DOCUMENT 9
FOI-24/25-0120
Research Request – Frequency modulation (FM) systems for ASD
literature review
The University of Melbourne - Autism Spectrum Disorder (ASD) Listening
Clinic, make very strong statements (See position paper attached)
suggesting that all children with ASD have central auditory processing
problems and all need to be fitted with an FM system which needs to be
worn all day for 2 years. Is this true? They present a list of research
articles to back up their claims.
Brief
They are very vocal about the need for these FM systems. We receive
many of these support requests in TAB. Our position has been that they
do not meet R&N. We have a meeting with Melbourne Uni in the
planning stages. The meeting will probably happen in early 2021. Your
expert opinion is very welcome to allow us to have informed
discussions.
Date
24/12/20
Jane s47F - personal p(Assistant Director – TAB)
Requester
Peta s47F - personal (Se
privacy
nior Technical Advisor – TAB)
Researcher
Jane s47F - personal
privac – (Research Team Leader – TAB)
Contents
Summary .......................................................................................................................................................... 2
References ..................................................................................................................................................... 18
Please note:
The research and literature reviews collated by our TAB Research Team are not to be shared external to
the Branch. These are for internal TAB use only and are intended to assist our advisors with their
reasonable and necessary decision making.
Delegates have access to a wide variety of comprehensive guidance material. If Delegates require
further information on access or planning matters they are to call the TAPS line for advice.
The Research Team are unable to ensure that the information listed below provides an accurate & up-
to-date snapshot of these matters
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Summary
• Abnormal responses to sensory stimuli across multiple modalities are a consistently
reported feature of ASD and are now a recognised component of diagnosis.
o Hearing impairment is relatively common in this population with 2–10% of cases
presenting with impaired sound detection thresholds [1, 2]
o A high proportion (>50% of paediatric cases) show auditory processing deficits
which are thought to be related to a distorted representation of temporal cues in
the central auditory pathways [3, 4]
• The resources provided in the position paper are mainly of low quality. Those that
conducted an investigation using FM systems are case studies (mainly without a control
group, use subjects as own control) with very small sample sizes. The remaining literature
are editorials, narrative reviews or thesis
• A systematic review has been conducted on FM system use in those with ASD. The
authors concluded that;
o Further research is clearly needed into improving SNR to improve classroom
performance in children with ASD, and at least two warnings from the studies
reviewed here should be heeded – these were
1) Some children with ASD are unable to tolerate the personal FM
systems used. This promotes the need to further investigate other
technologies that could increase the signal level in the classroom
without challenging the tactile sensitivities found in many students
with ASD, such as the Soundfield amplification systems
2) There is a need to include functional outcome measures in studies
involving children with ASD (such as video classroom observation,
sensory and listening experience-focussed questionnaires, etc) as some
children included in the studies were not able to complete some of the
more widely used behavioural outcome measures
• Studies commonly investigated FM systems over 5-6 weeks and for 45mins to 6 hours per
day (some studies didn’t even record use time).
Based on this, hard to justify 2 year
usage.
Given the level and quality of evidence provided, and the fact that less than 50 participants have
been investigated in total across all studies I would not support FM systems as evidence based
practice. However, the results are promising and require further investigation with bigger
samples using study designs which are less prone to bias.
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• Psychosocial: behaviour
assessment system for children:
second edition (BASC-2)
Keith and
No aim or objective,
Editorial
“Personal remote microphone
Level: N/A
Purdy [7]
however, a “learning
hearing aids are currently the
Quality = Very Low
outcome” is provided. Opinion based, no aims or methods as
only evidence-based amplification (The true effect is
to how literature was chosen.
treatment shown to improve
probably markedly
The participant will be
hearing in classrooms for children different from the
able to (1) list the
Predominantly gives an overview of
with APD.”
estimated effect
assistive and
some study findings and what FM
therapeutic benefits
systems are.
The literature cited to back this
Editorial – authors
of remote
up includes a study published on
opinion, not based on
microphone hearing
an FM manufacturer’s website, 2
stats. Can’t verify
aids for children with
case-control studies, a
methods.
auditory processing
conference presentation and a
disorder, and
quasi-randomised trial (level III
(2) Explain the
evidence). This is not enough to
importance of expert
make claims of it being an
intervention to
evidence based practice. There
support teachers to
are major biases in these study
achieve successful
designs, and further large scale
outcomes with
RCTs are needed.
amplification for
children with APD.
Rosenberg
N/A
Abstract only - Unable to obtain full
Can’t comment. Abstract doesn’t
N/A
[8]
text article
provide any results.
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Schafer,
To examine the
Case-Control study – repeated
Not all participants completed all
Level: III-2
Mathews [9]
potential benefit of a
measures design
trials (x2) so their data was
Quality: Low (The
frequency modulation
removed.
true effect might be
(FM) system for 11
Intervention group: 11 children (7 ASD
markedly different
children diagnosed
and 4 ADHD) (9-12 years) were
20% removed the FM receiver for from the estimated
with autism spectrum included in five separate investigative
some period of time because
effect)
disorders (ASD),
measures:
• the receiver was
attention-deficit
‘‘bothering his or her
Small sample of
hyperactivity disorder
• Speech recognition in noise
ear(s)”
convenience (2 drop
(ADHD), or both
• classroom observations of
• the receiver was
outs), no blinding, and
disorders
behaviour
‘‘uncomfortable’’
subjective measures
• teacher questionnaire to assess
• the child was asked by the used, lack of precision
educational need
teacher to remove the
due to no confidence
• teacher questionnaire to assess
receiver and leave the
intervals and
listening behaviours
room for behaviour issues descriptive statistics
• Social validation measures (i.e.,
used in some
informal questionnaires) with
Speech recognition in noise
instances.
the teacher and each
varied across participants.
participant
Improvement of at least 3dB was
Limitations provided
seen in one of the 2 trial sessions. by author
Control group: 11 gender- and age-
1) unable to
matched (9-12 years), typically
On-task behaviours were
generalise to
functioning peers participated in the
significantly higher in both FM
public school
speech recognition in noise measure in
trial periods as compared to both
students
a no-FM system condition.
no-FM trial periods (p < .05).
2) Participants in this
study were all
All recruited from a single private
Off-task behaviour: only 2/8
high-functioning
school classroom (lack of
codes were significant (Does not
children with
generalisability and causes sampling
follow teacher direction, but
relatively few
bias)
engages in distractible behaviours
behavioural issues
and Does not sit quietly when
3) Social
expected or asked, but instead,
consequences of
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Ear-level FM receivers worn on both
engages in other distractible
wearing an FM
ears (i.e., Phonak iSense Micro FM
behaviours)
system
receivers),
4) Control group only
Formal questionnaire results
used for speech
Multiple trial periods
SIFTER questionnaire: no
recognition
Trial 1 = 2 weeks
significant differences in the
measures
Trial 2 = 3 weeks
teacher ratings from the no-FM
5) Trial periods were
Only 45 minutes per day
to the FM system conditions (i.e.,
short – hard to
p > .05) for all comparisons.
determine what
Children’s Auditory Performance
effect that might
Scale: small to medium effect
have
sizes. Not all significant.
6) Participants did
not receive full
audiological
evaluations just
prior to the study
Future research is
warranted to examine
potential benefits of
FM system use for
children with ASD and
ADHD in other school
environments.
Schafer,
To provide research
Combined Editorial/Narrative Review
Descriptive results of reviewed
Level: N/A
Florence [10] evidence to support
studies include:
Quality = Very Low
the educational
No methods – only includes evidence in
(The true effect is
hearing needs of APD, support of FM systems (this is
“Across most of the studies, there probably markedly
ASD, ADHD and
inherently flawed)
is a clear improvement in speech
different from the
dyslexia populations.
recognition performance in
estimated effect
background noise in conditions
with versus without the FM
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• Provide an overview of the
system, with FM gains ranging
Editorial – authors
auditory deficits reported for
from 17% to 86% (pretty
opinion, not based on
these populations
significant variation – shows
stats. Can’t verify
• Review published studies that
uncertainty in results) for fixed-
methods.
support remote-microphone,
intensity stimuli and 6 to 10 dB
hearing-assistance technology
for adaptive test stimuli.”
Author is the editor of
• Recommend an evidence-based
the journal that
assessment and fitting protocol
“Results of these questionnaires
published the paper.
• Present a case study to
lend strong (subjective
Cannot tell whether
demonstrate how the
questionnaires are never
peer reviewed. High
recommended protocols may
considered strong evidence)
level of bias
be used to assess and fit remote
support for the use of FM systems
microphone HAT on children
in order to improve
with normal hearing and
communication, comprehension,
disabilities.
attention, and listening abilities,
particularly in noisy or
reverberant environments.”
Have copied table with evidence
in this paper and pasted below. In
total, only 29 participants with
ASD have been investigated. This
is not a significant number to
base practice off.
Schafer,
A series of case
Case study - Unable to obtain full text
Results taken from the Table
Level: IV
Traber [11]
studies on children
article
provided in Schafer, Florence [10] Quality: Difficult
diagnosed with APDs,
comment with only
ADHD, ASDs, and/or
Can’t comment on methods
1. Sentence recognition in babble abstract details. Likely
language disorders
at -5 dB SNR: Right ear FM, left
low to very low due to
will be presented to
12 participants included
ear FM and bilateral FM
sample size, lack of
(1) support specific
significantly better than no-FM
generalisability and
remote microphone-
condition by an average of 65
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fitting procedures and
to 86%
high possibility of bias
(2) to report speech-
2. Listening comprehension in
due to study design
recognition
classroom noise at -5 dB SNR:
performance in noise;
Significant improvement with FM
listening
vs. no FM on main idea, details,
comprehension; and
reasoning, vocabulary,
participant-, parent-,
and understanding messages
and teacher-rated
subtests
listening behaviors
3. Student LIFE-R (n=8) and CHILD
following a trial
(n=7): Significant benefit of FM at
period with the
school in classroom situations on
technology.
LIFE; significant benefit of FM at
home when
in noise and in social situations
on the CHILD
4. Parent CHILD: Significant
benefit of FM in quiet, in noise, at
a distance, in social situations,
and for media
Rance [12]
No aim/objective
Opinion piece/Journal club
Discusses a couple of papers
Level: N/A
relevant to the area.
Quality: N/A
States that Schafer paper should
be interpreted with caution due
to the study limitations (which
are listed above in the Schafer
study).
Makes a good point about the
Schafer study:
“Participants in this study were all
high-functioning children with
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relatively few behavioural issues.
It could be argued that
youngsters at the other end of the
disability spectrum would have an
even greater need for better
hearing, but expecting these kids
to tolerate any device, even for a
short period of time, may be
unrealistic.”
Rance,
to objectively
Case study – pre-test/post-test
Study A
Level: IV
Chisari [13]
evaluate the effect of
outcomes
Speech Perception
Quality: Low (The
auditory intervention
Mean score for the aided
true effect might be
Dr Rance is
on the stress
Twenty-six children (6 girls) with ASD
listening condition (M = 76.5, SD
markedly different
associate
response in children
participated
= 8.2%) was significantly higher
from the estimated
professor at
than for the unaided (M = 55.5%,
effect)
the
16 children (ASD1-16) participated in
SD = 13.8% (P < 0.001).
University of
Study A (mean age 9.5 years)
Small participant
Melbourne,
Hearing Disability
numbers, missing
where he
10 children (ASD17-26) took part in
Hearing disability ratings for the
parent data, only high
coordinates
Study B (mean age 14.9 years)
Background Noise subscale were
functioning children
the Master of
significantly lower for the device-
involved, non-
Clinical
Children were assigned to each Study
aided listening condition (M =
randomised, no
Audiology
based on their age and educational
28.7%, SD = 11.3%) than for the
control group – all
Program.
setting. Convenience sample, non-
unaided (M = 51.6%, SD = 20.0%
these factors lead to
randomised
(P < 0.001).
uncertainty around
results
Participant anxiety levels were
Ease of Communication subscale
evaluated using the Achenbach System
were lower for the aided listening
of Empirically Based Assessment.
condition (M = 15.0%, SD =
15.7%) than for the unaided (M =
For children in Study A, the parents
26.5%, SD = 21.3% (P = 0.025).
completed the Child Behaviour
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Checklist (CBCL) and for Study B, the
Parent‑
Reported Anxiety
Teacher Report Form (TRF) was used.
Only 6 parents completed the
questionnaire. Only 25% reported
Hearing disability survey (Abbreviated
changes in anxiety level
.
Profile of Hearing Aid Benefit) and an
audiometric assessment
Cortisol Concentration
comparison of within-session
Study A: Each participant was then
cortisol change for each
afforded 1–2 weeks of device
individual revealed a significant
experience (M = 8.8 days, SD = 2.1
difference between
days) in which the listening system was unaided and aided listening
worn at school and home for 4–6 h per
conditions
day.
(P = 0.003).
Salivary Cortisol concentrations were
Study B
obtained from saliva samples collected
Cortisol Concentration
before and after each structured
Comparison of within-session
listening session.
cortisol change for each
individual revealed a significant
Study B: Each child participated in three difference between unamplified
test sessions carried out in a standard
change and amplified change (P =
classroom. The first involved
0.005)
audiometric assessment carried out
one-on-one in a quiet (empty)
Participants with the poorest
classroom and expectoration training
functional hearing ability showed
as per Study A. Subjects then
the highest physiological stress
underwent two, 20 min listening
levels in structured
sessions in a standard (otherwise
listening/comprehension sessions
unoccupied) classroom
and also demonstrated the
greatest stress reduction with the
provision of auditory
intervention.
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Rance,
To evaluate both
Case study - pre-test/post-test
20 ASD and 20 normal controls
Level: IV
Saunders [4]
monaural and
outcomes (control group only used to
Quality: Low (The
binaural processing
determine differences of baseline
Hearing Disability Survey
true effect might be
skills in a group of
measures)
Mean APHAB scores were
markedly different
children with ASD and
significantly higher in this group
from the estimated
to determine the
Intervention group: Twenty children
than in controls across a range of
effect)
degree to which
with ASD participated (mean age 12
perceptual and communication
personal FM listening
years, range 8 to 15.4 years). Only
subscales (P < .001).
Small participant
systems could
children with no known coexisting
numbers, only high
ameliorate their
disabilities and Full-Scale IQ, Wechsler
Auditory Temporal Processing
functioning children
listening difficulties.
Intelligence Scale for Children values
Detection of amplitude
involved, non-
>70 were referred for the study.
modulation in ASD subjects was
randomised, no
significantly impaired relative to
comparison group –
Control group: age- and sex-matched
matched controls.
all these factors lead
control participants was also evaluated.
to uncertainty around
Age at data collection was within 12
Spatial Processing
results.
months of the ASD partner.
Mean spatial advantage for the
ASD group was 9.2 ± 3.2 dB and
Outcome measures
that for the control group was
- Hearing disability questionnaire—the
11.9 ± 1.4 dB (95% CI 1.0-4.4 dB;
Abbreviated Profile of Hearing Aid
P = .003).
Benefit (APHAB).
- Basic auditory processing and
Open-Set Speech Discrimination
functional hearing
Speech perception in noise was
- Listening in Spatialized Noise test
poorer in participants with ASD
- Consonant-Nucleus-Consonant-Word
than in matched controls (P =
test.
.009).
Following this “unaided” assessment,
FM Device Trial
the child was fitted with a Phonak
Only primary school group
Inspiro FM transmitter paired with
completed the device trial (other
iSense receivers (Phonak Org,
group used for baseline
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Murten, Switzerland). Speech testing
comparisons). 8/10 completed
repeated after fitting of FM system.
the study.
Day-to-day listening ability was
FM device use afforded
investigated in the primary-school ASD
significant listening and
group (n = 10) across a
6-week, take
communication benefits (P =
home device trial. A balanced design
.001).
(ABBA) was used, involving 2-week
periods of device use (B) and 2-week
Listening Inventory For Education
periods of non-use (A) to allow for
Questionnaire shoed positive
learning/experience effects.
improvements (“highly beneficial)
During “device-on” phases, the children
(and teachers/parents) were
encouraged to wear the system
throughout the day.
Four to 6 hours of
sustained use per day was typical.
Schafer,
To conduct assistive
Case study – within subject design
The individual and group teacher
Level: IV
Wright [14]
technology
(n = 8–9), parent (n = 8–9), and
Quality: Low (The
evaluations on 12
12 participants who completed the
participant (n = 9) questionnaire
true effect might be
children diagnosed
study (age 6 to 17 years)
ratings revealed substantially less markedly different
with ASD to evaluate
listening difficulty when RM
from the estimated
the potential benefits
5 participants did not complete the
technology was used compared
effect)
of remote
study due to one or more of the
to the no-device ratings.
microphone (RM)
following reasons:
small sample of
technology
1) the inability to tolerate wearing
Medium to large effect sizes and
children across the
the RM technology (n = 3)
significant benefit across all
ASD spectrum, actual
2) parent and teacher
questionnaires
use time was not
questionnaires were not
recorded, no control
returned following the trial
On the behavioural measures,
group, certain
period, and the child was unable individual data revealed varied
statements on the
to do behavioural testing (n = 1) findings (missing data).
questionnaires did not
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3) the child was identified with a
Variability in the data and the
directly apply to
profound sensorineural hearing
inability of some children to
situations that the
loss during the study (n = 1)
complete the behavioural
child experienced at
measures indicates that
home or at school
Digital Phonak Roger inspiro
individualized assistive
transmitter synced to bilateral, digital
technology evaluations including
Author concludes “it
Phonak Focus receivers with SlimTubes
functional questionnaires will be
should be noted that
and open SlimTip domes
necessary to determine if the RM the device does not
technology will be of benefit to a
cure children of
Questionnaires and test measures
particular child who has ASD.
attention deficits,
A total of five questionnaires were
language disorders,
given to teachers, parents, or
and auditory
participants to complete before and
processing issues.”
after a six-week trial period with the
RM technology.
• Listening Inventory for
Education-Revised
• Children’s Auditory
Performance Scale
• Children’s Home Inventory for
Listening Difficulties
• L.I.F.E.-R Student Version
• Short Sensory Profile
Behavioural measures
Laboratory-based behavioural test
measures included speech recognition
in noise, auditory comprehension and
working memory, and acceptable noise
levels.
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Children asked to use system 2 hours
per day. Actual use time was not
recorded
van der Kruk, Reviews the literature
Systematic Review
5 research studies included
Level: IV (only low
Wilson [15]
to determine if
level studies included)
improving the signal-
Six databases: PubMed, Scopus,
Limitations of these studies
Quality: Moderate
to-noise ratio (SNR)
Embase, ERIC, CINAHL and PsychInfo.
(which have been reviewed
(the authors believe
improves classroom
above)
that the true effect is
performance in
No publication time limit was applied,
• Lack of randomized
probably close to the
students with ASD
but publications in languages other
controlled trials
estimated effect)
than English and/or in non-electronic
• Lack of explicit
sources and grey literature were
descriptions of how ASD
Sold methods used.
excluded.
was diagnosed in
Studies included were
participating children
of low quality which
Participant inclusion criteria:
• Small sample sizes
impacts the certainty
1) school-aged children ASD with
• Potential participant bias
of results.
or without other comorbid
in some questionnaire
developmental disorders such
data
as ADD/ ADHD
• Low teacher response
2) Exposed for any duration to
rates
some form of SNR enhancement
• Relatively low number of
be that device (e.g. personal FM
‘low-functioning’ children
or soundfield amplification) or
with ASD.
environmental (e.g. acoustic
treatment of the classroom) in
While further research is clearly
nature.
needed into improving
SNR to improve classroom
performance in children with
ASD, at least two warnings from
the studies reviewed here should
be heeded.
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1) Some children with ASD being
unable to tolerate the
personal FM systems used in.
This promotes the need to
further investigate other
technologies that could
increase the signal level in the
classroom without challenging
the tactile sensitivities found
in many students with ASD,
such as the soundfield
amplification systems
2) The need to include
functional outcome measures
in studies involving children
with ASD (such as video
classroom observation,
sensory and listening
experience-focussed
questionnaires, etc) as some
of these children will not be
able to complete some of the
more widely used behavioural
outcome measures.
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References
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8.
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04.12.2002; 23(04):[309-18 pp.].
9.
Schafer EC, Mathews L, Mehta S, Hill M, Munoz A, Bishop R, et al. Personal FM systems for
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10.
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microphone technology for children with normal hearing and auditory differences. Journal of Educational
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11.
Schafer EC, Traber J, Layden P, Amin A, Sanders K, Bryant D, et al. Use of Wireless Technology for
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