NDIA Accountability Project

Submission 3 — Audiology Australia — Interventions for Children on the Autism Spectrum (NDIA Consultation Paper, 2021)

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SUBMISSION:

May 2021

EXECUTIVE SUMMARY

Audiology Australia (AudA) is the peak professional body for the health profession of audiology, representing over 3,000 audiologists across Australia.

Audiologists are hearing health practitioners who help their clients preserve, manage, and improve their hearing and balance and their ability to process and understand sounds. They provide hearing services to a wide range of clients, including to National Disability Insurance Scheme (NDIS) participants. Currently, there are 21,079 NDIS participants with a hearing impairment in Australia and around 137,300 participants with autism, including around 80,000 children aged under 13 years (NDIA 2020).

In recent months, AudA has received substantial feedback from AudA members that:

  • there is limited awareness amongst NDIA staff about the integral role of audiologists working with and providing important services to NDIS participants who are:

    • children with autism who have a hearing loss
    • children with autism with auditory processing or functioning listening difficulties

    leading to these NDIS participants’ needs not being met.

  • recommended “reasonable and necessary” interventions - especially assistive technology such as remote microphone technology (RMT) that substantive evidence shows are beneficial for the clinical needs of children with autism but are frequently and inconsistently declined by the NDIA on the basis that there is “no evidence” to support their use.

Therefore, AudA’s submission outlines:

(i) why audiologists should be considered and included as an integral part of the care for children with autism, particularly in early intervention years;

(ii) what evidence-based interventions, including auditory therapy and assistive technology, paediatric audiologists utilise for children with ASD; and

(iii) why - in appropriate cases - AudA considers that significant evidence supports the use of RMT as a “reasonable and necessary” intervention for children with autism and functional listening difficulties who are NDIS participants.

Introduction to ASD

Autism Spectrum Disorder (ASD) is a common but complex neurodevelopmental condition that impacts communication, social interaction, and behavioural flexibility. Due to the wide range of its symptoms and severities, autism is known as a ‘spectrum disorder’. ASD is far from a one-size-fits-all diagnosis. In children, the pace of language development, the presence of comorbid disorders, and the range of cognitive ability varies significantly from case to case.

The diagnosis of ASD in children is increasing such that currently in Australia, approximately one in 70 children are diagnosed with the condition.

AudA strongly supports the NDIS’s intention to review the current NDIS Early Childhood Early Intervention approach to improve the different ways it supports young children and their families to reach their full potential.

Typically, children diagnosed with ASD are supported by a range of medical and allied health professionals, often working in a multi-disciplinary or trans-disciplinary team. However, we note that the NDIS consultation paper and the accompanying Autism CRC evidence review makes no mention of the role of audiologists working with children with autism as part of this multi-disciplinary team.

Therefore, this submission outlines:

(i) why audiologists should be considered and included as an integral part of the care for children with ASD, particularly in early intervention years; and

(ii) what evidence-based interventions, including auditory therapy and _ assistive technology, paediatric audiologists utilise for children with ASD.

PART I - THE ROLE OF THE AUDIOLOGIST WORKING WITH CHILDREN WITH AUTISM SPECTRUM DISORDER

Due to low awareness of the role of audiologists working with children with ASD, audiologists are inconsistently consulted during the ASD diagnostic process and may often only be sporadically included to rule out a peripheral, permanent hearing loss.

This means that audiologists are often not part of the multidisciplinary team of health professionals (typically comprised of speech pathologists, psychologists, occupational therapists and developmental paediatricians) who usually contribute to the diagnosis and ongoing management of children with ASD. This omission is primarily due to the lack of awareness of the services audiologists provide in general, and more specifically, the value audiologists can add to the identification and management of debilitating and long-term

auditory deficits including chronic middle ear pathology and functional listening challenges, often present in children with ASD.

AudA believes that audiologists and audiology services should be considered at the following points when a child is being considered for an ASD diagnosis or for children with an established ASD diagnosis.

Diagnosis

AudA considers that no child should be diagnosed with ASD without first considering and ruling out potential hearing loss (conductive and fluctuating or permanent)_at the time of diagnosis, and having a full and current audiology assessment, preferably with a paediatric audiologist.

Audiologists regularly see children with developmental delays which resolve once a hearing loss is identified and medical care is provided. While children born in Australia receive a neonatal hearing screen at birth, a pass result on a neonatal hearing screen does not identify future middle ear pathologies, which impacts on normal speech and language development.

Audiologists also consistently see children that are non-verbal, or with ASD diagnoses who have moderate conductive hearing loss. Moderate conductive hearing loss can create behaviours, delayed speech and language, poor eating and sleeping patterns, sound sensitivities, and melt-downs, which can blur the diagnoses, or simply co-exist with ASD. We consider that a hearing assessment by an audiologist should be imperative prior to diagnosis as - based on the evidence - general practitioners and parents may not always detect middle ear complications.

We also note that currently NDIS planners have a limited understanding about hearing services and the role of audiologist under the National Disability Insurance Agency (NDIA) and that Hearing Australia - the statutory agency which provides support for children previously confirmed and diagnosed with permanent hearing impairment - is not the only source of hearing services for children with hearing loss and/or ASD. Audiology services can also be accessed via privately-based audiologists within the community, and/or not-for-profit organisations.

Monitoring and detection of Middle Ear Pathology

We consider that children who have been diagnosed with ASD and who also have middle ear pathology detected by an audiologist should be monitored regularly for relapse and recurrence. Middle ear pathology is associated with delayed speech and language, poor balance and poor behaviour. Audiological involvement ensures that hearing is functional

at therapy appointments such as speech pathology, psychology and occupational therapy.

Non-verbal children should be monitored from a young age, to allow time for detection of middle ear pathology potentially exacerbating the poor development of speech and language. Middle ear pathology is difficult to detect and often one audiology appointment is not enough. Checking of hearing post cold and flu or post Upper Respiratory Tract Infection is also important.

Early intervention- reaching potential

As highlighted, audiologists are often a missing part of a child’s multi-disciplinary team, hindering gains in therapies with early intervention. Audiologists frequently see children who have been accessing speech pathology and occupational therapy, with small gains, only to find moderate conductive hearing loss that is persistent in nature.

Auditory Processing

Children with ASD may also have co-morbidities, such as auditory processing disorders. This assessment is evidence based and is an objective measurement of auditory performance in various conditions and areas. In comparison to the sensory profile, used by occupational therapists, auditory processing is well-represented in the research and science.

The sensory profile asks questions about auditory sensitivities, from which occupational therapists make decisions about treatment, assistive technology, and therapy. However, we recommend that any child with sensitivities should have a review with a paediatric audiologist to rule out hearing loss and auditory processing disorders. The information acquired from this test can be very useful in management in both the short and long term and can provide therapy and strategies for implementation which will increase the child’s access to their community, increasing their safety and independence.

Auditory memory is often measured as part of an auditory processing assessment. At an early age, audiologists can assess auditory memory and provide advice and therapy that enhances this area for children with ASD.

Hypersensitivities to noise and Misophonia

Audiologists should be the first port of call when a child has hypersensitivity to noise. This is due to the fact that many sound sensitivities can be related in the early years (0-7years) to middle ear pathology and fluctuating hearing loss. It should be critical and mandatory for a child experiencing sound sensitivities to see an audiologist prior to any other allied health practitioner.

Assistive technology

There is now strong empirical evidence to indicate that remote microphone technology assists children with ASD to function. This technology will be discussed later within this submission.

Auditory training and therapy

Children with auditory processing challenges can be supported by evidence based therapy which can improve listening and assist daily function. Auditory training is another evidence-based intervention for management of listening deficits (esp. dichotic integration). Auditory training regimens have been shown to produce measurable, lasting dichotic listening improvements in children with ASD (Denman et al, 2015; Loo et al, 2016; Moncrieff et al, 2017; Barker et al, 2018; Kozou et al, 2018). Schafer et al. (2019) demonstrated improved dichotic listening skills, significantly reduced ear asymmetries, and enhanced auditory short-term memory in 15 children with ASD who participated in computerised auditory training. Paediatric audiologists are skilled at the provision of this training and supporting children to further develop these skills.

Support and wrap around services for children with ASD and hearing loss:

Currently, Hearing Australia provides hearing aids and devices for children with permanent hearing loss and ASD. However, private audiologists within the community are also able to provide cochlear implant services, auditory rehabilitation, assistive technology and supports within the community.

There is often a misunderstanding on the part of NDIS planners and Local Area Coordinators (LACs) about which children are eligible for Hearing Australia services, and that wrap around services from private community-based audiologists are also being utilised effectively for children with ASD and permanent hearing loss.

Role of audiologists in the provision of hearing services and supports to individuals with autism and auditory processing disorder.

In the early 2000s, neonatal hearing screening was introduced to ensure that all babies have their hearing screened prior to hospital discharge. This has had an incredible effect on the early detection and rehabilitation of children with permanent hearing loss.

However, whilst the program is highly successful, it fails to inform parents and caregivers of the effects of a commonly experienced childhood illness, such as middle ear pathology (also known as otitis media and glue ear), which can have a very detrimental effect on a baby’s hearing, sleep, behaviour, feeding, and speech and language development.

Of particular interest is that ASD has been found to be more common in children who have had an otitis media infection (Wimberley, et al., 2018). In addition, children with ASD have been shown to have had a significantly increased rate of acute otitis media, otitis media with effusion, otorrhea, and grommet placement (a common otological procedure to relieve the fluid behind the ear drum). In fact, studies have found that approximately 1 in 6 children with ASD underwent grommet insertion, more than double the rate in the general population (Ackermann et al., 2012). Children with ASD were more than twice as likely to develop mastoiditis, and to undergo mastoidectomy and tympanoplasty with an Ear, Nose & Throat Specialist. Children with ASD are also more likely to have middle ear infections and otitis-related complications.

In addition, the rate of serous otitis media with the associated conductive hearing loss was markedly increased in children with ASD (Rosenhall et al., 1999). These significant findings highlight the importance of routine audiology assessments, which typically include middle ear examinations, in addition to paying close attention to hearing impairment in this population (Adams, et al., 2016).

There are many studies which highlight the major links between ASD and hearing. In a study of children with ASD and their non-autistic siblings, a significantly greater number of children with autism had recurrent otitis media, upper respiratory and other hearing issues. A greater number of children with autism, with recurrent infections, had lower IQ scores, seizures, hearing deficits, delayed motor milestones, poorer speech, congenital anomalies, feeding problems, vomiting, diarrhoea, and other types of infections than children without autism who had mild or no infections. Half the families with more than one child with autism had recurrent infections and 72% of those children had concurrent diseases which effected the central nervous system (Mason-Brothers, et al., 1993).

Rosenhall et al. (1999) conducted a very large study on hospital admissions in children with ASD and found that the top three reasons for visiting the emergency department for children with ASD were acute upper respiratory infections, viral infections and otitis media. Despite this, AudA members have regularly raised the concern that audiologists are generally not recognised or considered to be an integral part of the multidisciplinary team of health professionals that contribute to the diagnosis and management of children with ASD.

The prevalence of permanent hearing loss in children with ASD is also highly relevant - mild to moderate hearing loss was diagnosed in 7.9% and unilateral hearing loss in 1.6% of those who could be tested appropriately. Pronounced to profound bilateral hearing loss or deafness was diagnosed in 3.5% of all cases, representing a prevalence considerably above that in the general population. Hyperacusis, or sensitivity to sounds was common, affecting 18.0% of the ASD group. The study highlights the need for

auditory evaluation of individuals with autism, in order to refer those with pronounced to profound hearing loss for aural habilitation and to follow those with mild to moderate hearing loss because of the risk of deterioration and impact on speech and language development (Rosenhall et al., 1999).

Hyperacusis, or sensitivity to sounds, is also a recognized complaint for children with ASD and is the main presenting complaint in many cases of ASD (Myne & Kennedy, 2018). The commonest age at presentation with this problem was 3-4 years. Unsurprisingly, this age bracket is also a peak prevalence period for otitis media and fluctuating hearing loss. As such, it is incredibly important for audiological care to occur when sound sensitivities are reported, in order to check for otitis media but also to inform parents about otitis media and its sequalae. It is common for occupational therapists to advise on headphone use for children with sound sensitivities, however this could have a concerning and detrimental effect on speech and language outcomes, without audiological involvement, monitoring and review to ensure that otitis media and fluctuating hearing loss is not the actual cause.

It is also common for audiologists to clinically see 3 to 5 year old children diagnosed with ASD, but who present to an audiologist for review and further investigation. In many cases, the audiologist finds evidence of middle ear pathology (otitis media) and facilitates ENT medical care, leading to surgery for treatment of the middle ear, to minimise the impacts of chronic or recurrent otitis media. It is not unusual for the audiologist to then see a distinct and marked improvement in autistic behaviours following surgery, previously expressed as impaired social interactions, qualitative abnormalities in communication, significant delays in language development, echolalia, and _ self-aggressive behaviours (Tajima-Pozo et al., 2010).

There are also clear neurobiological and behavioural links between abnormal auditory development, such as middle ear pathology, and the deficits in social communication and functional listening seen in autism (Yu & Wang, 2021).

Implication of middle ear pathology on development of listening skills

The implications of a history of otitis media on longer term functional listening has been explored in the scientific literature. Studies have found evidence of persistent listening deficits linked to early conductive hearing loss, even once hearing is restored (Pillsbury et al. 1991; Gravel & Wallace 1992; Hall, Grose, & Pillsbury 1995; Moore et al. 2003; Keogh, et al, 2009, Tomlin & Rance 2014).

Tomlin and Rance (2014) established that a reported history of otitis media in children resulted in poorer speech perception in background noise years after sound detection returned to normal. Graydon et al (2017) confirmed that the presence of a conductive

hearing loss associated with otitis media in the first four years of life can influence functional listening in the longer term. In this study of school-age children, 82 children who experienced at least one episode of conductive hearing loss in their first four years of life required significantly higher signal-to-noise ratios in a speech discrimination-in-noise task compared to 36 children with no otitis media history. In a study of speech comprehension, children with bilateral conductive hearing loss had the lowest mean scores when obtained in noisy conditions, confirming that young children, who are known to have poorer speech understanding in noise, show further disadvantage when a bilateral conductive hearing loss is present (Keogh et al., 2010).

Long-term difficulties are likely due to disruptions during developmental years, having a negative impact on auditory pathway development. Outcomes of these studies highlight the need for assessment and early intervention of listening skills in children who present with otitis media and conductive hearing loss.

What does it mean to have functional listening difficulties?

Hearing sounds in our environment is largely a passive process. We can sit back and perceive the sounds of birds chirping or a train going by outside, but not necessarily process, attend to, and interpret those sounds into something meaningful. This latter process describes listening, a more complex neurological process that is both active and purposeful. Functional listening refers to our ability to effectively listen to the important auditory information in our day-to-day lives - for example, to process and interpret a coach’s instructions during a sports match, or to participate in a conversation at a party. It is important to understand that functional listening difficulties are both common and disruptive, and can exist regardless of a person’s hearing ability.

A standard hearing test (audiogram) will describe a person’s ability to detect sounds, but not tell us anything about that person’s ability to actually listen. Further tests are required, including for example, an assessment of speech discrimination in the presence of background noise, to assess functional listening skills. Audiologists are the health care professionals with the skills and knowledge to assess both hearing acuity and functional listening ability.

Functional listening difficulties in children with ASD

Part of the sensory processing/filtering difficulties of children with ASD includes functional listening difficulties - sometimes referred to as auditory processing deficits. Auditory processing difficulties occur when a person’s ears and brain do not co-ordinate and this makes many sounds, particularly speech, difficult to interpret and is even more difficult when listening in a noisy environment. This means that a person can be easily distracted, find it difficult to follow directions and engage in conversation with new and familiar people even in quiet environments.

The Diagnostic Statistical Manual (DSM) Version V introduced sensory abnormalities as a core feature of the diagnosis of ASD, which often include those of the auditory system (American Psychiatric Association, 2013). Research indicates that auditory challenges are among the most common sensory issues affecting children with ASD (Ashburner et al., 2008; Adamson et al., 2006; Baker et al., 2008; Rogers et al., 2003; Tomcheck & Dunn, 2007). Auditory filtering refers to the ability to hear, function and respond to auditory information in the presence of noise (Ashburner et al., 2008). Ashburner et al. 2008 found that 75% of caregivers of children with ASD identified auditory filtering as their child’s most abnormal sensory processing characteristic on the Short Sensory Profile (SSP, McIntosh et al., 1999). Markedly high rates of auditory filtering abnormalities (93%) have also been reported by others (Lane et al., 2010). These listening difficulties can exist despite normal hearing sensitivity.

Children with ASD have been found to demonstrate both atypical auditory responses and attention to speech sounds (Kuhl et al., 2005; Tharpe et al., 2006; Whitehouse & Bishop, 2008). These challenges are supported by evidence of increased difficulty understanding speech in the presence of noise in children with ASD compared to neurotypical peers (Alcantara et al. 2004; Ashburner et al., 2008), and higher caregiver- and self-reported hearing difficulty than neurotypical peers (Rance et al., 2014, 2017; Schafer et al., 2013, 2016, 2020).

Many studies provide evidence that children with ASD who have normal hearing require a higher signal-to-noise ratio (SNR) than their normal-hearing peers when listening in the presence of high levels and different types of background noise (Alcantara et al., 2004; Peters et al., 1998; Rance et al., 2014; Russo et al., 2009; Schafer et al., 2013). This specific difficulty - hearing in the presence of background noise in the absence of hearing loss - will be referred to as functional listening difficulty in this document. This term refers to effectively listening to verbal speech in everyday settings that contain background noise, such as a classroom (Keller et al., 2021).

Children with ASD often exhibit co-occurring communication deficits. Language disorder occurs in at least 65% of children with ASD (D. K. Anderson et al., 2007; Tager-Flusberg, 1981; Turner et al., 2006). Language disorder refers to deficits in both expressive language and receptive language and has a substantial impact on an individual’s ability to communicate effectively. The processing of language input, which relies on the adequate processing of auditory stimuli, is critical to the development of speech and language and effective communication (Keller et al., 2021).

Comorhbid intellectual disabilities are also common in children with a diagnosis of ASD. Approximately a third of children with ASD in Australia also have an intellectual disability (Australia, AIHW, 2016b). Cognitive skills such as processing speed and working memory

that contribute to a standardised measure of intelligence can impact the ability to effectively process auditory input.

Children with ASD who present with comorbid language and intelligence disorders may not be able to reliably participate in traditional clinical assessments of auditory processing due to limitations in understanding the task, keeping up with the task and/or verbally responding to the task. This should not prevent these children from receiving professional audiological support and care to assist with their listening development. In addition to clinical observation and caregiver reporting, there are validated listening tools the audiologist can make use of to identify and document functional listening difficulties warranting evidence-based management and remediation.

An additional cognitive factor that significantly contributes to a child’s ability to effectively utilise their auditory processing skills is attention. A diagnosis of Attention Deficit Disorder (ADD) and/or Attention Deficit Hyperactivity Disorder (ADHD) have been reported in 40-70% of children with ASD (Antshel & Russo, 2019). Attentional problems impact the child with ASD in their ability to accurately perceive, understand and respond in a meaningful way to environmental and social stimuli. Consequently, individuals with ASD are reportedly worse/less motivated to direct and sustain their attention towards auditory stimuli.

Another factor that significantly influences a child’s functional listening skills is their processing of sensory information (Ashburner et al., 2008). Atypical behavioural responses, specifically hyper- or hypo-responsiveness to auditory information is very common in individuals with ASD. Atypical sensory processing of auditory information can disrupt functional listening in stimulating settings, and lead to unsafe behaviours such as accidental injuries, self-harm, and absconding. However, care needs to be taken when diagnosing hyper- or hypo-responsiveness to sounds, and this is clearly within the scope of audiological practice.

A listening assessment performed by an audiologist contributes to a child’s ‘story’ and helps to inform the multidisciplinary team of health professionals working with a child with ASD, the strengths, challenges and management opportunities for that child. Children with ASD commonly participate in formal assessments including language assessments performed by speech pathologists, cognitive (IQ) assessments performed by psychologists, and sensory processing assessments performed by occupational therapists. The results of these assessments, including a listening assessment, provide a valuable snapshot of a child’s current level of functioning and, importantly, contribute to inform best-practice, evidence-based management pathways for these children.

All the above-mentioned assessments across different disciplines can be influenced by factors including language ability, and cognitive ability such as poor attention and low IQ. It is the role of each clinician performing these assessments to consider these potential factors when interpreting results and recommending management strategies.

As a neurodevelopmental disorder, part of the symptomatology of ASD includes delays of the auditory system, which can present functionally and clinically as listening difficulties. It is the role of the audiologist to identify auditory deficits in children with ASD, regardless of whether they are capable of participating in traditional auditory processing assessments. Audiologists also provide support in the development of the auditory system with evidence-based management and intervention strategies.

Management of functional listening deficits

Critical to effective communication is the processing of language input, which relies on the adequate processing of auditory stimuli. Listening deficits can underlie language and learning difficulties. Children require access to a clear speech signal in order to develop their speech and language skills. Therefore, assistance with auditory processing is likely to influence development in other areas such as speech, language and cognitive skills; therefore, potentially reducing therapeutic requirements in these areas in the long-term (Keller et al., 2021).

Children who are assisted with the development of their functional listening skills from an early age will likely require less supports in their educational settings. The early effective management of functional listening skills, including sensory concerns around noise, can support and empower children to achieve their best academically, and participate in their community with confidence.

Remote Microphone Technology (RMT) has been suggested to enhance speech therapy effectiveness (Hodson, 2011), and improvement of signal-to-noise-ratio improves phonemic awareness learning (Flexer et al, 2002). There is evidence demonstrating improvement of functional listening/auditory processing impairments in children with ASD via remote microphone technology and auditory training (Schafer et al., 2013; Rance et al., 2014; Denman et al., 2015) and secondary benefits related to coexisting symptoms of inattention, stress and social functioning (Rance et al., 2017; Schafer et al., 2014, 2016, 2019; Johnston et al., 2009).

Combined, these findings highlight the importance of audiologists in the identification and management of impaired functional listening in children with ASD.

With this is mind, it is important to emphasise that the scope of practice of an audiologist does not specifically address the speech and language requirements of a child who requires support from a speech pathologist, and vice-versa.

PART II - INTERVENTIONS

What is Remote Microphone Technology (RMT)?

Remote microphone technology (RMT) is the primary evidence-based management strategy audiologists recommend to both children and adults with functional listening difficulties. These are ear level receivers which are designed for people with ‘normal hearing’ on a standard hearing test, but who have difficulties processing the sounds they hear - functional listening difficulties.

Is RMT different to noise-cancelling technology?

Yes, noise-cancelling technology significantly reduces the volume of sound, especially noisy background noise. Occasional use of noise-cancelling technology can be beneficial for children with ASD to use in noisy, busy environments where they are not required to listen to important speech or participate in conversations with others around them. This technology can assist children with ASD to attend and cope in particularly stimulating settings e.g. a concert.

However, noise-cancelling technology is not appropriate for use in environments where listening to an important speaker and/or having access to voices and ambient sounds is important. RMT provides the child with direct access to the clear instructions of a group leader/instructor/therapist/caregiver, whilst allowing them access to voices and sounds around them, which is often crucial to their continued social development. RMT reduces (as opposed to cancels) the level of background noise when it gets very loud.

How does RMT work?

RMT is made up of two components (see below) - a microphone/transmitter worn by a primary talker (can be a caregiver, therapist, friend) which is wirelessly connected to ear-worn receivers that deliver the primary talker’s voice directly to the user’s ears.

At present, Phonak Roger Focus RMT receivers are the only devices available on the market which are suitable for users with normal hearing acuity and can be worn by children and adults with normal hearing levels and functional listening difficulties.

The main feature of RMT is the significant improvement of the ‘signal-to-noise ratio’ (SNR) of the talker’s voice - that is, the target speaker’s voice ‘pops out’ amongst the background noise in the environment, making it much easier for the wearer to process and interpret the message.

These devices are medical devices approved for use by the Therapeutic Goods Administration and should always be prescribed by an appropriately qualified paediatric audiologist. The technology is not new and is supported by clinical evidence through randomised controlled trials (Cruz et al., 2020; Sharma et al., 2012).

There are no other ear level devices available for sale in Australia or overseas which are suitable for users with normal hearing. The old style of technology required children to wear headphones, which can result in stigma and exclusion from peer interactions. These older devices do not allow the child to develop normal auditory cues associated with their outer ears (pinna), which can diminish auditory processing development. This is due to the device being worn over the ears. The older style is also vulnerable to interference and static and is impractical for wear during physical activity. For these reasons, these devices are very rarely used or recommended by paediatric audiologists in Australia, or in developed countries.

It is important to note that the Roger Focus receiver is the only device available in the world suitable for people with normal sound detection thresholds (normal hearing) that sits at the ear, without wearing headphones. These devices are approved by the NDIA across Australia for children with ASD, though not consistently. The devices do not replicate any existing therapies, are not considered a therapy or therapeutic device and cannot cure hearing loss. The device does not occlude the ear and allows the child to continue to develop auditory cues from the ear. They cannot be funded through any other body for children with ASD and are personalised devices, in terms of an individualised ear mould and internal settings, appropriate for the child.

Who uses Phonak Roger Focus?

The Phonak Roger Focus receivers, paired with a compatible transmitter/microphone, are suitable for anyone identified as having functional listening difficulties in the presence of normal hearing levels. Research over the years has identified particular groups of people more likely to experience functional listening difficulties. These include children and adults with a history of chronic middle ear pathologies in their younger years, people with a unilateral hearing loss (sometimes referred to as ‘single-sided deafness’), and those with neurodevelopmental disorders such as ASD and Dyslexia.

How does Remote Microphone Technology help?

RMT receivers deliver a clear speech signal to the user’s ears, uninfluenced by the negative effects of distance, background noise and reverberation often present in adverse listening conditions. When used with a microphone/transmitter, RMT reduces the listening effort required for speech perception, while reducing the impact of loud background noise. A review of studies investigating the effects of RMT for children with functional listening difficulties consistently show assistive benefits. The immediate assistive benefits include improved attention, learning, behaviour and participation in an academic setting, and improved self-esteem and psychosocial development. Other benefits include lasting improvements across a broad range of auditory processing skills at both neural and behavioural levels (Keith & Purdy, 2014). Children with identified functional listening deficits who wear RMT typically do so for two to three years (Keith, 2019). Therefore, it is unlikely that RMT would need to be purchased more than once.

Where can RMT be used?

RMT is designed to be used in many environments and by many communication partners, including in the following daily living situations:

  • Home: background noises (e.g. TV, kitchen and laundry appliances running) can make listening across a room difficult for a child with autism and functional listening difficulties.
  • Mealtimes: dynamic conversation is made especially hard due to the complex mix of chatter, background noise and clinking cutlery. For a child to be an active participant in a conversation, they need to hear everyone at the table clearly.
  • Outdoor spaces: there is often surrounding noise in parks and playgrounds and speech reading is virtually impossible due to constant movement and activity. Using RMT gives caregivers and their child the confidence to explore outdoor spaces safely.
  • Car journeys: the constant hum from the vehicle along with road noise and other distracting sounds can make even a short trip frustrating for children with autism and functional listening difficulties. RMT enables children to easily hear and talk to their caregivers, even while sitting in the backseat.
  • Sports: it is easier to respond to a coach’s instructions when instructions can be detected and processed directly.
  • Extracurricular activities and clubs: these activities are crucial for the social development of a child. Being able to effectively listen to others in these group situations means there is less stress.
  • Educational setting: classrooms are a dynamic place for interaction and learning. In order to fully participate, every child needs clear access to their teacher’s voice, multimedia devices and their peers whilst participating in group work. RMT ensures this is the case.
  • TV, video, listening to music and gaming: being able to quickly connect to all audio devices and listen through the ear-level receivers ensures children are effectively processing the audio whilst also having access to people talking around them.

Benefits of RMT in children with functional listening difficulties

There are additional benefits, indicative of positive neuroplastic change, which are observed after periods of several months of RMT use in children with functional listening deficits compared to unaided age-matched control participants. Improvements in the following clinical skills have been measured in the unaided condition following the period of RMT use:

  • Consistency of auditory brainstem responses to speech stimuli
  • Amplitude and latencies of cortical auditory evoked potentials
  • Interaural temporal resolution
  • Frequency discrimination
  • Frequency pattern recognition
  • Auditory working memory
  • Language
  • Speech perception in spatially separated noise
  • Self-perceived listening ability
  • Parent and teacher ratings of hearing ability

(Friederichs & Friederichs, 2005; Hoen et al., 2010; Hornickel et al., 2012; Johnston et al., 2009; Phonak, 2004; Sharma et al., 2012; Smart et al., 2010, 2018; Umat et al., 2011; Yip & Rickard, 2011).

Functional listening performance of children with ASD has been shown to benefit from increased SNR (Rance et al., 2017; Schafer et al., 2016; van der Kruk et al., 2017). A 2017 systematic review of five studies concluded that improving SNR for children with ASD can lead to improved classroom performance (van der Kruk et al., 2017). RMT designed to improve SNR in typical listening environments might support children with ASD in gaining improved access to and understanding of spoken language (Keller et al., 2021).

There is a growing body of evidence demonstrating some improvement of functional listening impairments via RMT in children with ASD and associated functional listening difficulties, and secondary benefits related to coexisting symptoms of inattention, listening-related stress and social functioning (Rance et al., 2014, 2017; Schafer et al., 2013, 2014a, 2014b, 2016, 2019; Johnston, 2009). RMT not only improves specific auditory processing skills such as speech discrimination-in-noise that can be documented clinically, but can have broader, real-world benefits such as improved safety, independence, and social interaction.

Preliminary evidence for positive use of RMT in pre-school-aged children with ASD with a comorbid language disorder

The use of RMT in preschool-aged children with a comorbid language disorder (clinically documented receptive and expressive language delay) has been shown to decrease the prompt level required and the response latency to oral instructions (Keller et al., 2021).

Despite the effects being modest (e.g., 51% improvement in prompt level or latency relative to RMT-off condition), even small improvements in these measures of functional listening performance may be clinically significant. For example, decreased latency of responding to instructions and decreased level of prompting required can increase the amount of active instruction delivered in a given time period.

Small improvements in the receptive language performance, which relies on the listening performance, of this subset of the preschool ASD population, especially during the early years, could have positive ramifications for language development. Research has shown that receptive language ability in young children is predictive of outcomes in adulthood (Mawhood et al., 2000; Whitehouse et al., 2009).

Results of the Keller et al., 2021 study suggest that the use of RMT in this population of children with ASD and comorbid language disorder should be considered a tool that could work well in conjunction with other existing evidence-based behavioural practices and tools, such as augmentative and alternative communication devices, and could enhance the effects of these interventions. RMT may help augment the effects of instruction-based interventions by increasing the salience of spoken instructions to the child, thereby potentially improving the child’s active engagement with the intervention.

This is clinically significant given that many forms of evidence-based intervention in ASD involve spoken instruction and interaction and depend on the child having intact listening skills.

In providing both assistive and longer-term benefits to children with functional listening difficulties, AudA considers that RMT is a highly effective assistive technology for most children with ASD. There is strong evidence to indicate that amplification with RMT appears to treat a wide range of auditory skills simultaneously, facilitating neuroplastic change while also providing improved access to the auditory world.

Why is RMT “reasonable and necessary”?

NDIS funding of supports for children with autism, auditory processing and functional listening difficulties is based on what is considered “reasonable and necessary”.

As outlined in the Consultation Paper, reasonable and necessary supports are based on the functional capacity of a child, including the impact of their environment, their individual circumstances and access to community and mainstream supports.

We consider RMT to be a form of hearing assistive technology (AT) that is “reasonable and necessary” for children with autism and/or auditory processing difficulties who - after a clinical assessment from an audiologist - it is determined could benefit from this technology.

AudA notes the NDIS Operational Guidelines on Assistive Technology outlines what AT the NDIS will and will not fund. It highlights that AT is equipment that helps participants do things that they cannot normally do because of their disability. This includes items that reduce the need for assistance, that help maintain functioning, that allows a participant to complete tasks independently and that are personalised for that person.

The NDIA does not fund AT that is technology that is not related to a person’s disability, items for treatment or rehabilitation or assessment or therapy tools used by therapists.

In AudA’s view, RMT is a hearing AT device personalised for a child with autism and associated auditory processing difficulties that reduces the need for assistance, helps maintain functioning, and allows these children to complete tasks independently and are personalised for that child. This is outlined in further detail below. While there are some long-term benefits to using the device, RMTs do not cure hearing loss and are therefore not a therapy.

In addition to audiological monitoring and implementation of intervention strategies associated with auditory processing and functional listening, RMTs provide support to help the child participate and function more easily in their everyday lives. Use of this technology in children with auditory processing and functional listening difficulties can:

  • increase the child’s social participation
  • help pursue the child’s goals and aspirations
  • help the child become more independent
  • help the child take part in social activities and school
  • help the child to effectively participate in community activities.

In children with ASD and associated functional listening difficulties, RMT has been shown to:

  • increase on-task behaviour
  • result in improved listening behaviour ratings
  • reduce listening difficulty
  • reduce listening-related stress (as inferred from saliva cortisol levels)
  • improve oral comprehension in noise
  • improve auditory working memory in noisy situations

(Rance et al., 2017, 2014; Schafer et al., 2019, 2016, 2013).

In addition, the technology can be used in real world applications to provide safety and basic communication for non-verbal children. For example, a parent may tell their non-verbal child to stop at pedestrian lights when approaching a busy road, particularly if the child is walking ahead. Ordinarily, the parent would raise their voice and be anxious and concerned about gaining the child’s attention as they approached the road. With the RMT, the parent is able to provide instruction that is clearly received by the child. Another example may be a parent providing gentle reassurance or social coaching, from a distance, during peer social interactions at a playground.

Therefore, based on the above evidence, the RMT device will reduce a child’s need for assistance by:

  1. Increasing attention span.
  2. Increasing ability to hear in noisy backgrounds or busy areas.
  3. Increasing independence by providing support from a distance.
  4. Supporting therapists through the provision of clearer speech input.
  5. Improving self-esteem and behaviour.
  6. Improving working memory.

The RMT device makes receiving assistance safe or easy by:

  1. Allowing the provision of a clear signal even in noisy and busy environments (car parks and crossing roads).
  2. Allowing parents to provide support from a distance.
  3. Allowing parents and therapists to perform discrete social coaching.

The RMT helps maintain daily functioning by:

  1. Supporting access to communication in busy and noisy environments (shopping centres).
  2. Supporting access to communication from a distance (at a park).
  3. Supporting day to day living tasks by allowing direction from another room without raising voices or increasing the volume in voice.
  4. Assisting working memory and recall of tasks.

The RMT allows a child to complete tasks independently by:

  1. Encouraging emotional regulation and anxiety management from a distance.
  2. Providing a clear speech signal in noise, reducing clarifications and requests for assistance.
  3. Allowing for re-direction to maintain tasks, without parents being side-by-side with child.
  1. Improving psycho-social development and self-esteem whilst wearing the device.

The RMT is personalised to the child’s needs through:

  1. An impression of the ear is required to obtain a mould that fits the device. The device cannot be worn by others. We also note that the occlusion effect cannot occur with this ear fitting.
  2. The settings of the RMT can be tailored to the child’s individual needs.

Can the RMT be funded elsewhere?

It is important to recognise that funding for RMTs is not provided by State and Territory Departments of Education or by Hearing Australia for children with ASD. They are frequently trialled and provided by specialised, community based, paediatric audiologists who work specifically with children with autism. The devices are personalised and, due to infection control measures, they cannot be shared between children. Furthermore, each child is fitted with an open dome or ventilated mould ensuring that the ear canal remains open to facilitate the perception and development of normal auditory cues from the pinna. Listening needs do not cease at the end of the school day, and devices are required for after-school activities and communication in the car, with parents and when out and about in the community.

On this basis, AudA strongly submits that RMT - where clinically appropriate - is a “reasonable and necessary” intervention for children with autism and functional listening difficulties that should be funded under the NDIS.

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