Fix the Signal, See the Change

Introduction: Why Current Measures Miss the Point

In audiology, we like numbers. The audiogram shows the softest beeps a person can detect in a quiet booth. The Speech Intelligibility Index (SII) gives a number for how much of the speech spectrum is accessible, also in quiet. Real-ear measurement tells us how much sound reaches the eardrum, but not to the brain.

These are valuable tools. But they all stop at the cochlea or eardrum. None tell you what happens once sound enters the brain for auditory processing, and none guarantee comprehension. A perfect audiogram, a high SII score, and a textbook real-ear measurement can still belong to the same child who struggles to function in noise every day.

The Limits of “Objective” Testing

Even our most advanced physiological tools have ceilings. Auditory brainstem response (ABR) shows activation only up to the brainstem. The P300 oddball test shows cortical activation, but still only that. Functional MRI (fMRI) and PET scans can light up when a sound is heard, but they cannot prove comprehension.

The only way to know that a child understands is through behavior or communication. When a child does not yet have enough language to give that response, we must observe their functional hearing in real-world settings.

Real-Ear Measurement: Clarity at the Eardrum, Not the Brain

Real-ear measurement can use a speech-spectrum stimulus, which is better than a pure tone, but it still stops at the eardrum. It says nothing about what is processed or understood.

This is further complicated by children with fluctuating conductive loss, such as from middle ear fluid. In conditions like Ehlers-Danlos Syndrome, hearing can vary daily due to collagen-related changes in eustachian tube function and eardrum flaccidity or scarring due to PE tubes/grommets. This means that a "good" real-ear result today might not hold tomorrow.

Auditory Processing Testing: A Flawed Safety Net

Auditory processing testing is supposed to bridge the gap, but it has serious issues. Research has found that APD prevalence ranged from 7 percent to 96 percent depending on the test battery. Studies have shown that many APD protocols fail to separate auditory issues from language, attention, or memory problems.

A prominent speech pathologist and blogger has argued that many APD diagnoses are given without follow-through. After I posted one of my earlier articles in a telepractice SLP group, she commented publicly that fitting low-gain hearing aids to children with normal hearing was “not ethical.” I think we were coming from very different perspectives on the issue, to the point that I decided it would be worth discussing with her at a later time.

I do agree with her that there are issues with the APD diagnosis process, in that very often children are identified and then never receive treatment. However, that is not because of the diagnosis itself. It is because of the structures and systems surrounding how we handle children after they receive that diagnosis. My disagreement is with the idea that we should wait until these children have entrenched language, literacy, and emotional problems before providing earlier access to a clean signal.

No Prescriptive Target for These Kids

For neurodivergent children and those with processing vulnerabilities, the average classroom’s +5 to -5 dB signal-to-noise ratio is nowhere near enough. Many require +15 to +20 dB to thrive. Yet there is no prescriptive fitting target for children with normal thresholds who need this.

Our current formulas, like NAL2, are built for hearing loss. Without a valid target, audiologists either fake a loss to force a formula or guess, risking under-amplification or over-amplification.

Unsafe Workarounds: OTC Devices and FM Systems

This gap pushes parents toward over-the-counter (OTC) amplifiers or basic FM systems. Even when OTC devices use receiver-in-the-canal technology, the quality of the receivers tends to be lower than those used in prescription devices. In addition, the gain is calibrated for adult mild-to-moderate loss, meaning they are unsafe for normal-hearing children, both due to children's often smaller ear canal size as well as their normal auditory thresholds. They lack fine-tuning, integration with remote mics, and child-specific safety controls.

Standalone FM systems like the Phonak Roger Focus (and Focus II) or speaker systems such as the Redcat or Phonak DigiFocus also have their own problems. Standalone ear-level FM systems limit the child to hearing only the mic wearer, cutting off access to peer voices and killing opportunities for self-advocacy. They strip spatial cues and can cause limbic threat responses by forcing uncontrollable, sometimes painfully loud sound directly into the ears, whether it is the teacher addressing them or talking in the bathroom. Speaker systems often result in reverberation, that is, echo with areas of the room getting uneven amounts of amplification, which can result in too little or two much sound intensity for comfort and clarity.

Forbrain: A Better, Yet Still Imperfect Entry-Level Amplification Option

Some families try Forbrain. It is far cheaper than a high-end FM system, $270 to $300 compared to $2,500 to $3,500 for a Phonak Roger package. The bone conduction feature can bypass middle ear issues and increase awareness of the child’s own speech. The headband is not designed to be used without the parent microphone for hearing anyone but one's own voice. Furthermore, the fit is clumsy, outside of the confines of a still classroom. It certainly has some positive feature, and may be a reasonable entry-level tool, but it cannot be adjusted for individual needs. Therefore, it cannot match the flexibility or quality of a well-fit hearing aid system in combination with a customized remote microphone (RMHA) or FM microphone.

Case Studies: What Happens When You Fix the Signal?

Case 1: The Three-Year-Old with Ehlers-Danlos

She could not count, label pictures, or answer questions without delay. Her OT mother had been told to “wait and see.” An OTC amplifier caused a language explosion but risked permanent damage, so they came to me. With low-gain prescription hearing aids, in two weeks she could copy any sound, count to five independently, count to ten with support, identify objects, answer questions without delay, and navigate stairs without falling.

Case 2: The Engineer in India

A highly educated father used an amplifier on his 8-year-old child with reading and listening difficulties before moving to the U.S., knowing it was risky, but unwilling to miss their critical language window.

Case 3: Misprogrammed in Australia

A child’s hearing aids were programmed to suppress mid and high frequencies while blasting lows. The child then failed to make progress for six months. After I trained the audiologist, her outcomes improved dramatically.

The Ethical Challenge

Audiologists must stop hiding behind fake targets and insufficient real-ear justification. Speech pathologists must stop the “wait-and-see” delay. Physicians must acknowledge that while tubes and antibiotics can help, they also carry risks like tympanic scarring and gut biome disruption. We need to work with occupational therapists and other allied professionals to measure benefits beyond the audiogram—benefits like coordination, balance, fatigue reduction, and mood improvement.

If you fix the signal at the source, every other therapy has a better chance of working. Wait until the problem is obvious, and you may never fully repair it.

Collaboration: Stop the Turf Wars

We need to stop these interdisciplinary refusals to collaborate. It is for the children, and it is for us. We were once children too.

“Where should we start? At the signal or speech? Do we drill them in language or help them reach?”

“What's wrong with a good minimal pair?"

"What’s wrong is they can’t tell it’s even there.”

Listen to “Phoneme Dream Team” by Dr. Rae Stout: