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• What is the REDDI?

  The Rapid Evaluation and Documentation of Detection and Imitation (REDDI) is a digital way to document and evaluate the Ling Six Sounds and represents a child’s functional access to the sounds of speech over time. This evaluation can be used to determine responses for individual ears and for everyday listening conditions. The information provided by a child’s responses will provide guidance to your team in managing a child’s access to sound and determining ongoing clinical management. Clinical management may involve hearing device optimisation, audiological assessment review, middle ear pathology assessment, referral to an Ear, Nose and Throat Specialist, or further referrals if additional concerns are identified.

• What information does the REDDI provide?

  By entering information into the REDDI, you can:

  • Track a child’s responses to sounds across the speech frequency spectrum across time
  • Track a child’s responses to sounds at different distances
  • Track a child’s responses to sounds at different volumes
  • Identify when a child is having difficulty with access to certain speech frequencies
  • Ascertain when a child has learnt to imitate a sound
  • Establish a child’s next auditory development steps for detection and imitation of sounds
  • Determine the auditory and visual cues a child needs at certain speech frequencies
  • Work with a team to support a child’s optimal access to sound

• Who can the REDDI be used with?

  The REDDI can be used with children with all levels of hearing and types of hearing loss including unilateral and bilateral hearing, those diagnosed through universal newborn hearing of screening and those diagnosed later, children learning English as both a primary and additional language, and languages other than English, and children with additional needs. It is intended for use to track a child’s access to the sounds of speech.

• Who can administer the REDDI?

  It has been designed to be administered by a parent or health/education professional who knows the child well. At the moment, the REDDI digital assessment tool can be administered by anyone with a HearHub digital subscription. We encourage the HearHub user to complete the REDDI learning course before administering the REDDI for the first time.  

  The Ling sounds should be used regularly by anyone who is monitoring the child’s access to sound. We are working on a downloadable and parent version of the REDDI that can be used to track the child’s access to sound. 

• What does REDDI stand for?

  Rapid Evaluation and Documentation of Detection and Imitation

Distance in metres

Cues

• Why is distance important to measure?

  Distances between a speaker and a listener vary in everyday life. A child may be in one room listening to their parent speaking from the next room of a house, or in the playground listening to their sibling on another piece of play equipment.

  This measure indicates a child’s critical listening learning distance in which they can access speech sounds across the frequency spectrum. When a child can imitate all of the sounds at less than 1 metre, their critical listening learning distance is very close to the speaker. When a child can detect or imitate all the sounds from a distance of 3 metres (or more), we can be confident they have developed a good critical listening distance to support them in conversations in everyday listening environments.

• Do I need to measure the distance each time I conduct a REDDI?

  You need to select one of the distances to complete a REDDI round. Having an awareness of the distances in the typical space you present the sounds will help in choosing the most appropriate distance.  If you are unsure choose the closer distance.

• Why are pitch and duration combined as an Auditory cue?

  Pitch and duration are different types of auditory cues used to increase the acoustic components of a sound. Each speech sound lends itself to either pitch or duration and sometimes both. For example, /m/ can be presented with pitch and duration (e.g mmMMMM) – but could be presented with duration (e.g mmmmm), while /s/ is often presented with duration (e.g ssssssss or sss sass sss), and is difficult to present with changing pitch.

  Understanding a child’s access to speech sounds at conversational length and volume helps to support intervention targets to help them develop the auditory skills necessary to learn spoken language through listening.  

• Can I choose both auditory and visual cues?

  No, you can’t select both options. Where you have used both an auditory and visual cue, always choose visual. When a visual cue is provided, the child doesn’t respond through listening.

  If some sounds have been presented with auditory cues and other sounds with visual cues, you enter results as separate rounds.

Volume

• Why is the volume represented in dB SPL?

  Two commonly used measurements of decibels include dB HL (Hearing Level) and dB SPL (Sound Pressure Level) (Katz, Chasin et al. 1978).  The measurement of dB HL indicates the intensity of sound and represents audibility for an average typically hearing listener at a particular signal frequency. This unit is used during pure tone audiometric threshold measurement. 

  The pressure within a soundwave determines the intensity of the sound. The measurement of dB SPL is sensitive to the differences in sound pressure in the air that are present at different frequencies. Sound level meters are calculated in dB SPL; the condenser microphones are sensitive to sound pressure changes in the air, similar to the human ear. Thus, the REDDI tool represents volume using the measurement of dB SPL.

• Do I need to use a sound level meter to know the volume of the presented sounds?

  When completing the REDDI, you will select from two volume options for data entry – “Everyday Conversation (<55dB)” and “Loud (>=55dB)”.  You don’t need to use a Sound Level Meter each time you present the sounds during a REDDI. It is recommended that you have an awareness of your presentation volume for the sounds in order to choose the most appropriate option.

  Using a Sound Level Meter to check your presentation volume for each sound will help you to become familiar with how you need to present sounds for “Everyday Conversation (<55dB)” and “Loud (>=55dB)”.  Different distances will impact the level a sound is heard by the child. For ease in the REDDI tool, the volume is measured from the speaker. You can hold a Sound Level Meter or place it near you, or use a Sound Level Meter app available for smart devices from the Play or App Store. 

  Results then need to be interpreted with caution, understanding that the level is at the speaker, not at which the child heard the sound.  

• Why has 55dB SPL been chosen as the level for everyday conversation? I thought conversational levels were 65dB SPL and loud was 75dB SPL?

  Although louder levels are often used to reflect conversational levels, 55 dB SPL (40 dB HL) has been chosen to represent conversational levels of speech from 2 metres as per the American Academy of Audiology Clinical Practice Guidelines: Remote Microphone Hearing Assistance Technologies for Children and Youth from Birth to 21 Years (2011). In connected speech individual speech sounds can often be softer than when presented in isolation due to the effects of co-articulation, and as such we want to understand a child’s access to the sounds of speech at these softer levels.   

• Why are there only two levels of volume? What about a soft presentation level?

  Checking how a child responds to soft sounds is important so they can learn to listen to quieter words and conversations. The best way to monitor a child’s development of listening to soft sounds is on the Functional Listening Index – Paediatrics. In this tool there are a number of items throughout the scale that tracks the development of their skills in listening to soft speech, from sounds through to words and sentences.

  In line with the original Ling Six Sound test, as a quick functional check of access to sound, the REDDI tool has been developed with just the two levels: “Everyday Conversation (<55dB)” and “Loud (>=55dB)”. Changing the distance between where the child is and where the sounds are presented will naturally impact the volume at which the child hears the sound. So long as when you are using the tool you are always using the volume of the speaker, and the results are interpreted in this way, responses can be compared over time. If of clinical interest, you can also measure the sound at the child with a Sound Level Meter as well, and record this in the notes section of the REDDI. 

• Where do I measure the volume? At the speaker, or at the listener, or in between?

  The measurement is taken at the speaker. We know that an increase in distance will impact the volume the sound reaches the listener. This means when a speaker says a sound at 55dB, the child will be listening to the sound at a softer volume. The volume reduces as the distance increases.

  It is important to interpret the results knowing the child’s responses to a sound spoken at a certain level is the child’s response to the volume presented at the speaker. 

Listening condition

• What does "Everyday Listening Condition" mean?

  A child’s everyday listening condition refers to the typical listening condition they listen with throughout the day. If the sounds are presented without performing an action to isolate an ear (e.g. by removing a device), then select “Everyday Listening Condition”.

• How do I represent individual ear access to sound?

  If a hearing device is removed then either select left (right device off) or right (left device off).

  This logic makes sense in the context of a child with a unilateral hearing loss who is aided and the presenter wants to assess the ‘better ear’. For example, a child has a unilateral left hearing loss and wears a hearing device in the left ear. If you want to check the functioning of the better ear, then it is correct to say right (left device off). If you want to check access for the poorer ear, you may need to occlude the typical hearing ear or use streaming technology direct to the hearing device to determine the access to sound with this ear alone. 

  The intent of the left/right listening condition options is to record where an action has been taken to isolate an ear. Where further action is taken to manipulate the listening condition (e.g occluding a typically hearing ear or using streaming technology), there is not currently an option in the REDDI tool to detail this information under listening condition. You could make note of these details in the comments section in the REDDI tool. 

• I have conducted the REDDI check using device streaming directly to the child’s Cochlear Implant Processor. How do I record this in the REDDI?

  This is a great question and we are aware the current REDDI round set-up cannot accurately reflect when the Ling sounds are presented using direct streaming.

  The current advice for how to enter a response from a streamed device is:

  • Select the distance as 1m -1.9m. This will visually display as light green if the child detected or imitated the sounds with no additional visual or auditory cues.
  • Select the side the sound is being streamed, e.g Left (right device off) = CI streamed to the Left.
  • With a note written in the notes section: CI Streaming (Left)

  If you select a distance of 0.5 -0.9m (which is more reflective of the audiological condition), with no additional visual or auditory cues the visual display will be light orange which is not reflective of their correct detection or imitation responses.

  Longer-term we will consider other alternatives for entering and visually displaying a child’s response to the Ling sounds using direct device streaming to reflect this listening condition.

Detection

• Do I enter a round of detection if the child has also imitated the sound?

  You should enter the highest level of the child’s response in the REDDI.  If you change how you present the sound and the child gives different responses, these are entered as separate rounds.

• Do I have to enter all the sounds for every round in the REDDI?

  It is recommended to present all the sounds included in the REDDI when you are checking a child’s access to sound. On some occasions, you may only do some sounds. This may be as there are certain sounds you are particularly focusing on, or because all sounds couldn’t be completed on that day. You can then enter the sounds you presented, all sounds or just some.

  If you change the condition for a sound, you enter that as a new round. You don’t need to present all the sounds at that new condition, only the one you needed to change.

  For example, you present all sounds with no auditory cues (pitch/duration) and the child shows a detection response to all of the sounds but not ‘s’. You then present only ‘s’ again, with an added duration cue (‘ss-ss-ss’). Then the child correctly detects the sound. In this case, you would enter two rounds on the REDDI. The first, selecting ‘Detected’ for most of the sounds, and ‘Not Detected’ for ‘s’ with cues selected as ‘None’. The second round, select cues as ‘Auditory’ and select ‘s’ as ‘Detected’ leaving each of the other sounds empty. 

• The child is responding to the REDDI sounds by detection, and showing they know the sound by selecting an object that represents the sound and not yet imitating the sound. How do I represent this in the REDDI? Is there Identification?

  No, there is no “identification option”. To record this, you select ‘Detection’ as the response to the sound, and write a note ‘the child is able to identify the sound by selection of an object’. Similarly, some children learn to identify the sound by a gesture or pointing to a picture. You would write in the notes to inform others of how the child is responding to the REDDI sounds. When a child identifies the sound by imitation, you can start to select ‘Imitated correctly’ or ‘Imitated incorrectly’ as appropriate.

Ling 6 sounds presentation

• Do I need to present the sounds in order?

  No. It’s always good to use a different order to present the sounds. Children can be very clever, so they can start to guess the order if you present the sounds in the same order every time! You may want to start with a sound that you presented at the end of the last session to see if the child has a different response when they are more attentive at the beginning of the task.

• When do I know to add an auditory cue (pitch/duration)? Or decrease distance? Or increase volume? And in which order?

  If a child is unable to respond to a sound presented at everyday conversational volume with no additional cues added, changes will need to be made to determine the child’s level of access to sound. Consider adding the cue that changes the least amount of acoustic information first.

  If a child is beginning to listen, they may benefit from more cues. These cues are reduced as they become more familiar with the task and start to develop their listening skills. You may find you need to use visual cues when you are teaching the task, and then remove these to present the sounds through listening.

  If a child doesn’t detect a sound, or imitate it correctly, first try to repeat the sound, to give them another attempt at listening to it. If they still don’t respond, try reducing the distance. If they still aren’t detecting or imitating the sound correctly, try adding a pitch or duration cue (if you haven’t already). If there is still not a detection or correct imitation response, try increasing the volume. Finally, add a visual cue if the child needs it at this point.

  Here is a summary of the order to change your presentation of sounds:

  1.      Repeat the sound

  2.      Reduce the distance

  3.      Add an auditory cue (pitch or duration)

  4.      Add volume

  5.      Add a visual cue

• Does it matter where the presenter presents the sounds? Should we always present sounds from the front to utilise the directional microphone in the hearing technology? or Should we always present sounds from behind so the child can't see you?

  Most current hearing technology uses directional microphone technology, so presenting the sounds from the front of a child is ideal. When presenting the sounds with no visual cues, ensure the child is not using facial cues to respond to the sound. 

  When standing in front of the child, it is recommended you obscure your face with an object, such as your hand, a piece of paper or a book. The object should be slightly away from your face to ensure you don’t muffle the sound. If a child is able to close their eyes, or look at an object on the table to redirect their vision, this is also a good strategy to ensure the child is relying on listening alone to respond to the sound. 

  If you are going to present the sounds from behind the child, ensure the environment is as quiet as possible. This will maximise the chances the hearing technology will be in omnidirectional microphone mode, which means it’s picking up as much as possible from all around a person. 

• How do I record parent report of a child's responses to the Ling sounds in the REDDI tool?

  If a parent reports on their child’s responses to the Ling sounds at home, it’s important to note this in clinical records. You could use the notes section of the REDDI tool. A professional needs to observe the child’s responses in person or online to enter as separate responses to sounds in the REDDI tool.

Imitation

• When do you select imitation of a sound?

  Imitation is selected when a child repeats a sound after the presentation of sound. Select “imitate correctly” when a child imitates the same sound exactly as the adult presented it. If a child imitates the sound using a different vowel or consonant to the sound presented, select “imitate incorrectly” and the enter the imitated response in the pop-up box in the REDDI tool.  

• If a child vocalises, is this imitation?

  If a child vocalises as an attempt to imitate a sound presented, this would be considered an imitation. If the vocalisation is not the same sound as presented by the adult, select “imitate incorrectly” and the detail the imitated response in the pop-up box in the REDDI tool.   

• If a child has a consistent incorrect speech error, do I mark it as IMITATED CORRECTLY or IMITATED INCORRECTLY?  

  A sound production error is considered an incorrect imitation. Select ‘IMITATED INCORRECTLY’ button and in the pop-up section enter the produced sound. For example, if a child producing ‘b’ when imitating ‘m’, you would select ‘Imitated Incorrectly’ and write ‘b’ in the pop up box. Another example would be a lateral (I.e air coming out the side of the mouth and is ‘slushy’ sounding) ‘s’ and ‘sh’ production. Select ‘Imitated Incorrectly’ and in the pop-up boxes for ‘s’ and ‘sh’, transcribe the sound produced or write ‘lateral s’, ‘lateral ‘sh’. 

  The incorrect imitation of any speech sound could be listening based error due to access to sound issues, and it could be due to other phonological or articulation issues. Regardless of the reason for the error, it is marked as incorrect. Both incorrect and correct imitations of speech sounds can provide information about what the child’s access to the sounds around them.   

  To determine if a child is able to listen to the difference between 2 sounds, you can introduce listening discrimination tasks, i.e is a child able to identify by listening to the difference between 2 sounds. This can be noted in the ‘Notes’ section of the REDDI and will support how to remediate the child’s speech sound errors. If the errors are with ‘s’ and ‘sh’ production, there is a specific item on the FLI-P to acknowledge if a child is able to listen to the difference between ‘s’ and ‘sh’ as these are typically later developing speech sounds than imitation of the other Ling sounds that are documented in the REDDI. 

• Is an interdental ‘s’ a correct imitation or incorrect imitation?

  A sound production error, such as an interdental ‘s’ where the sound is produced with the child’s tongue between their teeth is considered an incorrect imitation. Select ‘imitate incorrectly’ button and in the pop-up section enter ‘interdental s’. 

Other

• Why is the Identification level (e.g. through pointing) not included?

  The REDDI tool provides a platform for clinical monitoring of detection and imitation of sounds heard. Imitation of a sound heard provides optimal information regarding access to sound, so working towards this level is clinically significant. Understanding what a child can identify through listening alone is helpful for monitoring clinical progress, particularly when a child is not at a stage or not able to imitate a sound heard. In instances such as these, this listening task would be checked on the FLI-P tool or other clinical tools to monitor listening development.  

• What about monitoring access to sound in background noise?

  Monitoring access to sound in the presence of background noise provides clinical information on how a client might manage with listening tasks in varying everyday environments, such as learning from a spoken piece of information in a noisy classroom. If a clinician is wanting to explore listening abilities in background noise, the FLI-P tool will support this.

• What about monitoring access to sound in background noise?

  Monitoring access to sound in the presence of background noise provides clinical information on how a client might manage with listening tasks in varying everyday environments, such as learning from a spoken piece of information in a noisy classroom. If a clinician is wanting to explore listening abilities in background noise, the FLI-P tool will support this.

• Can I edit or delete REDDI data after I have submitted the entry?

  HearHub are working on a solution for you to do this yourself. In the meantime, please contact [email protected] with the details of the client ID/name and date of entry to adjust and our team will make the changes for you. 

Telehealth

• I am seeing my clients using Telehealth, what distance and volume should I select?

  Consider what you are wanting to check with the child’s access to the Ling sounds before conducting the REDDI check in the session.

  • If you are wanting to check the child’s responses to live voice and their everyday listening, the presenter of the sounds will be in the same room as the child. Typically, this would be the parent, older sibling or educator presenting the sounds in a session. Guide the presenter of the sounds about the distance the child typically responds to the sounds – this could be any of the distance measures, including 8m or more. Guide the presenter to be aware of their volume of presentation of the sounds. Encourage the presenter to download and use a Sound Level Metre (SLM) application (app) on their smart device to coach the presenter about the different volume of different sounds from the speaker’s mouth. When a family is aware of their volume of presentation, they do not need to use a SLM app each time they present as long as they are able to determine if their presentation is Everyday conversation (<55dBSPL) or Loud (>55dBSPL).
  • If you are wanting to check the child’s responses using a digital signal across videoconference, the presenter of the Ling sounds will present the sounds across the screen. You will be checking the child’s access to sounds for your session over videoconference, but not their access to sounds in their everyday environment. This typically occurs if there are a hearing professional and school-age child working together in an Online Telehealth session without another adult in the same location as the child. In this case, the speaker presents the Ling sounds across the screen, you will not be able to control the volume at the listeners’ end. This situation is ok when you are wanting to know if the child can access all of the sounds for the day of the session. In this case where the presenter says the sounds over the screen, ensure the child is not looking at the screen or your face is covered when presenting the sounds. Select the distance as 1m -1.5m and the volume as ‘Everyday conversation (<55dBSPL)’ if the speaker is not raising their voice. Write a note that Ling sounds were presented over videoconference.
  •  

• How do I interpret the REDDI visualisation graph?

  The visualisation of the REDDI is designed to support a quick glance of a child’s access to the Ling Six sounds. There are eight colours in the traffic light system, from dark red to very bright green, to represent various levels of responses. 

  

  Green: Indicates a child is able to respond to the specific speech sound through listening alone. The darker the green the better access to a specific sound. Very bright green indicates access to the sound from 8m and beyond. 

  Yellow: Indicates a response from under 1m or auditory cues were needed. The darker the orange, the poorer access to that specific sound.  

  Red: Either no response, required visual cues, or increased volume to respond to that sound. 

  The asterisk symbol (*) indicates a detection or no detection response.  

  Any box without an asterisk symbol (*) indicates an imitation or incorrect imitation response to the sound.  

  

• Is the visualisation tracking sensitive to the age of a child?

  The visualisations have been built to show the progression of a child’s responses to sounds in detection and imitation regardless of their age. There are many factors that impact a child’s responses to sounds, so the visualisations have not been built to be sensitive to age.

• How do I explain the REDDI results to a caregiver?

  The information recorded in the REDDI can help to demonstrate the stages and progress of a child’s responses to sounds over time. The visualisation will provide an overview of the child’s progress over time. The visualisation graph can be used to explain the patterns observed in the child’s responses to speech sounds that represent the child’s access to sounds in the speech range.

• Will the visualisation be difficult for people with colour blindness to use?

  It may. We considered this in the build and trialled a number of patterns to assist. As the patterns made the visualisations difficult to read, the use of colour was implemented for REDDI visualisation. We will continue to explore the options that might be able to identify each child’s stage in the visualisation that doesn’t rely on colour.

• My client has good access to sound, but the colour on the graph shows orange and I think it should be green. How can I change it?

  The visual display of the traffic light system colours – green, orange, red – are determined by the responses to the round set-up in the REDDI. An orange or red display indicates the child requires additional visual or auditory cues, loud conversational volume, or a close distance. By adding any of these cues, it is indicating the child requires prompts to listen to the sounds around them.  If you believe the child has good access to sound, it is encouraged to remove additional cues, increase the distance the Ling sound are presented or decrease the volume to present the sounds at an everyday conversational volume of <55dBSPL. If the child responds to the new REDDI round set-up, the visual display will now be green.

References

1. Agung, K. B., et al. (2005). "The Ling sound test revisited." Australian and New Zealand Journal of Audiology, The 27(1): 33.

2. Cole, E. B. and C. Flexer (2015). Children with hearing loss: Developing listening and talking, birth to six, Plural Publishing.

3. Erber, N. P. (1982). Auditory Training, Alexander Graham Bell Association for the Deaf.

4. Katz, J., et al. (1978). Handbook of clinical audiology, Williams & Wilkins Baltimore.

5. Ling, D. (1976). Speech and the hearing-impaired child: Theory and practice, Alexander Graham Bell Association for the Deaf Washington, DC.

6. Ling, D. (1989). Foundations of spoken language for hearing-impaired children, Alexander Graham Bell Association for the Deaf Washington, DC.

7. Romanik, S. (1990). "Auditory skills program: For students with hearing impairment." Special Education and Focus Programs Division. NSW Department of School Education, Australia.

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