Listening effort and fatigue in school-age children with and without hearing loss

The effect of noise on listening effort in children as measured using different methods: a systematic review and meta-analyses

PURPOSE

Listening effort increases as background noise levels rise, affecting both children and adults. Understanding the impact of increased listening effort and identifying effective methods to estimate it in children is crucial, as higher listening effort can hinder learning. This systematic review and meta-analysis examined the effects of noise on listening effort, as measured using various methods, in children aged 5 to 13 years with normal hearing.

METHODS

Four scientific databases, PubMed, Scopus, Cochrane Library, and Web of Science, were searched to retrieve 23 eligible articles. The methodological quality of the studies was assessed using Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies. Meta-analysis was performed according to different methods of listening effort [behavioral (single-task paradigm and dual-task paradigm), subjective ratings, and physiological (pupillometry)].

RESULTS

Single-task paradigm and subjective ratings showed a medium effect of noise on listening effort, which was significant. Dual-task paradigm and pupillometry did not show statistically significant effects of noise on listening effort. Further, speech perception tasks show a greater effect of noise on listening effort as compared to listening comprehension.

CONCLUSIONS

Single-task paradigm and subjective rating methods revealed the negative effect of noise on listening effort during spoken language processing in children between 5-13 years of age. Thus, a combination of these two methods might provide useful information regarding the effect of noise on this population. The heterogeneity in the findings could be due to the multidimensional nature of listening effort and lack of construct validity of the methods used to assess listening effort.

Exploring short-term memory and listening effort in two-talker conversations: The influence of soft and moderate background noise

Listening to conversations and remembering their content is a highly demanding task, especially in noisy environments. Previous research has mainly focused on short-term memory using simple cognitive tasks with unrelated words or digits. The present study investigates the listeners' short-term memory and listening effort in conversations under different listening conditions, with and without soft or moderate noise. To this end, participants were administered a dual-task paradigm, including a primary listening task, in which conversations between two talkers were presented, and an unrelated secondary task. In Experiment 1, this secondary task was a visual number-judgment task, whereas in Experiments 2 and 3, it was a vibrotactile pattern recognition task. All experiments were conducted in a quiet environment or under continuous broadband noise. For the latter, the signal-to-noise ratio in Experiments 1 and 2 was +10 dB (soft-noise condition), while in Experiment 3 it was -3 dB (moderate-noise condition). In Experiments 1 and 2, short-term memory of running speech and listening effort were unaffected by soft-noise listening conditions. In Experiment 3, however, the moderate-noise listening condition impaired performance in the primary listening task, while performance in the vibrotactile secondary task was unaffected. This pattern of results could suggest that the moderate-noise listening condition, with a signal-to-noise ratio of -3 dB, required increased listening effort compared to the soft-noise and quiet listening conditions. These findings indicate that listening situations with moderate noise can reduce short-term memory of heard conversational content and increase listening effort, even when the speech signals remain highly intelligible.

The knowledge, experience, and awareness of professionals working with older adults on the auditory-cognitive interactions

INTRODUCTION

Hearing loss is a commonly occurring condition with dementia. Research already presented a theoretical framework for the auditory-cognitive interactions, though it is still unclear if and how professionals beyond audiologists act upon this interactions in clinical practice.

METHODS

An online 64-item questionnaire was developed and evaluated respondents' work setting as well as their knowledge, experience, and awareness regarding hearing loss, cognitive decline, and the auditory-cognitive link. The questionnaire was sent to Dutch professionals working with older adults. Respondents were surveyed from May to September 2022.

RESULTS

Two hundred and six non-physicians with a mean work experience of 16 years (range: 6 months - 42 years) and 25 physicians with a mean work experience of 13 years (range: 8 months - 42 years) filled in the entire questionnaire. There was a prevailing tendency to treat hearing and cognitive impairment as distinct entities, overlooking their coexistence and interactions. Results also showed a deficiency in assessing the hearing and cognitive status of older adults, with most relying on the older adult's self-report or indirect (non)verbal cues. Those strategies are strongly dependent on the professional's awareness and knowledge which were, especially for the hearing-related aspects, considered limited. For example, effortful listening was barely reported by the respondents as an important hearing-related complaint. Last, communication strategies fall short, with professionals adapting general approaches but lacking specificity.

CONCLUSION

Specific information for professionals beyond audiologists regarding the auditory-cognitive interactions as well as guidelines how to acted upon in clinical practice are needed to optimise person-centered care for older adults.

Assessment of listening effort, real-life outcome, auditory working memory and attention in school-going children with cochlear implant

PURPOSE

To compare the listening effort using objective test (dual-task paradigm), parents report using abbreviated version of the Speech, Spatial and Quality questionnaire (SSQ-P10) and Teachers' Evaluation of Aural/Oral Performance of Children and Ease of Listening (TEACH), working memory and attention span between children using cochlear implants (CI) and age-matched peers with normal hearing sensitivity, and assess the relationship between listening effort and real-life benefit in children using CI.

METHOD

Group I included 25 children with normal hearing sensitivity. Group II included 25 children with bimodal cochlear implantation with bilateral severe to profound hearing loss. The listening effort was assessed using the dual-task paradigm and SSQ-P10 whereas the TEACH questionnaire was used to assess the real-life outcome in children with CI. Also, digit span forward, digit span backward, and sound count test from CLAP-C were performed to assess working memory and attention, respectively.

RESULTS

The results revealed that children with normal hearing sensitivity performed significantly better in dual-task paradigm, real-life outcome measures, digit span forward test, digit span backward test and attention test of sound count than children with CI. There was a correlation between reaction time in dual-task paradigm and real-life outcome measures.

CONCLUSION

Listening effort and cognitive abilities are affected in children with CI. Listening effort can be measured in school-going children with cochlear implantation. Training may be required to improve real-life activities and improve the cognitive abilities of children with CI.

Self-Perception of Vocal Effort in Response to Modeled Communication Demands

OBJECTIVES

The optimization of vocal effort given a response to a voice demand is a common clinical and vocal performance goal. Increases in vocal effort are often in response to communication limitations from both the interlocutors and the communication environment. This study investigates the relationship between vocal effort and vocal demands from changes and limitations imposed by the communication environment.

METHODS

Thirty-seven participants rated their vocal effort associated with a map description task in a range of communication demands. These demands included communication distance (from 1 m to 4 m), loudness goal (54 dB-66 dB), and excess background noise (53 dBA-71 dBA). The vocal effort ratings were compared across the different types and extents of vocal demand conditions.

RESULTS

As would be expected, there were significant increases in vocal effort levels from the control condition to the extremes of the distance and loudness goal vocal demands. Each increase in background noise resulted in distinct increases in vocal effort level. Participants were able to use the vocal effort scale to efficiently quantify expected increases in vocal demands.

CONCLUSIONS

Increases of vocal effort level accompany increases to vocal demands that exceed the habitual or expected communication. While voice training and vocal therapy are essential for reducing internal vocal demands, clients with a goal to reduce vocal effort should also consider external vocal demands such as communication distance and background noise.

Listening Effort Measured With Pupillometry in Cochlear Implant Users Depends on Sound Level, But Not on the Signal to Noise Ratio When Using the Matrix Test

OBJECTIVES

We investigated whether listening effort is dependent on task difficulty for cochlear implant (CI) users when using the Matrix speech-in-noise test. To this end, we measured peak pupil dilation (PPD) at a wide range of signal to noise ratios (SNR) by systematically changing the noise level at a constant speech level, and vice versa.

DESIGN

A group of mostly elderly CI users performed the Dutch/Flemish Matrix test in quiet and in multitalker babble at different SNRs. SNRs were set relative to the speech-recognition threshold (SRT), namely at SRT, and 5 and 10 dB above SRT (0 dB, +5 dB, and +10 dB re SRT). The latter 2 conditions were obtained by either varying speech level (at a fixed noise level of 60 dBA) or by varying noise level (with a fixed speech level). We compared these PPDs with those of a group of typical hearing (TH) listeners. In addition, listening effort was assessed with subjective ratings on a Likert scale.

RESULTS

PPD for the CI group did not significantly depend on SNR, whereas SNR significantly affected PPDs for TH listeners. Subjective effort ratings depended significantly on SNR for both groups. For CI users, PPDs were significantly larger, and effort was rated higher when speech was varied, and noise was fixed for CI users. By contrast, for TH listeners effort ratings were significantly higher and performance scores lower when noise was varied, and speech was fixed.

CONCLUSIONS

The lack of a significant effect of varying SNR on PPD suggests that the Matrix test may not be a feasible speech test for measuring listening effort with pupillometric measures for CI users. A rating test appeared more promising in this population, corroborating earlier reports that subjective measures may reflect different dimensions of listening effort than pupil dilation. Establishing the SNR by varying speech or noise level can have subtle, but significant effects on measures of listening effort, and these effects can differ between TH listeners and CI users.

Parent-Reported Ease of Listening in Preschool-Aged Children With Bilateral and Unilateral Hearing Loss

OBJECTIVES

Evidence from school-aged children suggests that the ease with which children listen varies with the presence of hearing loss and the acoustic environment despite the use of devices like hearing aids. However, little is known about the ease of listening in preschool-aged children with hearing loss-an age at which rapid learning occurs and increased listening difficulty or effort may diminish the required capacity to learn new skills. To this end, the objectives of the present study were to (i) assess parent-reported aided ease of listening as a function of hearing loss configuration (hearing loss in one versus both ears) and device configuration among children with hearing loss in one ear (unilateral hearing loss), and (ii) investigate factors that influence children's ease of listening.

DESIGN

Parents of 83 children with normal hearing, 54 aided children with bilateral hearing loss (hearing loss in both ears), and 139 children with unilateral hearing loss participated in the study. Of the 139 children with unilateral loss, 72 were unaided, 54 were aided with a device on the ear with hearing loss (direct aiding) and 13 were aided with a device that routed signals to the contralateral normal hearing ear (indirect aiding). Mean age of children was 40.2 months (1 SD = 2.5; range: 36 to 51). Parents completed the two subscales of the Parents' Evaluation of Aural/Oral Performance of Children+ (PEACH+) questionnaire, namely functional listening and ease of listening. Individual percent scores were computed for quiet and noisy situations. Linear mixed-effects models were used to assess the effect of hearing loss configuration and device configuration in children with unilateral hearing loss. Multiple regression was used to assess factors that influenced ease of listening. Factors included hearing thresholds, age at first device fit, consistency in device use, condition (quiet/noise), presence of developmental disabilities, and functional listening abilities.

RESULTS

Children with direct aiding for their hearing loss, either unilateral or bilateral, had similarly lower functional listening skills and ease of listening than their normal hearing peers. Unaided children with unilateral hearing loss had lower functional listening skills and ease of listening than their normal hearing peers in noise but not in quiet. All aided children with unilateral hearing loss, irrespective of direct or indirect aiding had lower functional listening skills and ease of listening relative to normal hearing children in both quiet and noise. Furthermore, relative to unaided children with unilateral hearing loss, those with indirect aiding had lower functional listening and ease of listening. Regression analyses revealed functional listening as a significant predictor of ease of listening in all children with hearing loss. In addition, worse degrees of hearing loss and presence of noise reduced ease of listening in unaided children with unilateral hearing loss.

CONCLUSIONS

Bilateral hearing loss is associated with poorer-than-typical ease of listening in preschoolers even when aided. The impact of unilateral hearing loss on ease of listening is similar to that observed in children with bilateral hearing loss, despite good hearing in one ear and aiding. Given increased difficulties experienced by children with unilateral loss, with or without a device, additional strategies to facilitate communication abilities in noise should be a priority.

Listening effort in children and adults in classroom noise

It is well known that hearing in noisy situations is more challenging than in quiet environments. This holds true for adults and especially for children. This study employed a child-appropriate dual-task paradigm to investigate listening effort in children aged six to ten years and young adults. The primary task involved word recognition, while the secondary task evaluated digit recall. Additionally, subjective perception of listening effort was assessed using a child-appropriate questionnaire. This study incorporated plausible sound reproduction and examined classroom scenarios including multi-talker babble noise with two signal-to-noise ratios (0 dB and -3 dB) in an anechoic and an acoustically simulated classroom environment. Forty-four primary school children aged six to ten (17 first- to second-graders and 18 third- to fourth-graders) and 25 young adults participated in this study. The results revealed differences in listening effort between the noise conditions in third- to fourth-graders and supported using the dual-task paradigm for that age group. For all three age groups, a greater subjective perception of listening effort in noise was found. Furthermore, a correlation between the subjective perception of listening effort and behavioural listening effort based on the experimental results was found for third- to fourth-graders and adults.

Cross-Cultural Adaptation and Validation of the Listening Inventory for Education-Revised in Italian

BACKGROUND

Listening difficulties may frequently occur in school settings, but so far there were no tools to identify them for both hearing and hearing-impaired Italian students. This study performed cross-cultural adaptation and validation of the Listening Inventory for Education-Revised for Italian students (LIFE-R-ITA).

METHODS

The study procedure followed the stages suggested by the Guidelines for the Process of Cross-cultural Adaptation of Self-Report Measures. For the content validation, six cochlear implanted students (8-18 years old) pre-tested the initial version. Whenever any situation did not occur in Italy, the item was adapted to more typical listening situations in Italy. The final version of LIFE-R-ITA was administered to a sample of 223 hearing students from different school settings and educational degrees in order to collect normative data.

RESULTS

For the LIFE-R-ITA, hearing students showed an average score of 72.26% (SD = 11.93), reflecting some listening difficulties. The subscales (LIFE total, LIFE class, and LIFE social) indicated good internal consistency. All items were shown to be relevant. Most challenging situations happened when listening in large rooms, especially when other students made noise. LIFE social scores were significantly worse than those of LIFE class (p < 0.001).

CONCLUSIONS

The present study provides cross-cultural adaptation and validation for the LIFE-R-ITA along with the normative data useful to interpret the results of students with hearing loss. The LIFE-R-ITA may support teachers and clinicians in assessing students' self-perception of listening at school. Such understanding may help students overcome their listening difficulties, by planning and selecting the most effective strategies among classroom interventions.

Comparison of listening efforts in typically developing children and children with central auditory processing disorders

OBJECTIVES

The study's main objective was to compare Listening Effort (LE) in children with central auditory processing disorder [(C)APD] and typically developing children in quiet and at -2 and -6 dB SNR conditions. And to determine the relationship between LE and auditory processing abilities in children with (C)APD.

METHODS

The study included 30 children (15 typically developing children and 15 diagnosed with (C)APD) aged 10-12 years. LE was measured using a dual-tasking paradigm. The primary task required the child to repeat the words. The second task required the child to click the mouse based on the image displayed on the laptop's screen. The primary task was done at quiet, -2 dB SNR, and -6 dB SNR conditions. LE was correlated with dichotic CV, duration pattern test, speech perception in noise - Indian English, and gap detection test in children with (C)APD.

RESULTS

A mixed ANOVA was performed with LE in various conditions as the within-subject factor and group as the between-subject factor for both repetition and reaction time. The study found that LE repetition and reaction time had a significant main effect across conditions and groups. The correlation results revealed a significant relationship between LE reaction time with dichotic scores and GDT thresholds only at -2 dB SNR and -6 dB SNR conditions. There was no significant correlation between other auditory processing abilities and LE under different conditions, such as quiet, SPIN-IE, and DPT at -2 dB SNR and -6 dB SNR.

CONCLUSION

The study emphasizes the importance of cognitive abilities for adequate listening comprehension in challenging situations. As a result, assessing LE in this population may provide additional information for developing therapeutic activities and assisting the child in overcoming listening difficulties.

Do auditory brainstem implants favor the development of sensory integration and cognitive functions?

BACKGROUND

Information about the development of cognitive skills and the effect of sensory integration in children using auditory brainstem implants (ABIs) is still limited.

OBJECTIVE

This study primarily aims to investigate the relationship between sensory processing skills and attention and memory abilities in children with ABI, and secondarily aims to examine the effects of implant duration on sensory processing and cognitive skills in these children.

METHODS

The study included 25 children between the ages of 6 and 10 years (mean age: 14 girls and 11 boys) with inner ear and/or auditory nerve anomalies using auditory brainstem implants. Visual-Aural Digit Span Test B, Marking Test, Dunn Sensory Profile Questionnaire were applied to all children.

RESULTS

The sensory processing skills of children are statistically significant and positive, and moderately related to their cognitive skills. As the duration of implant use increases, better attention and memory performances have been observed (p < .05).

CONCLUSION

The study demonstrated the positive impact of sensory processing on the development of memory and attention skills in children with ABI. It will contribute to evaluating the effectiveness of attention, memory, and sensory integration skills, and aiding in the development of more effective educational strategies for these children.

Pediatric normative data for a novel and fast speech perception test in noise

OBJECTIVES

Communicating in noisy settings can be difficult due to interference and environmental noise, which can impact intelligibility for those with hearing impairments and those with normal hearing threshold. Speech intelligibility is commonly assessed in audiology through speech audiometry in quiet environments. Nevertheless, this test may not effectively assess hearing challenges in noisy environments, as total silence is rare in daily activities. A recently patented method, known as the SRT50 FAST, has been developed for conducting speech audiometry in noise. This new method enables the acceleration and simplification of free field speech audiometry tests involving competition noise. This study aims to establish normative scores and standardize the SRT50 FAST method as a test for evaluating speech perception in noise in pediatric patients.

METHODS

The study included 30 participants with normal hearing, consisting of 11 females and 19 males, ranging in age from 6 to 11 years. A series of speech audiometry tests were conducted to determine the speech reception threshold 50% (SRT50) in competing conditions. This included testing both the fast mode (SRT50 FAST) currently being studied and the traditional method (SRT50 CLASSIC). The SRT50, or Signal to Noise Ratio (SNR) at which 50% of speech recognition occurred, was investigated for both methods.

RESULTS

The mean SRT50 FAST test score was -2.69 (SD = 3.15). The dataset exhibited a normal distribution with values ranging from 3.60 to -8.60. Since the scores are expressed in SRT, higher scores indicate poorer performance. We have established a threshold of 3.60 as the upper limit of the normal range, therefore, patients with scores above this threshold are considered to have abnormal results.

CONCLUSIONS

This study aimed to establish normative data for the evaluation of free field speech in noise recognition using the SRT50 FAST method in the pediatric population. This method accurately investigates the necessary signal-to-noise ratio for achieving 50% recognition scores with bisyllabic words in a quick manner. The ultimate objective is to employ this test to identify the optimal configuration of hearing rehabilitation devices, particularly for pediatric patients with hearing aids and/or cochlear implants. Additionally, it can be used to assess pediatric patients with unilateral hearing loss.

Automated Measurement of Speech Recognition, Reaction Time, and Speech Rate and Their Relation to Self-Reported Listening Effort for Normal-Hearing and Hearing-Impaired Listeners Using various Maskers

In speech audiometry, the speech-recognition threshold (SRT) is usually established by adjusting the signal-to-noise ratio (SNR) until 50% of the words or sentences are repeated correctly. However, these conditions are rarely encountered in everyday situations. Therefore, for a group of 15 young participants with normal hearing and a group of 12 older participants with hearing impairment, speech-recognition scores were determined at SRT and at four higher SNRs using several stationary and fluctuating maskers. Participants' verbal responses were recorded, and participants were asked to self-report their listening effort on a categorical scale (self-reported listening effort, SR-LE). The responses were analyzed using an Automatic Speech Recognizer (ASR) and compared to the results of a human examiner. An intraclass correlation coefficient of r = .993 for the agreement between their corresponding speech-recognition scores was observed. As expected, speech-recognition scores increased with increasing SNR and decreased with increasing SR-LE. However, differences between speech-recognition scores for fluctuating and stationary maskers were observed as a function of SNR, but not as a function of SR-LE. The verbal response time (VRT) and the response speech rate (RSR) of the listeners' responses were measured using an ASR. The participants with hearing impairment showed significantly lower RSRs and higher VRTs compared to the participants with normal hearing. These differences may be attributed to differences in age, hearing, or both. With increasing SR-LE, VRT increased and RSR decreased. The results show the possibility of deriving a behavioral measure, VRT, measured directly from participants' verbal responses during speech audiometry, as a proxy for SR-LE.

The Impact of Hearing Aids on Listening Effort and Listening-Related Fatigue - Investigations in a Virtual Realistic Listening Environment

Participation in complex listening situations such as group conversations in noisy environments sets high demands on the auditory system and on cognitive processing. Reports of hearing-impaired people indicate that strenuous listening situations occurring throughout the day lead to feelings of fatigue at the end of the day. The aim of the present study was to develop a suitable test sequence to evoke and measure listening effort (LE) and listening-related fatigue (LRF), and, to evaluate the influence of hearing aid use on both dimensions in mild to moderately hearing-impaired participants. The chosen approach aims to reconstruct a representative acoustic day (Time Compressed Acoustic Day [TCAD]) by means of an eight-part hearing-test sequence with a total duration of approximately 2½ h. For this purpose, the hearing test sequence combined four different listening tasks with five different acoustic scenarios and was presented to the 20 test subjects using virtual acoustics in an open field measurement in aided and unaided conditions. Besides subjective ratings of LE and LRF, behavioral measures (response accuracy, reaction times), and an attention test (d2-R) were performed prior to and after the TCAD. Furthermore, stress hormones were evaluated by taking salivary samples. Subjective ratings of LRF increased throughout the test sequence. This effect was observed to be higher when testing unaided. In three of the eight listening tests, the aided condition led to significantly faster reaction times/response accuracies than in the unaided condition. In the d2-R test, an interaction in processing speed between time (pre- vs. post-TCAD) and provision (unaided vs. aided) was found suggesting an influence of hearing aid provision on LRF. A comparison of the averaged subjective ratings at the beginning and end of the TCAD shows a significant increase in LRF for both conditions. At the end of the TCAD, subjective fatigue was significantly lower when wearing hearing aids. The analysis of stress hormones did not reveal significant effects.

Parent-Reported Attention-Deficit/Hyperactivity Disorder-Linked Behaviors, Fatigue, and Language in Children Who Are Deaf and Hard of Hearing

Purpose

The purpose of this study was to find out if children who are deaf and hard of hearing (DHH), particularly those without substantially delayed language, appear to be at risk for overreporting of inattentive and hyperactive behaviors and if attention-deficit/hyperactivity disorder (ADHD) measures are influenced by the presence of language-based items, by child language skills, and by child and parent report of fatigue.

Method

This study included 24 children with typical hearing, 13 children with hearing aids (HA), and 16 children with cochlear implants (CI) in second through sixth grade. Parents of children in each group completed a measure reporting on inattentive and hyperactive behaviors, social and academic outcomes, and general fatigue for their child. Children participated in a norm-referenced language assessment and completed a self-report of fatigue.

Results

Analyses revealed an effect of hearing status on overall inattention ratings and social/academic performance: Children with CI had significantly lower ratings of inattention, and children with HA had more social/academic performance deficits. Differences in inattention scores for children with CI remained even when items biased toward language skills were removed from the measure, but differences in performance for children with HA disappeared. Omnibus language scores significantly correlated with academic and social outcomes, whereas parent report of fatigue significantly correlated with inattention and hyperactivity.

Conclusions

Parent report of behaviors linked with ADHD, including inattention and hyperactivity, is likely influenced by child language knowledge and overall fatigue. Comorbid diagnosis of ADHD in children who are DHH must consider these factors.

The effects of temporal cues, point-light displays, and faces on speech identification and listening effort

Among the most robust findings in speech research is that the presence of a talking face improves the intelligibility of spoken language. Talking faces supplement the auditory signal by providing fine phonetic cues based on the placement of the articulators, as well as temporal cues to when speech is occurring. In this study, we varied the amount of information contained in the visual signal, ranging from temporal information alone to a natural talking face. Participants were presented with spoken sentences in energetic or informational masking in four different visual conditions: audio-only, a modulating circle providing temporal cues to salient features of the speech, a digitally rendered point-light display showing lip movement, and a natural talking face. We assessed both sentence identification accuracy and self-reported listening effort. Audiovisual benefit for intelligibility was observed for the natural face in both informational and energetic masking, but the digitally rendered point-light display only provided benefit in energetic masking. Intelligibility for speech accompanied by the modulating circle did not differ from the audio-only conditions in either masker type. Thus, the temporal cues used here were insufficient to improve speech intelligibility in noise, but some types of digital point-light displays may contain enough phonetic detail to produce modest improvements in speech identification in noise.

EEG-based auditory attention decoding with audiovisual speech for hearing-impaired listeners

Auditory attention decoding (AAD) was used to determine the attended speaker during an auditory selective attention task. However, the auditory factors modulating AAD remained unclear for hearing-impaired (HI) listeners. In this study, scalp electroencephalogram (EEG) was recorded with an auditory selective attention paradigm, in which HI listeners were instructed to attend one of the two simultaneous speech streams with or without congruent visual input (articulation movements), and at a high or low target-to-masker ratio (TMR). Meanwhile, behavioral hearing tests (i.e. audiogram, speech reception threshold, temporal modulation transfer function) were used to assess listeners' individual auditory abilities. The results showed that both visual input and increasing TMR could significantly enhance the cortical tracking of the attended speech and AAD accuracy. Further analysis revealed that the audiovisual (AV) gain in attended speech cortical tracking was significantly correlated with listeners' auditory amplitude modulation (AM) sensitivity, and the TMR gain in attended speech cortical tracking was significantly correlated with listeners' hearing thresholds. Temporal response function analysis revealed that subjects with higher AM sensitivity demonstrated more AV gain over the right occipitotemporal and bilateral frontocentral scalp electrodes.

Listening effort and fatigue among cochlear implant users: a scoping review

Introduction

In challenging listening situations, speech perception with a cochlear implant (CI) remains demanding and requires high levels of listening effort, which can lead to increased levels of listening-related fatigue. The body of literature on these topics increases as the number of CI users rises. This scoping review aims to provide an overview of the existing literature on listening effort, fatigue, and listening-related fatigue among CI users and the measurement techniques to evaluate them.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statements were used to conduct the scoping review. The search was performed on PubMed, Scopus, and Web of Science to identify all relevant studies.

Results

In total, 24 studies were included and suggests that CI users experience higher levels of listening effort when compared to normal hearing controls using scales, questionnaires and electroencephalogram measurements. However, executing dual-task paradigms did not reveal any difference in listening effort between both groups. Uncertainty exists regarding the difference in listening effort between unilateral, bilateral, and bimodal CI users with bilateral hearing loss due to ambiguous results. Only five studies were eligible for the research on fatigue and listening-related fatigue. Additionally, studies using objective measurement methods were lacking.

Discussion

This scoping review highlights the necessity for additional research on these topics. Moreover, there is a need for guidelines on how listening effort, fatigue, and listening-related fatigue should be measured to allow for study results that are comparable and support optimal rehabilitation strategies.

The P300 Auditory Evoked Potential: A Physiological Measure of the Engagement of Cognitive Systems Contributing to Listening Effort?

OBJECTIVES

This study aimed to explore the potential of the P300 (P3b) as a physiological measure of the engagement of cognitive systems contributing to listening effort.

DESIGN

Nineteen right-handed young adults (mean age: 24.79 years) and 20 right-handed older adults (mean age: 58.90 years) with age-appropriate hearing were included. The P300 was recorded at Fz, Cz, and Pz using a two-stimulus oddball paradigm with the Flemish monosyllabic numbers "one" and "three" as standard and deviant stimuli, respectively. This oddball paradigm was conducted in three listening conditions, varying in listening demand: one quiet and two noisy listening conditions (+4 and -2 dB signal to noise ratio [SNR]). At each listening condition, physiological, behavioral, and subjective tests of listening effort were administered. P300 amplitude and latency served as a potential physiological measure of the engagement of cognitive systems contributing to listening effort. In addition, the mean reaction time to respond to the deviant stimuli was used as a behavioral listening effort measurement. Last, subjective listening effort was administered through a visual analog scale. To assess the effects of listening condition and age group on each of these measures, linear mixed models were conducted. Correlation coefficients were calculated to determine the relationship between the physiological, behavioral, and subjective measures.

RESULTS

P300 amplitude and latency, mean reaction time, and subjective scores significantly increased as the listening condition became more taxing. Moreover, a significant group effect was found for all physiological, behavioral, and subjective measures, favoring young adults. Last, no clear relationships between the physiological, behavioral, and subjective measures were found.

CONCLUSIONS

The P300 was considered a physiological measure of the engagement of cognitive systems contributing to listening effort. Because advancing age is associated with hearing loss and cognitive decline, more research is needed on the effects of all these variables on the P300 to further explore its usefulness as a listening effort measurement for research and clinical purposes.

The effect of age on the hearing-related quality of life in normal-hearing adults

INTRODUCTION

Recently, a new holistic Patient Reported Outcome Measure (PROM) to assess hearing-related quality of life was developed, named the hearing-related quality of life questionnaire for Auditory-VIsual, COgnitive and Psychosocial functioning (hAVICOP). The purpose of the current study was to evaluate if the hAVICOP is sufficiently sensitive to detect an age effect in the hearing-related quality of life.

METHODS

One-hundred thirteen normal-hearing participants (mean age: 42.13; range: 19 to 69 years) filled in the entire hAVICOP questionnaire online through the Research Electronic Data Capture surface. The hAVICOP consists of 27 statements, across three major subdomains (auditory-visual, cognitive, and psychosocial functioning), which have to be rated on a visual analogue scale ranging from 0 (rarely to never) to 100 (almost always). Mean scores were calculated for each subdomain separately as well as combined within a total score; the worse one's hearing-related quality of life, the lower the score. Linear regression models were run to predict the hAVICOP total as well as the three subdomain scores from age and sex.

RESULTS

A significant main effect of age was observed for the total hAVICOP and all three subdomain scores, indicating a decrease in hearing-related quality of life with increasing age. For none of the analyses, a significant sex effect was found.

CONCLUSION

The hAVICOP is sufficiently sensitive to detect an age effect in the hearing-related quality of life within a large group of normal-hearing adults, emphasizing its clinical utility. This age effect on the hearing-related quality of life might be related to the interplay of age-related changes in the bottom-up and top-down processes involved during speech processing.

Speech perception in noise, working memory, and attention in children: A scoping review

PURPOSE

Speech perception in noise is an everyday occurrence for adults and children alike. The factors that influence how well individuals cope with noise during spoken communication are not well understood, particularly in the case of children. This article aims to review the available evidence on how working memory and attention play a role in children's speech perception in noise, how characteristics of measures affect results, and how this relationship differs in non-typical populations.

METHOD

This article is a scoping review of the literature available on PubMed. Forty articles were included for meeting the inclusion criteria of including children as participants, some measure of speech perception in noise, some measure of attention and/or working memory, and some attempt to establish relationships between the measures. Findings were charted and presented keeping in mind how they relate to the research questions.

RESULTS

The majority of studies report that attention and especially working memory are involved in speech perception in noise by children. We provide an overview of the impact of certain task characteristics on findings across the literature, as well as how these affect non-typical populations.

CONCLUSION

While most of the work reviewed here provides evidence suggesting that working memory and attention are important abilities employed by children in overcoming the difficulties imposed by noise during spoken communication, methodological variability still prevents a clearer picture from emerging.

Auditory, Lexical, and Multitasking Demands Interactively Impact Listening Effort

PURPOSE

This study examined the extent to which acoustic, linguistic, and cognitive task demands interactively impact listening effort.

METHOD

Using a dual-task paradigm, on each trial, participants were instructed to perform either a single task or two tasks. In the primary word recognition task, participants repeated Northwestern University Auditory Test No. 6 words presented in speech-shaped noise at either an easier or a harder signal-to-noise ratio (SNR). The words varied in how commonly they occur in the English language (lexical frequency). In the secondary visual task, participants were instructed to press a specific key as soon as a number appeared on screen (simpler task) or one of two keys to indicate whether the visualized number was even or odd (more complex task).

RESULTS

Manipulation checks revealed that key assumptions of the dual-task design were met. A significant three-way interaction was observed, such that the expected effect of SNR on effort was only observable for words with lower lexical frequency and only when multitasking demands were relatively simpler.

CONCLUSIONS

This work reveals that variability across speech stimuli can influence the sensitivity of the dual-task paradigm for detecting changes in listening effort. In line with previous work, the results of this study also suggest that higher cognitive demands may limit the ability to detect expected effects of SNR on measures of effort. With implications for real-world listening, these findings highlight that even relatively minor changes in lexical and multitasking demands can alter the effort devoted to listening in noise.

Capability of Children with Hearing Devices: A Mixed Methods Study

We investigated 34 deaf and hard-of-hearing children with hearing devices aged 8-12 years and 30 typical hearing peers. We used the capability approach to assess well-being in both groups through interviews. Capability is "the real freedom people have to do and to be what they have reason to value." Speech perception, phonology, and receptive vocabulary data of the deaf and hard-of-hearing children, that were used retrospectively, showed a large variability. The analysis of the relation between clinical quantitative outcome measures and qualitative capability interview outcomes suggests that at this age, differences in clinical performance do not appear to translate into considerable differences in capability, including capability did offer insight into the factors that appeared to ensure this equivalence of capability. We argue that capability outcomes should be used to determine the focus of (auditory) rehabilitation and support, in line with the United Nations Convention on the Rights of the Child.

Effect of Auditory Distractors on Speech Recognition and Listening Effort

OBJECTIVES

Everyday listening environments are filled with competing noise and distractors. Although significant research has examined the effect of competing noise on speech recognition and listening effort, little is understood about the effect of distraction. The framework for understanding effortful listening recognizes the importance of attention-related processes in speech recognition and listening effort; however, it underspecifies the role that they play, particularly with respect to distraction. The load theory of attention predicts that resources will be automatically allocated to processing a distractor, but only if perceptual load in the listening task is low enough. If perceptual load is high (i.e., listening in noise), then resources that would otherwise be allocated to processing a distractor are used to overcome the increased perceptual load and are unavailable for distractor processing. Although there is ample evidence for this theory in the visual domain, there has been little research investigating how the load theory of attention may apply to speech processing. In this study, we sought to measure the effect of distractors on speech recognition and listening effort and to evaluate whether the load theory of attention can be used to understand a listener's resource allocation in the presence of distractors.

DESIGN

Fifteen adult listeners participated in a monosyllabic words repetition task. Test stimuli were presented in quiet or in competing speech (+5 dB signal-to-noise ratio) and in distractor or no distractor conditions. In conditions with distractors, auditory distractors were presented before the target words on 24% of the trials in quiet and in noise. Percent-correct was recorded as speech recognition, and verbal response time (VRT) was recorded as a measure of listening effort.

RESULTS

A significant interaction was present for speech recognition, showing reduced speech recognition when distractors were presented in the quiet condition but no effect of distractors when noise was present. VRTs were significantly longer when distractors were present, regardless of listening condition.

CONCLUSIONS

Consistent with the load theory of attention, distractors significantly reduced speech recognition in the low-perceptual load condition (i.e., listening in quiet) but did not impact speech recognition scores in conditions of high perceptual load (i.e., listening in noise). The increases in VRTs in the presence of distractors in both low- and high-perceptual load conditions (i.e., quiet and noise) suggest that the load theory of attention may not apply to listening effort. However, the large effect of distractors on VRT in both conditions is consistent with the previous work demonstrating that distraction-related shifts of attention can delay processing of the target task. These findings also fit within the framework for understanding effortful listening, which proposes that involuntary attentional shifts result in a depletion of cognitive resources, leaving less resources readily available to process the signal of interest; resulting in increased listening effort (i.e., elongated VRT).

Speech recognition in noise task among children and young-adults: a pupillometry study

Introduction

Children experience unique challenges when listening to speech in noisy environments. The present study used pupillometry, an established method for quantifying listening and cognitive effort, to detect temporal changes in pupil dilation during a speech-recognition-in-noise task among school-aged children and young adults.

Methods

Thirty school-aged children and 31 young adults listened to sentences amidst four-talker babble noise in two signal-to-noise ratios (SNR) conditions: high accuracy condition (+10 dB and  + 6 dB, for children and adults, respectively) and low accuracy condition (+5 dB and + 2 dB, for children and adults, respectively). They were asked to repeat the sentences while pupil size was measured continuously during the task.

Results

During the auditory processing phase, both groups displayed pupil dilation; however, adults exhibited greater dilation than children, particularly in the low accuracy condition. In the second phase (retention), only children demonstrated increased pupil dilation, whereas adults consistently exhibited a decrease in pupil size. Additionally, the children's group showed increased pupil dilation during the response phase.

Discussion

Although adults and school-aged children produce similar behavioural scores, group differences in dilation patterns point that their underlying auditory processing differs. A second peak of pupil dilation among the children suggests that their cognitive effort during speech recognition in noise lasts longer than in adults, continuing past the first auditory processing peak dilation. These findings support effortful listening among children and highlight the need to identify and alleviate listening difficulties in school-aged children, to provide proper intervention strategies.

Test-Retest Reliability and the Role of Task Instructions when Measuring Listening Effort Using a Verbal Response Time Paradigm

Listening amidst competing noise taxes one's limited cognitive resources, leading to increased listening effort. As such, there is interest in incorporating a reliable test of listening effort into the clinical test battery. One clinically promising method for measuring listening effort is verbal response time (VRT) because it can be obtained using already-established clinical tasks. In order for widespread implementation of the VRT paradigm, a better understanding of the psychometric properties is needed. The purpose of this work was to improve the understanding of the reliability and sensitivity of the VRT listening task. Using within-subject study designs, we completed a pilot study to evaluate the test-retest reliability (Study 1) and the effects of task instructions and listening condition (Study 2). Preliminary results show that the VRT paradigm enjoys good to excellent test-retest reliability and that neither task instructions nor listening condition meaningfully influence VRT once measurement error is accounted for. Future studies should account for measurement error when considering statistically significant versus meaningful effects of experimental parameters when using listening effort tasks.

Features of Cognitive Ability and Central Auditory Processing of Preschool Children With Minimal and Mild Hearing Loss

OBJECTIVE

This study aimed to investigate the current status of cognitive development and central auditory processing development of preschool children with minimal and mild hearing loss (MMHL) in Nanjing, China.

METHOD

We recruited 34 children with MMHL and 45 children with normal hearing (NH). They completed a series of tests, including cognitive tests (i.e., Wechsler Preschool and Primary Scale of Intelligence and Continuous Performance Test), behavioral auditory tests (speech-in-noise [SIN] test and frequency pattern test), and objective electrophysiological audiometry (speech-evoked auditory brainstem response and cortical auditory evoked potential). In addition, teacher evaluations and demographic information and questionnaires completed by parents were collected.

RESULTS

Regarding cognitive ability, statistical differences in the verbal comprehensive index, full-scale intelligence quotient, and abnormal rate of attention test score were found between the MMHL group and the NH group. The children with MMHL performed poorer on the SIN test than the children with NH. As for the auditory electrophysiology of the two groups, the latency and amplitude of some waves of the speech-evoked auditory brainstem response and cortical auditory evoked potential were statistically different between the two groups. We attempted to explore the relationship between some key indicators of auditory processing and some key indicators of cognitive development.

CONCLUSIONS

Children with MMHL are already at increased developmental risk as early as preschool. They are more likely to have problems with attention and verbal comprehension than children with NH. This condition is not compensated with increasing age during the preschool years. The results suggest a possible relationship between the risk of cognitive deficit and divergence of auditory processing.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22670473.

Dual-Task Paradigm Measures of Listening Effort: To Include or Not to Include Secondary Task Responses with Incorrect Primary Task Responses

Response time–based dual-task paradigms are commonly adopted to measure behavioral listening effort. Most extant studies used an all-response approach that included secondary task responses under both correct and incorrect primary task responses during analysis. However, evidence supporting this strategy is limited. Therefore, the current study investigated the potential differences between including all responses versus only including correct responses. Data from two previous studies were reanalyzed. Experiment 1 included 16 listeners and used a dual-task paradigm to examine the effect of introducing background noise on listening effort. Experiment 2 included 19 participants and used a different dual-task paradigm to examine the effect of reverberation and loudspeaker-to-listener distance on listening effort. ANOVA results obtained using both analysis approaches were compared. The all-response and correct-only approaches revealed similar results. However, larger effect sizes and an additional main effect were found with the all-response approach. The current study supports the use of an all-response approach due to its greater sensitivity to changes in behavioral listening effort. However, a correct-only approach could be utilized to suit specific study purposes.

Speech Understanding in Complex Environments by School-Age Children with Mild Bilateral or Unilateral Hearing Loss

Numerous studies have shown that children with mild bilateral (MBHL) or unilateral hearing loss (UHL) experience speech perception difficulties in poor acoustics. Much of the research in this area has been conducted via laboratory studies using speech-recognition tasks with a single talker and presentation via earphones and/or from a loudspeaker located directly in front of the listener. Real-world speech understanding is more complex, however, and these children may need to exert greater effort than their peers with normal hearing to understand speech, potentially impacting progress in a number of developmental areas. This article discusses issues and research relative to speech understanding in complex environments for children with MBHL or UHL and implications for real-world listening and understanding.

Short Implicit Voice Training Affects Listening Effort During a Voice Cue Sensitivity Task With Vocoder-Degraded Speech

OBJECTIVES

Understanding speech in real life can be challenging and effortful, such as in multiple-talker listening conditions. Fundamental frequency (fo) and vocal-tract length (vtl) voice cues can help listeners segregate between talkers, enhancing speech perception in adverse listening conditions. Previous research showed lower sensitivity to fo and vtl voice cues when speech signal was degraded, such as in cochlear implant hearing and vocoder-listening compared to normal hearing, likely contributing to difficulties in understanding speech in adverse listening. Nevertheless, when multiple talkers are present, familiarity with a talker's voice, via training or exposure, could provide a speech intelligibility benefit. In this study, the objective was to assess how an implicit short-term voice training could affect perceptual discrimination of voice cues (fo+vtl), measured in sensitivity and listening effort, with or without vocoder degradations.

DESIGN

Voice training was provided via listening to a recording of a book segment for approximately 30 min, and answering text-related questions, to ensure engagement. Just-noticeable differences (JNDs) for fo+vtl were measured with an odd-one-out task implemented as a 3-alternative forced-choice adaptive paradigm, while simultaneously collecting pupil data. The reference voice either belonged to the trained voice or an untrained voice. Effects of voice training (trained and untrained voice), vocoding (non-vocoded and vocoded), and item variability (fixed or variable consonant-vowel triplets presented across three items) on voice cue sensitivity (fo+vtl JNDs) and listening effort (pupillometry measurements) were analyzed.

RESULTS

Results showed that voice training did not have a significant effect on voice cue discrimination. As expected, fo+vtl JNDs were significantly larger for vocoded conditions than for non-vocoded conditions and with variable item presentations than fixed item presentations. Generalized additive mixed models analysis of pupil dilation over the time course of stimulus presentation showed that pupil dilation was significantly larger during fo+vtl discrimination while listening to untrained voices compared to trained voices, but only for vocoder-degraded speech. Peak pupil dilation was significantly larger for vocoded conditions compared to non-vocoded conditions and variable items increased the pupil baseline relative to fixed items, which could suggest a higher anticipated task difficulty.

CONCLUSIONS

In this study, even though short voice training did not lead to improved sensitivity to small fo+vtl voice cue differences at the discrimination threshold level, voice training still resulted in reduced listening effort for discrimination among vocoded voice cues.

Exploring the Correlations Between Measures of Listening Effort in Adults and Children: A Systematic Review with Narrative Synthesis

Listening effort (LE) describes the cognitive resources needed to process an auditory message. Our understanding of this notion remains in its infancy, hindering our ability to appreciate how it impacts individuals with hearing impairment effectively. Despite the myriad of proposed measurement tools, a validated method remains elusive. This is complicated by the seeming lack of association between tools demonstrated via correlational analyses. This review aims to systematically review the literature relating to the correlational analyses between different measures of LE. Five databases were used- PubMed, Cochrane, EMBASE, PsychINFO, and CINAHL. The quality of the evidence was assessed using the GRADE criteria and risk of bias with ROBINS-I/GRADE tools. Each statistically significant analysis was classified using an approved system for medical correlations. The final analyses included 48 papers, equating to 274 correlational analyses, of which 99 reached statistical significance (36.1%). Within these results, the most prevalent classifications were poor or fair. Moreover, when moderate or very strong correlations were observed, they tended to be dependent on experimental conditions. The quality of evidence was graded as very low. These results show that measures of LE are poorly correlated and supports the multi-dimensional concept of LE. The lack of association may be explained by considering where each measure operates along the effort perception pathway. Moreover, the fragility of significant correlations to specific conditions further diminishes the hope of finding an all-encompassing tool. Therefore, it may be prudent to focus on capturing the consequences of LE rather than the notion itself.

Subjective Fatigue in Children With Unaided and Aided Unilateral Hearing Loss

OBJECTIVES

Fatigue is frequently observed in children with chronic diseases and can affect the quality of life (QoL). However, research in children with unilateral hearing loss (UHL) is scarce. Subsequently, no studies investigated the effects of hearing aids on fatigue in children. This study investigates subjective fatigue and hearing-related QoL in children with UHL. Furthermore, it evaluates the influence of hearing aids, subject-specific factors, and respondent-type on subjective fatigue.

STUDY DESIGN

A cross-sectional study was conducted from June 2020 until September 2020 at the department of otorhinolaryngology in a tertiary referral center.

METHODS

The primary outcome was the difference in subjective fatigue and hearing-related QoL between children with unaided UHL, aided UHL, and normal hearing. Subjective fatigue and hearing-related QoL were measured using the Pediatric Quality of Life Inventory™ Multidimensional Fatigue Scale (PedsQL™-MFS) and Hearing Environments and Reflection on Quality of Life (HEAR-QL™) questionnaires.

RESULTS

Along with 36 aided children with UHL, 34 unaided and 36 normal-hearing children were included. Child reports revealed significantly more cognitive fatigue in children with aided UHL than children with normal hearing (median difference 12.5, P = .013). Parents reported more fatigue in children with UHL compared to normal-hearing siblings. Especially children with aided UHL seemed at increased risk for fatigue. Children with UHL scored lower on hearing-related QoL than children with normal hearing. No apparent differences were found in fatigue and QoL between children with unaided and aided UHL.

CONCLUSION

Children with unaided and even aided UHL seem to experience more subjective fatigue and lower hearing-related QoL than children with normal hearing. Prospective longitudinal studies are required to investigate the influence of hearing aids on fatigue and QoL in individual patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021 Laryngoscope, 133:189-198, 2023.

Self-reported listening effort in adults with and without hearing loss: the Danish version of the Effort Assessment Scale (D-EAS)

PURPOSE

Hearing-impaired individuals experience higher levels of listening effort in challenging situations, affecting their communication in daily life. The purpose of this study was to linguistically and culturally adapt the Effort Assessment Scale (EAS) into Danish (D-EAS) and to investigate its reliability and validity in normal-hearing and hearing-impaired listeners.

METHODS

The translation and cross-cultural adaptation of the EAS aligns with recommendations to adapt hearing-related questionnaires for different languages and cultures. Participants were 157 listeners (85 females) aged 20-86 years (M_age = 62.5, SD = 16.8), with (non-hearing aid and hearing aid users) and without hearing loss.

RESULTS

Reliability analysis showed good internal consistency for the six items in the D-EAS (Cronbach's α= 0.93). Exploratory and confirmatory factor analyses showed that D-EAS is a one-dimensional instrument. Significant differences were observed across items and overall scores between normal hearing (NH) and hearing loss groups.

CONCLUSIONS

The D-EAS reliably estimates self-perception of listening effort in adults with and without hearing loss and is sensitive to the impact of hearing loss. Thus, the D-EAS can provide hearing care professionals and hearing researchers with valuable insights into people's self-perception of listening effort to help guide clinical and other rehabilitation decisions.Implications for RehabilitationThe Effort Assessment Scale (EAS) into Danish (D-EAS) is a reliable tool to estimate self-perception of listening effort in hearing-impaired adults.The D-EAS could be a helpful tool providing insights about aspects of hearing disability that is not commonly addressed with the traditional hearing assessments.The D-EAS can be incorporated in the hearing rehabilitation process as a tool for evaluating self-perception of listening effort in daily life situations.The D-EAS is easy to administer and requires a short time to answer, allowing its use by clinicians and hearing researchers in different settings.

Effects of Critical Distance and Reverberation on Listening Effort in Adults

PURPOSE

Mixed historical data on how listening effort is affected by reverberation and listener-to-speaker distance challenge existing models of listening effort. This study investigated the effects of reverberation and listener-to-speaker distance on behavioral and subjective measures of listening effort: (a) when listening at a fixed signal-to-noise ratio (SNR) and (b) at SNRs that were manipulated so that word recognition would be comparable across different reverberation times and listening distances. It was expected that increased reverberation would increase listening effort but only when listening outside critical distance.

METHOD

Nineteen adults (21-40 years) with no hearing loss completed a dual-task paradigm. The primary task was word recognition and the secondary task was timed word categorization; response times indexed behavioral listening effort. Additionally, participants provided subjective ratings in each condition. Testing was completed at two reverberation levels (moderate and high, RT₃₀ = 469 and 1,223 ms, respectively) and at two listener-to-speaker distances (inside and outside critical distance for the test room, 1.25 and 4 m, respectively).

RESULTS

Increased reverberation and listening distances worsened word recognition performance and both behavioral and subjective listening effort. The effect of reverberation was exacerbated when listeners were outside critical distance. Subjective experience of listening effort persisted even when word recognition was comparable across conditions.

CONCLUSIONS

Longer reverberation times or listening outside the room's critical distance negatively affected behavioral and subjective listening effort. This study extends understanding of listening effort in reverberant rooms by highlighting the effect of listener's position relative to the room's critical distance.

Benefits of Text Supplementation on Sentence Recognition and Subjective Ratings With and Without Facial Cues for Listeners With Normal Hearing

OBJECTIVES

Recognizing speech through telecommunication can be challenging in unfavorable listening conditions. Text supplementation or provision of facial cues can facilitate speech recognition under some circumstances. However, our understanding of the combined benefit of text and facial cues in telecommunication is limited. The purpose of this study was to investigate the potential benefit of text supplementation for sentence recognition scores and subjective ratings of spoken speech with and without facial cues available.

DESIGN

Twenty adult females (M = 24 years, range 21 to 29 years) with normal hearing performed a sentence recognition task and also completed a subjective rating questionnaire in 24 conditions. The conditions varied by integrity of the available facial cues (clear facial cues, slight distortion facial cues, great distortion facial cues, no facial cues), signal-to-noise ratio (quiet, +1 dB, -3 dB), and text availability (with text, without text). When present, the text was an 86 to 88% accurate transcription of the auditory signal presented at a 500 ms delay relative to the auditory signal.

RESULTS

The benefits of text supplementation were largest when facial cues were not available and when the signal-to-noise ratio was unfavorable. Although no recognition score benefit was present in quiet, recognition benefit was significant in all levels of background noise for all levels of facial cue integrity. Moreover, participant subjective ratings of text benefit were robust and present even in the absence of recognition benefit. Consistent with previous literature, facial cues were beneficial for sentence recognition scores in the most unfavorable signal-to-noise ratio, even when greatly distorted. It is interesting that, although all levels of facial cues were beneficial for recognition scores, participants rated a significant benefit only with clear facial cues.

CONCLUSIONS

The benefit of text for auditory-only and auditory-visual speech recognition is evident in recognition scores and subjective ratings; the benefit is larger and more robust for subjective ratings than for scores. Therefore, text supplementation might provide benefit that extends beyond speech recognition scores. Combined, these findings support the use of text supplementation in telecommunication, even when facial cues are concurrently present, such as during teleconferencing or watching television.

Listening Effort in Prelingual Cochlear Implant Recipients: Effects of Spectral and Temporal Auditory Processing and Contralateral Acoustic Hearing

OBJECTIVE

Considering the impact of listening effort (LE) on auditory perception, attention, and memory, it is a significant aspect in the daily hearing experiences of cochlear implant (CI) recipients. Reduced spectral and temporal information on an acoustic signal can make listening more difficult; as a result, it is important to understand the relationship between LE and spectral and temporal auditory processing capacities in CI receivers.

STUDY DESIGN, SETTING, AND PATIENTS

This study used spectral ripple discrimination and temporal modulation transfer function to evaluate 20 prelingually deafened and early implanted CI recipients. The speech perception in noise test (primary) and the digit recall task (DRT-secondary) were used to assess LE using the dual-task paradigm. To assess the effects of acoustic hearing, contralateral acoustic hearing thresholds between 125 Hz and 8 kHz with a hearing aid were also acquired. To examine the relationship between the research variables, correlation coefficients were generated. Furthermore, the Mann-Whitney U test was used to compare unilateral and bimodal users.

RESULTS

There was a statistically significant correlation between LE and spectral ripple discrimination (r = 0.56; p = 0.011), 125 Hz (r = 0.51; p = 0.020), 250 Hz (r = 0.48; p = 0.030), 500 Hz (r = 0.45; p = 0.045), 1,000 Hz (r = 0.51; p = 0.023), 2000 Hz (r = 0.48; p = 0.031), and 4,000 Hz (r = 0.48; p = 0.031), whereas no statistically significant correlations were observed between temporal modulation transfer function in four frequencies and LE. There was no statistically significant difference between unilateral and bimodal CI recipients ( p > 0.05).

CONCLUSION

As a result of the improved signal-to-noise ratio in the auditory environment, CI users with better spectral resolutions and acoustic hearing have a reduced LE. On the other hand, temporal auditory processing, as measured by temporal modulation detection, does not contribute to the LE.

Task force Guideline of Brazilian Society of Otology - hearing loss in children - Part II - Treatment

OBJECTIVES

To provide an overview of the main evidence-based recommendations for the diagnosis of hearing loss in children and adolescents aged 0-18 years.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on childhood hearing loss were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 parts: (1) treatment of sensorineural hearing loss: individual hearing aids, bilateral cochlear implants, cochlear implants in young children, unilateral hearing loss, and auditory neuropathy spectrum disorder; and (2) treatment of conductive/mixed hearing loss: external/middle ear malformations, ventilation tube insertion, and tympanoplasty in children.

CONCLUSIONS

In children with hearing loss, in addition to speech therapy, Hearing AIDS (HAs) or implantable systems may be indicated. Even in children with profound hearing loss, both the use of HAs and behavioral assessments while using the device are important.

Development and Evaluation of Pediatric Versions of the Vanderbilt Fatigue Scale for Children With Hearing Loss

PURPOSE

Growing evidence suggests that fatigue associated with listening difficulties is particularly problematic for children with hearing loss (CHL). However, sensitive, reliable, and valid measures of listening-related fatigue do not exist. To address this gap, this article describes the development, psychometric evaluation, and preliminary validation of a suite of scales designed to assess listening-related fatigue in CHL: the pediatric versions of the Vanderbilt Fatigue Scale (VFS-Peds).

METHOD

Test development employed best practices, including operationalizing the construct of listening-related fatigue from the perspective of target respondents (i.e., children, their parents, and teachers). Test items were developed based on input from these groups. Dimensionality was evaluated using exploratory factor analyses (EFAs). Item response theory (IRT) and differential item functioning (DIF) analyses were used to identify high-quality items, which were further evaluated and refined to create the final versions of the VFS-Peds.

RESULTS

The VFS-Peds is appropriate for use with children aged 6-17 years and consists of child self-report (VFS-C), parent proxy-report (VFS-P), and teacher proxy-report (VFS-T) scales. EFA of child self-report and teacher proxy data suggested that listening-related fatigue was unidimensional in nature. In contrast, parent data suggested a multidimensional construct, composed of mental (cognitive, social, and emotional) and physical domains. IRT analyses suggested that items were of good quality, with high information and good discriminability. DIF analyses revealed the scales provided a comparable measure of fatigue regardless of the child's gender, age, or hearing status. Test information was acceptable over a wide range of fatigue severities and all scales yielded acceptable reliability and validity.

CONCLUSIONS

This article describes the development, psychometric evaluation, and validation of the VFS-Peds. Results suggest that the VFS-Peds provide a sensitive, reliable, and valid measure of listening-related fatigue in children that may be appropriate for clinical use. Such scales could be used to identify those children most affected by listening-related fatigue, and given their apparent sensitivity, the scales may also be useful for examining the effectiveness of potential interventions targeting listening-related fatigue in children.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19836154.

The Views and Experience of Audiologists Working in Flemish Hearing Aid Centers Concerning Cognition Within Audiological Practice

PURPOSE

This study aimed to get insight into the views and experience of audiologists, employed in Flemish hearing aid centers, concerning cognition within audiological practice.

METHOD

An online 49-item questionnaire was developed and subdivided into five categories: (a) work setting, (b) practical experience regarding hearing aid fitting linked to cognition, (c) knowledge regarding the auditory-cognitive perspective of speech understanding, (d) willingness and guidelines to implement cognitive measures within audiological practice, and (e) demographics. Respondents were surveyed during January and February 2021.

RESULTS

One hundred twenty-nine audiologists working in Flemish hearing aid centers responded to the entire questionnaire and showed a mean work experience of 8.0 years. Results revealed that cognition was taken into account, especially within the anamnesis interview and general communication strategy, whereas only a minority took cognition into account when actually fitting hearing aids. Knowledge and experience did not determine whether or not respondents took cognition into account. A willingness to implement cognitive measures in a time-efficient manner in audiological practice was observed among respondents.

CONCLUSION

Evidence-based guidelines regarding hearing aid fitting based on an individual's auditory-cognitive profile are needed to improve the quality of hearing rehabilitation.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19593388.

Remote-Microphone Benefit in Noise and Reverberation for Children Who are Hard of Hearing

BACKGROUND

 Remote-microphone (RM) systems are designed to reduce the impact of poor acoustics on speech understanding. However, there is limited research examining the effects of adding reverberation to noise on speech understanding when using hearing aids (HAs) and RM systems. Given the significant challenges posed by environments with poor acoustics for children who are hard of hearing, we evaluated the ability of a novel RM system to address the effects of noise and reverberation.

PURPOSE

 We assessed the effect of a recently developed RM system on aided speech perception of children who were hard of hearing in noise and reverberation and how their performance compared to peers who are not hard of hearing (i.e., who have hearing thresholds no greater than 15 dB HL). The effect of aided speech audibility on sentence recognition when using an RM system also was assessed.

STUDY SAMPLE

 Twenty-two children with mild to severe hearing loss and 17 children who were not hard of hearing (i.e., with hearing thresholds no greater than 15 dB HL) (7-18 years) participated.

DATA COLLECTION AND ANALYSIS

 An adaptive procedure was used to determine the signal-to-noise ratio for 50 and 95% correct sentence recognition in noise and noise plus reverberation (RT 300 ms). Linear mixed models were used to examine the effect of listening conditions on speech recognition with RMs for both groups of children and the effects of aided audibility on performance across all listening conditions for children who were hard of hearing.

RESULTS

 Children who were hard of hearing had poorer speech recognition for HAs alone than for HAs plus RM. Regardless of hearing status, children had poorer speech recognition in noise plus reverberation than in noise alone. Children who were hard of hearing had poorer speech recognition than peers with thresholds no greater than 15 dB HL when using HAs alone but comparable or better speech recognition with HAs plus RM. Children with better-aided audibility with the HAs showed better speech recognition with the HAs alone and with HAs plus RM.

CONCLUSION

 Providing HAs that maximize speech audibility and coupling them with RM systems has the potential to improve communication access and outcomes for children who are hard of hearing in environments with noise and reverberation.

Investigation of the Relation Between Tinnitus, Cognition, and the Amount of Listening Effort

PURPOSE

This study aimed to investigate the effect of chronic tinnitus on measures of listening effort and cognitive performance, as well as the relation between cognitive performance and the amount of listening effort obtained by those measures.

METHOD

Thirteen normal-hearing young adults with chronic tinnitus were matched with a control group. First, behavioral listening effort was measured using a dual-task paradigm in various favorable and unfavorable listening conditions. Furthermore, verbal working memory, processing speed, selective attention, and cognitive flexibility and inhibition were evaluated.

RESULTS

A significant and nonsignificant trend toward more listening effort in the tinnitus group was, respectively, found for the quiet listening condition and the condition with a signal-to-noise ratio of +2 dB. No significant differences in cognitive performances were found between the groups, nor were there significant relationships between the cognitive factors and listening effort scores for either the control or tinnitus group.

CONCLUSIONS

Listening effort was increased in the tinnitus group. Although no clear differences in cognitive performance could be found between the tinnitus group and their controls, a trend could be seen whereby selective attention deficits in the subjects with tinnitus may be an important factor that affects the amount of listening effort.

Speech discrimination and word identification with a consumer-level bone-conduction headset and remote microphone for children with normal hearing

OBJECTIVE

This study investigated the use of bone-conduction headsets paired to a wireless, remote microphone on speech discrimination and word identification for children with normal hearing.

DESIGN

Children were tested with and without the headset, using the McCormick speech discrimination test in quiet and in speech-shaped noise to measure word-discrimination thresholds. Additionally, open-set word identification in noise was assessed while children were simultaneously engaged in a visual-monitoring task.

STUDY SAMPLE

Twenty normal-hearing children, aged 4-11 years.

RESULTS

Median word-discrimination threshold in quiet (n = 20) was 20.5 dB(A) without a headset and 11.5 dB(A) with a headset (Z = -3.826, p = 0.0001). In noise, the median word-discrimination threshold (n = 20) was 52 dB(A) without a headset and 40.5 dB(A) with a headset (Z = -3.926, p< 0.0001). For open-set word identification (n = 11), children performed significantly better with a headset than without it, with an average improvement of 23 percentage points (t(10) = -5.227, p = 0.0004, two tailed).

CONCLUSIONS

A bone-conduction headset paired to a Bluetooth microphone improved discrimination of distant speech in quiet and in noise and open-set word identification in noise.

Are children with unilateral hearing loss more tired?

OBJECTIVE

To determine whether children with unilateral sensorineural hearing loss (USNHL) and unilateral conductive hearing loss (UCHL) have higher levels of fatigue than literature reported normal hearing (LRNH) children.

METHODS

This was a cross-sectional survey utilizing the PedsQL™ Multidimensional Fatigue Scale administered to children with unilateral hearing loss (UHL) and their parents at two tertiary care academic medical centers and a nationwide microtia/atresia conference. The PedsQL™ Multidimensional Fatigue Scale was used to compare child and parental proxy reports of fatigue among USNHL, UCHL, and LRNH children. ANOVA and post-hoc Tukey Honest Significant Difference testing were used for statistical analysis.

RESULTS

Of 69 children included in the study, 42 had UCHL (61%) and 27 (39%) had USNHL. Children with USNHL reported more total fatigue (mean 69.1, SD 19.3) than LRNH children (mean 80.5, SD 13.3; difference -11.4; 95% CI: -19.98 to -2.84) and children with UCHL (mean 78.0, SD 14.5; difference -8.95; 95% CI: -17.86 to 0.04). Children with UCHL reported similar levels of fatigue compared to LRNH children (difference -2.5; 95% CI: -9.95 to 5.03). Parents of children with USNHL reported greater levels of fatigue (mean 67.6, SD 22.6) in their children than parents of LRNH children (mean 89.6, SD 11.4; difference -22.0; 95% CI: -29.8 to -14.3) and parents of children with UCHL (mean 76.2, SD 17.3; difference -8.6; 95% CI: -17.5 to 0.21). Parents of children with UCHL also report higher levels of fatigue than parents of LRNH children (difference -13.4; 95% CI: -19.98 to -6.84).

CONCLUSIONS

Children with USNHL reported greater levels of fatigue than LRNH children and children with UCHL. Results implicate cognitive load as an important consideration in children with hearing loss. The measurement of fatigue may be a useful indicator to determine the benefit of intervention (e.g., amplification) for these children.

Noise Exposure and Use of Hearing Protection Among Adolescents in Rural Areas

PURPOSE

Noise-induced hearing loss (NIHL) has been found in rural children, potentially due to occupational and recreational noise exposure without consistent use of hearing protection devices (HPDs). However, questions remain regarding the specifics of rural adolescents' noise exposure and use of hearing protection around different types of noise. As such, the purpose of the current study was to provide preliminary results on rural adolescents' noise exposure and use of hearing protection for gunfire, heavy machinery, power tools, all-terrain vehicles (ATVs), and music.

METHOD

A questionnaire was administered to 197 students (seventh to 12th grade) from rural schools in West Texas. Questions were related to noise exposure and use of HPDs for specific categories of noise. Testing was performed at the schools, with an investigator recording each student's responses.

RESULTS

Approximately 18%-44% of adolescents reported exposure 12 or more times a year to gunfire, heavy machinery, power tools, and ATVs. Only 1%-18% of the adolescents reported never being exposed to such noise sources. Almost half of rural adolescents never used hearing protection around gunfire, and 77%-91% reported never wearing hearing protection when exposed to heavy machinery, power tools, and ATVs.

CONCLUSIONS

The current study revealed that rural adolescents are exposed to noise sources that could damage their hearing. However, the majority of rural adolescents do not consistently wear hearing protection. Additional research is now needed to extend these findings by assessing rural adolescents' duration of exposure to different noise sources, in addition to investigating prevention of NIHL in this population. Supplemental Material https://doi.org/10.23641/asha.17139335.

Unveiling teachers' beliefs on visual cognition and learning styles of deaf and hard of hearing students: A Portuguese-Swedish study

Vision is considered a privileged sensory channel for deaf and hard of hearing (DHH) students to learn, and, naturally, they recognize themselves as visual learners. This assumption also seems widespread among schoolteachers, which led us to analyse the intersection between teachers' beliefs on deaf and hard of hearing students' academic achievement, visual skills, attentional difficulties, and the perceived importance of image display in class. An online survey was designed to analyse the beliefs of the schoolteachers about the deaf and hard of hearing students learning in educational settings from Portugal and Sweden. Participated 133 teachers, 70 Portuguese and 63 Swedish, from the preschool to the end of mandatory education (ages 3-18) with several years of experience. The content analysis and the computed SPSS statistical significance tests reveal that surveyed teachers believe that deaf and hard of hearing students have better visual skills when compared with their hearing peers yet show divergent beliefs about visual attentional processes. Within the teachers' perceptions on learning barriers to DHH students, the distractibility and cognitive effort factors were highlighted, among communicational difficulties in class. Conclusions about the prevalence of learning misconceptions in teachers from both countries analysed, corroborate previous studies on neuromyths in education, and bring novelty to Deaf Education field. The work of translation of scientific knowledge, teacher training updating, and partnership between researchers and educators are also urgently needed in special education.

Speech Recognition and Listening Effort in Cochlear Implant Recipients and Normal-Hearing Listeners

The outcome of cochlear implantation is typically assessed by speech recognition tests in quiet and in noise. Many cochlear implant recipients reveal satisfactory speech recognition especially in quiet situations. However, since cochlear implants provide only limited spectro-temporal cues the effort associated with understanding speech might be increased. In this respect, measures of listening effort could give important extra information regarding the outcome of cochlear implantation. In order to shed light on this topic and to gain knowledge for clinical applications we compared speech recognition and listening effort in cochlear implants (CI) recipients and age-matched normal-hearing listeners while considering potential influential factors, such as cognitive abilities. Importantly, we estimated speech recognition functions for both listener groups and compared listening effort at similar performance level. Therefore, a subjective listening effort test (adaptive scaling, “ACALES”) as well as an objective test (dual-task paradigm) were applied and compared. Regarding speech recognition CI users needed about 4 dB better signal-to-noise ratio to reach the same performance level of 50% as NH listeners and even 5 dB better SNR to reach 80% speech recognition revealing shallower psychometric functions in the CI listeners. However, when targeting a fixed speech intelligibility of 50 and 80%, respectively, CI users and normal hearing listeners did not differ significantly in terms of listening effort. This applied for both the subjective and the objective estimation. Outcome for subjective and objective listening effort was not correlated with each other nor with age or cognitive abilities of the listeners. This study did not give evidence that CI users and NH listeners differ in terms of listening effort – at least when the same performance level is considered. In contrast, both listener groups showed large inter-individual differences in effort determined with the subjective scaling and the objective dual-task. Potential clinical implications of how to assess listening effort as an outcome measure for hearing rehabilitation are discussed.

Age and Hearing Ability Influence Selective Attention During Childhood

OBJECTIVES

The purpose of the present study was to determine whether age and hearing ability influence selective attention during childhood. Specifically, we hypothesized that immaturity and disrupted auditory experience impede selective attention during childhood.

DESIGN

Seventy-seven school-age children (5 to 12 years of age) participated in this study: 61 children with normal hearing and 16 children with bilateral hearing loss who use hearing aids and/or cochlear implants. Children performed selective attention-based behavioral change detection tasks comprised of target and distractor streams in the auditory and visual modalities. In the auditory modality, children were presented with two streams of single-syllable words spoken by a male and female talker. In the visual modality, children were presented with two streams of grayscale images. In each task, children were instructed to selectively attend to the target stream, inhibit attention to the distractor stream, and press a key as quickly as possible when they detected a frequency (auditory modality) or color (visual modality) deviant stimulus in the target, but not distractor, stream. Performance on the auditory and visual change detection tasks was quantified by response sensitivity, which reflects children's ability to selectively attend to deviants in the target stream and inhibit attention to those in the distractor stream. Children also completed a standardized measure of attention and inhibitory control.

RESULTS

Younger children and children with hearing loss demonstrated lower response sensitivity, and therefore poorer selective attention, than older children and children with normal hearing, respectively. The effect of hearing ability on selective attention was observed across the auditory and visual modalities, although the extent of this group difference was greater in the auditory modality than the visual modality due to differences in children's response patterns. Additionally, children's performance on a standardized measure of attention and inhibitory control related to their performance during the auditory and visual change detection tasks.

CONCLUSIONS

Overall, the findings from the present study suggest that age and hearing ability influence children's ability to selectively attend to a target stream in both the auditory and visual modalities. The observed differences in response patterns across modalities, however, reveal a complex interplay between hearing ability, task modality, and selective attention during childhood. While the effect of age on selective attention is expected to reflect the immaturity of cognitive and linguistic processes, the effect of hearing ability may reflect altered development of selective attention due to disrupted auditory experience early in life and/or a differential allocation of attentional resources to meet task demands.

Remote Microphone Systems Can Improve Listening-in-Noise Accuracy and Listening Effort for Youth With Autism

OBJECTIVES

This study examined whether remote microphone (RM) systems improved listening-in-noise performance in youth with autism. We explored effects of RM system use on both listening-in-noise accuracy and listening effort in a well-characterized sample of participants with autism. We hypothesized that listening-in-noise accuracy would be enhanced and listening effort reduced, on average, when participants used the RM system. Furthermore, we predicted that effects of RM system use on listening-in-noise accuracy and listening effort would vary according to participant characteristics. Specifically, we hypothesized that participants who were chronologically older, had greater nonverbal cognitive and language ability, displayed fewer features of autism, and presented with more typical sensory and multisensory profiles might exhibit greater benefits of RM system use than participants who were younger, had less nonverbal cognitive or language ability, displayed more features of autism, and presented with greater sensory and multisensory disruptions.

DESIGN

We implemented a within-subjects design to investigate our hypotheses, wherein 32 youth with autism completed listening-in-noise testing with and without an RM system. Listening-in-noise accuracy and listening effort were evaluated simultaneously using a dual-task paradigm for stimuli varying in complexity (i.e., syllable-, word-, sentence-, and passage-level). In addition, several putative moderators of RM system effects (i.e., sensory and multisensory function, language, nonverbal cognition, and broader features of autism) on outcomes of interest were evaluated.

RESULTS

Overall, RM system use resulted in higher listening-in-noise accuracy in youth with autism compared with no RM system use. The observed benefits were all large in magnitude, although the benefits on average were greater for more complex stimuli (e.g., key words embedded in sentences) and relatively smaller for less complex stimuli (e.g., syllables). Notably, none of the putative moderators significantly influenced the effects of the RM system on listening-in-noise accuracy, indicating that RM system benefits did not vary according to any of the participant characteristics assessed. On average, RM system use did not have an effect on listening effort across all youth with autism compared with no RM system use but instead yielded effects that varied according to participant profile. Specifically, moderated effects indicated that RM system use was associated with increased listening effort for youth who had (a) average to below-average nonverbal cognitive ability, (b) below-average language ability, and (c) reduced audiovisual integration. RM system use was also associated with decreased listening effort for youth with very high nonverbal cognitive ability.

CONCLUSIONS

This study extends prior work by showing that RM systems have the potential to boost listening-in-noise accuracy for youth with autism. However, this boost in accuracy was coupled with increased listening effort, as indexed by longer reaction times while using an RM system, for some youth with autism, perhaps suggesting greater engagement in the listening-in-noise tasks when using the RM system for youth who had lower cognitive abilities, were less linguistically able, and/or have difficulty integrating seen and heard speech. These findings have important implications for clinical practice, suggesting RM system use in classrooms could potentially improve listening-in-noise performance for some youth with autism.

Interdisciplinary Approaches to the Study of Listening Effort in Young Children with Cochlear Implants

Very early bilateral implantation is thought to significantly reduce the attentional effort required to acquire spoken language, and consequently offer a profound improvement in quality of life. Despite the early intervention, however, auditory and communicative outcomes in children with cochlear implants remain poorer than in hearing children. The distorted auditory input via the cochlear implants requires more auditory attention resulting in increased listening effort and fatigue. Listening effort and fatigue may critically affect attention to speech, and in turn language processing, which may help to explain the variation in language and communication abilities. However, measuring attention to speech and listening effort is demanding in infants and very young children. Three objective techniques for measuring listening effort are presented in this paper that may address the challenges of testing very young and/or uncooperative children with cochlear implants: pupillometry, electroencephalography, and functional near-infrared spectroscopy. We review the studies of listening effort that used these techniques in paediatric populations with hearing loss, and discuss potential benefits of the systematic evaluation of listening effort in these populations.