Introduction Adaptive behaviour has become increasingly important in the assessment of intellectual disabilities (ID), but is also useful in terms of developing individual behavioural goals. Although measures of adaptive behaviour are widely used, there is little agreement on how to conceptualise the construct and how this may vary cross-culturally. Researchers have previously noted methodological and validity difficulties with the assessment of ID. This research aimed to clarify the construct of adaptive behaviour and consider how to measure this with d/Deaf adults with suspected ID. Methods A systematic literature review, identification of critique of current measures, and gaps within the literature formed the structure of a new item pool. An expert panel (N = 13) were consulted about the usefulness and relevance of these items through a Delphi consensus methodology. Based on the feedback obtained throughout the research process, the design was modified from pursuing a statistics-driven approach to item refinement, to using mixed-methods to clarify issues of construct validity before the content could be further addressed. The second round of the Delphi comprised a feedback report, concluding with a working definition of adaptive behaviour. Participants were asked to comment upon the findings, and provide additional responses to develop a normal base standard of adaptability of a Deaf adult of average functioning. Results The first round of the Delphi consensus yielded wide variation in item ratings. A thematic analysis of the questionnaire comments identified two overarching themes related to the way in which adaptive behaviour was conceptualised: ‘structure’ and ‘content’. The theme of structure contained sub-themes of ‘assessment’, ‘language’, and ‘repetition’ which are arguably common to all psychometric development. The ‘content’ factors pertained to ‘accessibility’, ‘developmental factors’, and ‘cultural differences’, highlighting differences in the expression of adaptive behaviour based on the unique experiences of d/Deaf people. The second round of the Delphi procedure elicited feedback on a working definition of adaptive behaviour generated from the analysis, showing that the adaptive behaviour of d/Deaf people may be conceptualised differently, particularly in hearing contexts where there are differential communication demands. These research findings have been summarised to form initial guidelines for the assessment of adaptive behaviour in Deaf people. Discussion This research provided some insight into how adaptive behaviour may be measured with Deaf people. Limitations of this research included not being able to generate consensus through the Delphi methodology used and, due to the newly developed understanding of adaptability for this population advanced throughout the research process, it was not possible to subject the items from the proposed scale to further psychometric testing. However, recommendations for further research were made in terms of expanding and validating this preliminary work with a sample of Deaf adults.

Internet-based self-management interventions have the potential to reduce the current disparity in access to psychological support for people with tinnitus. One example is the Tinnitus E-Programme, which was developed in the United Kingdom to support self-management in people with tinnitus. Although freely available online, there was little understanding of how the intervention is used, its active ingredients, how it works, the circumstances in which it works best, and whom it works best for. This PhD aimed to address these issues by evaluating and optimising the Tinnitus E-Programme. A systematic review of self-help interventions for tinnitus was conducted, which concluded that there was a need for further evaluations of unguided self-help interventions in UK populations. A mixed methods study explored past, current, and new users’ (n=40) views and usage of the Tinnitus E-Programme (1.0), demonstrating that it was acceptable to people with tinnitus. However, its implementation was limited by instances of poor usability, user engagement, and adherence to behavioural goals. Consistent with a person-based approach, the findings from this mixed methods study were used alongside evidence-based (i.e. systematic and literature reviews) and theory-based (i.e. behavioural analysis and logic modelling) approaches to develop the Tinnitus E-Programme 2.0. Think aloud interviews with 19 people with tinnitus evaluated this new version of the intervention and findings revealed that the Tinnitus E-Programme 2.0 was acceptable to its target users. The two primary research studies highlighted how users’ pre-existing beliefs regarding tinnitus and self-management, their perceptions of relevance, and the nature of tinnitus can influence users’ engagement with the Tinnitus E-Programme 1.0 and 2.0. Several cognitive factors (e.g. illness beliefs), behavioural factors (e.g. practicing relaxation), and behavioural determinants (e.g. motivation to practice relaxation) were identified by users to explain how changes in intervention outcomes may occur. Further development and implementation work is needed that introduces and evaluates additional intervention content and design features, and explores how the intervention can fit into current clinical service models for tinnitus. Future evaluation work should test the hypothesised mechanisms of impact and contextual factors proposed in this work, and assess the acceptability and feasibility of procedures for subsequent randomised controlled trials that will assess the efficacy of the intervention.

Psychological treatment is effective at alleviating tinnitus distress when delivered by a psychologist. In the United Kingdom (UK), best practice guidance for tinnitus advises that audiologists should deliver Cognitive Behavioural Therapy (CBT) and other counselling techniques where psychologists are unavailable. However, there is a lack of evidence for the effectiveness of audiologist-delivered psychological tinnitus treatment, and no consensus among clinicians and researchers on what form, if any, this should take. Furthermore, training in CBT and other counselling techniques is not a part of standard audiologist training in the UK. The aims of this PhD were to define the components and measure the effects of an audiologist-delivered psychological tinnitus treatment for people with tinnitus. Potential treatment components to include were identified in two studies. The first study was a comprehensive scoping review in which components were extracted from 64 records on psychological tinnitus treatment delivered by psychologists. The components were predominantly extracted from studies of CBT. The second study was a Delphi survey of a panel of 39 patients and clinicians who were asked to rate the importance of 160 different treatment components for an audiologist-delivered psychological tinnitus treatment. These data were used to inform the development of a treatment manual, underpinned by a cognitive behavioural model of tinnitus distress. The manual comprised tinnitus education, psychoeducation, relaxation, graded exposure, thought challenging, physical exercise, sleep hygiene, an introduction to acceptance and defusion techniques, and sound enrichment, which could be implemented flexibly according to patient need. To measure the effects of the psychological tinnitus treatment, appropriate outcome domains and instruments were identified by applying template analysis to the treatment manual. Potential domains were selected from a list constructed by grounded theory using existing questionnaires. Outcome instruments were identified if they were responsive to therapeutic change and possessed good content validity and internal consistency. It was predicted that the treatment would affect tinnitus-specific emotional impact and negative thoughts. Based on current evidence, the Tinnitus Functional Index (TFI) and the Tinnitus Cognitions Questionnaire (TCQ) were identified to best measure these domains. A feasibility randomised controlled trial (RCT) was conducted over six months to determine the feasibility of a definitive RCT of audiologist-delivered psychological tinnitus treatment. Nineteen patients were recruited to the trial. Attrition rates were high, though all patient withdrawals occurred before their first appointment. The trial indicted that a definitive RCT of audiologist-delivered psychological tinnitus treatment is not feasible due to poor site compliance with returning questionnaires, and low recruitment rates in smaller trial sites. Patients and audiologists were invited to attend post-treatment semi-structured interviews to explore treatment fidelity and experience. Patients reported that the treatment was acceptable and effective in reassuring them about their tinnitus. Audiologists reported focusing on psychoeducation with limited use of specific techniques such as thought challenging and graded exposure. Patients and audiologists thought that the TFI and TCQ comprehensively measure the important tinnitus domains and are useful for planning treatment and encouraging discussion about patients’ negative thoughts. A lack of confidence due to the brevity of training was given by audiologists as a reason they avoided implementing certain treatment components.

Gap-induced pre-pulse inhibition of the acoustic startle (GPIAS) is a behavioural test for tinnitus in animals. It relies on a short gap in a continuous background noise which provides a cue to the loud startling stimulus which follows. As a result, gap conditions demonstrate an inhibition of the response to the startling stimulus compared to no-gap conditions. The disrupting effect of tinnitus on the normal GPIAS has been shown in a number of species, including in humans. Such disruption was originally thought to be caused by tinnitus ‘filling in’ the gap, but recent studies have challenged this explanation. Preliminary work in humans measuring the eye blink reflex showed gap detection deficits in tinnitus subjects, but the underlying mechanisms of this effect are unclear. The eye blink response has a relatively long latency (>40ms) and therefore is not a simple primary reflex, nor is it specifically related to the auditory system. In small rodents the acoustic startle is measured by the whole body response involving axial muscles but in larger animals like the guinea pig this response habituates very quickly. Thus here a variation of the GPIAS method is used in which the acoustic startle is measured in guinea pigs using the simple pinna reflex. This reflex has been used to provide evidence of tinnitus in guinea pigs and postulated that it might be possible to use a similar method to obtain objective evidence of tinnitus in humans. The post-auricular muscle reflex (PAMR) is the human analogue of the pinna reflex and may represent a metric for an objective tinnitus test. The PAMR is a short-latency (15-18ms) response that involves only two or three synapses in the brainstem and provides a much tighter link between auditory input and motor output than the eye blink reflex. However, gap-induced pre-pulse inhibition (PPI) of the PAMR has not previously been demonstrated. This question is one of the main objectives examined in this thesis, using measures taken in guinea pigs and in humans, with and without tinnitus. The work reports two feasibility experiments and two-hypothesis testing studies in which I have sought to optimise the stimulus parameters for maximising the magnitude of the PAMR, and reflects on the challenges of working at the first translational gap developing adequate animal models of human hearing-related problems.

Hearing loss is a prevalent condition that can have negative implications on the day-to-day lives of those with hearing loss, and their communication partners. Several reviews have identified numerous questionnaires that explore the impact of hearing loss, with little consensus among researchers as to their preference. One reason for this is a lack of an agreed framework concerning exactly what is the impact of hearing loss, and what is important to those who live with the condition. To address this gap in understanding, the experiences of those living with hearing loss or with someone that has hearing loss was investigated using various systematic research methods and tools. A comprehensive review of published studies exploring the impact of hearing loss on those with hearing loss and/or their communication partner was conducted. An inductive (data-driven) synthesis of the research evidence led to the development of two frameworks; one for each perspective. Each framework comprised of three higher-level ‘supra-domains’ (i.e. Auditory, Social and Self) which capture the broader implications of hearing loss, and numerous lower-level ‘domains’ and ‘subdomains’ that tap into distinct aspects of life. The frameworks were evaluated for face-validity in focus groups with hearing aid users, communication partners and audiologists. Hearing aid users and communication partners were then asked to rank the domains in order of importance based on their experience of living with hearing loss. The domain ‘communicating’ was ranked most important from both perspectives. A subdomain mutual to both frameworks, ‘raising the volume of the television/radio’ was explored further in a case-control study. The preferred TV volume across 42 couples where one partner was a hearing aid user and the other was a non-hearing aid user was measured. A mean difference in volume preference of 6.3dB was observed between groups across the TV programmes viewed by all participants. The hearing aid prescription of hearing aid users was not verified. Future research should explore how domains in the frameworks are currently being measured and addressed in clinic. Also, data-driven methods should be applied to identify coping mechanisms adopted by people with hearing loss and their partner to accommodate for the diverse range of hearing-related difficulties depicted in the frameworks.

The aims of this research were to identify and compare auditory processing, speech intelligibility, cognitive, listening, language and communication abilities in (i) typically developing, mainstream school (MS) children (n = 122) for direct comparison with (ii) children presenting to clinical services with auditory processing disorder (APD) (n = 19) or specific language impairment (SLI) (n = 22), and in (iii) a large population sample (n = 1469) who were categorised by their functional listening and communication abilities according to parental report rather than clinical diagnosis. All had normal hearing sensitivity. The clinically referred APD and SLI groups shared many behavioural characteristics across the broad range of measures. Both clinical groups significantly underperformed compared to the MS children, and the APD and SLI groups were virtually indistinguishable. This suggests diagnosis was based more on the referral route than on the actual differences. There was little association of auditory processing deficits with listening or language problems in either the clinical or the population sample after accounting for nonverbal IQ. The only exceptions were backward masking and frequency discrimination, the AP tests with the highest cognitive load. Poor general cognitive abilities were evident in those children with listening or language problems. These results suggest that top-down processing influences listening and language more than bottom-up sensory processing. It is argued that the term APD is a misnomer and should be renamed listening impairment. The co-occurrence of APD, or listening impairment, with both language impairment and autistic behaviours in the clinical and population samples suggests that APD is not a discrete and categorical disorder. Instead, APD as it is currently conceptualised, is dimensional, positioned more towards the language than the autistic extreme. Children with listening impairment who attend Audiology or ENT clinics should be screened for functional everyday measures of language and autistic behaviours to ensure appropriate onward referrals.

Introduction: This work explored the concept of ‘empowerment’ in health care. A concept map of ‘empowerment’ was generated based on theories of linguistic analysis to locate aspects of empowerment in conversational data. The process of empowerment was understood within the theory of transformative learning as ‘perspective change’. A ten phase model of the transformative learning process was used to provide evidence of perspective transformation. The empowerment process was explored through the delivery of the intervention Video Interaction Guidance to 16 hearing families of pre-lingual deaf children. Methods: The parents of the deaf children and the intervention guide engaged in conversations reviewing video clips of the parent and child in interaction. These conversations were processed through a corpus analysis software programme to discern key extracts of the participants’ conversational data. These extracts were to subject to discourse analysis to find evidence of transformative learning. Analysis: Transformative learning was observed in 10 families. Transcript extracts representing the model of transformative learning were variable. Principles of conversation analysis were applied to explore the learning process in interaction. Participant speech was tagged to assess their level of engagement. Outcomes: The corpus analysis-driven tagging process offers an original approach to representing the key content of large sets of interview data but in this work, was limited in showing how the interaction created opportunities for learning. Transformative learning processes were variable and the ten phase model could not be characterised in terms of discourse features alone. The intervention encouraged critical reflection but warrants directed focus to achieve learning. The participants were effective in acting as co-collaborators in the intervention process. Discussion and concluding remarks: Models of empowerment must focus on the process, of the ways in which the guide and the participant create learning opportunities and evidence of this must be multimodal. Patient-centred interventions should be supported by an open, communicative relationship with the health service provider.

Otitis Media with Effusion (OME) is a common childhood condition leading to hearing loss, and its treatment with ventilation tubes (VTs) is one of the commonest surgical procedures. However, aetiology of OME is poorly understood, and its current treatment requires improvement as OME frequently recurs once VTs extrude. The first, clinical part of this thesis showed that 63.6% of children randomised to VT insertion in a clinical trial will require VTs again, and even with additional adenoidectomy the need for repeat surgery remains high. Although published national guidelines set out criteria for surgery, the multicentre study presented here showed that only 32.2% of children that had VTs met these criteria, and guidelines' publication had limited impact on clinical practice. The second, laboratory part of this thesis demonstrated the importance that bacteria and biofilms play in aetiology of OME, as live bacteria were demonstrated in 91.9% of middle ear effusions (using culture and confocal microscopy). Following from this, a Staphylococcus aureus biofilm model was developed, and used to show that biofilm eradication requires antibiotic (rifampicin and lindamycin) levels 1,000 times higher than those required to inhibit planktonic bacteria, over a period of 2-3 weeks. To achieve this in the middle ear, a local delivery strategy using biodegradable poly (Iactic-coglycolic acid) antibiotic pellets was proposed. Drug release from these pellets was investigated with High Performance Liquid Chromatography and Serial Plate Transfer Testing, which demonstrated that antibiotics can be released for up to 3 weeks. Importantly, the pellets were able to eradicate biofilms in the in vitro model. This thesis has shown that current OME treatment has significant deficiencies, but better understanding of OME pathogenesis raises the possibility of rational new therapeutic strategies. Biodegradable antibiotic pellets designed to eradicate OME biofilms may be a better future treatment that could improve the lives of countless children.

Spatial attention is an essential mechanism that helps us perceive our surroundings by bringing into consciousness environmental occurrences or objects that may be of importance. Studies of spatial attention have classically recorded behavioural responses to targets presented in a region of space where attention had previously been allocated to. Such investigations show a behavioural facilitation at the same location due to cueing, but less in known about the effects of shifts of attention when the cued location is not the location of interest. This thesis presents seven experiments aimed at investigating this by implementing and revising the attentional repulsion effect (ARE). The ARE is a perceptual localisation error when attention is diverted from the region of interest and it has been extensively studied in the visual domain, however, the rising number of ARE studies has created numerous research methodologies used to evoke the effect, which may have led to isolated reports. This thesis attempts to combine past methodologies with a new approach to quantify the effect, and will address some methodological differences evident in the literature, in order to optimise the stimulus paradigms and maximise the effect. The results show that a robust ARE can be elicited in the visual modality, but the same is not observed in the auditory modality. Furthermore, when using cues that are of different modality than the targets, the ARE is only observed in the visual target modality. Using visual cues and auditory targets will produce an attraction effect, in line with the ventriloquism theory. However, the implementation of interstimuli intervals up to 1.5 seconds would be enough to disrupt the ventriloquism illusion, but it did not alter the resulted attraction. Lastly, one question regarding the role of attention in sensory adaptation was addressed. I hypothesise that sensory adaptation could be further a contributor to the ARE given that most psychophysics paradigms of the ARE repeat the same stimuli thousands of times, uninterruptedly. The results are inconclusive mainly due to experimental design. All results are discussed in relation with theories of spatial and multimodal attention.

Hearing loss is a widespread condition that can substantially affect not only auditory functioning but also social functioning. Therefore, it is essential to demonstrate that auditory rehabilitation can improve social participation in individuals with hearing loss. However, currently, there is a lack of agreed-upon, gold-standard, hearing-specific outcome measures. Consequently, the primary aim of this research was to develop a high quality measure of hearing-related social participation restrictions for use in research and practice. To achieve this aim, four consecutive studies were carried out using best practice questionnaire design techniques. Study 1 generated content for the Social Participation Restrictions Questionnaire (SPaRQ) through semi-structured interviews with 25 adults with hearing loss and nine hearing healthcare professionals. Study 2 evaluated the content of the measure through a subject matter expert panel with 20 hearing healthcare professionals and cognitive interviews with 14 adults with hearing loss. Study 3 assessed the psychometric properties of the SPaRQ by applying Rasch analysis to data collected from 279 adults with hearing loss. Finally, Study 4 further assessed the psychometric properties of the SPaRQ by applying traditional psychometric analysis to data collected from a further 102 adults with hearing loss. This research led to the development of a 19-item questionnaire that measured two key elements: social behaviours (e.g. difficulties with social interactions) and social perceptions (e.g. feelings of isolation). There was strong evidence to support the measurement properties of SPaRQ, including construct validity, person separation reliability, and internal consistency. Furthermore, the response scale was statistically justified and respondent burden was minimal. Future research should examine additional measurement properties, such as responsiveness and cross-cultural validity. Also, the best practice techniques used in this research should be applied to other new and existing hearing-specific questionnaires to ensure that they meet the requisite standards for use in clinical trials and clinical practice.