hearing and speech as a

hearing child would, through listening. Their method was based on the normal development of

auditory discrimination and on the comprehension and production of speech. Fry and Whetnall

(1954) believed training should begin young, preferably in the first year of the child’s life. Based

on clinical observations, Fry and Whetnall (1954) considered training should be conducted with

the individual’s normal hearing assistive devices (if any) and in an environment where there are

sounds available to enhance auditory development.

Synthetic and Analytic Auditory Training

The auditory training approach, as defined by Erber (1982) has since been refined and now

includes two auditory training approaches, synthetic and analytic. The synthetic approach focuses

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on gaining the meaning of a message through various communication strategies, such as

improved hearing, attention, use of context and repair strategies (Sweetow & Palmer, 2005).

In the analytic approach, the individual will practise identifying the sounds of speech, rather than

work at the word, sentence, or meaning level as in the synthetic approach (Sweetow & Palmer,

2005). An intervention programme may start with one approach and move towards the other,

whilst a combination of both approaches is also commonly used. The intervention is often

constructed based on the underlying stages defined by Erber (1982), detection, discrimination,

identification and comprehension.

Auditory Training in Adults

Sweetow and Palmer (2005) conducted a review of auditory training literature in the acquired

adult hearing impaired population. The question that they explored through the review was “Does

evidence exist supporting improvement in communication skills through individual auditory

training in an adult hearing impaired population?”

In the auditory training literature Sweetow and Palmer (2005) looked at both synthetic and

analytic auditory training. To compare the efficacy of the studies, consonant recognition, speech

perception (words to sentence level) and self perception were the variables used as the outcome

measures. The results for both the synthetic and analytic types of auditory training revealed that

two out of three studies showed a significant improvement in at least one outcome measure.

The review by Sweetow and Palmer (2005) included a study by Ruinstein and Boothroyd (1987)

which combined both analytic and synthetic auditory training approaches. The relevant goal of

this study was to determine whether the inclusion of analytic tasks in a training programme

would produce more improvements than found with synthetic tasks alone (Rubinstein &

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Boothroyd, 1987). The 20 adult subjects in this study were divided into two groups. Group one

was assigned a purely synthetic approach to auditory training, where the activities involved

sentence perception and perceptual strategies. Group two was assigned a synthetic and analytic

approach. The effectiveness of the intervention was measured by the changes in results from

three assessments of speech perception; Nonsense Syllable Test (NST), the low predictability

items of the Revised Speech Perception in Noise test (RSPIN), and the high predictability items

of the RSPIN. These assessments were administered at the beginning of the study, after one

month of ‘no treatment’ (so each participant can act as their own control as a measure of

improvements), after one month of intensive auditory training and after a further month of ‘no

treatment’ (to measure retention effects). The intensive auditory training intervention for both

groups consisted of eight, one hour training sessions over four weeks. For group two, half of their

intervention time was spent on activities involving sentence perception and perceptual strategies,

the rest was spent on activities involving consonant discrimination and identification (Rubinstein

& Boothroyd, 1987). The results from this study showed no significant difference in performance

between the two groups. This implied that the inclusion of the analytic training did not result in

improvement to any of the outcome measures when compared to the result found with synthetic

training alone.

Another of the studies reviewed by Sweetow and Palmer (2005) compared an analytic training

programme directly against a synthetic training programme for hearing impaired adults. The

results indicated that the adults receiving the synthetic method showed significant improvement

on a self perception communication measure. The adults receiving the analytic training did not

show any significant improvements for any of the outcome measures. Thus concluding that in

this study, synthetic training was a more effective type of auditory training method.

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Overall, the review of the literature by Sweetow and Palmer (2005) does not provide good

evidence for the effectiveness of individual auditory training in the acquired hearing impaired

adult population. Given the results obtained, Sweetow and Palmer believe that synthetic training

is more effective as an auditory training method, rather than analytic training for this population.

Auditory Training in Children

Ertmer, Leonard, and Pachuilo (2002) conducted two case studies of acquired hearing loss in

children. Both case studies followed a twenty-month intervention programme for each child

including intervention in the following areas: auditory perception, speech production, language

skills and integration of the language skills. Analytic and synthetic auditory training approaches

were used as the intervention for auditory perception and speech production. Ertmer et al. (2002)

commented that the use of non-speech sounds in intervention were useful when they sounded like

real life situational sounds and were not distorted or atypical. Tye-Murray (1993, cited in Ertmer,

et al. 2002) questioned the use of non-speech sounds in auditory training as practise with these

materials may have little or no benefit for speech perception.

The results from Ertmer et al.’s (2002) study do not directly examine the effect of auditory

training on children but overall the analysis showed that both children improved significantly in

all the areas of intervention. However, Ertmer et al. (2002) believed the success of intervention

relied on many variables including personality, aided thresholds, length of time since

implantation of assistive devices, amount of normal hearing before acquiring deafness, mother-

child interactions, and the child’s attitude towards listening and learning.

Hoekstra, Snik, Van Der Borne and Van Der Broek (1999) also conducted research that evaluated

the effectiveness of auditory training in 45 young children with severe to profound hearing

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impairments. The children in the study were receiving weekly therapy. The basal auditory

abilities of each child were assessed with a sound discrimination and identification test. This test

used environmental sounds, musical instruments, animal sounds, and toy sounds. Communicative

abilities were measured using the scales of early communication skills for hearing impaired

children, developed by Moog and Geers (1975). The intervention that the children received was

an oral-aural training programme, specifically designed for each child. All the children in the

study responded positively to the auditory training. However, Hoekstra et al. (1999) did not

provide any details about the statistical analysis used. The study was not a randomised controlled

trial (RCT), and did not use blind assessment of outcomes. Although the children responded

positively to the intervention, the evidence for their improvements is weak. Auditory training

intervention for children with a hearing impairment is an area that Hoekstra et al. (1999) and

Ertmer et al. (2002) believe warrants further investigation. Due to positive yet unsubstantiated

results from these studies, there is a need for better-designed studies to provide evidence for the

effectiveness of auditory training in hearing impaired children.

Computers in Auditory Training

Sweetow and Palmer (2005) suggested computer aided auditory rehabilitation could be an

effective part of intervention training programme, for either adults or children with hearing

impairments. Sweetow and Palmer (2005) compiled a list of features of computer software,

which they believe would contribute to the success of an auditory training programme. These

features include the following: cost effective, easy, fun and rewarding for the client, practical,

easily accessible, incorporation of both synthetic and analytic approaches and provide feedback

regarding progress.

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Kaplan, Mahshie, Moseley, Singer and Winston (2006) also comprised a list of features which

they believed were important to the success of computer-based auditory training intervention.

These features included a game-like interface, graphical reinforcement rather than lexical

reinforcement, minimum amounts of text, auditory features coupled with visual components,

visual prompts all of which are easy to use and motivating for the students. These features were

supported by research, which included clinical experience of the authors and selected individuals

specialising in working with hearing impaired children.

There is similarity between the features described by Kaplan et al. (2006) and those described by

Sweetow and Palmer (2005). Diehl (1999) provided a list of software expectations in a review of

the Earobics software, a programme designed to provide auditory processing and phonics

awareness training. These expectations contain similar features to those mentioned in studies by

Kaplan et al. (2006) and Sweetow and Palmer (2005). These expectations are not yet evidence-

based but are based on the knowledge and experience of clinical users of the software.

Schery and O’Conner (1992) reported that there was very little research evaluating the gains in

communication development that were attributed to computer-based intervention. However, since

1992 there has been more evidence contributed to evaluating the effectiveness of computer use as

an intervention tool. Recently Cohen et al. (2005) investigated the effectiveness of the computer

software programme Fast ForWord (FFW). FFW is a computer-based intervention for children

who have Specific Language Impairment (SLI). The programme used acoustically enhanced

speech stimuli that were modified to exaggerate their time and intensity as part of an adaptive

training process. This study was a RCT with blind assessment of outcomes (Cohen et al. 2005).

Seventy-seven children participated in this FFW study. The children were divided into three

groups. The first group received a home based intervention with the FFW computer software. The

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second group received home based intervention with generic computer activities that used

unmodified speech stimuli, but the activities were designed to promote language development.

The third group was a control group. During the intervention period, all the children in the study

continued to receive their regular speech and language therapy. The participants in groups one

and two were instructed to play the computer intervention game for ninety minutes, five days a

week. Cohen et al. (2005) reported that children in all three groups made significant gains in the

primary outcome measures of expressive and receptive language scores. As the children in the

control group also made significant gains in their language scores, the gains made by the children

in the FFW intervention group cannot be attributed directly to the FFW computer intervention

programme.

The findings from Cohen et al’s. (2005) study are in conflict with an earlier FFW study

conducted by Tallal et al. (1996). The research by Cohen et al. (2005) is a lot more powerful and

the techniques used such as RCT, and blind assessment of outcomes were very detailed. These

techniques were not used in the Tallal et al. (1996) study. The mismatch in results could also be

attributed to a lower number of participants in the Tallal et al. (1996) study (seven compared to

seventy-seven). Each child in the Tallal et al. (1996) study received three hours of training

exercises per day for five days a week. Each child also completed one to two hours of homework,

seven days a week. In the Cohen et al. (2005) study the participants engaged in only ninety

minutes of therapy per day. This appears to be a more reasonable amount of therapy time, which

may have been a factor contributing to the insignificance of the results.

Other authors such as Schery and O’Conner (1992) and Shirberg, Kwiatkowski and Snyder

(1990) have shown the effectiveness of computer-based intervention in children with speech and

language disorders and/or delays. However, in the childhood hearing impaired population there

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appears to be limited evidence to evaluate the effectiveness of the use of computers as a tool for

intervention. Furthermore, there appears to be even less evidence to examine the effectiveness of

computer-based intervention to aid auditory training in hearing impaired children, however it is

widely used among speech and language therapists working in the hearing-impaired field.

A pilot study by Jamieson and Hodgetts, (2002) is a step in the direction of evidence for the

effectiveness of computer-based auditory training intervention for hearing impaired children. The

pilot research involved five case studies using ‘Listen-Hear’ software. Listen-Hear software was

developed by Auditory-Verbal Therapists and designed to “help children learn to listen and

understand spoken language following paediatric cochlear implant” (AVAAZ-Innovations,

2004). The intervention activities in the computer programme included listening to, and

understanding sounds and words at sound, syllable, word, and phrase levels. In the study, each

child’s auditory comprehension skills were assessed prior to beginning a four-week intervention

block, and then assessed again at the conclusion of the intervention. One of the children in the

pilot investigation served as a control and did not begin intervention until after the final

assessment. All of the children (except the control) improved dramatically from pre-test to post-

test, showing that further investigation and statistical analysis is warranted for the Listen-Hear

software (Jamieson & Hodgetts, 2002). No information about the participants, study methods, or

the evaluation of results is available therefore this pilot study by Jamieson and Hodgetts (2002) is

not a strong source of evidence for the effectiveness of computer-based auditory training.

Computer-based auditory training intervention for hearing impaired children is an area that

warrants further research. Auditory training is an exceptionally important area of learning for

hearing impaired children, as those who have never heard normally must learn to interpret sounds

and extract speech information from the acoustic cues available. There is some research to

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support the effectiveness of traditional auditory training (Tyler, Tye-Murray, & Gantz, 1991, &

Sweetow & Palmer 2005).

The aim of the present study is to determine if weekly auditory training therapy using Otto’s

World of Sound computer-based auditory training software, produces improvements in auditory

attention, auditory discrimination and speech perception skills in children who have a hearing

impairment.

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METHODOLOGY

Participants

Four children enrolled in a deaf unit at an Auckland primary school were invited by their class

teacher and the Speech Language Therapist at the school to participate in the present study.

Selection criteria were: The child will

1. Have a significant hearing impairment (moderate hearing loss or greater)

2. Use some oral/verbal language for communication

3. Use English when speaking verbally

4. Have a computer to play Otto’s World of Sound at home

5. Have appropriate cognitive abilities to conduct the testing

Written consent was obtained from the parents or legal guardians of the children, and assent

was obtained from the children themselves, in accordance with guidelines of the University of

Auckland Human Participants Ethics Committee. The demographic data of the four

participants is presented in Table I below and in Appendix A. Further information about each

child’s aided thresholds is presented in Figure I.

Frequency Modulation (FM) Systems were not used in the therapy sessions. FM systems work

by transmitting sounds/voices directly to the hearing aid of the hearing-impaired person. The

transmission happens on reserved radio spectrum 216-217 MHz in New Zealand. P4 was the

only participant fitted with an FM system. He used the FM system only in the classroom. All

four children used New Zealand Sign Language (NZSL). NZSL was the primary method of

classroom instruction for P1, P2, and P3. Oral English was the primary method of classroom

instruction for P4.

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Participant P1 P2 P3 P4
Age
7;11 7;5 8;6 10;7
(years;months)
Sex F F F M
Aetiology of Genetic - Goldenhar
Genetic Unknown
hearing loss Maternal Syndrome
Age Diagnosed 2;5 0;3 1;7 5;7
Age aided 2;7 3;5 2;7 5;7
Mild sloping to Severe to
Left Ear Profound Profound
moderate Profound
Atresia of
Severe to
Right Ear Severe external Profound
Profound
auditory meatus
Right only Left only Right cochlear Bilateral hearing
Amplification
Hearing aid hearing aid implant aids
Ethnicity Samoan Cook Island European Arabic
Language of
Classroom NZSL NZSL NZSL Oral English
Instruction
Cook Island
Language Samoan, English English & Arabic, English
Maori, English
Spoken at home & NZSL NZSL & NZSL
& NZSL

Table I – Demographic data for the four individual participants.

-10
0
10
20
30
40
Level in dB HL

P1
50 P2
60 P3
P4
70
80
90
100
110
120
125 250 500 1000 2000 4000 8000
Frequency in Hz

Figure I – Audiogram of P1, P2, P3 and P4’s aided hearing thresholds in the better ear (P4) or

in the only ear with a hearing aid (P1, P2) or cochlear implant.(P3).

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Study Design

This research project took the form of four individual case studies. A within subjects design was

used to look at changes in the auditory attention, auditory discrimination and speech perception

skills of the participants. Some group analyses were also used and the worrisome heterogeneity

between participants was taken into consideration when interpreting the results.

Materials

Assessment tasks included:

Phonological Auditory Discrimination Test – This assessment tested the participants’

phonological discrimination skills. The test used “manipulated word pairs according to the

position of contrasting phonemes and the degree of phonemic difference” (Tapp, 2005, p. 2).

The participant was seated 30 cm directly in front of the Compact Disc (CD) player that played

the forty pre-recorded monosyllabic nonsense word assessment. The speech level was calibrated

using a 1000 Hz calibration tone and a using a sound level meter to set the presentation level at

70 dBSPL. There were 28 minimal non-word pairs that required a ‘different’ response and 12

non-word pairs requiring a ‘same’ response in a randomised order. The participant put a counter

into the ‘different’ box when the words were discriminated as ‘different’, and into a ‘same’ box

when the words were discriminated as being the ‘same’. In this assessment, there is a 50%

chance that the child will be successful on each answer, therefore this must taken into

consideration when evaluating the results.

Dependent variables were percent correct, percent of correctly discriminated non-word minimal

pairs according to type of phoneme contrast and percent of correctly discriminated non-word

minimal pairs according to position of phoneme.

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Lexical Neighbourhood Test (LNT) – This assessment is a pre-recorded test of speech

perception that measures the child’s ability to recognise speech sounds in a multi-syllabic

context. For this assessment, the participant was seated in front of a speaker that was connected

to an audiometer. The lists of multi-syllabic words were pre-recorded onto a (CD). The

participant listened to two lists of 12 words; “easy” (frequent words with few lexical

neighbours) and “hard" (infrequent words with many lexical neighbours). After each word, the

child was instructed to repeat exactly what they heard. The participant’s responses were

recorded on an audiotape for later analysis. Dependent variables were percent syllables correct,

percent phonemes correct and percent words correct. Percent syllables correct were a measure

of the participants’ abilities to identify the supra-segmental features of the words.

Integrated Visual and Auditory– Continuous Performance Test (IVA) – This assessment is

a computerised test of attention, processing, and self-control. The main task lasts about 13

minutes and presents 500 of one and two in a random pattern. This allows the shifting of sets

between the visual and auditory tasks. The participant was required to click the mouse only

when they saw or heard a "one". They would be expected to inhibit this clicking when a "two"

was presented. Participants were seated in front of a computer screen with external speakers on

either side of the screen. The experimenter adjusted the volume of the speakers to a comfortable

listening level for the participant. The computer simultaneously presented the instructions

visually, and verbally. The participant is required to attend, listen, and follow the instructions

given by the computer. The IVA is divided into four sections: warm-up period, practice period,

main test, and cool-down period.

The warm-up period is designed to sensitise the subject to the task, thus the subject is presented

with the target stimuli ‘one’ visually for one minute followed by a minute of auditory stimuli.

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The practise period lasts one and a half minutes and combines both visual and auditory targets.

The targets ‘one’ and ‘two’ are used in the practise period. When a ‘two’ is seen or heard, the

subject must inhibit a response. The main test is also a combination of visual and auditory stimuli

and it lasts for 13-minutes. There are five sets of 100 visual and auditory trials, making 500 trials.

A single trial is one and a half seconds. The visual stimuli ‘one’ and ‘two’ are presented for

167ms and the auditory stimuli ‘one’ and ’two’ are presented for 500ms. The cool down period

presents the target stimuli ‘one’ visually for one minute followed by one minute of auditory

stimuli. In all four of the subtests, the subjects are required to click the mouse button once

whenever the target ‘one’ is seen or heard. The subject must inhibit this clicking response when a

‘two’ is seen or heard.

On completion of the assessment, the IVA formulated a graph of each of the subjects’

performances. All the scores were reported as standard scores, with a mean of 100 and a standard

deviation of 15. For each subject an auditory response score, a visual response score, an auditory

attention score, and a visual attention score were obtained. The auditory and visual response

scores are a measure of the subjects’ auditory and visual impulsivity respectively. For example, is

the child able to inhibit clicking the mouse button when a two is presented auditorially or

visually? The auditory and visual attention scores are a measure of the child’s ability to attend to

the auditory and visual demands of the task.

Therapy

Each child received each of the three assessments in a separate session before therapy

commenced and after therapy had finished (pre and post-test assessments). All of the

assessment and therapy sessions were individual sessions and took place in a quiet room at the

school during school hours. All participants received between eight and ten, 30-minute therapy

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sessions (excluding the assessment sessions). The therapy sessions were conducted on a weekly

basis during the third and forth school terms using the auditory training software, Otto’s World

of Sound provided, by Oticon.

The Otto’s World of Sound programme was played on the same computer each week, using

external speakers on either side of the screen to amplify the sound. The participant sat in front

of the computer, with access to the mouse, and the experimenter sat on the side of the

participant’s best hearing ear. From the beginning the child was allowed to navigate their way

around the programme, however once they entered a scene they had to finish it in order to move

on to the next scene.

During the sessions, the experimenter asked the participant questions about the items in the

scene. For example in the Zoo scene, the child clicked on the elephant, which made an elephant

sound. The experimenter then asked, “What’s that called?” If the child did not know, they were

prompted to click on the word, listen to it and then repeat it. Further, the experimenter often

engaged in conversation with the participant about the scene. Conversation was useful as it

allowed the introduction of extended vocabulary, and built on the oral environment of the

sessions. For example in the beach scene, the experimenter asked, “Have you been to the

beach? What’s your favourite flavour of ice-cream?” etc. In attempt to keep the participant on

task, the experimenter used comments such as “You’re listening really well today”, “Look, Otto

says good work”, “I can see you’re listening carefully” and “Well done, good listening”. A

sticker was used as a reward at the end of each session.

Towards the end of the therapy block P4 appeared to be getting bored with the programme, so

the experimenter introduced listening games into his sessions. In the listening games, the

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experimenter said the word for an item in a scene and P4 had to listen carefully and click on the

item requested. He was rewarded by a correct or incorrect response given by the experimenter.

When he was incorrect, or did not hear the word accurately the first time, he was prompted to

ask the experimenter to repeat the word for him. This activity was extended by increasing the

number of words presented orally to two, then three at a time. Roles were also reversed in this

game. P4 told the experimenter to click on an item, and then judged it to be correct or incorrect.

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RESULTS

Auditory Discrimination Assessment

Overall, the participants scored an average of 45.0% on the pre-test and 58.8% on the post-test

(see Figure II). When judging similarities in the non-words, the participants scored an average

of 79.2% on the pre-test and 85.4% on the post-test. When judging differences in the non-

words, the participants scored an average of 30.4% on the pre-test and 47.3% on the post test.

This showed that when the participants needed to make a ‘different’ judgement, the task was

too difficult. These results are less than chance (50%).

110
100
90
80
Percent Correct (%)

70
60
50 Pre
40 Post
30
20
10
0
Combined Same Different

Figure II – Average percent of correctly discriminated non-pairs (%) pre-test versus post-test

(n=4). Error bars indicate standard deviation.

As the data from this assessment was not normally distributed, a wilcoxon matched pair’s test

was conducted to determine if the ‘combined’, ‘same’ or ‘different’ results were statistically

significant, from pre-test to post-test. The results showed that there was no statistical significant

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difference for the ‘combined’ and ‘different’ tasks, however there was a statistical trend for the

participants to be better on the ‘same’ discrimination task (p=0.067).

This assessment was also analysed in terms of percent correct position of phoneme substitution in

non-word minimal pairs and percent of correctly discriminated non-word minimal pairs

according to type of phoneme contrast. These results are shown on Figure III and Table II

respectively below. Figure III shows that overall the participants scored higher on the initial

position sounds. Final sounds were more difficult for the participants. A Wilcoxon matched pairs

test was conducted to determine if any statistically significant improvements were made from

pre-test to post-test. The results showed that P4 had improved significantly for the items in initial

position. Other than this, there were no statistically significant results for initial or final position

when comparing the pre-tests to the post-tests.

100
90
80
70
Pecent Correct

60
Initial
50
40 Final

30
20
10
0
Pre Post Pre Post Pre Post Pre Post

P1 P2 P3 P4

Figure III – Percent correct of position of phoneme substitution in non-word minimal pairs (pre-

test versus post- test) for the four individual participants.

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Type of Phoneme Contrast

Voice +
Voice Manner Place Voice + Voice + Manner Manner
Participant Test only only only Manner Place + Place + Place
P1 Pre 0 0 0 0 0 0 25
Post 25 25 0 50 75 0 75
P2 Pre 75 75 25 75 25 25 25
Post 75 50 25 50 75 75 50
P3 Pre 50 75 0 50 50 25 75
Post 0 50 0 75 25 0 75
P4 Pre 0 25 0 75 0 25 50
Post 75 50 50 75 75 75 50

Table II - Percent of correctly discriminated non-word minimal pairs according to type of

phoneme contrast for the four individual participants.

Table II shows there were no consistent patterns across participants for discrimination of non-

word pairs according to type of phoneme contrast. However, it appeared that place cues were

the most difficult for all the participants to discriminate.

Lexical Neighbourhood Test

The analysis of the lexical neighbourhood test results in Figure IV below shows that all

participants found this task relatively difficult. Overall, there was no clear difference between the

easy and hard lists therefore, they were combined. Further, the repetition of the words was most

difficult, phonemes was the next difficult, and marking of the syllables was the least difficult for

the participants. A Wilcoxon matched pairs test was conducted to determine if there were any

statistically significant effects of the therapy on this assessment. The results showed that there

was no significant effects for words or syllables, however there was a trend for phoneme scores

to improve significantly (p=0.067).

Individually P1 improved on all the measures of the speech perception test, however making the

greatest improvements in word and phoneme scores. P2 also made improvements on all the levels

of the test. The improvements that were made by P2 were equal across all the measures: words,

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phonemes and syllables. P3 did not make any improvements on the speech perception test. The

scores P3 obtained were similar at both pre-test and post-test. P4 made gains on the speech

perception test. The most noticeable improvements made by P4 were in words and phoneme

scores.

100

90

80

70

60
Percent (%)

Word
50
Phonemes
40

30 Syllable
Count
20

10

0
Pre Post Pre Post Pre Post Pre Post

P1 P2 P3 P4

Figure IV - Average of easy and hard lexical neighbourhood test scores (%) pre versus post test

for the four individual participants.

IVA

The results in Table III show that three out of four participants responded to auditory stimuli

more consistently and accurately than visual stimuli. P3, who responded equally to auditory and

visual stimuli, has a cochlear implant and has been aided for the longest time.

In terms of auditory and visual modalities, the results show that the participants scored well

below the mean on this task. Overall, participants showed preference for the auditory modality,

and thus gained the most successful scores for their auditory responses. For most participants

their auditory response measures improved from pre-test to post-test. The participants showed

very poor auditory attention skills, with some small improvements observed during the post-test.

23
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As shown by the results, visual response and visual attention skills of P1, P2 and P4 appeared to

be underdeveloped. The results for these three participants were invalid, thus showing they

were not able to control visual responses, or attend to the visual stimuli.

Individually, P1 made the most gains with the visual response and visual attention scores. Her

auditory response and auditory attention scores remained the same for both assessment periods.

P2 performed relatively poorly on both auditory and visual parts of the assessment on the pre-test.

However, on the post-test P2 made gains with the auditory response and auditory attention scores.

P3 improved from the pre-test on all parts of the assessment. Overall, P3’s visual scores were

slightly more dominant than her auditory scores. P4 did not make any gains with this assessment

from pre-test to post-test.

Age Auditory Visual Auditory Visual

Participant (Years) Test Response Response Attention Attention
Invalid Invalid
P1 7;11 Pre 70 Score 87 Score
Post 80 91 74 53
Invalid Invalid Invalid Invalid
P2* 7;5 Pre Score Score Score Score
Invalid Invalid
Post 77 Score 52 Score
P3 8;6 Pre 73 85 58 61
Post 85 92 92 111
Invalid Invalid
P4 10;7 Pre 64 Score 44 Score
Invalid Invalid
Post 48 Score 37 Score

Table III – Auditory and visual response and attention scores for the IVA assessment. *No

hearing aid during assessment.

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DISCUSSION

The aim of the present research was to determine if weekly therapy using Otto’s World of

Sound computer-based auditory training software resulted in improvements in auditory

discrimination, speech perception and auditory attention skills. Given the small size of the study

and the limited ability to conduct statistical analysis, the results obtained are promising. The

therapy did not produce any measurable improvement in auditory discrimination skills, based

on results for the phonological discrimination task. However on the lexical neighbourhood test,

speech perception skills did improve for three of the four children (with the exception of P3,

whose results did not change). Phoneme scores showed the most improvement from the

therapy. This was reflected in the statistical analysis that showed a trend towards significant

improvement in phoneme scores. Results for the IVA assessment of sustained auditory and

visual attention are difficult to interpret, as a number of the results obtained pre-treatment were

not valid due to insufficient attention and concentration abilities of the participants. After the

treatment, three of the children showed improvements on this assessment. This improvement

includes several results that initially were described as “invalid score” that improved to a

measurable (but still poor) score after the treatment. Further support for the training came from

the participants’ teacher who reported that “Through the therapy the students became more

confident in themselves, they are more vocal, and their intonation changed, which is more

noticeable in their reading”.

The results of the present study are very encouraging, consistent with previous research which

has suggested that a computer-based auditory training therapy approach may be useful for

improving auditory comprehension skills in hearing impaired children (Jamieson & Hodgetts,

2002). Also, other auditory training literature has shown that traditional auditory training can be

effective for improving auditory perception, speech production, language skills (Ertmer, Leonard

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& Pachuilo, 2002) and general auditory skills in individuals who have a hearing impairment

(Sweetow & Palmer, 2005). Although these authors have presented research in which results

have been significant and effective, Ertmer et al. (2002) points out that there may be many

characteristics of the child and their environment that help to determine the success of the

intervention. These characteristics include personality, aided thresholds, length of time since

implantation or obtaining assistive devices, amount of normal hearing before acquiring deafness,

mother-child interactions, and the child’s attitude towards listening and learning.

Auditory Discrimination Outcomes

The Otto’s World of Sound therapy did not produce any measurable improvement in auditory

discrimination outcomes, based on results for the phonological discrimination task. This result is

not surprising, as the majority of the training did not include the use of speech sounds. Although

the therapy programme was based on the analytic training approach, it used gross auditory stimuli

for training, such as environmental sounds, rather than individual speech sounds. In the case

studies by Ertmer et al. (2002), practice with non-speech stimuli was discontinued after a few

sessions in order to focus exclusively on speech stimuli during auditory training. Ertmer et al.

(2002) found that the non-speech sounds were useful for the orientation of a child to sound, but

when they were distorted or atypical, became less useful. Perhaps an auditory discrimination

assessment that used non-speech auditory stimuli (e.g., an environmental sound or tonal

discrimination task) would be a way of gaining a more accurate and sensitive measure of the

improvements made by the participants.

Speech Perception Outcomes

Overall, the participants obtained very high scores for the syllable count on the pre-test and the

post-test, indicating that the supra-segmental features of the words were the easiest to identify.

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The most promising results from the present study were the improvements made by the

participants in the speech perception test. Three of the four participants made improvements with

speech perception on post-testing, with the exception of P3, whose results stayed the same.

Phoneme scores showed the most improvements from the therapy. This was reflected in the

statistical analysis that showed a trend towards significance for phoneme scores. These results

should be interpreted cautiously as the improvements may reflect a practice effect rather than a

training effect. Further investigation using a series of pre- and post- intervention assessment

periods, or using a randomised controlled trial format would verify whether this apparent

improvement in speech perception scores is due to the training. The apparent improvement in

phoneme scores after the training is a very interesting result as the usefulness of auditory training

with non-speech stimuli has been questioned. It has been suggested that practice with these

materials may have little or no benefit for speech perception (Tye-Murray, 1993 & Ertmer et al.

2002).

P4 made the greatest improvements on all measures of speech perception: word score, phoneme

score, and syllable count. This was a surprising result because, as shown in the audiogram in

Figure I P4 has the poorest aided thresholds in the high frequencies. P4 was, however, the most

oral participant in the study, and his language of classroom instruction is oral English. These

factors may have contributed to his positive results on the speech perception test.

Blamey, Sarant, Paatsch, Barry, Bow, Wales, et al. (2001) conducted research on “the

relationships among speech perception and production scores, spoken language measures, hearing

loss, and age in a group of primary-school children with impaired hearing” (p. 266) and found

that rates of improvement for the individual children were not correlated significantly with degree

of hearing loss. Blamey, et al. (2001) reported that speech perception scores for the children in

their study were strongly related to language level abilities and speech production scores. P4 was

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the oldest participant in the study. Language was not formally assessed, but anecdotally he

appeared to have the most advanced language abilities amongst the four participants.

P3 who has very good aided thresholds did not perform well on the lexical neighbourhood test.

According to Blamey, et al., (2001) this result may be explained by P3’s poor language abilities

and/or poor speech production skills. Other characteristics could also impact on the findings in

this and other auditory training studies, such as nonverbal intellectual quotient (IQ), and interest

and co-operation with the task.

Auditory Attention Outcomes

The results for the IVA assessment of sustained auditory and visual attention were difficult to

interpret as some results obtained pre-treatment were not valid due to insufficient attention and

listening skills. However, three participants did appear to show improvements after the therapy.

As for the speech perception findings, a more robust study design is needed to verify these

findings.

An important finding from the IVA assessment was that the participants responded more

accurately and consistently to the auditory stimuli than to the visual stimuli. An explanation for

this result may be explained by the development of auditory and visual systems in typically

developing children. Sloutsky and Napolitano (2003) hypothesised that young children (3.5-4.5

years) exhibit dominance in the auditory modality. Sloutsky & Napolitano (2003) reported that

dominance for the auditory modality has been well researched previously in infants (6-10 month

olds) but not in preschool children. Sloutsky & Napolitano (2003) examined the responses of pre-

school children when visual stimuli were presented simultaneously with auditory stimuli,

compared to when visual stimuli were presented alone. Young children “made equivalence

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judgements based on the equivalence of the auditory and not just the visual component”

(Sloutsky & Napolitano, 2003, p. 830). Results indicated that young children encoded the

auditory components more readily than the visual components when both modalities were

presented simultaneously, although the children did not have difficulty processing the visual

stimuli. (Sloutsky & Napolitano, 2003)

Although the participants in the present study were not typically developing (their hearing age

was well below their chronological age), the patterns of development would be expected to have

followed that of a typically developing child. Therefore, just as young children show a preference

for the auditory modality, children with a young hearing age may also be expected to show a

preference for the auditory modality, as they did in the present study. This is somewhat

incongruent with the common view that children will compensate for their hearing loss by

developing better visual processing skills.

Many authors (Horn, Davis, Pisoni, & Miyamoto, 2005; Quittner, Smith, Osberger, Mitchell, &

Katz, 1994; Sloutsky & Napolitano, 2003 & Smith, Quittner, Osberger, & Miyamoto, 1998) have

researched the development of visual attention skills in hearing impaired children. These authors

concluded that children who are pre-lingually deaf or hearing impaired have underdeveloped

visual attention skills compared to their hearing peers. Quittner et al. (1994) also reported greater

distractibility and impulsivity in the hearing impaired children compared to normal hearing

children. Quittner et al. (1994) and Smith et al. (1998), believe that early auditory deprivation

may lead to the ‘remodelling’ of visual attention processes, thus, children who are hearing

impaired are forced to use vision to monitor their environment. Quittner, Smith and their

colleagues argued that visual attention processes in children with late identified hearing loss

would reorganise and adapt to maintain a wide spatial focus, rather than a narrow task-specific

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focus such as a CPT (Quittner, Smith, Osberger, Mitchell, & Katz, 1994; Smith, Quittner,

Osberger, & Miyamoto, 1998). If this is the case one might expect poor results for a focussed

visual attention task such as the IVA.

Horn et al. (2005) conducted a retrospective analysis that investigated visual attention skills in

children who use cochlear implants. The authors used a continuous performance test (CPT) to

measure visual attention skills [similar to the IVA task used in the current study]. The children’s

scores were very low compared to normal hearing children, “performance improved as a function

of length of cochlear implant use and chronological age” (Horn, Davis, Pisoni, & Miyamoto,

2005, p. 389). The results indicated that cochlear implantation leads to improved sustained

attention over the two or more years of cochlear implant use. In the IVA assessment, P3 (cochlear

implant user) did not display a preference for the auditory modality over the visual modality. She

has had her cochlear implant for approximately five years. P3 who has the cochlear implant has

the best hearing sensitivity with the device, and made the greatest gains in auditory and visual

attention scores.

Perceptual Learning

The small improvements that occurred for some children during the present study are likely to be

due to the auditory training therapy. However, improvements may also be attributed to more

general perceptual learning effects resulting from engaging in therapy on a weekly basis. Amitay,

Irwin and Moore (2006), conducted a study that examined the effects different types of training

on perceptual learning in listeners with normal hearing. Their goal was to better understand the

mechanisms underlying perceptual learning. They defined perceptual learning as ‘learning or

improvements on a certain task that occurs in the absence of training on that task’. Amitay et al.

(2006) hypothesised that optimal learning would be achieved by using a training task that was

30
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neither too easy nor too difficult. Their results however support only the first part of this

hypothesis suggesting that “effective auditory training tasks can not be made too difficult,

provided that sufficient, task-appropriate attention is engaged during learning” (Amitay et al.,

2006, p. 1447). In Amitay et al.’s (2006) research, frequency discrimination learning occurred in

the absence of a discriminable difference between the stimuli during training. This shows that

perceptual learning does not necessarily involve training using a stimulus comparison

mechanism. Instead the authors suggested that the “training might improve the ability to attend to

a task specific stimulus and the ability to access a low-level representation and make it available

for further processing” (Amitay et al., 2006, p.1447). As in Amitay et al’s., (2006) study, the

participants in the present study were not being directly trained on the stimuli examined in the

assessment tasks. The therapy was providing participants with the opportunity to attend to the

task and access low-level auditory representations, which could be further built upon when

further processing was required. Amitay et al.’s study suggests that improved speech perception

and auditory and visual attention scores could result from auditory training using simple stimuli

such as those incorporated in Otto’s World of Sound.

Clinical Implications of the Study

There are many ideas that have come from the present study that could be taken into

consideration when using computers for auditory training therapy in young hearing-impaired

children. Firstly, to make improvements with listening, the child must be interested in the task.

The task must be age-appropriate, and user friendly. The child must be able to navigate their way

around the programme with minimal difficulty. The child must be able to focus adequately,

therefore, an optimum amount of visual and auditory stimuli on the screen is desirable. Next, for

improvements to occur with listening abilities, the child must be attending to the auditory stimuli

of the task. Previous research has shown that young hearing impaired children find it difficult to

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attend to auditory stimuli when visual stimuli are also present (Sloutsky & Napolitano, 2003).

Therefore, when visual stimuli are reduced, auditory attention may improve, and perhaps vice

versa. Lastly, when planning auditory training activities using a computer, it is essential that the

activities be designed to suit the individual needs and requirements of the child. This will ensure

that the child receives maximum benefit from the therapy.

Limitations of the Study

It is difficult to attribute the improvements made in the present study to therapy alone as a control

group (participants who did not receive therapy) was not included in the study. An alternative

design would have been to incorporate baseline pre-training and post-training assessment periods

with multiple assessment points to see if improvements were due to therapy alone and not other

factors, and to see if changes were stable after completion of the training.

In addition to the therapy, improvements may be due to: maturation (there was a five-month gap

between pre-testing and post-testing), continual day-to-day teaching from the classroom teacher,

learning that occurs in the home environment, the effect of general perceptual learning associated

with wearing amplification.

Further, many of the participants are multi-lingual, using NZSL, speaking English and their

native language. The current research was conducted in English only. It would be of interest to

investigate the effects of the therapy if it was conducted in one or more of their other languages.

The timeframe available was a major limitation of the study. As previously mentioned, the

participants only received between eight and ten half hour therapy sessions. Studies that have

been successful such as Tallal et al. (1996) had a much longer time frame, with a longer period of

intervention. Therefore, a longer, more intensive period of therapy may have resulted in more

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conclusive results. Also due to the timeframe available, the participants were not able to complete

the whole Otto’s World of Sound programme. The programme is developed in a hierarchy,

working through the stages of listening, from detection to identification and comprehension of

sounds. These stages progressively move from easy to difficult. If a longer timeframe had been

available the participants could have completed the programme. This may have had an impact on

the results, as the participants would have needed more advanced listening skills in order to

successfully complete the more difficult stages of the programme.

Formal assessments of receptive and expressive language abilities were not available to the

experimenter. It would have been interesting to look at these scores, as this may have indicated

relationships with speech perception and auditory attention abilities. It would also be of interest

to look at the differences in training outcomes between conventional hearing aid users and

cochlear implant users.

Summary and Conclusion

The aim of the present study was to determine if weekly auditory training therapy using Otto’s

World of Sound produces improvements in auditory attention, auditory discrimination and speech

perception skills in children who have a hearing impairment. The results from the speech

perception and auditory attention measures were very encouraging considering the small sample

size and limited ability to conduct statistical analysis. Support for these promising results comes

from the participants’ classroom teacher who reported that the participants made some important

gains during the therapy. Due to limitations in study design, further research is warranted using

Otto’s World of Sound to determine if it is an effective tool for improving auditory attention,

auditory discrimination and speech perception skills in children who have a hearing impairment.

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Acknowledgements: The author wishes to thank, the participants and families for their

involvement in, and co-operation with the study; Kelston Deaf Education Centre (KDEC) staff,

for their support with the project; Judy Lemberg (SLT at KDEC) for help with recruiting

participants and support with all aspects of the study on a weekly basis; her mother - Penny Carey

and friend - Robyn Pettigrew for their help with editing, Suzanne Purdy for her ongoing support

throughout the year and lastly my partner Luke for all his support with all aspects of the project.

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Appendix Contents Page

A= Demographic data about each of the participants

B= Raw scores from auditory discrimination assessment

C= Raw scores from lexical neighbourhood test

D= Raw scores from IVA assessment

E= Child assent form

F= Parent/Guardian of Participant: Information sheet

G= Speech-Language Therapist/KDEC Staff information sheet

H= Speech-Language Therapist/Staff: Consent Form

I= Child Participant Information sheet

J= Parent/Guardian of Participant: Consent Form

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Appendix A – Demographic Data about each Participant

1. P1, a girl of Samoan heritage, who was 7,11 years when the research commenced. P1

has a severe hearing loss in her right ear and a profound hearing loss in her left ear. She

is a monaural hearing aid user, with aided thresholds of 40 DB HL and better in her right

ear. She has no amplification in her left ear. She is exposed to both English and Samoan

languages in her home environment, however she is competent in English only and uses

it predominantly.

2. P2, a girl who was 7;5 when research commenced. P2 is of cook island heritage. She has

Goldenhar Syndrome and some mild learning difficulties. P2 has some astigmatism in

her eyes, but this is corrected with glasses. P1 has a mild sloping to moderate hearing

loss in her left ear and no useable hearing in her right ear. She is a left hearing aid user

and receives thresholds of 40 DB HL and better through the aid.

3. P3, a girl who was 8;6 when research commenced. P3 wears a Cochlear Implant in her

right ear. She was implanted at the age of 2;7 years and has had numerous different

types of processors since. During the therapy block P3 upgraded to a new FREEDOM

speech processor. Through the cochlear implant P3 receives amplification of 40 DB HL

or better. P3 does not wear a hearing aid in her left ear and hasn’t done so since she

received the implant in her right ear.

4. P4, a boy who was aged 10;7 years when research commenced. He is of Arabic heritage.

P4 is a binaural hearing aid user and obtains thresholds of 45 DB HL or better up to

2000htz. P4 speaks English at school and at home to his brother, however his parents

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have limited English, therefore he speaks to them in Arabic. Part way through the

research therapy, P4 moved to a new classroom in which the main form of teaching was

by oral means rather than in sign language.

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Appendix B – Raw Scores from auditory discrimination assessment

Percent of correctly discriminated non pairs (%)

Participant Test Combined Same Different
P1 Pre 27.5 83.3 3.6
Post 52.5 91.7 35.7
P2 Pre 47.5 50.0 46.4
Post 57.5 58.3 57.1
P3 Pre 60 91.7 46.4
Post 52.5 100.0 32.1
P4 Pre 45 91.7 25.0
Post 72.5 91.7 64.3
Average Pre 45 79.2 30.4
Post 58.8 85.4 47.3
Table 1 - Percent of correctly discriminated non-pairs (%) pre-test versus post-test

100
90
80
Percent Correct (%)

70
60
50 Combined

40 Same

30 Different

20
10
0
Pre Post Pre Post Pre Post Pre Post Pre Post

P1 P2 P3 P4 Average

Figure 1 - Percent of correctly discriminated non-pairs (%) pre-test vs. post-test

Position of phoneme substitution in non-word minimal pair

Participant Test Initial Final
P1 Pre 0 7.14
Post 50 21.4
P2 Pre 42.86 50
Post 71.4 42.9
P3 Pre 57.14 35.7
Post 35.7 28.6
P4 Pre 21.43 28.57
Post 78.6 50
Table II - Position of phoneme substitution in non-word minimal pairs (pre-test versus post- test)

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100
90
80
70
Pecent Correct

60
Initial
50
40 Final

30
20
10
0
Pre Post Pre Post Pre Post Pre Post

P1 P2 P3 P4

Figure II - Position of phoneme substitution in non-word minimal pairs (pre-test versus post-
test)

Type of Phoneme Contrast

Voice +
Voice Manner Place Voice + Voice Manner Manner +
Participant Test only only only Manner + Place + Place Place
P1 Pre 0 0 0 0 0 0 25
Post 25 25 0 50 75 0 75
P2 Pre 75 75 25 75 25 25 25
Post 75 50 25 50 75 75 50
P3 Pre 50 75 0 50 50 25 75
Post 0 50 0 75 25 0 75
P4 Pre 0 25 0 75 0 25 50
Post 75 50 50 75 75 75 50
Table III - Percent of correctly discriminated non-word minimal pairs according to type of
phoneme contrast

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Appendix C – Raw scores from lexical neighbourhood test

Participant Test Word Phonemes Syllable Count

Easy Hard Easy Hard Easy Hard
P1 Pre 0.0 0.0 26.7 22.6 92.0 87.5
Post 16.7 33.3 52.5 52.7 92.6 100.0
P2 Pre 0.0 0.0 4.9 7.3 11.1 58.3
Post 25.0 25.0 58.3 58.5 88.0 91.7
P3 Pre 0.0 0.0 8.3 7.6 80.0 87.5
Post 0.0 0.0 9.8 14.5 74.0 83.3
P4 Pre 33.3 16.7 59.0 50.9 92.6 91.7
Post 66.7 50.0 90.0 69.8 100.0 95.8
Table IV – Lexical neighbourhood test raw scores (%) pre-test versus post-test

Participant Test Word Phonemes Syllable Count

P1 Pre 0.0 24.7 89.8
Post 25.0 52.6 96.3
P2 Pre 0.0 6.1 34.7
Post 25.0 58.4 89.6
P3 Pre 0.0 7.9 83.8
Post 0.0 12.2 78.7
P4 Pre 25.0 55.0 92.1
Post 58.4 79.9 97.9
Table V - Average of easy and hard lexical neighbourhood tests (%)

100

90

80

70

60
Percent (%)

Word
50
Phonemes
40

30 Syllable
Count
20

10

0
Pre Post Pre Post Pre Post Pre Post

P1 P2 P3 P4

Figure III - Average of easy and hard lexical neighbourhood test scores (%) pre-test versus
post-test

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Appendix D – Raw scores from IVA assessment

Age Auditory Visual Auditory Visual

Participant (Years) Test Response Response Attention Attention
Invalid Invalid
P1 7;11 Pre 70 Score 87 Score
Post 80 91 74 53
Invalid Invalid Invalid
P2* 7;5 Pre Score Score Invalid Score Score
Invalid Invalid
Post 77 Score 52 Score
P3 8;6 Pre 73 85 58 61
Post 85 92 92 111
Invalid Invalid
P4 10;7 Pre 64 Score 44 Score
Invalid Invalid
Post 48 Score 37 Score
*No hearing aid
Table VI – IVA raw scores pre-test versus post-test (Average =100, SD=15)

Pre-Test Auditory Visual Auditory Visual Scoring of IVA

Response Response Attention Attention
P1 2 0 3 0 0 = < 54
P2* 0 0 0 0 Invalid Score
P3 2 3 1 1 1 = 55 - 69
P4 1 0 0 0 Within 3SD of mean
Auditory Visual Auditory Visual
2 = 70 - 84
Post Test Response Response Attention Attention
Within 2SD of mean
P1 2 3 2 0
P2* 2 0 0 0 3 = 85 - 100
P3 3 3 3 4 Within 1SD of mean
4 = 100 - 115
P4 0 0 0 0 1SD above the mean
*No hearing aid
Table VII – IVA scores for statistical analysis

44