This review aimed at presenting the benefits regarding the speech perception in noise shown by children who wear hearing aid devices and/or cochlear implants with the Frequency Modulation (FM) System at school.
A bibliographic survey was conducted in an electronic database with standardized search until the year 2012, and a manual search was performed by using specific keywords.
For the selection and evaluation of the scientific studies chosen in the search, criteria were established covering the following aspects: type of study, participants, adopted intervention, and evaluation of results.
The FM system was verified to improve speech perception and speech threshold in noise in all studies.
Regarding the performance as to type, the best results were obtained when children used the personal FM system, followed by the table and the sound field systems.
After extensive review of national and international literature, it was concluded that the studies indicate the need for further research concerning mainly the impact of the FM system on the school performance of children who have sensory devices coupled to the FM system. Findings in the literature with relation to the publications focused on speech perception in noise did not relate educational and auditory aspects.
Hearing Loss; Hearing Aids; Cochlear Implantation; Self-Help Devices; Noise; Child; Faculty; Learning
Esta revisão teve como objetivo apresentar os benefícios, em relação à percepção de fala no ruído, que crianças usuárias de aparelho de amplificação sonora individual e/ou implante coclear demonstram com o Sistema de Frequência Modulada (FM) na escola.
ESTRATÉGIA DE PESQUISA:
Foi realizado levantamento bibliográfico conduzido em base eletrônica de dados com busca padronizada até o ano de 2012 e busca manual, utilizando palavras-chave específicas.
CRITÉRIOS DE SELEÇÃO:
Para a seleção e avaliação dos estudos científicos levantados na busca, foram estabelecidos critérios contemplando os aspectos: tipo de estudo, participantes, intervenção adotada e avaliação dos resultados.
ANÁLISE DOS DADOS:
Foi possível verificar que o Sistema de FM melhora a percepção de fala e o limiar de fala no ruído, sendo esses resultados encontrados em todos os estudos.
Em relação ao desempenho quanto ao tipo, os melhores resultados foram obtidos quando as crianças utilizavam o Sistema de FM pessoal, seguido pelo de mesa e o campo livre.
Após a extensa revisão da literatura nacional e internacional, foi possível concluir que os estudos indicam a necessidade de pesquisas voltadas principalmente ao impacto do Sistema de FM no desempenho escolar de crianças usuárias de dispositivos sensoriais acoplados ao Sistema de FM. O que foi encontrado na literatura específica quanto às publicações voltadas à questão da percepção de fala no ruído não relacionaram os aspectos educacionais e auditivos.
Perda Auditiva; Auxiliares de Audição; Implante Coclear; Equipamentos de Autoajuda; Ruído; Criança; Docentes; Aprendizagem
Recent progress in the treatment of children with hearing impairment has enabled the access to the auditory perception of speech sounds for individuals with sensorineural hearing loss, thus providing valuable benefits for communication and quality of life of these people.
Such progress can mostly be seen in sensory devices applied to hearing impairment. Among them, hearing aid devices and cochlear implant (CI) stand out, as well as the Frequency Modulation (FM) systems.
With early diagnosis and the activation of the National Policy of Hearing Health
11 Brasil [Internet]. Portaria GM nº 2.073, de 28 de setembro de 2004.
Institui a Política Nacional de Atenção à Saúde Auditiva. Projeto de Lei do Senado nº
504, de 2003. [cited 2010 Jul 5]. Available from:
http://www.senado.gov.br/senadores/Senad... ), implemented in September 2004, many children with hearing impairment gained free access to sensory devices such as the hearing aids and the CI; so, they could go to school and use these devices, which favors the learning process in the school context( 22 Delgado-Pinheiro EMC, Antonio FL, Libardi AL, Seno MP. Programa de acompanhamento fonoaudiológico de professores de alunos deficientes auditivos que utilizam a comunicação oral. Distúrb Comum. 2009;21(1):67-77. ). Currently, we are living in a new historical moment, with the implementation of the program "Viver sem Limites"( 33 Brasil [Internet]. Plano Nacional dos Direitos da Pessoa com Deficiência "Viver sem Limite". Pauta Inclusiva nº 1. Dez./2011 [cited 2012 Nov 17]. Available from: http://www.pessoacomdeficiencia.gov.br/app/sites/default/files/arquivos/.pdf
http://www.pessoacomdeficiencia.gov.br/a... ), which is organized in four principles: access to education, social inclusion, health care, and accessibility of people with disabilities in a vulnerable situation, as well as to promote initiatives with the Union, state, and city. According to the National Policy on Special Education( 44 Brasil [Internet]. Política Nacional de Educação Especial. Livro 1/MEC/SEESP. Brasília: Secretaria de Educação Especial; 1994. ), the integration between education and school refers to the process of educating - teaching the child both with and without impairment, in the same group, part or full time at school.
When the child has a disability, it is important to ensure access to education. The FM
system is seen as an alternative among all support resources used by students with
hearing impairment, aiming at assisting the integration between education and school.
For some authors, the FM system is the most important and essential educational tool
that has ever been developed for people with hearing impairment; regardless of type
(personal, self-contained, and free-field), it is the most effective means that favors
signal-to-noise ratio, especially in an education environment(
55 Ross M. Room acoustics and speech perception. In: Ross M, editor. FM
auditory training systems: characteristics, selection and use. Timoniun: York Press.
1992. p. 21-44.
6 Ross M. FM Systems: a little history and some personal reflections. In: Fabry D, Johnson CD, editors. Acess: Achieving Clear Communication Employng Sound Solutions. In: 1st International FM Conference; 2004; Great Britain. Proceedings. Great Britain: Cambrian Printers; 2004;17-27. - 77 Blasca WQ, Ferrari DV, Jacob RTS. Dispositivos eletrônicos aplicados à surdez: conceitos básicos. In: Genaro KF, Lamonica DC, Bevilacqua MC, organizadores. O processo de comunicação: contribuição para a formação de professores na inclusão de indivíduos com necessidade educacionais especiais. São José dos Campos: Pulso; 2006. p. 197-213.8. Brasil. Conselho Nacional de Secretários de Saúde. Portaria nº 1.274, de 25 de junho de 2013. Brasília: Conselho Nacional de Secretários de Saúde; 2013. ).
The benefit regarding speech perception in the school environment of children with hearing impairment wearing sensory devices (hearing aid and CI) together with the FM system is important in school and in studies of the Audiology field.
The current hearing health reality in public services provides better conditions for the development of the auditory function and language among children who received an early diagnosis of hearing impairment; therefore, they have more access to specialized treatment. However, even if these children show good functional performance in terms of hearing and oral language, during their development and when attending school they are faced with many obstacles, such as noise in the classroom, distance between the teacher and the child (speaker-listener), and reverberation in the classroom. These adverse conditions are mostly owed to the large number of students in the same classroom and classrooms with little or no acoustic treatment; besides, teachers in general have little or no prior knowledge regarding hearing impairment. It is estimated that guidance on management and necessary conditions to value the use of sensory devices is also scarce.
These adverse conditions lead to difficulties acquiring academic content, and, in more severe cases, the educational performance is totally harmed.
In this sense, the FM system is an electronic device used for the accessibility of people with hearing impairment, especially in the educational setting. It enables children with hearing impairment who wear sensory devices to perceive the voice of the teacher in the classroom, regardless of distance and noise that is usually generated in classrooms. Therefore, it is considered to be an assistive instrument that is part of the treatment for hearing impairment. This resource is used in school, regardless of age; however, it is potentially addressed to children.
In Brazil, sensory devices (hearing aid and CI) are already made available by the
Unified Health System (SUS), and the use of the FM system was an important step toward
the academic accessibility of children with hearing impairment since it was included in
Recommendation n. 1,274, from June 25, 2013, in the table of Procedures, Medications,
Orthoses, Prostheses and Special Materials of SUS(
89 Oxford Centre for Evidence-Based Medicine [Internet]. Levels of
Evidence. 2009 [cited 2012 Aug 19]. Available from:
As the essential principle of a study based on evidence, the question of this study's investigation was: does the child with hearing impairment who wears sensory devices (hearing aid and CI) have benefits regarding speech perception in school environment when using the FM system in the classroom?
The search strategy used in the literature review was oriented by the combination of nine descriptors indexed in the Health Sciences Descriptors (DeCS), in Portuguese and in English; besides, keywords that are not considered to be health sciences descriptors were also used, however, they were used to help the bibliographic survey in the databases. All of the descriptors were used in groups with, at least, two keywords (Chart 1).
The scientific databases chosen for the study were the following: LILACS, MEDLINE, SciELO, Cochrane Library, PubMed, EMBASE, Institute for Scientific Information (ISI), and Science Direct. The manual search was also conducted, with the objective of finding bibliographic references when they were not present in the electronic bases.
This study considered publications produced from 2000 to 2012, and the last search was made in the electronic databases in October 2012.
The selection of articles followed the inclusion criteria based on the agreement of the limits of the topics and the objectives of this study. The adopted criteria were as follows:
participants: children wearing sensory devices (hearing aids and/or CI) who attended elementary school and high school;
intervention: studies were selected in case the intervention had been performed by standardized tests, aiming at assessing speech perception of the child wearing hearing aid devices and/or CI together with the FM system;
measured outcomes: according to categories of interest - results are expressed as percentage of hits in tests of perception and speech intelligibility, by the classification of scales related to the development of hearing skills and description of academic status;
period: published in the past 12 years (2000-2012);
language: studies in Portuguese, English, and Spanish; and
types of study: published in indexed journals with level of evidence 1A, 1B, 1C, 2A, 2B, 2C, 3A, 3B, and 4, according to the classification from the Oxford Centre for Evidence-Based Medicine ( 910 Davies MG, Yellon L, Purdy C. Speech-in-noise perception of children using cochlear implants and FM Systems. The Australian and New Zealand J Audiol. 2001;23(1):52-62. ) (Table 1).
Levels of scientific evidence according to the classification from the Oxford Centre for Evidence-Based Medicine
Studies were selected in three stages, and this process was oriented by the aforementioned criteria. First, three reviewers analyzed all of the studies identified by the combination of the descriptors in all of the proposed databases, by verifying the study title and selecting the ones that presented the predetermined eligibility criteria.
In that stage, it was possible to conduct a manual search of the articles that were not in the electronic databases (first stage). Afterwards, in the stage of text selection, abstracts were analyzed regarding the information available about the use of any assessment instrument on the speech perception of children enrolled in the elementary school and high school with the FM system. The full texts were analyzed when the title or the abstract left doubts (second stage). The main data from each selected paper were collected in detail in a standard file used for this study. Articles were fully read (third stage).
The descriptive analysis of the selected publications was performed according to the objectives of the review.
In total, 2,241 papers were identified in all of the electronic databases and in manual searches (Table 2). When these texts were preselected, based on the titles and the abstracts of all of the studies located in the electronic search, 2,233 were excluded; therefore, eight papers were fully read (Table 3).
Reasons to exclude the papers found in each analyzed database and number of papers selected for reading
Number of articles identified in the databases and in the manual search
In Figure 1, it is possible to see a summary of the survey conducted in the electronic databases and in the manual search.
Finally, eight papers met the inclusion criteria. From the articles included in the review, seven studies were classified as being cross-sectional, 2B level of evidence, and one was characterized as a systematic review, classified as level 2A, according to the Oxford Centre for Evidence-Based Medicine classification( 910 Davies MG, Yellon L, Purdy C. Speech-in-noise perception of children using cochlear implants and FM Systems. The Australian and New Zealand J Audiol. 2001;23(1):52-62. ) (Table 1).
The systematic review was described in Chart 2 as to the name of authors, title, name of the journal, year of publication, objective of the study, study method and participants, levels of scientific evidence in each study, results, and conclusion.
SUMMARY OF FINDINGS
On the basis of the analysis of the studies, it was possible to identify the reasons for the exclusion of articles; they were not fully analyzed for being repeated, or for presenting nonrelated themes, for not including the studied age group, for being in another language, among others. Out of the eight studies that were selected for the systematic review, three included only the population wearing CI: studies number 1, 2, and 6. Study number 1 investigated speech perception in noise among children wearing CI together with the FM system, and study number 2 investigated speech perception, noise, and reverberation with a single FM system (free field) in two situations that were acoustically different in the school environment (ideal and poor acoustics). In study number 6, through a systematic review and a meta-analysis, the authors verified if the three types of FM system provide better speech recognition in noise than the CI alone.
The analysis of the selected articles showed that study number 3 investigated speech perception, noise, and reverberation only among children wearing hearing aid devices, by using three types of technology (infrared, desktop FM, and personal FM).
Two other articles analyzed both users of hearing aid devices and CI. Study number 4 investigated speech perception among users of CI and/or hearing aid devices exposed in acoustically poor and ideal rooms, using three types of technology from the FM system (infrared, desktop FM, and personal FM). Study number 5 assessed the improvement in speech perception in noise provided by the three types of stimulation (bilateral, bimodal, and monaural) among users of hearing aid devices and/or CI together with the FM system. Studies number 7 and 8 only assessed children wearing hearing aid devices.
Regarding the evaluations performed in the studies in relation to speech perception in noise, it was possible to observe that six of them evaluated speech perception in noise (studies number 1, 3, 5, 6, 7, and 8) and two of them compared the speech perception in acoustically different environments: one that was acoustically poor and the other that was acoustically ideal (studies number 2 and 4).
From the articles that were fully analyzed, studies number 1, 5, 7, and 8 only assessed the performance with the personal FM system, and the other studies analyzed the following three types of FM: free field, desktop FM, and personal FM, comparing their results.
The analysis of the papers regarding the type and level of evidence of each of them showed that only study number 6 was considered to be a systematic review and a meta-analysis with 2A level of evidence, and the rest of the studies were considered to be cohort, with 2B level of evidence, according to the classification from the Oxford Centre for Evidence-Based Medicine (9) (Table 1).
It was possible to verify that the FM system improves speech perception and speech threshold in noise, and these results were found in all of the papers. Concerning the performance with relation to the type of FM system, the best results were obtained when children were wearing personal FM system, followed by desktop FM system and free field.
After a national and an international literature review, it was possible to conclude that studies indicate the need for analyses addressed to the impact of FM system on school performance of children who wear sensory devices together with the FM system because the findings in the eight papers analyzed in this study were addressed to the matter of speech perception in noise.
I thank all of the researchers participating in the study "Proposta de Formação de Profissionais da Área da Educação sobre Deficiência de Audição e uso do Sistema de FM em Âmbito Nacional" (Multicenter Study: Cooperation Report N. 15850/FNDE).
1Brasil [Internet]. Portaria GM nº 2.073, de 28 de setembro de 2004. Institui a Política Nacional de Atenção à Saúde Auditiva. Projeto de Lei do Senado nº 504, de 2003. [cited 2010 Jul 5]. Available from: http://www.senado.gov.br/senadores/Senador/PauloPaim/pages/projetos/Projetos/PLS/PLS%20Nº%20504%20de%202003%20%20teste%20da%20orelinha.PDF http://dtr2001.saude.gov.br/sas/PORTARIAS/Port2004/GM/GM-2073.htm
» http://www.senado.gov.br/senadores/Senador/PauloPaim/pages/projetos/Projetos/PLS/PLS%20Nº%20504%20de%202003%20%20teste%20da%20orelinha.PDF» http://dtr2001.saude.gov.br/sas/PORTARIAS/Port2004/GM/GM-2073.htm
2Delgado-Pinheiro EMC, Antonio FL, Libardi AL, Seno MP. Programa de acompanhamento fonoaudiológico de professores de alunos deficientes auditivos que utilizam a comunicação oral. Distúrb Comum. 2009;21(1):67-77.
3Brasil [Internet]. Plano Nacional dos Direitos da Pessoa com Deficiência "Viver sem Limite". Pauta Inclusiva nº 1. Dez./2011 [cited 2012 Nov 17]. Available from: http://www.pessoacomdeficiencia.gov.br/app/sites/default/files/arquivos/.pdf
4Brasil [Internet]. Política Nacional de Educação Especial. Livro 1/MEC/SEESP. Brasília: Secretaria de Educação Especial; 1994.
5Ross M. Room acoustics and speech perception. In: Ross M, editor. FM auditory training systems: characteristics, selection and use. Timoniun: York Press. 1992. p. 21-44.
6Ross M. FM Systems: a little history and some personal reflections. In: Fabry D, Johnson CD, editors. Acess: Achieving Clear Communication Employng Sound Solutions. In: 1st International FM Conference; 2004; Great Britain. Proceedings. Great Britain: Cambrian Printers; 2004;17-27.
7Blasca WQ, Ferrari DV, Jacob RTS. Dispositivos eletrônicos aplicados à surdez: conceitos básicos. In: Genaro KF, Lamonica DC, Bevilacqua MC, organizadores. O processo de comunicação: contribuição para a formação de professores na inclusão de indivíduos com necessidade educacionais especiais. São José dos Campos: Pulso; 2006. p. 197-213.8. Brasil. Conselho Nacional de Secretários de Saúde. Portaria nº 1.274, de 25 de junho de 2013. Brasília: Conselho Nacional de Secretários de Saúde; 2013.
9Oxford Centre for Evidence-Based Medicine [Internet]. Levels of Evidence. 2009 [cited 2012 Aug 19]. Available from: http://www.cebm.net/ocebm-levels-of-evidence/
10Davies MG, Yellon L, Purdy C. Speech-in-noise perception of children using cochlear implants and FM Systems. The Australian and New Zealand J Audiol. 2001;23(1):52-62.
11Iglehart F. Speech perception by students with cochlear implants using sound-field systems in classrooms. Am J Audiol. 2004;13:62-72.
12Anderson KL, Goldstein H. Speech perception benefits of FM and infrared devices to children with hearing aids in a typical classroom. Lang Speech Hear Serv Sch. 2004;35:169-84.
13Anderson KL, Goldstein H, Colodzin L, Iglehart F. Benefit of S/N enhancing devices to speech perception of children listening in a typical classroom with hearing aids or a cochlear implant. J Educ Audiol. 2005;12:16-30.
14Schafer EC, Thibodeau LM. Speech recognition in noise in children with cochlear implants while listening in bilateral, bimodal, and FM-System arrangements. Am J Audiol. 2006;15:114-26.
15Schafer EC, Kleineck MP. Improvements in speech recognition using cochlear implants and three types of FM Systems: a meta-analytic approach. J Educ Audiol. 2009;15:4-14.
16Jacob RT, Molina SV, Amorim RB, Bevilacqua MC, Lauris JR, Moret ALM. FM Listening Evaluation for Children: adaptação para a Língua Portuguesa. Rev Bras Ed Esp. 2009;16(3):359-74.
17Jacob RTS, Bevilacqua MC, Molina SV, Queiroz M, Hoshii L A, Lauris JRP, et al. Sistema de frequência modulada em crianças com deficiência auditiva: avaliação de resultados. Rev Soc Bras Fonoaudiol. 2012;17(4):417-21.
Study carried out at the Speech Language and Audiology Department, Dental School of Bauru, Universidade de São Paulo - USP - Bauru (SP), Brazil.
ALLB and RTSJ were in charge of the project, search and analysis of the studies included in the review, and the elaboration of the article; RTSJ, ACP, MM, MANM, MCB, SAB, and ALMM were responsible for the general orientation of the stages of execution and elaboration of the manuscript.
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