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SamanthaGustafson, AuD,CCC-A
OptionSchools,Inc.AnnualMeeting
May3,2016
Wakeup!Let'stalkaboutfatigueintheclassroom
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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
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WhatisFatigue?
• Occursinthephysicalandmental/cognitive domains
• Subjectively- fatigueisamoodorfeelingoftiredness,exhaustion,orlackofenergy
• Behaviorally- fatigueaffectsfocus,concentration,alertness,and/ormentalefficiency
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FatigueisCommon!
Transientfatigue• Common,eveninhealthy
populations
Recurrent,severefatigue• Uncommoninhealthy
populations,butcommoninmanychronichealthconditions– Cancer,HIVAIDs,Parkinson’s,
Multiple Sclerosis
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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
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? ? ? ? Fatigue
Whatcontributestofatigue?
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DegradedListeningConditions
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ConsequencesofListeninginNoise
Listeningeffort referstotheallocationofattentionalandcognitiveresourcestoward
auditorytasks.
Howardetal.,2010;Downs1982;Pichora-Fulleretal.,1995
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ClassroomListening
Conditions
Increased Listening
Effort
Decline in Available Top-Down
Processing Resources
Stress Fatigue
Bess and Hornsby (2014)
Whatcontributestofatigue?
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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
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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
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ClassroomListening
Conditions
Increased Listening
Effort
Decline in Available Top-Down
Processing Resources
Stress Fatigue
Bess and Hornsby (2014)
ImplicationsforChildrenwithHearingLoss
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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
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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
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ClassroomListening
Conditions
Increased Listening
Effort
Decline in Available Top-Down
Processing Resources
Stress Fatigue
Bess and Hornsby (2014)
ImplicationsforChildrenwithHearingLoss
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AssessingListeningEffortintheLab:Dual-TaskParadigm
Primarytask:WordRecognition
Secondarytask:VisualReactionTime
ThreeSNRsrangingfrom-4to+12dBinmulti-talkerbabble
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ListeningEffort
Nodifference inwordrecognitionperformancebetween single- anddual-
tasks.
Longerresponse timesmeasuredwithadditionof
second task.
Cognitive resourceswereallocatedtowardmaintainingword
recognitionperformance inthedual-taskcondition.
Unpublished data
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ClassroomListening
Conditions
Increased Listening
Effort
Decline in Available Top-Down
Processing Resources
Stress Fatigue
Bess and Hornsby (2014)
ImplicationsforChildrenwithHearingLoss
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AssessingChangeinAvailableProcessingResources
Event-related potentials (ERP)arechangesinongoingEEGactivitythataretime-lockedtotheonsetoftheauditoryevent.
ERPsreflectchanges inbrainactivityassociatedwithprocessingofanauditorystimulus.
Centro-parietalP300response
• ”Cognitive”potential
• Sensitivetoattention
Lessavailableprocessingresourcesà reduced
amplitude
StandardTarget
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AssessingChangeinAvailableProcessingResources
ERP1 ERP2SpeechProcessingTasks
3 hours
Stimuli• Oddballparadigm(70/30)• Speechsyllables
• (“gi” and“gu”)• 65dBSPL
• Multi-talkerbabble• +10dBSNR
Outcome• ERP1vsERP2
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ChangeinProcessingResources:ChildrenwithNormalHearing
Cognitive processing was reduced following sustained speech-processing tasks (p<.05).
Key, Gustafson, Rentmeester, Hornsby, and Bess, (in review)
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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
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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)
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ChangeinProcessingResources:ChildrenwithHearingLoss
Trend for cognitive processing to be reduced following sustained speech-processing tasks (p=.087).
Gustafson, Hornsby, Bess, and Key (in preparation)
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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)
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ClassroomListening
Conditions
Increased Listening
Effort
Decline in Available Top-Down
Processing Resources
Stress Fatigue
Bess and Hornsby (2014)
ImplicationsforChildrenwithHearingLoss
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AssessingStress
• Stress isthebody’sreaction tochangethatrequiresaphysical,mental,oremotionalresponse
– Stress iscausedbygoodandbadexperiences
• Cortisol levelsprovideaphysiologicmeasure ofstress
– Regulated bythehypothalamic-pituitary-adrenal (HPA)axis
– Related tosugarlevels inthebloodthatfluctuatebasedontheneedtomobilizeenergy
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“Typical”CortisolPatterns
Innon-fatiguedindividuals,cortisollevelshaveatypicaldiurnalpattern
Jerjes, et al., (2005).
– Build-upofcortisolduringsleep
– Rapidriseuponawakening• CortisolAwakeningResponse;CAR
– Slowdeclineincortisolthroughouttheday
CAR
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“Atypical”CortisolPatterns
Sustainedstresscanleadtoabnormaldiurnalcortisolpatterns
Bhagwagar, Z., Hafizi, S., & Cowen, P. J. (2005).
“Elevated”CARinpatientswithdepression
Controls
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“Atypical”CortisolPatterns
Sustainedstresscanleadtoabnormaldiurnalcortisolpatterns
Jerjes, et al., (2005).
Reducedresponsewith“ChronicFatigue
Syndrome”
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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*
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ComparingMeasuredCortisolLevels
Childrenwithhearinglosshavehighercortisol levels atawakening than
controls
ChildrenwithhearinglosshaveareducedCARcompared tocontrols
Suggestschildrenwithhearinglossareexperiencing perceived stressandanincreasedburdenofworryingabout
theupcomingday
Bess, Gustafson, Corbett, Lambert, Camarata, and Hornsby (2016)
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ClassroomListening
Conditions
Increased Listening
Effort
Decline in Available Top-Down
Processing Resources
Stress Fatigue
Bess and Hornsby (2014)
ImplicationsforChildrenwithHearingLoss
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Canwemeasurethesubjectiveexperienceoffatigue?
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AssessingFatiguewiththePedsQL MFS
Ourpreliminarydataanddatafromchildrenwithcochlearimplantssuggeststhatchildrenwithhearinglossreportmore
fatigueonthePedsQL MultidimensionalFatigueScale
(Hornsby, Werfel, Camarata, and Bess, 2014; Werfel and Hendricks, 2015)
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SubjectiveFatigueReports
Childrenwithmild- to-moderately-severehearinglossdonotreportmorefatiguethanpeerswithhearinglossonthePedsQL
MultidimensionalFatigueScale
Unpublished data
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Parent-ReportedFatigue
Parentsofchildrenwithhearinglossreporttheirchildtobemorefatiguedinthecognitivedomainthandoparentsof
childrenwithnormalhearing(p<.05)
Unpublished data
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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
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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
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ClassroomListening
Conditions
Increased Listening
Effort
Decline in Available Top-Down
Processing Resources
Stress Fatigue
Bess and Hornsby (2014)
ImplicationsforChildrenwithHearingLoss
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ImplicationsforPractice
Beonthelookoutforfatigue!
– Fatiguecanmanifestitselfinavarietyofways• tiredness
• sleepiness inthemorning
• inattentiveness anddistractibility
• moodchanges(irritability, frustration,etc.)
• changesinclassroomcontributions
• difficulty following instructions
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ImplicationsforPractice
Helpuseducatethecommunity&thestudents
– Discusswithfamilies,generaleducationteachers,andotherserviceprovidersthatchildrenwithhearinglossareatincreasedriskforfatigue
• Importanceoflisteningbreaks
• Arrangelessons socognitively demandingmaterial isearlyintheday
– Helpstudentswithhearinglossrecognizesignsoffatiguesotheycanlearnhowandwhentotakelisteningbreaks
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ImplicationsforPractice
Monitoractionsthatmayreducestress/fatigue
– Evidenceinadultssuggeststhatproperlyfittedhearingaidscanreducelisteningeffortandcognitivefatigue(Hornsby,2013)
– Promotestrategiestocopewiththeincreasedstressofchildrenwithhearingloss• Relaxation,avoidanceofhigh-fatdiets,andregularexercisecanallhelpreducethenegativeeffectsofstress(McEwen,1998;Ratey,2008)
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VisittheListeningandLearningLab’swebsiteathttp://my.vanderbilt.edu/listeninglearninglab