SamanthaGustafson, AuD,CCC-A

OptionSchools,Inc.AnnualMeeting

May3,2016

Wakeup!Let'stalkaboutfatigueintheclassroom

Acknowledgements• FacultyInvestigators

• LabMembers (previous andcurrent)

o FredH.Besso StephenCamarata

o BenW.Y.Hornsbyo AlexandraKey

o NicholasBennett

o AngelaChen

o HilaryDavis

o ToniaDavis

o StoneDawson

o AndyDeLong

o Caralie Focht

o EmilyFustos

o ElizabethGeller

o OliviaGutierrez

o AmandaHeadley

o Dorita Jones

o RalphLeverett

o LindseyRentmeester

o Quela Royster

o RebeccaSchoon

o SaraSeckman

o AmeliaShuster

o BethSuba

o KrystalWerfel• Project/Staff Funding

o InstituteofEducationSciences,U.S.DepartmentofEducationthroughgrantR324A110266(Bess,PI)toVanderbiltUniversity

o DanandMargaretMaddoxCharitableTrusto AmericanSpeechLanguageandHearingAssociation

WhatisFatigue?

• Occursinthephysicalandmental/cognitive domains

• Subjectively- fatigueisamoodorfeelingoftiredness,exhaustion,orlackofenergy

• Behaviorally- fatigueaffectsfocus,concentration,alertness,and/ormentalefficiency

FatigueisCommon!

Transientfatigue• Common,eveninhealthy

populations

Recurrent,severefatigue• Uncommoninhealthy

populations,butcommoninmanychronichealthconditions– Cancer,HIVAIDs,Parkinson’s,

Multiple Sclerosis

ConsequencesofFatigue

Adults• stress, inattention, reducedconcentration,slowed

mentalprocessing, andimpaireddecision-making

• lessproductiveandmorepronetoaccidents

• lessactive,moreisolated, lessabletomonitorownself-care

Children• inattention, reducedconcentration,highdistractibility

• poorerschoolachievement, higherabsenteeism

Amato, et al. 2001; van der Linden et al. 2003; DeLuca, 2005; Eddy and Cruz, 2007; Ricci et al. 2007

? ? ? ? Fatigue

Whatcontributestofatigue?

DegradedListeningConditions

ConsequencesofListeninginNoise

Listeningeffort referstotheallocationofattentionalandcognitiveresourcestoward

auditorytasks.

Howardetal.,2010;Downs1982;Pichora-Fulleretal.,1995

ClassroomListening

Conditions

Increased Listening

Effort

Decline in Available Top-Down

Processing Resources

Stress Fatigue

Bess and Hornsby (2014)

Whatcontributestofatigue?

FatigueandHearingLoss

“Processingandconstructingmeaningoutofhalf-heardwordsandsentences. Makingguesses andfiguringoutcontext.Andthenthinkingofsomethingintelligent tosayinresponse toaninvariablyrandomquestion. It’slikedoingjigsaws,Suduku andScrabbleallatthesametime.”

– IanNoon,2013

“…since Ilostmostofmyhearing…, I'vehadperiodic boutsoftiredness thataredeeperandofadifferentqualitythanIeverexperienced before.”

– DavidCopithorne,2006

"Mychildstayedonlyfiveminutesatarecentsocialevent.Hetendstowithdrawandgetoverwhelmedinbiggroupsofpeople. He'sseemingmorefrustratedbytheseexperiences.”

- Motherofachildwithhearing loss

"Firstthing IdowhenIgethomeistakemyhearingaidsout.Ijustneedabreak.”- Studentwithhearing loss

VanderbiltStudyonListeningEffort&Fatigue

• 6-12yearoldchildren– Bilateral,mildtomoderately-severe,

permanent hearing loss

• Inclusion/Exclusion:– Nocochlear implantusers

– Generaleducationclassroom

– MonolingualEnglishspeakers

– Nodiagnosisofcognitiveimpairment,autism,orotherdevelopmental disorder

• Experimentalgroup(n=60)– 31males,29females

– Age=9.96(1.92)years

• ControlGroup(n=43)– 26males,17females

– Age=9.10(2.32)years

ClassroomListening

Conditions

Increased Listening

Effort

Decline in Available Top-Down

Processing Resources

Stress Fatigue

Bess and Hornsby (2014)

ImplicationsforChildrenwithHearingLoss

OverallSpeech+NoiseLevelsinMiddleTennesseeClassrooms

Unpublished data

0

5

10

15

20

25

30

40 45 50 55 60 65 70 75 80 85

Numbero

fRecordings

MeasuredLevel(dBSPL)

ClassroomNoiseLevels

City TrafficRefrigerator HumVacuum CleanerRainfall

Air Conditioner

Levels of Common Noises

ClassroomObservations

Childrenwithlesshearing loss,andthose inhighergrades (5th-7th)werelesslikelytousehearingaidsinthe

classroom.

HearingAidUse

24%(n=9)

66%(n=25)

10%(n=4)

FMSystemUse

12%(n=3)

46%(n=12)

42%(n=11)

FMsystemavailable?

89%of1st- 4th graders

47%of5th -7th graders

Davis et al., 2015; Gustafson et al., 2015

ClassroomListening

Conditions

Increased Listening

Effort

Decline in Available Top-Down

Processing Resources

Stress Fatigue

Bess and Hornsby (2014)

ImplicationsforChildrenwithHearingLoss

AssessingListeningEffortintheLab:Dual-TaskParadigm

Primarytask:WordRecognition

Secondarytask:VisualReactionTime

ThreeSNRsrangingfrom-4to+12dBinmulti-talkerbabble

ListeningEffort

Nodifference inwordrecognitionperformancebetween single- anddual-

tasks.

Longerresponse timesmeasuredwithadditionof

second task.

Cognitive resourceswereallocatedtowardmaintainingword

recognitionperformance inthedual-taskcondition.

Unpublished data

ClassroomListening

Conditions

Increased Listening

Effort

Decline in Available Top-Down

Processing Resources

Stress Fatigue

Bess and Hornsby (2014)

ImplicationsforChildrenwithHearingLoss

AssessingChangeinAvailableProcessingResources

Event-related potentials (ERP)arechangesinongoingEEGactivitythataretime-lockedtotheonsetoftheauditoryevent.

ERPsreflectchanges inbrainactivityassociatedwithprocessingofanauditorystimulus.

Centro-parietalP300response

• ”Cognitive”potential

• Sensitivetoattention

Lessavailableprocessingresourcesà reduced

amplitude

StandardTarget

AssessingChangeinAvailableProcessingResources

ERP1 ERP2SpeechProcessingTasks

3 hours

Stimuli• Oddballparadigm(70/30)• Speechsyllables

• (“gi” and“gu”)• 65dBSPL

• Multi-talkerbabble• +10dBSNR

Outcome• ERP1vsERP2

ChangeinProcessingResources:ChildrenwithNormalHearing

Cognitive processing was reduced following sustained speech-processing tasks (p<.05).

Key, Gustafson, Rentmeester, Hornsby, and Bess, (in review)

Who’satrisk?

For children with normal hearing, younger children and those who have poorer speech recognition in noise were more likely to show reductions

in cognitive processing due to sustained speech-processing.

Children with Normal Hearing

Reduced Cognitive

Processing

r = -.406

r = -.417

Unpublished data

ChangeinProcessingResources:ChildrenwithHearingLoss

Normal Hearing(n=27)

Unaided Hearing Loss(n=34)

Children with hearing loss show delays in cognitive processing when

compared to children with normal hearing.

Gustafson, Hornsby, Bess, and Key (in preparation)

ChangeinProcessingResources:ChildrenwithHearingLoss

Trend for cognitive processing to be reduced following sustained speech-processing tasks (p=.087).

Gustafson, Hornsby, Bess, and Key (in preparation)

Who’satrisk?

Age, Language, Nonverbal Intelligence, or Speech in Noise Recognition did not

significantly relate with cognitive processing changes following sustained

speech processing.

The lack of relationship with degree of hearing loss suggests that all children with hearing loss, even mild hearing loss, are at risk of negative effects of

increased listening effort.

Children with Hearing Loss

Reduced Cognitive

Processingr = .114

Gustafson, Hornsby, Bess, and Key (in preparation)

ClassroomListening

Conditions

Increased Listening

Effort

Decline in Available Top-Down

Processing Resources

Stress Fatigue

Bess and Hornsby (2014)

ImplicationsforChildrenwithHearingLoss

AssessingStress

• Stress isthebody’sreaction tochangethatrequiresaphysical,mental,oremotionalresponse

– Stress iscausedbygoodandbadexperiences

• Cortisol levelsprovideaphysiologicmeasure ofstress

– Regulated bythehypothalamic-pituitary-adrenal (HPA)axis

– Related tosugarlevels inthebloodthatfluctuatebasedontheneedtomobilizeenergy

“Typical”CortisolPatterns

Innon-fatiguedindividuals,cortisollevelshaveatypicaldiurnalpattern

Jerjes, et al., (2005).

– Build-upofcortisolduringsleep

– Rapidriseuponawakening• CortisolAwakeningResponse;CAR

– Slowdeclineincortisolthroughouttheday

CAR

“Atypical”CortisolPatterns

Sustainedstresscanleadtoabnormaldiurnalcortisolpatterns

Bhagwagar, Z., Hafizi, S., & Cowen, P. J. (2005).

“Elevated”CARinpatientswithdepression

Controls

“Atypical”CortisolPatterns

Sustainedstresscanleadtoabnormaldiurnalcortisolpatterns

Jerjes, et al., (2005).

Reducedresponsewith“ChronicFatigue

Syndrome”

MeasuringSalivaryCortisolLevels• Participants

– Childrenwithhearingloss(n=32)– Controlgroup(n=28)

• Sixsamplesperday

• Sampledontwoseparateschooldays

*Samples taken by parents at home

Bess, Gustafson, Corbett, Lambert, Camarata, and Hornsby (2016)

1. Awakening*2. 30 min post-wake up*3. 60 min post-wake up*

4. 10:00 am5. 2:00 pm6. 8:00 pm*

ComparingMeasuredCortisolLevels

Childrenwithhearinglosshavehighercortisol levels atawakening than

controls

ChildrenwithhearinglosshaveareducedCARcompared tocontrols

Suggestschildrenwithhearinglossareexperiencing perceived stressandanincreasedburdenofworryingabout

theupcomingday

Bess, Gustafson, Corbett, Lambert, Camarata, and Hornsby (2016)

ClassroomListening

Conditions

Increased Listening

Effort

Decline in Available Top-Down

Processing Resources

Stress Fatigue

Bess and Hornsby (2014)

ImplicationsforChildrenwithHearingLoss

Canwemeasurethesubjectiveexperienceoffatigue?

AssessingFatiguewiththePedsQL MFS

Ourpreliminarydataanddatafromchildrenwithcochlearimplantssuggeststhatchildrenwithhearinglossreportmore

fatigueonthePedsQL MultidimensionalFatigueScale

(Hornsby, Werfel, Camarata, and Bess, 2014; Werfel and Hendricks, 2015)

SubjectiveFatigueReports

Childrenwithmild- to-moderately-severehearinglossdonotreportmorefatiguethanpeerswithhearinglossonthePedsQL

MultidimensionalFatigueScale

Unpublished data

Parent-ReportedFatigue

Parentsofchildrenwithhearinglossreporttheirchildtobemorefatiguedinthecognitivedomainthandoparentsof

childrenwithnormalhearing(p<.05)

Unpublished data

ImmediateFatigueReports

ERP1 ERP2SpeechProcessingTasks

3 hours

Response Time Attention Lapses Fatigue Ratings

1. I feel tired2. It is easy for me to do

these things3. My head hurts4. It’s hard for me to

pay attention5. I have trouble

thinking

ImmediateFatigueReports

Response Time Attention Lapses

Marginally significant increase in response

time (p=.083)

Significant increase in lapses of attention

(p<.05)

Fatigue Ratings

No change in ratings of fatigue (p=.929)

Although both groups showed increased lapses of attention following sustained speech processing, our brief fatigue rating scale did not capture

subjective fatigue in children with and without hearing loss.

Unpublished data

ClassroomListening

Conditions

Increased Listening

Effort

Decline in Available Top-Down

Processing Resources

Stress Fatigue

Bess and Hornsby (2014)

ImplicationsforChildrenwithHearingLoss

ImplicationsforPractice

Beonthelookoutforfatigue!

– Fatiguecanmanifestitselfinavarietyofways• tiredness

• sleepiness inthemorning

• inattentiveness anddistractibility

• moodchanges(irritability, frustration,etc.)

• changesinclassroomcontributions

• difficulty following instructions

ImplicationsforPractice

Helpuseducatethecommunity&thestudents

– Discusswithfamilies,generaleducationteachers,andotherserviceprovidersthatchildrenwithhearinglossareatincreasedriskforfatigue

• Importanceoflisteningbreaks

• Arrangelessons socognitively demandingmaterial isearlyintheday

– Helpstudentswithhearinglossrecognizesignsoffatiguesotheycanlearnhowandwhentotakelisteningbreaks

ImplicationsforPractice

Monitoractionsthatmayreducestress/fatigue

– Evidenceinadultssuggeststhatproperlyfittedhearingaidscanreducelisteningeffortandcognitivefatigue(Hornsby,2013)

– Promotestrategiestocopewiththeincreasedstressofchildrenwithhearingloss• Relaxation,avoidanceofhigh-fatdiets,andregularexercisecanallhelpreducethenegativeeffectsofstress(McEwen,1998;Ratey,2008)

VisittheListeningandLearningLab’swebsiteathttp://my.vanderbilt.edu/listeninglearninglab

Samantha.Gustafson@Vanderbilt.edu