ERIC ED603268: Listening-Related Fatigue in Children with Unilateral Hearing Loss

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by  ERIC

LSHSS
Review Article
Listening-Related Fatigue in Children
With Unilateral Hearing Loss
Fred H. Bess,a Hilary Davis,a Stephen Camarata,a and Benjamin W. Y. Hornsbya
Purpose:Listening-relatedfatigueisanunderstudied Results:Resultsofourliteraturereviewandexploratory
constructthatmaycontributetotheauditory,educational, analysessuggestthatadultsandCHLareatincreased
andpsychosocialproblemsexperiencedbychildrenwith risk for listening-related fatigue. Importantly, this
unilateralhearingloss(UHL).Herein,wepresentanoverview increased risk was similar in magnitude regardless
oflistening-relatedfatigueinschool-agechildrenwithhearing of whether the loss was unilateral or bilateral.
loss(CHL),withafocusonchildrenwithUHL. Subjective ratings, based on child self-report and
Method:Followingareviewofresearchexamininglistening- parent proxy report, were consistent, suggesting
relatedfatigueinadultsandCHL,wepresentpreliminary that children with unilateral and bilateral hearing loss
findingsexploringtheeffectsofunilateralandbilateralhearing experienced greater listening-related fatigue than
lossonlistening-relatedfatigueinchildren.Forthese childrenwithnohearing loss.Incontrast, resultsbased
exploratoryanalyses,weuseddatacollectedfromour onteacherproxyreportwerenotsensitivetotheeffects
ongoingworkdevelopingandvalidatingatool,theVanderbilt ofhearingloss.
FatigueScale,formeasuringlistening-relatedfatiguein Conclusions:ChildrenwithUHLareatincreasedrisk
children.Presently,weareassessing3versionsofthe forlistening-relatedfatigue,andthemagnitudeoffatigue
fatiguescale—childself-report,parentproxy,andteacher issimilartothatexperiencedbychildrenwithbilateral
proxy.Usingthesescales,datahavebeencollectedfrom hearingloss.Problemsoflistening-relatedfatiguein
morethan900participants.Datafromchildrenwithunilateral school-ageCHLmaybebetteridentifiedbyCHL
andbilateralhearinglossandforchildrenwithnohearingloss themselvesandtheirparentsthanbyteachersand
arecomparedwithadultVanderbiltFatigueScaledata. specialistsworkingwiththechildren.
U
nilateralhearingloss(UHL)inchildrenisacom- Prevention[CDC],2005;Tharpe&Sladen,2008).Theleading
moncondition.Althoughtheestimatedpreva- causesofUHLinchildrenarecongenitalcytomegalovirus
lenceofcongenitalsensorineuralhearingloss followedbycongenitalinnerearmalformation(e.g.,enlarged
(HL;>40dBHL)atbirthisonlyapproximatelytwoper vestibularaqueduct),bacterial/viralmeningitis,viral/bacterial
1,000and30%–40%exhibitUHL(Kral,Hubka,Heid,& mumps,andChiarimalformation(Porter,Bess,&Tharpe,
Tillein,2013;vanWieringen,Boudewyns,Sangen,Wouters, 2016;Tharpe&Sladen,2008;vanWieringenetal.,2019).
&Desloovere,2019),theprevalenceofUHLappearsto AlthoughdefinitionsofUHLmayvaryacrossstudies,
increasewithage.Forexample,theprevalenceofUHLin complicatingcomparisons,proceedingsfromthe2005
school-agechildren(Grades3,6,and9)is3%orapproxi- NationalWorkshoponMildandUnilateralHearingLoss
mately1,380,000childrenintheUnitedStates(Bess,Dodd- suggestUHLexistswhentheaveragepure-toneair-conduction
Murphy,&Parker,1998;CentersforDiseaseControland thresholdat0.5,1,and2kHzis≥20dBHLorwhenpure-
toneair-conductionthresholdsare>25dBHLattwoormore
frequenciesabove2kHzintheaffectedear,coupledwith
anaveragepure-toneair-conductionthresholdinthegood
aDepartmentofHearingandSpeechSciences,VanderbiltBillWilkerson earof≤15dBHL(CDC,2005).
Center,VanderbiltUniversitySchoolofMedicine,Nashville,TN
Researchfindingsrelatedtothepsychoeducational
CorrespondencetoFredH.Bess:[email protected]
outcomes of children withUHL aremixed.Nonetheless,
Editor-in-Chief:ElizabethA.Walker
numerousstudies have reportedthat school-agechildren
Editor:DawnaE.Lewis
withUHLexperiencea varietyofauditory,educational,
ReceivedFebruary15,2019
andpsychosocialproblems(Bess,1982;Bessetal.,1998;
RevisionreceivedJuly17,2019
Bess&Tharpe,1984;Fitzpatricketal.,2019;Lewisetal.,
AcceptedAugust9,2019
https://doi.org/10.1044/2019_LSHSS-OCHL-19-0017
PublisherNote:ThisarticleispartoftheForum:Evidence-Based
PracticesandOutcomesforChildrenWithMildandUnilateral Disclosure:Theauthorshavedeclaredthatnocompetinginterestsexistedatthetime
HearingLoss. ofpublication.
84 Language,Speech,andHearingServicesinSchools (cid:129) Vol.51 (cid:129) 84–97 (cid:129) January2020 (cid:129) Copyright©2020AmericanSpeech-Language-HearingAssociation
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2016;Porteretal.,2016;Reeder,Cadieux,&Firszt,2015). riskofrecurrentlistening-relatedfatigueanditsnegative
Compared to children without HL, children with UHL consequences(Bess,Gustafson,&Hornsby,2014;Bess
exhibit more difficulty understanding speech in noisy etal.,2016;Bess&Hornsby,2014a;Hornsby,Werfel,
conditions (Bess, Tharpe, & Gibler, 1986; Hartvig Jensen, Camarata,&Bess,2014;Hornsbyetal.,2017;McGarrigle,
Johansen, & Borre, 1989; Lewis et al., 2016), localizing Gustafson,Hornsby,&Bess,2019).Giventhesefindingsand
sounds in the horizontal plane (Bess et al., 1986; Humes, theunderlyingdeficitsinbinauralprocessingresultingfrom
Allen, & Bess, 1980; Reeder et al., 2015), developing age- UHL,itisreasonabletosuspectthatchildrenwithUHL
appropriatelanguageandcognitiveskills(Fitzpatricketal., mightalsoexperiencefatiguedifficulties,especiallyinthe
2019;Halliday,Tuomainen,&Rosen,2017;Klee&Davis- schoolsetting.
Dansky,1986),andmaintainingsatisfactoryperformance Here,weofferareviewonlistening-relatedfatiguein
inschool(Bessetal.,1998;Bess&Tharpe,1984;Brookhouser, childrenwithUHL.GiventhatresearchspecifictoUHL
Worthington,&Kelly,1991;Lieu,2004,2013;Lieu,Tye- doesnotexist,wefirstprovideafocusedreviewofthelit-
Murray,&Fu,2012;Oyler,Oyler,&Matkin,1988).In eraturerelatedtosubjectivefatigueinadultswithHLand
addition,somechildrenwithUHLhavelowself-esteem, childrenwithbilateralHL.Additionally,weexploreexisting
anxiety,strainedpeerrelations,anddecreasedsocial evidencerelatedtofatigueinadultswithUHLandpresent
support(Bessetal.,1998).EvenwhentheUHLisidentified somepreliminaryfindingsonlistening-relatedfatiguein
early,childrenmaystillexperiencesomeoftheabove- childrenwithUHLusingvalidationdatafromourongoing
referencedcommunicativeandeducationalproblems workdevelopingtheVanderbiltFatigueScale(VFS).
(Fitzpatricketal.,2019;Yoshinaga-Itano,Johnson,Carpenter,
&Brown,2008).
Fatigue, Effort, and HL
Althoughmanystudieshaveshownthatchildrenwith
UHLexperienceavastarrayofacademicandcommunica- Acomprehensiveexaminationoffatigueisbeyondthe
tiveproblems,suchfindingsarenotuniversal(Hallmo, scopeofthisreviewarticle;readersinterestedinanin-depth
Møller,Lind,&Tonning,2009;Keller&Bundy,1980). coverageofthissubjectarereferredtootheroverviewpapers
Theseconflictingresultsmaybeduetoalackofstatistical (Bess&Hornsby,2014a;Hornsby,Naylor,&Bess,2016;
power(Keller&Bundy,1980)and/orafailuretoinclude McGarrigleetal.,2014).Briefly,fatigueiscommonplace
standardizedtestmeasuresoracontrolgroup(Hallmoetal., inoursociety.Itisacomplexconstructwithphysicaland
2009);however,contemporaryresearchclearlydemonstrates mental/cognitivedimensions,anditisoftencharacterized
thatsomechildrenwithUHLhaveanincreasedriskfor byfeelingsofweariness,tiredness,agenerallackofenergy,
communicationandeducationaldifficulties(Fitzpatrick and/orareduceddesiretocontinueonwithatask.When
etal.,2019;Porteretal.,2016). fatigueissevereandrecurrent,thesesubjectiveeffectsmay
Themechanismsresponsibleforthecommunicative alsobeaccompaniedbyfatigue-relateddecrementsinphys-
andpsychoeducationalproblemsexperiencedbychildren icaland/ormentalperformance.
withUHL arenot wellunderstood;however,a primary Whilemanyfactorsmodulateitsmagnitude,fatigue
factorfrequentlyreferencedintheliteratureisrelatedto —bothmentalandphysical—isacommonconsequenceof
theimportanceofbinauralhearingincommunication.Itis sustainedhigh levels of effort (Hockey, 2013).Here, we
welldocumentedthatbinaurallisteningoffersdistinctad- focusonfatigueresultingfrommental,ratherthanphysi-
vantagesovermonaurallistening,especiallyinnoisycondi- cal,effortasitismostrelevanttotheproblemsofchildren
tions.Factorssuchasbinauralsummation,headshadow, withhearingloss(CHL).Ourspecificfocusisonlistening
andbinauralreleasefrommasking(squelcheffect)provide effort,atypeofmentaleffortthathasbeendescribedas
listenerswithoutHLtheuniqueabilitytoidentifyandlo- theallocationofmentalresourcestolisten,process,and
calizesoundsources(Blauret,1997).Whenchildrenhave understandspeechandotherauditorystimuli(Downs,1982;
UHL,however,thesebinauralcuesarediminished,thus McGarrigleetal.,2019;Pichora-Fulleretal.,2016).
producingrippleeffectsthatmayimpactareassuchasedu- Children in classroom settings havemanydifferent
cation,speechrecognitioninnoise,andlanguageandcog- demands placedonthemthat requiresignificant mental
nitiveskills.Otherfactorsthatmightalsocontributetothe effortforsuccessfulcompletion.Forexample,mentaleffort
problemsofchildrenwithUHLincludechangesinauditory isrequiredtocompleteawrittenassignment,readaschool-
andbrainstructuresasaresultofauditorydeprivation,age book,orlistentotheteacherandotherchildrenintheclass-
ofidentification/intervention,degreeofHLintheimpaired room.Themagnitudeoflisteningeffortrequiredinthese
ear,andourinabilitytoidentify“earlyon”thosechildrenat situationscandependonmanyfactors,suchasthestudent’s
riskforacademicandcommunicativedifficulties(Fitzpatrick cognitiveandattentioncapabilitiesandtheclassroom
etal.,2019; Kumpik & King, 2019; Tharpe, 2008; van acoustics(McGarrigleetal.,2019).Importantly,tocompen-
Wieringen et al., 2018). satefortheirlisteningdifficulties,childrenandadultswith
Althoughresearchislimited,emergingevidencesug- HLmustincreasetheirmentaleffortcomparedtopersons
geststhatlistening-relatedeffortandfatiguemayalsobean withoutHLwhenattemptingtodetect,process,andre-
importantcontributortosomeofthedifficultiesexperienced spondtoauditorystimuli,suchasspeech(Hicks&Tharpe,
bychildrenwithUHL.Recentinvestigationshaveshownthat 2002;McGarrigleetal.,2014,2019).Thisrecurrentneed
children,somewithevenmild,bilateralHL,areatincreased forhighlevelsoflisteningeffortputsindividualswithHL
Bessetal.:Listening-RelatedFatigue 85
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atriskfordevelopmentoflistening-relatedfatigueandits haveconcentratedonfatigueintheadultpopulation
negativeconsequences. (Alhanbali,Dawes,Lloyd,&Munro,2017;Hetuetal.,
Formostchildren,complaintsofmildtransientfatigue 1988;Hornsby&Kipp,2016;Nachtegaaletal.,2009).
arenormal,andsuchfatiguetypicallyresolvesreadilywith Many of these studies focused on quality of life in the
ashortrestorbreaks.Hence,theimpactoftransientfatigue workplace using broad interviews and general surveys, as
onacademicperformanceandqualityoflifeisexpectedto opposed to validated, fatigue-specific measures. However,
beminimal.Forsomechildren,however,theirfatiguecanbe interview and survey results suggested that adults with
moresevereandrecurrentandelicitedbyroutinedailyactiv- HL experienced more stress, a common antecedent of fa-
ities,suchasself-care;completingdifficult,buttypical,class- tigue (Hockey, 1983) in the workplace, than their peers
roomassignments;orrelevanttoCHL,listeninginnoisy withoutHL,andsuchstressandfatiguenegativelyimpacted
conditions(Bess&Hornsby,2014b).Thistypeoffatigueis workperformance(Hasson,Theorell,Wallén,Leineweber,
knowntoimposeadverseconsequencesonbothadultsand &Canlon,2011;Krameretal.,2006;Morataetal.,2005;
children.Forexample,researchsuggeststhatfatigueexperi- Nachtegaaletal.,2009).
encedbyworkingadults,withorwithoutHL,cannegatively HornsbyandKipp(2016)wereoneoftheearliestto
impactworkperformanceandoveralllifequality(Deluca, investigatefatigueand vigor1usinga validated,fatigue-
2005;Hetu,Riverin,Lalande,Getty,&St-Cyr,1988;Kramer, specificmeasure.TheyusedtheProfileof MoodStates
Kapteyn,&Houtgast,2006;Morataetal.,2005). (McNair,Lorr,& Droppleman,1971) to assessfatigue
Likewise,researchexaminingchildrenwithchronic andvigorinalargesampleofadultswithmild-to-profound
healthconditions(CHCs;e.g.,cancer,cerebralpalsy,rheu- losswhopresentedtoanaudiologyclinicseekinghelpfor
maticdiseases,andchronicfatiguesyndrome)suggeststhat hearingdifficulties.Theirresultsshowedthat,comparedto
thistypeoffatiguecanimposeadverseeffects.Forinstance, normativedata,adultsseekinghelpforhearingdifficulties
comparedtononfatiguedchildren,thosesufferingfrom weremorethantwiceaslikelytoexperienceseverefatigue
fatiguearemorelikelytohaveincreasedschoolabsences, andmorethanfourtimesaslikelytoreportseveredeficits
reducedacademicperformance,andareducedabilityto inenergy.2Interestingly,regressionanalysesrevealedno
engageinnormaldailyactivities,allofwhichnegatively associationbetweendegreeofHLandsubjectiveratings
affectqualityoflife(Gaba&Howard,2002;Hockenberry- offatigueorvigor.Thatis,adultswithamildHLorapro-
Eatonetal.,1999;Ravid,Afek,Suraiya,Shahar,&Pillar, foundlosswereequallysusceptibletoincreasedfatigueand
2009).Importantly,individualswithadditionalhandicap- vigordeficits.
pingconditions,asarecommonlyfoundinCHL,areespe- Alhanbalietal.(2017)usedadifferentvalidatedfatigue-
ciallyvulnerabletofatigueanditsnegativeconsequences specificmeasure,theFatigueAssessmentScale(Michielsen,
(Hardy&Studenski,2010).Thesignificanceofthefatigue DeVries,VanHeck,VandeVijver,&Sijtsma,2004),torepli-
experiencedbyCHLishighlightedwhenwecomparetheir cateandexpandonthefindingsofHornsbyandKipp.They
fatiguetothatofchildrenwithotherCHCs.Theoverallfa- comparedfatigueratingsfromthreedifferentgroupsofadults
tigueofCHLissimilarto,orsignificantlygreaterthan,that withHL(UHL:n=50;bilateralhearingaidusers:n=50;
ofchildrenwithmostotherCHCsknowntoaffectfatigue andcochlearimplantusers:n=50)toratingsfromanage-
(e.g.,cancer,diabetes,rheumatoidarthritis,andinflamma- matchedcontrolgroupwithoutHL(n=50).AllHLgroups
toryboweldisease;Hornsbyetal.,2017). reportedsignificantlymoresubjectivefatiguethantheage-
Summarizingtothispoint,fatigueisacommonphe- matchedcontrolgroup.Importantly,fatigueratingswere
nomenoninoursociety,andtheconsequencesoffatigue similarforallthreeHLgroups,regardlessofwhetherthey
canbesignificant.Mountingevidencesuggeststhatadults worebilateralhearingaids,usedacochlearimplant,or,rele-
andCHLareatincreasedriskforlisteningeffortandfatigue. vanttothisreviewarticle,hadonlyUHL.Thus,researchin
Becauseoftheirhearingdifficulties,agreaterlevelofeffortis adultssuggeststhatHLofanykind(e.g.,bilateraloruni-
requiredinordertolistenattentivelyandunderstandspeech laterallosses,cochlearimplantusersorhearingaidusers)
innoisyconditions.Theadditionalattention,concentra- mayincreaseriskforfatigue.However,additionalwork
tion,andlisteningeffortrequiredtoovercomeauditory isneededtoensureotherfactors,suchassamplebias,
deficitsassociatedwithHLresultsinincreasedreportsof arenotdrivingthisfinding(seeHornsby&Kipp,2016;
listening-relatedfatigue.Moreover,asthelisteningeffort Alhanbalietal.,2017,fordiscussions).
andfatigueofCHLincreasesthroughouttheday,their
impactonimportantcognitiveabilities(e.g.,listening,memo-
rizing,attending)forprocessing/decodingspeechandlearning
mayalsoincrease(Bessetal.,2014;Hornsbyetal.,2016). 1Vigor,likefatigue,isamoodstate.Itisassociatedwithageneral
Thesectionbelowhighlightssomeoftheevidencerelated feelingofbeingenergetic,alert,andfullofenergyorpep.Although
tofatigueinadultsandCHL. fatigueandvigorareoftenstronglyandnegativelycorrelated,validation
studiessuggesttheyareindependentconstructs,ratherthanasingle
bipolarfactor(McNair&Heuchert,2010;Stein,Jacobsen,Blanchard,
HL and Listening-Related Fatigue in Adults &Thors,2004;Stein,Martin,Hann,&Jacobsen,1998).
2Severefatigueandvigordeficitsweredefinedasratingsthatwere
StudiesexaminingfatigueinindividualswithHLare, 1.5SDsormoreabove(highfatigue)orbelow(vigordeficit)the
ingeneral,scant.Mostofthosethathavebeenconducted ProfileofMoodStatesnormativemeans.
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HL and Listening-Related Fatigue in Children associationbetween degree of HLandfatigueratings was
observed,suggestingchildrenwithevenmildhearinglosses
Inthepast,muchofwhatweknewaboutfatiguein
were as equally susceptible to fatigue as children with
CHLwasbasedonanecdotalreportsandpilotstudies.In
more moderately severe losses. In addition, highlighting
recentyears,however,wehavelearnedmuchmoreabout
thepotentialimportanceofincreasedfatigueinCHL,sig-
fatigueinpediatricHL.Similartoadults,thereisagrow-
nificantassociationsbetweenlanguageabilityandratings
ingbodyofresearchshowingthatsustainedlisteningde-
ofcognitivefatiguewereobservedinthatstudy.Werfeland
mandsexperiencedbyCHLputthematincreasedriskfor
Hendricks(2016)reportedasimilarfindinginchildrenwith
listening-relatedfatigueanditsadverseconsequences.The
profoundHLwhousedcochlearimplants.Theseauthors
studiestofollowfocusonareviewofsubjectivefatiguein
foundthatchildrenwithcochlearimplants(Grades3–6,
childrenwithbilateralHLandchildrenwithUHL.
N=19)reportedPedsQL-MFSratingssimilartothoseof
theCHLfromthestudyofHornsbyetal.(2014).Impor-
BilateralHL tantly,theyalsofoundthattheincreasedfatigueratings
OneoftheearlieststudiestoexplorefatigueinCHL wereassociatedwithpoorerlanguageandliteracyskills
wasBess,Dodd-Murphy,andParker(1998).Theseinvesti- intheirCHL.Whethertheincreasedfatigueexperienced
gators conducteda clinical-basedstudyonchildren with byCHLleadstolanguageandliteracydeficitsorviceversa
minimalHL—minimal HL included threecategoriesof remainsanunknown,butimportant,researchquestion.
HL(unilateralsensorineuralHL,minimalbilateralsenso-
rineural HL,andhigh-frequency sensorineuralHL;for UHL
definitions,seeCDC,2005).Onecomponentofthisstudy AlthoughinformationonfatigueinchildrenwithUHL
wasananalysis of functionalhealth statusinschool-age islimited,pilotstudiesandreportsfromparents,clini-
children (Grades6 and 9) using theCOOPAdolescent cians,andteachersofferindirectevidencethatchildrenwith
Chart Method (COOP;Nelson et al.,1987).TheCOOP UHLcouldbeatincreasedriskforfatigue,suchastheir
chartsmeasurefunctionalstatusonacoresetoffunctional peerswithbilateralHL.Forexample,inthe1998studyby
dimensions—physical,emotional,andsocial.Childrenwith Bessandcoworkersdescribedearlier,COOPresults(partic-
minimalsensorineuralHLexhibitedmoredysfunctionthan ularlyonthestressandenergysubtests)showedthatCHL
normalcontrolsonmanyofthesubtests—especiallystress experiencedmoredysfunction.Althoughthestudydidnot
andenergy,twoconstructscloselyassociatedwithfatigue. parsethescoresforeachHLgroup,itisnoteworthythat
Inapilotstudy,Hornsbyetal.(2014)assessedfatigue morethanhalfoftheparticipantsthatcompletedtheCOOP
inasmallgroup(n=10)ofschool-ageCHLandanage- hadUHL.Additionalsupportcanbefoundinthestudy
matchedgroup(n=10)ofchildrenwithoutHLusinga byHornsbyetal.(2014),inwhichthePedsQL-MFSwas
generic,validatedsubjectivemeasureoffatigue,thePediatric administeredtoasmalldiversegroupofCHL(n=10)
QualityofLifeInventoryMultidimensional Fatigue Scale andanage-matchedcontrolgroup.TwooftheCHLin
(PedsQL-MFS; Varni, Burwinkle, Katz, Meeske, & thatstudyhadUHL,andtheirfatigueratingswereamong
Dickinson, 2002; Varni, Burwinkle, & Szer, 2004). The themostsevereofanychildparticipant.
PedsQL-MFS is a self-reportscaledesignedtoassessthree Recently,ourongoingresearchonlistening-related
differentfatiguedomains(cognitive,sleep/rest,andgeneral) fatiguehasledustoholdinterviewsandfocusgroupsthat
andhasbeencommonlyusedtoassessfatigueinchildren includedparentsofchildrenwithUHLandtheirteachers
withavarietyofCHCs.Hornsbyandcoworkersfoundthat andclinicianstodiscussissuesaroundlistening-relatedfatigue.
asmallgroupofschool-ageCHLreportedmorefatiguethan Reportsfromthesestakeholdershavebeeninsightful.Forex-
anage-matchedcontrolgroupofchildrenwithoutHLacross ample,aparentofachildwithUHLstated,“Mydaughteris
allthreedomains—althoughthedifferencesbetweengroups exhaustedmostdaysafterschoolorwhenshehastolisten
werenotsignificantforthecognitivedomain.Theseverity foralongtime.”Aneducationalaudiologistofferedthese
ofthefatigueinCHL,whencomparedtoexistingworkin comments:“OurkidswithUHLlossaresimilartochildren
theliterature,wasequivalenttoorgreaterthanfatigueratings withmildtomoderatehearinglosses—theyrequireaudi-
reportedbychildrenwithotherCHCs. torybreaksthroughoutthedayandstrugglemoreaca-
In a follow-up to the aforementioned pilot study, demicallythanonewouldexpectgiventheirhearingloss.”
Hornsby et al. (2017) collected PedsQL-MFS data on a Commentssuchasthesefromparentsandprofessionalsof-
much larger population of school-age CHL (n = 60) with feradditionalsupportforthepremisethatchildrenwith
mild to moderately severe hearing losses.Moreover, in UHLmaybecomefatiguedfollowingsustainedlistening
additiontoobtainingdatafromthechildren,parentproxy demandsinschool—andsuchfatiguemayimpactonschool
reportswerealsoobtained.Thesedatawerecomparedto performance.
reportsfromacontrolgroup(n=43)ofchildrenwithout
HL and theirparent proxies. Consistent withoutcomes APreliminaryExaminationofListening-RelatedFatigue
fromthepilotstudy,resultsshowedthatCHLexperienced inCHLasReportedbytheChild,Parent,andTeacher
significantlymoreoverallfatigueand cognitivefatigue Giventhescarcityofinformationrelatedtofatigue
thanchildren withoutHL.Also,consistent withresults inchildrenwithUHL,weuseself-reportdatainthissection
fromtheadult population (Hornsby & Kipp,2016),no toconductapreliminaryexplorationoflistening-related
Bessetal.:Listening-RelatedFatigue 87
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fatigueinchildrenwithunilateralandbilateralHL.Theself- thatshowtheseverityoflistening-relatedfatigueforagiven
reportdatawerecollectedaspartofourongoingwork individual.Thus,anIRTscoreof0reflectsascoreequalto
developingascaletoassesslistening-relatedfatiguein themeanscoreacrossallscalerespondents(i.e.,acrossall
children.Someoftheinformationreportedhereisbased HLandnoHLgroups).Incontrast,anIRTscoreof–3and
on a conferenceposter (Hornsby, Davis, Cho, & Bess, +3 reflects very low and very high ratings of listening-
2018). related fatigue, respectively.
TheVFS:AToolforMeasuringListening-RelatedFatigue VFSDataCollectionandParticipants
Althoughnearingcompletion,theVFSisstillbeing Potentialparticipantswererecruitedinpersonfollow-
developed,andassuch,weonlybrieflydescribeherethe ingroutineaudiologicalappointmentsatourclinicaswell
developmentprocessofthescalestodate.Currently,we asviasocialmediaandotheronlinerecruitmentportals.As
areconductingvaliditystudiesonthreeversionsoftheVFS aresult,datacollectionwascompletedusingonlineversions
—achild,aparent,andateacherversion.Todevelopthese oftheVFSandinpersonusinghardcopiesofthescales.
scales,weusedinformationfrominterviews/focusgroups Parentsandteacherscompletedthescalesthemselves.Chil-
(separategroupsofchildren,parents,andteacherspartici- drenalsocompletedthescalethemselveswhenpossible,al-
pated)tocreatealargepoolofpotentialtestitems(157– thoughforyoungerchildren(<10yearsold)oranychild
212itemsdependingonthetargetrespondent).Usingbest whohadquestionsorneededassistance,theparent(orre-
practicesandaniterativeprocess,includingfactoranaly- searchassistantifpresent)wasavailabletoreadthescale
ses,classicaltesttheory,anditemresponsetheory(IRT), itemsaloudtothechildandansweranyquestions.Datafor
weevaluateditemqualitytoreducethetotalnumberof allthreeversionsoftheVFSwerecollected,stored,and
itemsdowntoeightto12,dependingonthescale.Factor managedusingResearchElectronicDataCapture(Harris
analysesrevealedaunidimensionalstructureforthechild etal.,2009).ResearchElectronicDataCaptureisasecure,
andteacherscales.However,theparentscalewasbestfit web-basedsoftwareplatformdesignedtosupportdatacap-
asatwo-factormodelconsistingofaphysicalfactorand tureforresearchstudies.Allprocedureswerereviewedand
asocial–emotional–cognitivefactor.IRTanalysesconfirmed approvedbyVanderbilt’sInstitutionalReviewBoard,and
allscaleitemswerehighquality(i.e.,allitemshadhighin- allparticipantsprovidedinformedconsentorassentprior
formationanddiscriminability).Theparentversioncontains tostartinganystudyprocedure.
12items,theteacherversionhaseightitems,andthechild Participantresponseswereobtainedfrom(a)399par-
versionconsistsof10items.Allinstrumentsusea5-point entsofchildren(aged6–17years)with(n=263)andwith-
Likertscaletoassessthefrequency(1=neverto5=almost out(n=136)HL,(b)137children(aged10–17years)with
always)offatigue-relatedcomplaints.Examplesofitemsin- (n=98)andwithout(n=39)HL,and(c)363teachersof
cludedinallthreeversionsoftheVFSandanadultversion students(aged6–17years)with(n=289)andwithout(n=70)
(VFS-A)areshowninTable1.AllscalesallowforIRT HL.Notallparentsofthe137childrespondentscompleteda
scoringandusingsummedLikert-scalescores.Inthisreview parentversionofthescale.Likewise,somechildrenofparents
article,scaleresultswillbedescribedusingIRT,ratherthan whocompletedthescaledidnotcompleteachildversionof
summedscores.AnIRTanalysisandscoringapproachhas thescale.Inthisreviewarticle,wedonotinvestigateparent
severaladvantagescomparedtomoretraditionalscale proxyandchildagreementoragreementbetweenteacherre-
assessmentmethods(seeHambleton&Swaminathan,2013, sponsesandparentorchild.Thosetopicswillbeexploredin
forareview).Importantly,anIRTanalysismethodtakes futureworks.Thechild’sHLwasself-reportedbytheparent
thesensitivityofeachtestitemintoaccountinthescoring andteacherasunilateralorbilateral.Degreeoflosswasself-
process,providingamorepreciseestimateoftheunderlying reportedbythechild’sparentasmild/slight,moderate,severe,
latentconstructbeingmeasured—inourcase,listening- orprofoundbasedontheirperceivedspeechunderstanding
relatedfatigue(Embretson&Reise,2000).IRTscoresob- (WorldHealthOrganization,2019).Adetaileddemographic
tainedusingtheVFSarestandardizedscores(likezscores) descriptionoftheparticipantsisprovidedinTable2.
Table1.ExamplesofquestionnaireitemsfromtheVanderbiltFatigueScale(VFS)forlistening-relatedfatigueinchildren.
VFS-A:Adultitems VFS-C:Childitems
(cid:129) Ifeelwornoutfromeverydaylistening. (cid:129) Afterschool,I’msotiredIdon’twanttotalktoanyone.
(cid:129) Ittakesalotofenergytolistenandunderstand. (cid:129) Listeningatschoolwearsmeout.
VFS-P:Parentitems VFS-T:Teacheritems
(cid:129) Itishardformychildtoconcentrateforalongtime. (cid:129) Whenthestudentgetstiredfromlistening,heorshe“checksout.”
(cid:129) Mychildiscompletelywornoutafterlisteningfora (cid:129) Thestudentappearswornoutafterworkinghardtolistenallday.
longtime.
Note. ThethreeversionsoftheVFSforchildrenincludeachildself-report(VFS-C),aparentproxyreport(VFS-P),andateacherproxy
report(VFS-T).SamplesfromtheadultversionoftheVanderbiltFatigueScale(VFS-A;Hornsbyetal.,2018)areprovidedasacomparison.
Responsesareona5-pointLikertscalefromnevertoalmostalways.
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Table2.ParticipantcharacteristicsforrespondentscompletingthevariousversionsoftheVanderbiltFatigueScaleforchildren.
Variable Parentrespondents Childrespondents Teacherrespondents
No.ofparticipants 399 137 363
Male/female/NR 209/189/1 73/64/0 186/169/8
Age(years) 10.7(3.4) 13.6(1.9) 10.4(3.3)
HL/noHL/NR 263/136/0 98/39/0 289/70/4
UHL/BHL 64/199 28/70 40/249
Note. Gender,meanage(1SD),andhearingstatusofchildrenbeingreportedonareprovidedforallthreeparticipantgroups.NR=not
reported;HL=hearingloss;UHL=unilateralhearingloss;BHL=bilateralhearingloss.
VFSInitialAnalysesandResults reportedbyeachrespondentgroup(parents,children,
Itisimportanttonotethatthedatausedintheanaly- andteachers).ThemeanIRTscoreforagroupofadults
sesdescribedbelowwerenotcollectedforthepurposeofex- withHL,basedonresultsusinganadultversionofour
aminingtheeffectsofunilateralorbilateralHLonlistening- listening-relatedfatiguescale,theVFS-A,isalsoprovided
relatedfatigue.Rather,thesedatawerecollectedtoassistin asacomparison(Hornsbyetal.,2018).
developingavalid,reliablescaleforassessinglistening- Amongparentrespondents,therewasasignificant
relatedfatigue.Thus,theanalysesdescribedbelowareex- maineffectofgroup(F=24.5,p<.001).Posthoctesting,
ploratoryinnature.Nonetheless,giventhepaucityofdata usingaseriesofBonferroni-adjustedttests,revealedsignifi-
relatedtofatigueinCHL,wefeltsuchanalyseswouldbeof cantlyhigherIRTscores(higherfatigue)forbothHLgroups
interesttocliniciansandcouldprovideusefulinformation compared to the control group without HL (t = –6.6,
toguidefutureresearchinthisarea.Weusedasingle-factor p < .001 and t = –4.9, p < .001 for the bilateral
adj adj
analysisofvariance(ANOVA)tocompareIRTratingsof and UHL groups, respectively). Interestingly, parent rat-
listening-relatedfatigueinchildrenwithself-reportedbilat- ings for children with unilateral and bilateral HL were
eralandUHLtoacontrolgroupofchildrenwithnoHL. quite similar in magnitude and not significantly different
SeparateANOVAswereconductedforeachrespondent (t = 0.019, p > .05). A significant main effect of group
adj
group—parent,teacher,andchildren.Inaddition,forthe wasalsoobservedforthechildratings(F=3.27,p<.05).
two-factorstructurefortheparentscale,an“overall”fatigue Aswiththeparentdata,posthoctestingrevealedthatthe
scorewascreatedbyaveragingtheIRTscoresofeach bilateralgroupreportedsignificantlyhigherlevelsoffatigue
factor.Separateanalyseswereconductedoneachfactor thanthecontrolparticipants(t=–2.5,p <.05).However,
adj
scoreandontheoverallfatiguescore.Thestatisticalfind- thefatiguescoresforchildrenwithUHLfellbetweenthose
ingswerethesameforeachanalysismethod,soonlythe ofthebilateralHLgroupandthecontrolgroupofchildren
resultsforoverall(average)fatiguearereportedforthe withoutHL.Listening-relatedfatiguescoresforchildren
parentdata. withUHLwerenotsignificantlydifferentthaneitherthe
Figure1showsthemeanIRTscaledscoresforthose controlgroup(t=–0.9,p >.05)orthechildrenwith
adj
childrenwith(bilateralandunilateral)andwithoutHLas bilateralHL(t=–1.36,p >.05).
adj
Figure1.Meanitemresponsetheory(IRT)scalescoresofrespondentswithself-reportedunilateral,bilateral,andnohearingloss(HL)
obtainedusingthreeversionsoftheVanderbiltFatigueScale(VFS)forassessinglistening-relatedfatigueinchildren(VFS-C,VFS-P,VFS-T).
ThemeanscalescoresforadultswereobtainedusingtheVanderbiltFatigueScaleforAdults(Hornsbyetal.,2018)andareprovidedfor
comparison.Solidlinesoverthebarsreflectsignificantdifferencesbetweengroups.
Bessetal.:Listening-RelatedFatigue 89
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Finally,ananalysisofteacherratingsalsorevealeda Figure2.Percentageofchildrenwithunilateralandbilateral
hearingloss(HL)exhibitingmoderate-to-severefatigue(item
significantmaineffectofgroup(F=3.52,p<.05).How-
responsetheoryscores>0.5)ascomparedtoagroupofchildren
ever,posthoctestingusingaseriesofBonferroni-adjusted
withoutHL.Solidlinesoverthebarsreflectsignificantdifferences
ttestsrevealednosignificantdifferencesbetweenanyof betweengroups.
thegroups(allp values>.05).Themaineffectappeared
adj
tobedrivenbythedifferenceintheteachers’fatiguerat-
ingsforchildrenwithbilateralandUHL,notdifferences
betweenCHLandthecontrolgroup.AsseeninFigure1,
themeanfatigueratingsfromteachersforchildrenwith
UHL were lower than that of the children without HL
(control group) and the children with bilateral HL. We
discuss this unexpected finding in more detail later in the
reviewarticle.
Additionally,recallthat HornsbyandKipp(2016)
foundthat adults seeking help forHLweremuchmore
likelytoreportseverefatigueandvigordeficitsthanexpected
basedonnormativedata.Toexploretheissueofsusceptibility
tomoreseverefatigueinchildren,weusedanIRTscore
of>0.5asacut-pointtooperationallydefine“moderate-
to-severe”listening-relatedfatigue.Wethencomparedthe
prevalenceofmoderate-to-severefatigueinchildrenwith
andwithoutHLacrossrespondentgroups.Todoso,we
calculatedthepercentageofindividualswithandwithout
HLineachrespondentgroupwhoreportedmoderate-to-
severelistening-relatedfatigue.Althoughtheuseof0.5as
acut-pointisarbitrary,forourpurposes,itseemsareason-
ableestimatebecauseonlyabout31%ofthepopulation
wouldbeexpectedtoreportgreaterfatigueproblems.
Resultsforadults,parents(IRTscoreaveragedover
Factors1and2),andchildrenareshowninFigure2.The
teacherdataarenotplottedas,similartoourmeanresults,
they showed no significant difference between groups.
A series of chi-square analyses (see Table 3) showed that
moderate-to-severe listening-related fatigue is much more
common in adults and children with unilateral or bilateral
HL when compared to those without HL. More specifi-
cally, adults with bilateral and UHL were significantly
(approximately nine times) more likely to report moderate- withUHL.Todoso,wereviewedanddiscussedexisting
to-severe fatigue than adults without HL. A similar sig- workinthisarea.Ourreviewrevealedthatsystematicre-
nificant finding, although smaller in magnitude, was searchonfatigueinchildrenwithUHLisscant.Themost
observed for the parent proxy respondents. Parents of relevantinformationcomesfromstudiesexamininglistening-
children with bilateral or UHL were approximately four relatedfatigueinchildrenandadultswithbilateralHL.While
times more likely to report their children experienced limitedinscope,someresearchexamininglistening-related
moderate-to-severe fatigue than parents of children with- fatigueinadultswithUHLandgeneralfatigueinchildren
out HL. Finally, children with bilateral and UHL were withotherCHCsalsoprovidedrelevantinformation.
approximately 2.5 and 2.0 times more likely, respectively, Giventhelimitedworkinthisarea,wealsoincluded
to report moderate-to-severe fatigue than children without preliminaryanalysesofself-reportedlistening-relatedfatigue
HL—although the difference for the children with UHL inCHL,includingUHL.Datafortheseanalyseswerecol-
did not reach statistical significance. Importantly, there lectedaspartofaseriesofstudiestodevelopandvalidate
were no significant differences in relative risk for moderate- asuiteofscalesforassessinglistening-relatedfatigue(the
to-severe fatigue between children with unilateral and VFS)inchildren.Consideringtheavailableliteratureand
bilateral HL (see Table 3). ourself-reportfatiguedataleadsustoconcludethatchil-
drenwithunilateralandbilateralHLareatincreasedrisk
forlistening-relatedfatigue.Moreover,themagnitudeof
Discussion
fatigueobservedinchildrenwithUHLappearstobesimilar
Aprimarygoalofthisreviewarticlewastointroduce tothatexperiencedbychildrenwithbilateralHL—again
theconstructoflistening-relatedfatigueandhighlightits highlightingthesignificantimpactofUHLinchildren.This
importanceforCHL,withaparticularfocusonchildren reviewarticleisthefirsttoaddressthetopicofsubjective
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Table3.Chi-squareanalysesofprevalenceof“moderate-to-severe”listening-relatedfatigueamongourhearingloss
andnohearinglossgroupsaswellasbetweenrespondentswithbilateralandunilateralhearingloss.
Variable χ2 p Prevalenceratio
AdultswithnoHLvs.bilateralHL 106.1 <.001 9.2[5.1,16.6]
AdultswithnoHLvs.unilateralHL 48.8 <.001 8.7[4.4,17.2]
Adultswithbilateralvs.unilateralHL 0.1 .76 0.9[0.6,1.4]
CNHLvs.CBHL 5.9 <.05 2.5[1.1,5.6]
CNHLvs.CUHL 2.3 .13 2.0[0.8,5.0]
CBHLvs.CUHL 0.5 .47 0.8[0.4,1.5]
ParentsofCNHLvs.parentsofCBHL 32.1 <.001 3.8[2.2,6.4]
ParentsofCNHLvs.parentsofCUHL 31.1 <.001 4.4[2.5,7.9]
ParentsofCBHLvs.parentsofCUHL 1.2 .28 1.2[0.9,1.7]
Note. Responseswereobtainedfromadults,children,andtheirparentsasproxyreporters.Valuesin[]showconfidence
intervalsaroundtheprevalenceratio.Boldedvaluesshowsignificantdifferences.HL=hearingloss;CNHL=children
withnohearingloss;CBHL=childrenwithbilateralhearingloss;CUHL=childrenwithunilateralhearingloss.
fatigueinchildrenwithUHL.Clearly,additionalworkex- usedinthisanalysiswerebasedonresponsesfromall
aminingthiscomplex,multifacetedconstructanditsrela- 60items.Incontrasttoourinitialanalysis,asingle-factor
tionshiptoHLisneeded. ANOVAonthissmallsubsetofdata(comparingagiven
Oneimportantareaofinquiryistobetterunderstand teachersIRTscoreforachildwithandwithoutHL)
whyourcurrentteacherdatawerenotsensitivetotheeffects revealedasignificantmaineffectofgroup(F=10.7,
ofHLonlistening-relatedfatigueinschool-agechildren p<.05).ThemeanIRTscoresprovidedbyteachersfor
(seeFigure1).Thisdiscrepancycouldsimplysuggestthat theCHL(–0.10)weresignificantlyhigherthanthatof
teachersarenotsufficientlyawareofthesignsandsymp- thechildrenwithoutHL(–0.71).Infact,theteacherIRT
tomsoflistening-relatedfatigueinCHL.Suchanexplana- scoresforCHLwerehigherin16ofthe21cases.
tion,however,isinconsistentwithanecdotalreportsand Theresult aboveisencouraging and suggests that
commentsmadeduringourfocusgroupswithteachers, teachersmaybesensitivetotheproblemsoflistening-related
educators,andsupportstaffwhoworkwithCHL.Inthese fatigueinCHL,atleastwhencomparingchildrenwithand
discussions,reportsofthesubstantialdifficultieswith withoutHLwithintheirownclassroom.However,addi-
listening-relatedfatigueamongCHLwerecommon—hence, tionalresearchisclearlyneeded.Forexample,itispossible
theunderlyingreasonforthediscrepancyremainsunclear. thattheformatofthecurrentscalemaynotbeoptimalfor
Althoughfocusgroupcommentssuggestotherwise, teacheruse.Scalemodifications,suchasspecifically
ourreducedabilitytodetecttheeffectsofHLinourteacher instructingrespondentstofirstconsiderhowtheymight
datacouldreflectalimitedinsightofthisgroupintothe respondiftheywereratingatypicallydevelopingchild
fatigueoftheirstudents.Recallthatteachersmustprovide priortocompletingthescaleforanat-riskchild(e.g.,one
proxyratingsofachild’sfatigue.Assuch,theirabilityto withHL),mayenhancethescale’sabilitytoidentifythose
dosomaybelimitedbyhowmuchtheyinteractwiththe atmostrisk.
childduringtheday.Unlikeparents,theteachermayonly Alternatively,factorsotherthanthescaleitselfcould
seethechildforalimitedperiodoftimeeachday,poten- alsohaveinfluencedouroutcomes.Recallthatourteacher
tiallylimitingtheirinsightintothefatigueofachild.Ifthis datawerecollectedforthepurposeofidentifyinghigh-quality
werethecase,wemightexpectarepeated-measuresanaly- scaleitemsandvalidatingafinalversionofthescale—not
sis,inwhichthesameteacherratesthefatigueofachild toempiricallyexaminetheeffectsofHLonself-reported
withandwithoutHL,wouldbebettersuitedtodetecting fatigue.Tothisend,wespecificallycastawiderecruitment
between-groupsdifferencesshouldtheyexist. netwithagoalofincludingrespondentswithawiderange
Unfortunately,onlytwoteachersprovidedVFSratings offatigueratings.Itispossiblethatthesampleofchildren
forachildwithandwithoutHLaspartofthevalidationdata ratedbyteachershadadditionalfactors,otherthanHL,
collectiondescribedabove.Bothteachersreportedonchildren that may have affected their fatigue (e.g., some other
withbilateralHL,andthoseoutcomesweremixedwith disability)—potentially masking the effects of HL. To
oneteacherreportinggreaterfatigueforthechildwithHL be certain, we need to develop a better understanding of
andtheotherreportingtheopposite.However,wewereable the factors responsible for the apparent limited sensitivity
totestthishypothesisusingdatafromanearlierversion of the teacher scale.
ofourscalethatwasobtainedfromasubsetofteachers
whoprovidedratingsforbothchildrenwithandwithout
HL(n=21).Thisearlyversionofthescalehadatotalof IdentificationandManagementofFatigueinCHL
60items.Althoughthescaleincludedthe10itemsused GiventhatchildrenwithUHLandbilateralHLare
inourcurrentteacherversionoftheVFS,IRTscores atincreasedriskforlistening-relatedfatigue,anincreasingly
Bessetal.:Listening-RelatedFatigue 91
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importantroleforpediatricandeducationalaudiologistswill SuggestionsforFatigueInterventions
betheidentificationandmanagementoflisteningeffortand Althoughevidence-basedinterventionprotocolsarenot
fatigueinschool-agechildrenwithUHLaswellasthose presentlyavailable,someobviouscommonsensestrategies
withbilateralHL.School-ageCHLareofteneligiblefor seemappropriateforimplementationintheschoolsetting.
specializedinstructionundertheIndividualswithDisabil- Importantly,giventheriskforfatigueappearstobesimilar
itiesEducationAct(Johnson&Seaton,2012). forthosewithunilateralorbilateralHL,thesuggested
IfachilddoesnotqualifyforanIndividualizedEdu- intervention/managementstrategiesthatappearbelow
cationProgram(IEP),theymaybeconsideredfora504plan couldbeappropriateforallCHL.Manyofthesestrategies
undertheSection504oftheRehabilitationActof1973,an weresuggestedanddiscussedduringourfocusgroups
antidiscriminationcivilrightsstatutethatrequiresthatthe withteachersandotherschoolserviceproviders.
needs of students with disabilities be met as adequately
astheneedsofchildrenwithoutdisabilities(Zirkel,2009). ClassroomStrategies
Bothplansrequireeducationteammemberstoholistically Theclassroomisoftenadifficultlisteningenviron-
reviewachild’sperformanceintheclassroomandconsider mentforCHL,asthespacesdonotmeetrecommended
potentialaccommodationstoprovideequalcommunica- standardsfornoiselevelsandreverberationtimes(Gremp
tionaccesstoclassroominstruction. &Easterbrooks,2018;Knecht,Nelson,White,&Feth,
Asapartofspecializedinstruction,ateamofprofes- 2002).Evenwhenutilizingproperlyfittedamplification,
sionals(educationalaudiologists,certifiedteachersofthe CHLmaystillstruggleinthissetting.CHLmaystruggle
hearingimpaired,andspeech-languagepathologists)work tolistenandcomprehendinnoisysettingsandhavediffi-
togetherwithCHLandtheirfamiliestosupportacademic cultylocalizingtalkersduringgroupdiscussions.
success.Theycollaboratetodeterminewhetherthechild Ourfocusgroupdiscussionswithteacherswhowork
should receivepreferentialseating,is meeting auditory withCHLrevealedthattheeducationalteammayconsider
goals in their IEP,and is appropriatelyutilizinghearing- severalanecdotalinterventionswhenachildwithhearing
assistivetechnology,ifrecommended.Inaddition,theteam lossdemonstratesbehaviorstheybelievetobefatiguerelated.
reviewsthechild’seducationalprogressperiodicallyand Forexample,focusgroupparticipantsnotedthatCHLtend
considersadditionalfactorsthatmaybeimpactingeduca- tobe“morezonedout”comparedtotypicalhearingpeers,
tionalprogress. especially“towardtheendoftheschoolday.”Hence,itwas
Insuchreviews,theconceptoffatigueisfrequently notsurprisingtolearnthatmanyteachersandclinicians
discussedandoftenconsideredintheeducationalprogram- reportedarrangingtheircaseloadschedulestoaccommodate
mingofCHL;however,systematicidentificationandman- CHLinthemorningtoreducethepossibleeffectsoffatigue
agementprotocolsarenotavailable.Themostlogicalway onachild’stherapysessions.TohelpCHLcopewithfa-
todetermineachild’sriskforfatigueisforeducational tigue,teachersreportedinterventions,suchasallowingthe
audiologists,speech-languagepathologists,andteachers childtoremovetheirhearing-assistivetechnologyforshort
tolookforsymptomsandbehaviorscommonlyassociated listeningbreaksorschedulingconsistent“movementbreaks,”
withfatigueinchildren.Ourresultssuggestthatteachers wherethechildcouldmoveandstretch,intotheroutineof
andsupportstaffmayneedtobetrainedtoidentifypromi- theclassroom.
nentcharacteristicsoflistening-relatedfatigue(seeFatigue MostCHLareprovidedwithflexible,preferential
Educationsectionbelow).Suchcharacteristicswouldinclude seating(i.e.,seatingthatallowsforthebestaccesstoboth
reportsorbehaviorsindicativeoftiredness/weariness,mood visualandauditoryinformation)intheclassroomsetting.
changes,sleepiness(especiallyinthemorning),adecrease ForchildrenwithUHL,preferentialseatingmayneedto
instaminaorenergy,oralackofdesiretocontinuewitha bereviewedbasedontheactivityoftheclassroom;how-
task.Iffatigueissuspectedforagivenchild,theaudiologist ever,thenormalhearingearshouldtypicallybefacedto-
orspeech-languagepathologistwouldadministeravalidated wardthespeakerofinterest.
fatiguemeasuretothechildand/orparentandteacher.This
typeofmeasurecouldalsobeincorporatedintoexisting ListeningBreaks
(ornew)self-advocacycompetencycheckliststobeused Toourknowledge,thereisnoresearchspecifically
duringIEP/504meetings.Examplesoffatiguescalesfor focusedonusinglisteningorrestbreakstoreducefatiguein
childrenincludethePedsQL-MFS(Varnietal.,2002),the school-ageCHL.Despitethisabsence,discussionsamongour
ChildhoodFatigueScale(Hockenberryetal.,2003),andthe focusgroupparticipantssuggestitisacommonstrategy
soon-to-be-availableVFS,whichspecificallyassesseslistening- ofcliniciansandteacherswhoworkwithCHL.Whilere-
relatedfatigue.Thesestandardizedmeasuresprovidesup- searchonrestbreaksinCHLisnonexistent,thereisalarge
portforanecdotalevidencethataCHLmaybestruggling relatedliteraturefromstudiesofdrivingbehavior,flight
withfatigueintheclassroomsetting,animportantfactor simulation,andworkforce,suggestingrestbreaksarean
whendeterminingspecializedservicesintheschoolsetting. effectivetoolforreducingfatigueanditsnegativeeffects.
Whilethisisalogicalapproach,additionalresearchis Intheworkforce,forexample,restbreaksareimportantfor
neededtoevaluatethesensitivityandbenefitsofsuchan increasingperformance,avoidingaccidents,andpromoting
approachtoidentificationoflistening-relatedfatiguein goodhealth(Fritz,Lam,&Spreitzer,2011).Manystudies
children. havereportedthatrestbreaks,especiallyshortrestbreaks,
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havemanypositivebenefits,includingdecreasesinfatigue, devices)toprovideaccesstoauditoryinformation.Forchil-
stress,anddiscomfortandincreasesinvitalityandtimespent drenwithUHL,theseamplificationoptionsaswellasa
ontask(Arlinghausetal.,2012;Henning,Jacques, Kissel, contralateralroutingofsignalmayberecommended.Personal
Sullivan, & Alteras-Webb, 1997;Tucker,2003;Zacher, devicesaimtoimproveaudibilitysothatachildisbetterable
Brailsford,&Parker,2014).Forexample,Zacheretal.(2014) tohearandcommunicatewiththosearoundhim.Clinical
studiedtheimpactofmicrobreaksonfatigueandvitalityin audiologistsoftenmaketherecommendationfor“full-
agroupofworkingadults(N=124).Usingadiarystudy timeuseofamplification,”which,foratypicalschool-age
design,theyshowedthatmicrobreaksresultedinadecrease child,wouldrangefromapproximately10to14hrperday
infatigueandanincreaseinvitality. (Walkeretal.,2013).Somecliniciansandteachersbelieve
Consistentwiththisrelatedresearch,someteachers thatwell-fittedamplificationhelpstoreducefatigueeffects
reportthatallowingachilda“listeningbreak”—theoppor- duetoalongdayoflisteningintheclassroom.However,
tunitytostepawayfromtheclassroomforafewminutesto evidencesupportingsuchanassumptionislimited.Hornsby
gototherestroomorrestinanotherteacher’sclassroom— (2013)istheonlystudytodatetoexaminethisempirically,
allowsthechildtocomebacktotheactivityrefreshedand andparticipantsinthatstudywereadults.Participantswere
preparedforre-engagement.However,thereisnoconsen- requiredtocompleteacognitivelydemandinglisteningtask
susconcerningthenumberofrestbreaksorthedurationof forapproximately60minwithoutabreak.Testingwascom-
breaksthatshouldbeused.Itisanticipatedthattherecov- pletedwithandwithouthearingaids.Resultsshowedasmall
erytimeneededbyastudentmayvary,basedonthechild’s benefitofhearingaidsforreducinglisteningeffortandmen-
age,additionaldisabilities,orotherfactors.Furthermore, talfatigue—definedasadecrementincognitiveprocessing
thereisnovalidatedmethodforteachersandcliniciansto speedovertime.Specifically,whenwearinghearingaids,
knowwhenachildrequiresinterventionorhowtosystem- participantswerebetterabletomaintainvigilantattention
aticallyprovidetheintervention. duringthesustainedlisteningtask.However,subjective
ratingsofeffortandfatiguewerenotsignificantlydifferent
FatigueEducation intheunaidedandaidedconditions.
Althoughfatigueanditsnegativeeffectsarepervasive, Inaddition,recentevidencefromfocusgroupsand
notallindividualslivingorworkingwithCHLareaware interviewswithadults suggests that extended deviceuse
ofthepotentialsideeffectsthatsustainedfatiguecanhave itself can befatiguing(Holman,Drummond,Hughes,&
onanindividual’soverallwell-being.Inaddition,ourinter- Naylor,2019;Hughes,Hutchings,Rapport, McMahon,
viewdatawithCHLsuggestthatmany(evenmiddleand & Boisvert,2018).Similarcommentsweremadebysome
highschoolers)areunawareoftheirpresentationofcom- CHLduringfocus groupandinterviewsconducted as
monfatiguesymptomsascomparedtotheirpeers.Infocus part of our fatiguescaledevelopmentproject.Themixed
groupsandinterviews,someteenagersdeniedanyfatigue- findings related to benefitsfrom deviceusemay beduein
relatedproblems,whiletheirparents,whoalsoparticipated parttothelimitationsofhearingaidsandcochlearimplants
inseparatefocusgroups,reportedsignificantdifficultieswith aloneinnoisyenvironments.Moreover,notallCHLwear
listening-relatedfatigueintheirCHL.Onechildreported theiraidswhileattendingschool—24%ofchildren(6.5–
“neverfeelingwornoutfromlistening”whilehermother 12.9yearsold)withmild-to-moderatelossesdonotuse
sharedthatthischildoften“camehomefromschool,took theirpersonaldevicesonaday-to-daybasis(Gustafson,
offherimplants,”and“laiddownfor30minutesorsowith Davis,Hornsby,&Bess,2015).
thelightsoff.”AyoungadultwithHLsharedthatitwas Inadditiontopersonalhearingaidsandcochlearim-
not“untilthecaseloadofcollege”thatshewasabletolook plants,accesstoimportantclassroominformationcanbe
backandrecognizehowmuchlistening-relatedfatigueaf- achieved byusing apersonalremotemicrophone(RM)
fectedherthroughheradolescentyears. system.RMsystemseffectivelyimprovesthesignal-to-noise
Thesefindings suggestthatadditionaleducation ratioandallowsthechildtoheartheteacher’svoicemore
aboutlistening-related fatigueanditsnegativeeffects is clearlyinthepresenceofexcessiveclassroombackground
requiredto informandequip CHL,parents,andschool noise(Wolfe,Morais,Schafer,Agrawal,&Koch,2015).
personnelworkingwith this population(i.e.,teachersand ThebenefitsofRMtechnologyforCHLarewellrecog-
therapists).Structured educationalprograms that target nized,andthesesystemsarewidelyacceptedintheeduca-
theidentificationofcommonsymptomsassociated with tionalsetting(Anderson&Goldstein,2004).Incontrast,
fatigueandprovideguidelinesforidentificationandman- researchexaminingthebenefitsofRMsystemsforreduc-
agement,includinginterventionstrategies,arelikelytoim- ingfatigueislimited.However,arecentstudybyRance,
proveoutcomesforCHL.Additionally,schoolprofessionals, Saunders,Carew,Johansson,andTan(2014)suggests
audiologists,andparentsshouldworkwithCHLtohelp thatRMsystemsmayhelptoreducestressassociatedwith
themidentifysymptomsassociatedwithlistening-related difficultlisteningconditions,thuspotentiallyreducingfa-
fatigueandself-advocatefortheirlisteningneeds. tigue.Inaddition,someprofessionalsworkingwithCHL
intheschoolsettingreportobservingadecreaseinfatigue
HearingDevicesandAssistiveTechnology symptomswhenthestudentusesanRMsysteminthe
CHLaretypicallyprescribedpersonalamplification classroom;however,systematicresearchinsupportofthese
devices(i.e.,hearingaids,cochlearimplants,bone-anchored accountsislacking.
Bessetal.:Listening-RelatedFatigue 93
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