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The child’s cognitive status and motor abilities, which are
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
•
critical for selecting the appropriate behavioral test protocol
(BOA, VRA, or CPA)
The child’s speech, language, and developmental levels, which
•
are important in selecting test materials for speech perception
testing
During the audiologic evaluation, the audiologist determines
whether the initial impressions were accurate or not. It may be
helpful to try to estimate the audiogram from history information,
from observation of the child, and from listening to the child’s
utterances, before beginning the test. Doing so over a period of
time will improve the audiologist’s ability to take a history and
make accurate observations of a child’s auditory status.
6.5 Functional Auditory
Assessments
An important part of a basic test battery for an infant or child
of any age is an evaluation of auditory function. Numerous tests
and surveys have been developed for this purpose. Functional
auditory assessments are typically accomplished by having the
teacher, student, or parent complete a questionnaire before and
after the use of a hearing aid, cochlear implant, personal remote
microphone (RM), or soundfield system or the delivery of therapy or educational services. Most important, functional auditory
assessments can monitor the child’s auditory progress over time
by repeating assessments periodically. Table 6.2 displays a summary of functional auditory assessment tools.
Discussion Questions
1. Discuss the factors that need to be taken into consideration
before beginning the actual pediatric assessment.
2. Identify ve reasons for taking a case history.
3. Detail some of the reasons for performing functional auditory
assessments, and summarize four tools.
4. Discuss the tests that are included in a pediatric test battery
for a typical 12-month-old baby; include the concept of the
cross-check principle.
6 Hearing Test Protocols for Children
References
[1] American Academy of Audiology. Pediatric Diagnostics. http://www.audiology.
org/resources/documentlibrary/Pages/PediatricDiagnostics.aspx. 2017. Accessed
December 7, 2017
[2] Jerger JF, Hayes D. The cross-check principle in pediatric audiometry. Arch Oto-
laryngol 1976;102(10):614–620
[3] Stach BA. Clinical Audiology: An Introduction. San Diego, CA: Singular Publishing
Group; 1998
[4] American Speech-Language-Hearing Association. Permanent Childhood Hearing
Loss (Practice Portal). http://www.asha.org/PRPSpecificTopic.aspx?folderid
=8589934680§ion=Assessment#Audiological_Test_Battery-Developmental
_Age_of_Birth-to-6_Months 2017. Accessed December 7, 2017
[5] Purdy SC, Farrington DR, Moran CA, Chard LL, Hodgson S-A. A parental question-
naire to evaluate children’s auditory behavior in everyday life (ABEL). Am J Audiol
2002;11:72–82
[6] Anderson K, Smaldino J. Children’s Home Inventory for Listening Diculties
(CHILD). https://successforkidswithhearingloss.com/for-professionals/tests
-informal-assessments-for-parents-students-teachers/. Redesigned 2011.
Accessed December 6, 2017
[7] Williams C. The Children’s Outcome Worksheets (COW): an outcome measure
focusing on children’s needs (ages 4–12). News from Oticon, 2005 (January)
[8] Anderson K. Early Listening Function (ELF). Oticon version. https://
successforkidswithhearingloss.com/for-professionals/tests-informal-assessments
-for-parents-students-teachers/. Revised 2007. Accessed December 6, 2017
[9] Stredler-Brown A, Johnson DC. Functional Auditory Performance Indicators
(FÁPI): an integrated approach to auditory development. https://www
.arlenestredlerbrown.com/wp-content/uploads/2017/06/FAPI-Protocol-for
-distribution.pdf. Updated 2004. Accessed December 6, 2017
[10] Robbins AM, Renshaw JJ, Berry SW. Evaluating meaningful auditory integration
in profoundly hearing-impaired children. Am J Otol 1991;12(Suppl):144–150
[11] Anderson K, Smaldino J, Spangler C. The Listening Inventory for Education—
Revised (LIFE-R). https://successforkidswithhearingloss.com/for-professionals/
listening-inventory-for-education-revised-life-r/. Copyright 2017. Accessed
December 6, 2017
[12] Kuhn-Inacker H, Weichbold V, Tsiakpini L, Coninx S, D’Haese P. LittlEARS: Audito-
ry questionnaire. Innsbruck, Austria: MED-EL; 2003
[13] Ching TC, Hill M. Parents’ Evaluation of Aural/Oral Performance of Children
(P.E.A.C.H). Sydney, Australia: Australian Hearing; 2005 https://outcomes.nal.gov
.au/Assesments_Resources/PEACH%20ratings%20with%20coverpage%20260509.
pdf. Accessed December 6, 2017
[14] Anderson K, Arnoldi KA. Documenting Skills for Success: Data-Gathering Re-
sources. Tampa, FL: Success for Children with Hearing Loss; 2017 https://
successforkidswithhearingloss.com/product/documenting-skills-for-success
-data-gathering-resources/. Accessed December 6, 2017
[15] Ching TC, Hill M. Teacher’s Evaluation of Aural/Oral Performance of Children
(T.E.A.C.H.) Sydney, Australia: Australian Hearing; 2005 https://outcomes.nal.gov
.au/Assesments_Resources/TEACH%20ratings%20with%20coverpage%20260509.
pdf. Accessed December 6, 2017
[16] Ehrlich C. A case history for children. In: Katz J, ed. Handbook of Clinical Audiolo-
gy. 3rd ed. Baltimore, MD: Williams and Wilkins; 1983:607–620
71
II Diagnosing Hearing Disorders in Infants and Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
6.6 Appendix 6.1 Developmental Milestones
Appendix Table 6.1 Developmental Milestones, 2–6 Months
2 months 4 months 6 months
Social/emotional
Language/
communication
Cognitive (learning,
thinking, problem
solving)
Movement/physical
development
Contact doctor if
child . . .
Begins to smile at people
•
Can briey calm self (may bring hands
•
to mouth and suck on hand)
Tries to look at parent
•
Coos, makes gurgling sounds
•
Turns head towards sounds
•
Pays attention to face
•
Begins to follow things with eyes and
•
recognize people at a distance
Begins to act bored (cries, fussy) if
•
activity doesn’t change
Can hold head up and begins to push
•
up when lying on tummy
Makes smoother movements with
•
arms and legs
Doesn’t respond to loud sounds
•
Doesn’t watch things as they move
•
Doesn’t smile at people
•
Doesn’t bring hands to mouth
•
Can’t hold head up when pushing up
•
when on tummy
Smiles spontaneously, especially at
•
people
Likes to play with people and might
•
cry when playing stops
Copies some movements and facial
•
expressions, e.g., smiling or frowning
Begins to babble
•
Babbles with expression and copies
•
sounds heard
Cries in dierent ways to show
•
hunger, pain, or being tired
Lets you know whether happy or sad
•
Responds to aection
•
Reaches for toy with one hand
•
Uses hands and eyes together, such as
•
seeing a toy and reaching for it
Follows moving things with eyes from
•
side to side
Watches faces closely
•
Recognizes familiar people and things
•
at a distance
Holds head steady, unsupported
•
Pushes down with legs when feet are
•
on a hard surface
May be able to roll over from tummy
•
to back
Can hold a toy and shake it and swing
•
at dangling toys
Brings hands to mouth
•
When lying on tummy, pushes up to
•
elbows
Doesn’t watch things as they move
•
Doesn’t smile at people
•
Can’t hold head steady
•
Doesn’t coo or make sounds
•
Doesn’t bring things to mouth
•
Doesn’t push down with legs when
•
feet are placed on a hard surface
Has trouble moving one or both eyes
•
in all directions
Knows familiar faces and begins to
•
know whether someone is a stranger
Likes to play with others, especially
•
parents
Responds to other people’s emotions
•
and often seems happy
Likes to look at self in a mirror
•
Responds to sounds by making
•
sounds
Strings vowels together when
•
babbling (“ah,” “eh,” “oh”)
Likes taking turns with parent while
•
making sounds
Responds to own name
•
Makes sounds to show joy and
•
displeasure
Begins to produce consonant sounds
•
(jabbering with “m,” “b”)
Looks around at things nearby
•
Brings things to mouth
•
Shows curiosity about things and tries
•
to get things that are out of reach
Begins to pass things from one hand
•
to the other
Rolls over in both directions (front to
•
back, back to front)
Begins to sit without support
•
When standing, supports weight on
•
legs and might bounce
Rocks back and forth, sometimes
•
crawling backward before moving
forward
Doesn’t try to get things that are in
•
reach
Shows no aection for caregivers
•
Doesn’t respond to sounds around
•
him
Has diculty getting things to mouth
•
Doesn’t make vowel sounds (“ah”,
•
“eh”, “oh”)
Doesn’t roll over in either direction
•
Doesn’t laugh or make squealing
•
sounds
Seems very sti, with tight muscles
•
-Seems very oppy, like a rag doll
•
72
Appendix Table 6.2 Developmental Milestones, 9–18 Months
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
9 months 1 year 18 months
Social/emotional
Language/
communication
Cognitive (learning,
thinking, problem
solving)
Movement/physical
development
Contact doctor if
child . . .
May be afraid of strangers
•
May be clingy with familiar adults
•
Has favorite toys
•
Understands “no”
•
Makes a lot of dierent sounds like
•
“mamamama” and “bababababa”
Copies sounds and gestures of others
•
Uses ngers to point at things
•
Watches the path of something as it
•
falls
Looks for things he sees you hide
•
Plays peek-a-boo
•
Puts things in her mouth
•
Moves things smoothly from one
•
hand to the other
Picks up things like cereal O’s
•
between thumb and index nger
Stands, holding on
•
Can get into sitting position
•
Sits without support
•
Pulls to stand
•
Crawls
•
Doesn’t bear weight on legs with
•
support
Doesn’t sit with help
•
Doesn’t babble (“mama,” “baba,”
•
“dada”)
Doesn’t play any games involving
•
back-and-forth play
Doesn’t respond to own name
•
Doesn’t seem to recognize familiar
•
people
Doesn’t look where you point
•
Doesn’t transfer toys from one hand
•
to the other
Is shy or nervous with strangers
•
Cries when mom or dad leaves
•
Has favorite things and people
•
Shows fear in some situations
•
Hands you a book when he wants to
•
hear a story
Repeats sounds or actions to get
•
attention
Puts out arm or leg to help with
•
dressing
Plays games such as “peek-a-boo” and
•
“pat-a-cake”
Responds to simple spoken requests
•
Uses simple gestures, like shaking
•
head “no” or waving “bye-bye”
Makes sounds with changes in tone
•
(sounds more like speech)
Says “mama” and “dada” and
•
exclamations like “uh-oh!”
Tries to say words you say
•
Explores things in dierent ways, like
•
shaking, banging, throwing
Finds hidden things easily
•
Looks at the right picture or thing
•
when it’s named
Copies gestures
•
Starts to use things correctly; for
•
example, drinks from a cup, brushes
hair
Bangs two things together
•
Puts things in a container, takes things
•
out of a container
Lets things go without help
•
Pokes with index (pointer) nger
•
Follows simple directions like “pick up
•
the toy”
Gets to a sitting position without help
•
Pulls up to stand, walks holding on to
•
furniture (“cruising”)
May take a few steps without holding
•
on
May stand alone
•
Doesn’t crawl
•
Can’t stand when supported
•
Doesn’t search for things that child
•
sees you hide
Doesn’t say single words like “mama”
•
or “dada”
Doesn’t learn gestures like waving or
•
shaking head
Doesn’t point to things
•
Loses skills child once had
•
6 Hearing Test Protocols for Children
Likes to hand things to others as play
•
May have temper tantrums
•
May be afraid of strangers
•
Shows aection to familiar people
•
Plays simple pretend, such as feeding
•
a doll
May cling to caregivers in new
•
situations
Points to show others something
•
interesting
Explores alone but with parent close
•
by
Says several single words
•
Says and shakes head “no”
•
Points to show someone what he
•
wants
Knows what ordinary things are for;
•
for example, telephone, brush, spoon
Points to get the attention of others
•
Shows interest in a doll or stued
•
animal by pretending to feed
Points to one body part
•
Scribbles on own initiative
•
Can follow 1-step verbal commands
•
without any gestures; for example,
sits when you say “sit down”
Walks alone
•
May walk up steps and run
•
Pulls toys while walking
•
Can help undress self
•
Drinks from a cup
•
Eats with a spoon
•
Doesn’t point to show things to
•
others
Can’t walk
•
Doesn’t know what familiar things
•
are for
Doesn’t copy others
•
Doesn’t gain new words
•
Doesn’t have at least 6 words
•
Doesn’t notice or mind when a
•
caregiver leaves or returns
Loses skills child once had
•
73
II Diagnosing Hearing Disorders in Infants and Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Appendix Table 6.3 Developmental Milestones, 2–5 Years
2 years 3 years 5 years
Social/emotional
Language/
communication
Cognitive (learning,
thinking, problem
solving)
Movement/physical
development
Contact doctor if
child . . .
Copies others, especially adults and
•
older children
Gets excited when with other children
•
Shows more and more independence
•
Shows deant behavior (doing what
•
child has been told not to)
Plays mainly beside other children,
•
but is beginning to include other
children, such as in chase games
Points to things or pictures when they
•
are named
Knows names of familiar people and
•
body parts
Says sentences with 2 to 4 words
•
Follows simple instructions
•
Repeats words overheard in
•
conversation
Points to things in a book
•
Finds things even when hidden under
•
two or three covers
Begins to sort shapes and colors
•
Completes sentences and rhymes in
•
familiar books
Plays simple make-believe games
•
Builds towers of 4 or more blocks
•
Might use one hand more than the other
•
Follows two-step instructions such as
•
“Pick up your shoes and put them in
the closet”
Names items in a picture book such as
•
a cat, bird, or dog
Stands on tiptoe
•
Kicks a ball
•
Begins to run
•
Climbs onto and down from furniture
•
without help
Walks up and down stairs holding on
•
Throws ball overhand
•
Makes or copies straight lines and
•
circles
Doesn’t use 2-word phrases (for
•
example, “drink milk”)
Doesn’t know what to do with common
•
things, like a brush, phone, fork, spoon
Doesn’t copy actions and words
•
Doesn’t follow simple instructions
•
Doesn’t walk steadily
•
Loses skills child once had
•
Copies adults and friends
•
Shows aection for friends without
•
prompting
Takes turns in games
•
Shows concern for a crying friend
•
Understands the idea of “mine” and
•
“his” or “hers”
Shows a wide range of emotions
•
Separates easily from mom and dad
•
May get upset with major changes in
•
routine
Dresses and undresses self
•
Follows instructions with 2 or 3 steps
•
Can name most familiar things
•
Understands words like “in,” “on,” and
•
“under”
Says rst name, age, and sex
•
Names a friend
•
Says words like “I,” “me,” “we,” and
•
“you” and some plurals (cars, dogs, cats)
Talks well enough for strangers to
•
understand most of the time
Carries on a conversation using 2 to 3
•
sentences
Can work toys with pushbuttons,
•
levers, and moving parts
Plays make-believe with dolls,
•
animals, and people
Does puzzles with 3 or 4 pieces
•
Understands what “two” means
•
Copies a circle with pencil or crayon
•
Turns book pages one at a time
•
Builds towers of more than 6 blocks
•
Screws and unscrews jar lids or turns
•
door handle
Climbs well
•
Runs easily
•
Pedals a tricycle (3-wheel bike)
•
Walks up and down stairs, one foot on
•
each step
Falls down a lot or has trouble with
•
stairs
Drools or has very unclear speech
•
Can’t work simple toys (such as peg
•
boards, simple puzzles, turning handle)
Doesn’t speak in sentences
•
Doesn’t understand simple
•
instructions
Doesn’t play pretend or make- believe
•
Doesn’t want to play with other
•
children or with toys
Doesn’t make eye contact
•
Loses skills child once had
•
Enjoys doing new things
•
Plays “Mom” and “Dad”
•
Is more and more creative with make-
•
believe play
Would rather play with other children
•
than alone
Cooperates with other children
•
Often can’t tell what’s real and what’s
•
make-believe
Talks about likes and interests
•
Knows some basic rules of grammar,
•
such as correctly using “he” and “she”
Sings a song or says a poem from
•
memory such as “Itsy Bitsy Spider” or
“Wheels on the Bus”
Tells stories
•
Can say rst and last name
•
Names some colors and some
•
numbers
Understands the idea of counting
•
Starts to understand time
•
Remembers parts of a story
•
Understands the idea of “same” and
•
“dierent”
Draws a person with 2 to 4 body parts
•
Uses scissors
•
Starts to copy some capital letters
•
Plays board or card games
•
Tells you what child thinks is going to
•
happen next in a book
Hops and stands on one foot up to 2
•
seconds
Catches a bounced ball most of the
•
time
Pours, cuts with supervision, and
•
mashes own food
Can’t jump in place
•
Has trouble scribbling
•
Shows no interest in interactive
•
games or make-believe
Ignores other children or doesn’t
•
respond to people outside the family
Resists dressing, sleeping, and using
•
the toilet
Can’t retell a favorite story
•
Doesn’t follow 3-part commands
•
Doesn’t understand “same” and
•
“dierent”
Doesn’t use “me” and “you” correctly
•
Speaks unclearly
•
Loses skills child once had
•
74
7 Behavioral Evaluation of Hearing in Infants and Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
7 Behavioral Evaluation of Hearing in Infants and Children
Jane R. Madell
Summary
Behavioral evaluation is the gold standard for evaluation of hearing in infants and children. Behavioral testing is used to determine
degree and type of hearing loss and can also be used to monitor
performance with technology. The chapter will assist audiology
students and experienced clinicians in building and improving
skills. The chapter reviews techniques for testing using behavioral
observation audiometry (BOA) for infants cognitively birth to 6
months of age, visual reinforcement audiometry (VRA) for infants
and children cognitively 5 to 36 months of age, and conditioned
play audiometry (CPA) for children 30 months and older. The chapter discusses why we need behavioral testing for infant and young
children, how to assess cognitive age to select the appropriate test
protocol, and the specifics of diagnostic testing using BOA, VRA,
and CPA. The chapter discusses how to use test information to
begin to proceed with management of hearing loss.
Keywords
behavioral observation audiometry (BOA), visual reinforcement
audiometry (VRA), conditioned play audiometry (CPA), cognitive
age, assessing physical status, functional assessment
Key Points
Behavioral audiologic testing is the protocol that provides a
•
direct measure of hearing.
Although auditory brainstem response, auditory steady-state
•
response, and otoacoustic emissions testing are considered
the gold standard for testing infants, and although they
provide critical information about the status of the auditory
pathways, they are not direct measures of hearing.
When carefully per formed using appropriate criteria, behavioral
•
testing can accurately measure thresholds in infants from birth.
Behavioral observation audiometry can be used to
◦
measure hearing behavior in infants birth to 6 months
cognitive age.
Visual reinforcement audiometry is used to measure hear-
◦
ing in infants 5 to 36 months of age.
Conditioned play audiometry is used to measure hearing
◦
in infants 30 months of age and older.
Behavioral testing can be used to test children using
•
earphones, the bone conduction transducer, hearing aids,
cochlear implants, or remote microphone systems.
By being creative, the pediatric audiologist can nd tasks that
•
keep the young child interested and suciently cooperative
to obtain necessary testing information.
The audiologist needs to own the responsibility for obtaining
•
test results. If testing is not completed, using any and all available test protocols, the audiologist must take responsibility
and say “On this day, I cannot test this child.” Poor or absent
test results cannot be blamed on the child.
7.1 Why We Need Behavioral
Testing for Infants and Young
Children
Currently, most states have mandated newborn hearing screening programs. (See Chapter 5 for a complete discussion of newborn hearing screening.) As a result, audiologists are being asked
to assess hearing in very young infants who have been referred
from newborn screening and to manage hearing loss when it is
identified. One of the first steps in hearing loss management is
the selection and fitting of appropriate amplification. Hearing
aid fitting requires an accurate assessment of the degree and
type of hearing loss, with ear- and frequency-specific informa-
tion obtained by air and bone conduction testing.
Many audiologists feel comfortable testing hearing in infants
older than 6 months of age using visual reinforcement audiometry (VRA) or conditioned play audiometry (CPA) but do not feel
comfortable testing younger infants or infants who are developmentally delayed infants or critically ill. The Joint Committee on
Infant Hearing guideline
with hearing loss at birth, hearing aids should be fitted within
a few weeks. Work by Yoshinaga-Itano and others
has demonstrated that infants who are fitted with appropriate
technology and receive appropriate intervention before they are
6 months old can develop speech and language skills commensurate with their normal-hearing peers. However, infants fitted with
technology when they are older than 6 months may not catch up
to those fitted earlier.
Nonbehavioral tests, such as auditory brainstem response
testing (ABR), auditory steady-state-response testing (ASSR), and
otoacoustic emissions testing (OAEs), are frequently used to estimate hearing sensitivity in infants.11 These tests are an important
part of the audiology practice and are the gold standard for testing
infants. They are, however, not tests of hearing. ABR, ASSR, and
OAE measures provide information about the integrity of specific
sites within the auditory system.
the response of the entire auditory system, from the outer ear
through the cerebral cortex. Behavioral tests permit measurement
of what an infant or child actually perceives, measure functional
hearing abilities not available in any other way, and are a critical
component of a complete audiologic evaluation.
Behavioral testing allows the parents to participate in testing
by permitting them to observe when the infant is responding to
a sound and when he is not. If parents are provided with information about what to observe, they can be active participants in
testing, a process that facilitates acceptance and understanding of
hearing loss and motivates families to proceed with treatment.
Critically important, behavioral testing provides information
about what an infant can hear when wearing technology.
Numerous authors have posited the necessity for cross-checking physiologic results with behavioral data by using a battery
of tests to determine hearing sensitivity.
1,2
suggests that if an infant is identified
3,4,5,6,7,8,9,10
6,12,13,14
Behavioral tests measure
6,14,15,17,18,19
It is critical,
15,16
75
II Diagnosing Hearing Disorders in Infants and Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
therefore, that audiologists working with children be comfortable
with the behavioral assessment of infants of all ages (Video 7.1).
7.2 Assessing the Child’s Cognitive
Age
Prior to beginning testing with any behavioral test technique, the
first task is to determine the child’s cognitive age. That is, regardless of the child’s chronologic age, behavioral testing requires
determining the child’s cognitive age. Behavioral observation
audiometry (BOA) can be used to measure auditory behavior
with infants who are cognitively birth to 6 months of age. VRA
is appropriate for the measurement of hearing thresholds in
children 5 to 36 months cognitive age, and CPA is appropriate
for the measurement of hearing thresholds in children who are
cognitively older than 3 years and can often be accomplished
between 18 to 24 months of age when audiologists, therapists,
and the family work collaboratively to develop the child’s ability
to participate in CPA. Selecting the wrong test procedure means
that one may be unable to obtain any thresholds, or obtain very
few thresholds, or obtain inaccurate thresholds.
ple, asking a 6-month-old to raise his hand will result in poor
responses. It would be wrong to assume that the infant could
not hear because he did not raise his hand to sound. If a child is
cognitively at an age where VRA is the appropriate test, and the
child tires of the task, trying to use BOA or CPA will also result in
inaccurate responses.
Cognitive information can be obtained in several ways. A good
case history will provide some information. Speech-language
or psychoeducational evaluations also will provide useful information. If speech and language development are grossly within
normal limits as determined by evaluation reports, discussion
with parents, and observation of the child,22 and if the child’s
motor development is within normal limits, cognitive levels can
be assumed to be close to normal. If a child has other developmental disabilities, cognitive levels will be harder to ascertain;
results of specific developmental tests may be required. Appendix
6.1 describes developmental milestones for infants from birth
through 5 years. This table can be used to help identify a child’s
developmental level.
Once a child is determined to be cognitively 6 months of age,
VRA should be attempted. Once it is determined that a child is
cognitively older than 30 months, play audiometry can be tried.
Children who have frequent hearing tests, such as those with
hearing loss or recurrent otitis media, and those involved in
auditory therapy programs are likely to learn the listen-and-drop
task (CPA) earlier, frequently between 18 and 24 months. VRA
often becomes boring after repeated test sessions, so when a child
becomes familiar with the audiologist and the test environment,
the child may be able to perform CPA at a younger age.
11,19,20,21
For exam-
7.3 Diagnostic Audiologic
Evaluation
The primary goal of an audiologic evaluation of an infant or
young child is usually to determine whether the child has
sucient hearing (auditory brain access) to develop speech and
language. A complete diagnostic evaluation includes frequency-
and ear-specific threshold information throughout the frequency
range, using both air and bone conduction procedures. The most
common test protocols for evaluating infants and young children
include acoustic immittance testing (with a high-frequency
probe tone necessary for infants under 6 months of age), ABR,
auditory steady-state evoked potential (ASSEP), and OAE, in
addition to behavioral testing. See Chapter 6 for a detailed discussion of hearing test protocols.
Acoustic immittance testing assesses middle ear status but does
not provide information about hearing. However, acoustic reex
testing can suggest to the clinician the presence of a hearing loss.
Tonal ABR is an excellent predictor of hearing thresholds. OAEs
assess function of the outer hair cells of the cochlea. Information
about an infant’s ability to attend to auditory stimuli is obtained
only with behavioral testing. In addition, behavioral testing is a
very useful technique for assessing hearing with technology.
Testing should not be considered complete for an infant or child
with hearing loss until behavioral test results are obtained.
If a child is identified with a hearing loss, it is essential that
technology be fitted and monitored over time. ABR, ASSEP, and
OAE cannot be used to monitor technology. Behavioral testing can
be used to monitor hearing and technology.
Pearl
Immittance, ABR, ASSR, and OAE testing provide critical information about the status of the auditory system. Behavioral
testing directly tests hearing. For this reason, it is critical that
audiologists have skills to test infants and children using both
electrophysiologic and behavioral techniques from birth through
childhood.
7.4 The Basics of BOA: Birth to 6
Months
7.4.1 Who Is a Candidate for BOA?
Behavioral observation testing, using the protocol discussed
in this chapter, is intended as a technique to measure auditory
responsiveness in infants as well as a technique to help both
families and all the clinicians working with a child to observe
responses to sound. This protocol uses observation of sucking
responses and is appropriate only for infants who are cognitively
birth to 6 months of age and who are capable of sucking. The
technique may be useful for older infants who, because of
developmental delay, are cognitively less than 6 months of age.
Infants older than 6 months cognitive age will likely not suck
consistently, so the responses may be less reliable. In addition,
infants who are cognitively 6 to 7 months of age can be reliably
tested using VRA. While there is limited research evaluating the
BOA technique, the clinical experience of the author, as well as
numerous other clinicians, supports its value.
There are two instances when BOA is particularly valuable.
First, if responses to auditory stimuli using sucking is significantly
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Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
below hearing levels suggested by ABR, it would be useful to
repeat ABR and to take BOA thresholds into consideration when
programming hearing aids. Second, in children with auditory
neuropathy spectrum disorder (ANSD; Chapter 33), BOA is
helpful in trying to determine auditory response levels, since
ABR cannot be used as a predictor of hearing sensitivity with this
population.
7.4.2 What Is Being Observed?
Historically, many behaviors have been used to assess hearing
in infants (arousal, limb movement, respiration changes, facial
grimace, eye blink), but these behaviors have not proven to be
suciently repeatable, and, more importantly, they have not
been good indicators of threshold. In the experience of this
author and other clinicians, the behavior most likely to provide
threshold responses is a change in sucking. While responses
can be obtained by arousal responses, limb movements, and
eye blinks, these are frequently suprathreshold-level responses
but rarely threshold response. Sucking responses, however,
although present at suprathreshold levels, can also be observed
at softer levels. Either initiation or cessation of sucking is an
acceptable response. Some infants will start sucking when a
sound is presented, others will cease sucking, and some will do
both.
Pearl
Cessation or initiation of sucking is a reliable response for observing auditory behavior in infants younger than 6 months.
7.4.4 How Does One Know That the
Sucking Behavior is a Response to a
Sound Stimulus?
As with all other behavioral responses and also with ABR, timing
is the key factor. When using play audiometry with a child, we
question the validity of the child’s response if it comes a long
time after presentation of the stimulus. With any test protocol,
behavioral or electrophysiologic, responses can be accepted only
if they fall within a specified time window after presentation
of the stimulus. Infants are fairly consistent, internally. Some
respond to the “on” of the stimulus, and others respond to the
“o.” The timing of the response is also usually consistent. Infants
respond at about the same number of seconds after presentation
of the stimulus each time, with the response time slightly shorter
for louder stimuli.
15,19
7.4.5 Positioning the Infant
The necessity of appropriately positioning the infant cannot be
overstated. Positioning may, in fact, be the most important factor
in enhancing the likelihood of observing repeatable responses
with BOA. The infant needs to be resting in a comfortable position with full support of the head and torso, and with the mouth
isible to the testers. Figs. 7.1a–c demonstrate infants sucking.
v
The infant may be held or placed in an infant seat. The advantage
of an infant seat is that the infant will not be receiving any “signals” from the mother when she hears the sound. If the infant is
being held, the mother or other person holding the infant should
be very carefully instructed about the need to remain silent and
still throughout testing to avoid interfering with testing.
7.4.3 Maximizing Observation of the
Sucking Response
Sucking can be observed with a bottle, at the breast, or on a
pacifier. The family should be instructed to bring the infant to
the evaluation session hungry so that she will be ready to suck.
The infant needs to be as comfortable as possible during testing,
so, if the infant normally drinks from a bottle, the family should
bring one. If the infant normally nurses, it is best if the infant
nurses during testing. If the infant uses a pacifier, the family
should bring one along. After the infant is finished eating, testing
can frequently continue by observing sucking with a pacifier. If
an infant is very hungry, it is best to allow her a little time to
eat to enable her to get over that initial extreme hunger before
beginning testing.
As soon as the baby settles down, testing can begin. To observe
the sucking response, it is necessary to see the infant’s mouth
close-up. A good view of the mouth can sometimes be obtained
by looking through the test room window, or by having a test
assistant in the test room, who can help in observing the baby.
However, the sucking response will be more easily observed by
having a video camera with a zoom lens in the test room that can
be adjusted from the control room.
7.4.6 The Role of the Parents
The parents cannot be relied upon as the primary observers.
Their stakes are too high, they are not experienced in the task,
and they may not understand exactly what constitutes an acceptable response. Parents are, however, very valuable in helping the
esters to understand the baby and in assisting in making the
t
baby comfortable. At least one parent should be in the test room
whenever possible to assist in understanding the test protocols
and test results. If both parents are present, the other parent can
observe from the control room. Parent observation of how the
baby responds will be helpful in helping parents understand test
res u lts).
7.4.7 Adding Objectivity to Behavioral
Observation Audiometry
The Test Setting (Box 7.1)
Infant State and Positioning
Monitor the infant’s state to increase the likelihood that it will
be possible to observe responses accurately. “State” refers to
the infant’s level of arousal, from deep sleep to hysterical crying
(Fig . 7. 2).
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Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
a
b
c
Fig. 7.2 Positioning the infant for behavioral observation audiometry.
Box 7.1 Behavioral Observation Test
Protocol
1. Bring infant into test room in hungry state.
2. Seat infant so torso is supported and infant is not fi dgety,
and so tester(s) can easily see the infant’s mouth.
3. Monitor infant state during testing and stop if infant
becomes fi dgety.
4. Instruct parents not to respond to test stimuli or responses
from the child.
5. Test assistant will keep infant centered, observe responses,
and monitor parents’ behavior.
6. Begin testing in soundfi eld.
7. Begin testing with a stimulus that is slightly above esti-
mated threshold.
8. Test one low (500 Hz) and one high (2,000 Hz) frequency
initially and select additional frequencies to test depending on initial responses.
9. Reduce thresholds in 10-dB steps and increase in 5- to
10-dB steps to bracket threshold. Record a response after
three reversals.
10. Take breaks as needed to calm the infant and increase
usable test time.
11. If soundfi eld testing indicates a hearing loss, test bone
conduction.
12. If infant is still responding, or at the next test session, test
with insert earphones.
13. Test with technology as needed.
Fig. 7.1 Positioning the infant for testing: (a) using a bottle, (b) using a
paci er, (c) at the breast.
respond to the stimulus by altering the movement of the toy or
facial expressions.
Movement of Audiology Assistant and Parent/
Caregiver
As with all other behavioral testing, everyone in the test room
with the child must be still and nonresponsive to the test stimuli, keep the infant focused at midline, and be reminded not to
Test Stimuli and Response
The most critical element in obtaining reliable responses is to
predetermine what will constitute a response.
been decided that sucking is the acceptable response, then the
audiologist should not also accept eye widening or a head turn as a
15,19,23,24
If it has
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7 Behavioral Evaluation of Hearing in Infants and Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
response. The response must be time-locked to the presentation of
the stimulus. All of the infant’s responses must be repeatable. The
use of multiple observers to determine whether a response is present also will increase reliability, as will the use of silent controls.
15,16
Infant Thresholds
Because b ehavioral test protoc ols for infants frequent ly did not reveal
threshold responses at soft levels, some audiologists have proposed
that responses at 60 to 70 dB sound pressure level (SPL) be interpreted
as normal hearing for very young infants.25 Others reported that
thresholds of 3-month-olds were worse than thresholds of adults.
Olsho25 postulated that some of the threshold dierences may be
related to sensory immaturity. However, others demonstrated that
infants hear at essentially adult levels.
15,25,26,27,28,29,30,31
Comparison of BOA Thresholds to VRA, CPA
Fi g s . 7. 3 a - d are typical of many multiple audiograms that
demonstrate that thresholds can be obtained accurately by
using BOA. Although some infants will not provide reliable BOA
thresholds, some respond near threshold levels. These audiograms compare thresholds on four children obtained with BOA,
VRA, and CPA over several years. Fig. 7.4 demonstrates results of
infants whose test results using BOA and ABR were not in good
agreement. Results of clinical work with many children, and by
a
c
Fig. 7.3a–d Comparison of thresholds with behavioral observation (BOA; here shown as OA), visual reinforcement audiometry (VRA), and conditioned play audiometry (CPA; here shown as Play).
b
d
79
II Diagnosing Hearing Disorders in Infants and Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
a
b
Fig. 7.4 Comparison of test results obtained using (a) BOA and (b) ABR for infants that are not in good agreement.
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