Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_4488_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

38 Мб

Скачать

☆

<<< < Предыдущая 1 2 3 4 5 6 7 8 9 1011 / 4311 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

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.

many clinicians, over many years indicates that BOA, appropriately conducted, using the sucking paradigm discussed in this chapter and demonstrated in V ideo 7. 2, can be an important part of the audiologic test battery along with ABR thresholds. There

is currently insucient peer-reviewed research comparing BOA

and ABR thresholds, but clinical experiences indicates its value.

7.4.8 Developing Comfort Using BOA

Clinicians who are comfortable using ABR to assess infants may want to add BOA to their protocol to gain experience with the technique before making BOA testing a regular part of clinical practice. As with most other skills, it takes experience to become a competent tester when using the BOA sucking paradigm.

BOA testing can be squeezed in before the baby falls asleep for ABR testing or when she wakes up. It is important to be certain that the test situation is appropriately organized so as to maximize the ability to observe changes in sucking. The clinicians should have good communication with each other to enable them to share observation information during testing. All infant responses must be repeatable prior to concluding they are reliable. Video

7.2, Video 7.3, and Video 7.4 will be helpful in developing the necessary BOA skills.

7.5 The Basics of VRA: 5 to 36

Months

VRA is the test technique that is most appropriate for infants who

are of a developmental age of 5 to 36 months of age. The most

common VRA test techniques involve training the infant to make a conditioned head turn in response to a test stimulus. Infants only a few months of age will naturally turn toward a sound source. Most infants will turn toward the sound source a few times, but the head-turning behavior will habituate to repeated stimuli if not reinforced. Fortunately, this head-turning behavior can be shaped using an operant discrimination procedure that permits obtaining numerous responses to auditory stimuli. The sound stimulus is used to cue the child to seek the visual reinforcement. Use of a positive reinforcement, such as a lighted toy or short video clip, will increase the number of responses before the responses are extinguished. Conditioned responses have the advantage of being more repeatable than unconditioned responses, and more responses usually can be obtained during one sitting.

The foundation for VRA was laid by Suzuki and Ogiba,32 and

the term itself was ﬁrst used by Lidén and Kankkunen.33 The technique was reﬁned by Wilson and Thompson et al discussed in numerous other publications between 1977 and

1984. The audiologist presents a stimulus. If the child detects the

stimulus, she will turn toward it. The audiologist then activates a reinforcer. After a few repetitions, the child learns to seek the reinforcer when she hears the sound.

37,38

34,35,36

and

7.5.1 Conditioned Orientation Reex Audiometry

Conditioned Orientation Reex (COR) testing, originally described

by Suzuki and Ogiba,32 uses the same conditioning techniques as VRA. Sound may be presented from either the right or the left loudspeaker, but the child will be reinforced only when turning to the correct side. Standard hearing testing requires only the ability to identify whether a sound is present. It does not require that the listener identify where the sound is coming from. Young

babies may have a dicult time determining which way to turn,

but older babies and children will be able to perform the task.

The ability to localize a sound close to threshold can be dicult

for anybody. As a result, VRA rather than COR is used for clinical assessment. In other words, the child is reinforced for a head turn regardless of whether she turns toward the side of the ear in which the stimulus was presented.

7.5.2 Visual Reinforcers

A variety of toys are available for use as reinforcers. Moore et al39 investigated use of dierent reinforcers and their eect on responses. They compared no reinforcement, social reinforcement, blinking lights, and complex visual reinforcement and

oncluded that the complex reinforcement resulted in signiﬁ-

cantly more localizations than simple reinforcers did. The best reinforcers are novel and interesting. Mechanical toys that are brightly illuminated, such as clowns that play drums, dogs that bark, or elephants that eat ice cream cones, are excellent.

The reinforcer should be enclosed in a translucent plastic box so that it is not easily observable until it is turned on. Stacking two or three toys on top of each other in individual plastic boxes permits the audiologist to vary the reinforcer and increase the novelty, thereby increasing the length of time a child will attend to the task (Fig. 7.5). Most VRA systems permit turning on the

sound and lights separately or together. This on-o switch is

particularly useful when a child is frightened by the noise made by the reinforcing toy. Occasionally, children react negatively to the reinforcers. Some children are frightened by the sound or the

movement. If the sound is the problem, it can be turned o and

the lights can be used alone.

For older children, or children who are no longer interested in the VRA toys, a cartoon video works particularly well as a reinforcer (Fig. 7.6). with test stimuli. Because the video is constantly changing, it will be of ongoing interest. A small TV monitor can be placed near the loudspeaker with the DVD player on the tester’s side of the booth. The audiologist can activate the video in the same way as a mechanical toy.

If a child is frightened by all VRA toys, it is sometimes possible

to darken the test room and shine a ashlight through the test room window as a reinforcer. The light can either ash on and o or be waved around in circles. A head turn toward the tester’s

window will be used to determine a response.

The sound should be o so as not to interfere

II Diagnosing Hearing Disorders in Infants and Children

Fig. 7.5 VRA toys.

Pearl

Reinforcement should be provided only when it is certain that the child is responding to the stimulus. Turning on the reinforcing toy when the child has not heard the sound will decrease the reliability of conditioning.

7.5.3 Positioning in VRA Testing

A critical factor for obtaining reliable VRA thresholds is the ability to keep the infant’s or child’s attention focused at midline in a position that easily permits a head turn. Proper positioning is critical. The child needs to be seated comfortably so that the upper body is steady and allows the infant or child to turn easily to look at the toy. The child should not be leaning over trying

to get something from the oor, trying to maintain balance, or

looking for something or someone seated behind.

An infant who does not yet have good upper body control because of young age or neurologic or developmental concerns, or does not sit comfortably, will have diculty making a head- turning response. Positioning for these children will be especially critical. A child without good upper body control should be seated leaning back in a reclining seat or leaning against a parent so that she does not need to struggle to maintain position. This position will leave the infant with enough energy to make a head turn toward the reinforcer.

The child should be positioned so that the VRA reinforcer is located ± 90° to the position of the child so that the child must make a full head turn in order to see the reinforcer. The location of the reinforcers at ± 90° is important because it requires the child to make a full head turn to the left or right, which reduces the uncertainty of whether a response has occurred that might exist if the reinforcers are located in the frontal plane. Older children with very good body control may be able to make a head turn

Fig. 7.6 Video VRA.

of 180° to look for the reinforcer, but a young or neurologically

impaired child will not. For these children, a head turn of more

than 90° is very dicult and may signiﬁcantly reduce their ability

to respond, so it is critical that the children be carefully focused at midline (Fig. 7.7).

Pearl

Positioning is critical. The infant needs to be seated so that she can easily make a conditioned head turn. If the child does not sit up easily, she should be positioned in a reclining position leaning back against someone or in a reclining chair, so she does not need energy to control her torso, Reinforcers should be located at ± 90° relative to the position of the child.

Fig. 7.7 Positioning for VR.

7 Behavioral Evaluation of Hearing in Infants and Children

7.5.4 Distractors

A variety of toys can be useful as distractors. They should be quiet, simple, and interesting but not engrossing. Colorful toys, puppets, ﬁnger games, stacking toys, toys with pieces that connect, magnets on a magnet board or on the test room wall, or the audiology assistant making funny faces will keep the infant focused straight ahead so that a clear head turn can be observed. Young children should view the toys being manipulated by the test assistant but should not manipulate them, since this will likely be too distracting. Older children may be able to manipulate some toys as long as they are not too interesting or require too much concentration. Edible distractions can be useful, provided they are not too noisy or distracting. (Crunchy food will interfere with listening, and food that takes too long to swallow

can signiﬁcantly extend test time and interfere with the ow of

testing.)

7.5.5 Training and Conditioning the

Response

The operant conditioning paradigm begins with a discriminative stimulus; the subject then makes a response and receives reinforcement. In VRA, the stimulus will be tones, noise bands, or speech stimuli. The infant’s response will be a head turn, and the reinforcer will be either a moving toy or a video and may include cheering from the audiology assistant. The VRA

procedure involves two distinct phases. The ﬁrst is the training/

conditioning phase, where the baby or toddler is conditioned to respond to the visual reinforcer. The second is the testing phase, during which thresholds are obtained once the baby is conditioned.

Operant behavior is willful behavior elicited by a stimulus and controlled by the behavior that is increased or decreased by changes in the environment. turning response is increased by the positive reinforcement of the reinforcing toy. There are two approaches to training the

response. The ﬁrst approach is to pair the stimulus with the

reinforcer, turning both on at the same time. The child will frequently turn to the reinforcing toy and learn the task. If the child looks up but does not turn, the audiologist can attract the child’s

attention to the reinforcer by pointing or a head turn. The ﬁrst

approach requires that the audiologist be certain that the signal is audible to the child. If the sound is not audible, the audiologist runs the risk of attempting to condition the child to an inaudible signal, which would obviously jeopardize the validity of the VRA task.

The second and preferred approach is to begin by observing the child’s response and then providing a reinforcer when the child naturally turns to the sound. The audiologist can be certain that the child is hearing the sound. If it appears as though the child is hearing the test signal but not producing a head turn, then the audiologist informs the audiology assistant that it appears the test signal is audible to the child but the child is not responding and that the next test signal will be delivered at a level that should be audible to the child. Then, the audiology assistant will attempt to shape the child’s response by directing the child’s attention toward the reinforcer while the test signal is being presented. If

13,41,42

In VRA or COR, the head-

Box 7.2 Protocol for Visual Reinforcement Audiometry

1. Seat child in high chair, in a child’s chair, or on a parent’s lap.

2. The test assistant or parent keeps child’s attention focused to the front using quiet toys.

3. The auditory stimulus is presented at a comfortably loud level above expected threshold. The conditioning/reinforcing toy is turned on, and if the child does not turn, the test assistant calls attention to the toy. The auditory stimulus and

the conditioning toy are kept on together for 3 to 4 seconds.

4. Step 3 is repeated until the child consistently turns to the auditory stimulus.

5. When the child is conditioned to respond, the auditory stimulus is presented without turning on the conditioning/reinforcing toy. If the child turns toward the sound, the reinforcing toy is turned on and conditioning is complete.

6. Testing proceeds, obtaining thresholds for one low-frequency (500 Hz) and one high-frequency (2,000 Hz) stimulus. The stimulus intensity is decreased until the child stops responding, and is then increased to bracket the threshold.

Three responses at the same intensity are sucient.

7. Additional frequencies to be tested will be determined by the responses to the initial frequencies tested.

8. Testing proceeds using insert earphones, bone vibrator, and technology (e.g., hearing aids and FM systems).

9. The reinforcing toy is turned on only when the child makes a conditioned head turn in response to a sound. When in doubt, do not turn on the reinforcer.

the child turns toward the reinforcer upon the direction of the audiology assistant, then the audiologist should simultaneously present the test signal and reinforcement in order to facilitate pairing between the stimulus and reinforcement. After response shaping takes place, a test signal should be presented again at the same level in order to determine whether the child will produce a volitional head turn without prompting from the audiology assistant.

During the training/conditioning phase, the stimulus should always be presented at an intensity that the audiologist is sure the child can hear, and every correct head turn should be reinforced. If the reinforcer is activated when there is no stimulus or when t be able to make the association between the sound and the reinforcer and will only be confused. If there is any question at all about whether or not the child heard the stimulus, the reinforcer should not be activated. Training/conditioning is considered complete when the infant consistently turns when a stimulus is presented, and when there are very few random head turns.

used for testing: noise bands, warble tones, or speech stimuli. Research by Thompson and Folsom43 and others has demonstrated that the particular stimulus used for training will not

aect test results, although responses to noise bands may be obtained at 5 to 10 dB softer levels than those to pure tones.

Video 7.5 and Video 7.6 will assist in demonstrating VRA test protocols (Box 7.2).

he child cannot hear the stimulus, the infant will not

The stimulus used for conditioning can be the same stimuli

II Diagnosing Hearing Disorders in Infants and Children

7.5.6 Computer-Assisted Reinforcement

A computer-assisted reinforcement procedure uses a laptop computer that is placed in the sound room with the child, parent, and audiology assistant. On the computer screen is an interesting PowerPoint program that is controlled by a remote mouse operated by the audiologist in the control room. Every click of the mouse adds a feature to a picture on the screen so as to complete a clown face, for example. The child has a mouse or other apparatus that is not actually connected to the computer. The child is conditioned to click his mouse every time he hears a sound. Of course, his mouse does not do anything, but the child does not know that. If the child clicks his mouse when a sound is presented, the audiologist uses her remote mouse to add a feature to the picture on the screen. If the child clicks his mouse when a sound is not presented, no feature is added to the picture. Computer pictures or games can be changed as needed to maintain the child’s interest.

7.6 The Basics of CPA: 30 Months and Older

Play audiometry, or CPA, was ﬁrst described by Hoversten and coworkers in the 1950s.44 Their technique provided valuable

guidance for the audiologic evaluation of very young children. Audiologists have been following their protocol, with slight

modiﬁcations, ever since.

As has been known for decades, once children reach a cognitive

age of ~ 24 to 30 months, they can begin to cooperate voluntarily

in hearing testing. By this age, children can be taught to drop a toy in a bucket, build a tower, or put a ring on a ring stand when they hear a sound. If the child can be enticed to cooperate, a great deal can be learned about his hearing. The challenging task for

the pediatric audiologist is to ﬁnd ways to keep the young child

entertained for a long enough time to complete the hearing test. Conditioned play should be fun. The audiologist needs to be cheerful, toys need to be interesting, and they need to be varied frequently.

7.6.2 Training the Task

The play audiometry task requires the child to hold a toy up

to his ear and perform a motor task (“listen and drop”: drop

the toy in the bucket, etc.) when the sound is presented.11 The

toy is held up to the ear for two reasons: (1) as a speciﬁc signal

that the child is ready to listen and (2) as a clear indication of the motor act of dropping the toy in the bucket in response to the test stimuli. To explain, if the child is playing with the toy or holding it right above the bucket, it is not clear, when the toy goes into the bucket, whether the drop was truly an active response to the sound or whether the child just decided to drop the toy at that moment. When training the listen-anddrop task, begin with an easy play activity, such as dropping a block in a bucket. Do not start with a task that requires good

dexterity, such as slipping a chip into a slot or ﬁtting a small peg

into a hole (Fig. 7.8).

Pearl

Having a variety of interesting toys will increase the probability of keeping the child’s attention long enough to get the information needed for testing.

There are several ways to begin the training. The audiology assis-

tant can begin by demonstrating the task. She holds the toy to her

ar and, when the sound is presented, says “I hear that” and drops

the toy in the bucket. If the child seems hesitant, allow the parent to try for one or two sound presentations. Then hand the child the toy, hold his hand up to his ear, and, when the sound is presented, say

“We heard that” and, hand over hand, with the tester’s hand over

the child’s hand, move the child’s hand to drop the toy in the bucket. After a few tries, the tester should feel the child’s hand start to move when the sound is presented. That is the clue to let the child carry

7.6.1 Training a Child for Play Audiometry

When conditioning a child to play audiometry, it is critical to be sure that the child hears the stimulus used to train the response. If the child does not hear the sound, the audiologist will be conditioning the child to silence, resulting in a great deal of confusion and inaccurate test results. After obtaining a case history and interacting with the child during the interview, the audiologist should have some idea about the loudness level at which to begin presenting stimuli. If the child responds to speech at a normal conversational level, testing can probably begin by presenting

test stimuli at 40 to 50 dB hearing level (HL). If the child does not

respond to speech at a normal conversational level but seems to be developing normally in other ways (motor development and

play activities), it is possible that the child has signiﬁcant hearing

loss and a loud stimulus will be needed.

Fig. 7.8 Testing with conditioned play.

Box 7.3 Test Protocol for Conditioned

Play Audiometry

1. Set the child in a high chair or at a children’s table so the child is comfortably seated.

2. Select a toy that will be enjoyable for the child and within the child’s skill range.

3. Begin using a test stimulus that you expect the child to be able to hear.

4. Begin by demonstrating the task. The audiology assistant holds the toy to her ear. When she hears the sound, she

says “I hear that” and drops the toy into the bucket.

5. After a few presentations, the child is given the toy and the audiology assistant holds the toy to the child’s ear. When the sound is heard, the audiology assistant helps the child drop the toy into the bucket.

6. Care must be taken to encourage the child to drop the toy in the bucket only when you are certain the child heard the sound.

7. This is repeated until the child is able to perform the task without assistance.

8. Once the child is conditioned and performing reliably, testing can begin.

9. If the child appears to be bored, change toys to increase interest.

10. Testing can be accomplished by air and bone conduction and with hearing aids, cochlear implants, osseointegrated implants, and FM systems.

out the task alone. If the child seems hesitant and you are certain that he hears the sound, give his hand a little nudge to help him get going. If he still needs assistance, try demonstrating the task

again saying “Okay, it’s my turn.” Doing the task together, with both

the tester and the child holding a toy and dropping it in the bucket when the sound is presented, may help. It is important to be careful that the child is not simply imitating the motor task or dropping the block when the audiology assistant does but is, in fact, responding to a sound stimulus. After several attempts, the child will need to do

the listen-and-drop task himself. Say “It’s your turn” and let the child

perform the task. If the child looks up when the sound is presented and you are certain he heard the sound, but he is hesitant about

putting the toy in the bucket, it is all right to say, “You heard that, put it in.” Once again, however, the test assistant must be certain

that the test signal is audible to the child before prompting the child to respond. If the child continues to look to the audiology assistant for approval before putting the toy in the bucket, the audiology

assistant should look away, at the oor or at the bucket, to signal to

the child that he is on his own. If the child is still unable to execute the task, start over again and retrain the task. The speech-language pathologist or listening and spoken language specialist who is working with the child can work on CPA for a few minutes during therapy sessions to facilitate the child developing the skill.

If there is uncertainty as to whether the child has heard the sound even at loud levels, try conditioning the child with the bone vibrator from the audiometer. Even a child with no hearing

will feel the tactile stimulation of the bone vibrator at 250 Hz at

7 Behavioral Evaluation of Hearing in Infants and Children

maximum output. Place the vibrator on the mastoid with a headband, or on the child’s knee or in his hand with the hand closed

ith your own. Use your other hand to help the child hold the toy

w up to his ear, and then place it in the bucket when the vibrator is turned on. Once the child learns the task with the vibrator, return to an air-conducted stimulus and try again. Video 7.7 and Video

7.8 demonstrates CPA test techniques (Box 7.3).

7.7 Test Protocols for Behavioral Evaluation

7.7.1 Soundeld, Earphone, and Bone Conduction Testing

A complete audiogram includes air and bone conduction thresh-

olds in each ear at frequencies from 250 to 8,000 Hz. However,

infants and young children will provide only a limited number of responses in one test session, so testing protocols need to be designed to obt ain the most infor mation with th e fewest responses. The goal of the initial audiologic evaluation of an infant is usually

to be certain that the infant has sucient hearing (auditory brain access) to develop speech and language. Soundﬁeld testing can

provide some basic information and may be less stressful for the

child. Obtaining one or two soundﬁeld thresholds can ensure the

child understands the task and gives the audiologist some infor-

mation about hearing levels. If testing in soundﬁeld conﬁrms that

hearing is good in at least one ear, the child can return to obtain separate ear testing at a subsequent visit. If the initial testing indi-

cates that hearing is not within normal limits in the soundﬁeld, then ear-speciﬁc information is critical so that management can

proceed. No child should be released from audiologic follow-up

until ear-speciﬁc information is obtained.

When earphone testing is being attempted, insert earphones are the earphones of choice for infants. Insert earphones (Fig. 7.9) will remain appropriately seated in the ear canal and will provide

Fig. 7.9 Testing with earphones.

II Diagnosing Hearing Disorders in Infants and Children

the most accurate results in tiny ears. Circumaural earphones are

frequently too large and are very dicult to keep well positioned.

The use of insert earphones along with the measurement of the

child’s real-ear-to-coupler dierence is the only way to determine

the child’s hearing loss precisely in dB SPL, which is important for

the completion of real ear–aided response assessment obtained

with probe microphone measures.

If testing indicates thresholds at poorer than normal hearing levels, bone conduction testing is essential. The bone vibrator should be held in place with either a pediatric-sized headband or a fabric one that goes around the head and across the forehead, using Velcro to secure it in place. If a metal headband is used, soft material such as foam or other padding should be used for comfort and to keep the headband from moving. If a hearing

loss is conﬁrmed, the same test protocols can be used to assess functional gain with ampliﬁcation in soundﬁeld.

7.7.2 Selecting the Test Stimulus

The goal of the testing is to obtain frequency-speciﬁc test results.

Warble tones or narrow bands of noise will provide this information. Broadband stimuli such as music, conversational speech, or white noise will not. Narrow bands of noise are frequently easier for an infant or young child to respond to

thresholds that are 5 to 10 dB softer than those obtained with

warble tones.

In addition to tonal thresholds, speech perception testing provides critical information. Speech awareness thresholds are critical for infants who cannot perform more advanced speech perception

tasks. Thresholds to low-frequency (“ba”), mid-high-frequency (“sh”), and high-frequency (“s”) speech stimuli can be used to conﬁrm warble tone/noise band thresholds. The threshold for “ba” should be close to the child’s best threshold in the 250 to 1,000-Hz range; “sh” should be close to the best threshold obtained at the

2.000 to 4.000-Hz range, and “s” should be close to the best threshold obtained in the 3,000 to 8,000-Hz range. referenced, calibrated, recorded Ling-6 speech sounds have been

developed and are available for use in clinical settings.48 These cal-

ibrated Ling-6 sounds may be presented with the use of a compact

disc player or computer. The use of recorded stimuli, rather than live voice presentation, allows for greater precision, standardization, and reliability in the assessment process. A broadband speech stimulus, such as running speech or music, is not a good

test stimulus, since it is not frequency-speciﬁc and cannot provide information that could be useful in ﬁtting technology or in devel-

oping a management protocol. However, it is sometimes useful in training a child for frequency-speciﬁc testing. (See Chapter 9 for more detailed information about speech perception testing.)

For infants being tested using VRA, speech awareness thresholds to low-, mid-high-, and high-frequency speech stimuli can be

used to conﬁrm warble tone/noise band thresholds. Some older

infants using VRA may be able to point to body parts or familiar toys to obtain a speech reception threshold.

For older children, if a child responds to speech (e.g., if the child answers when called), it may be best to begin with a speech

stimulus (e.g., “beep, beep” or “Hi Josh”), since it may be more

interesting for the child. For children who can perform CPA, the

easiest response may be the command “Put it in.” The child will

understand the verbal command and learn the task easily. Use of

13,15,19

and may provide

15,19,46,47

Of note, norm-

a speech stimulus will provide a speech awareness threshold but

will not give any frequency-speciﬁc information. Once the child is

conditioned to the listen-and-drop task, change the stimulus to tones or narrowband noise to obtain an audiogram.

If the child displays some developmental concerns, such as autism spectrum disorder, the child may not respond to speech stimuli. In that case, testing should begin with tones, noise bands, or music. (See Chapter 8, Evaluation of Hearing in Children with Special Needs.)

7.7.3 Test Order

Test protocol needs to take into consideration the fact that infants and children are not always very cooperative. Testing should begin with the tasks that require the least cooperation

and move on to more dicult tasks as the child becomes more

comfortable. Earphone testing is critical. Whenever possible, testing should begin with earphones. That said, some children will resist earphones and it may be easier to begin testing in

soundﬁeld, obtain two or three thresholds, and then move to

earphones. Remember, once earphones are used, twice as many thresholds are required. That is, twice as many responses from the child are necessary to obtain an audiogram because each frequency needs to be tested for both ears. A good protocol is to start at 2,000 Hz in one ear and then move to 2,000 Hz in the

other ear. Then repeat at 500 Hz. By alternating between ears it

is possible to get a good idea of hearing in both ears even if not all thresholds are obtained at every frequency in both ears.

If conductive hearing loss (CHL) is the concern, begin with a high-frequency stimulus, which should be more easily heard. If the concern is that the child might have a sensorineural hearing loss (SNHL), begin with a low-frequency stimulus, since hearing is often better in the low frequencies in such cases.

When the audiologist is ready to try earphone testing, a decision needs to be made about what kind of headphones to use. Insert

earphones are the earphones of choice and will deﬁnitely be in

the right place (directly in the ear canal), but they require more

eort to insert, and poking at the child’s ears may be distressful

to the child. Nevertheless, whenever possible, it is best to attempt to persuade the child to accept insert earphones because they will provide the best test results.11 Insertion of earphones can be accomplished by having one person (likely a parent) distract the child with a toy, gently holding the child’s arms down, while a second person inserts the earphones.

Regardless of the type of hearing loss suspected, an attempt should be made to obtain bone conduction thresholds. Once the child accepts the bone vibrator, thresholds are usually easy to obtain. If time or attention is a problem, two to three thresh-

olds should be sucient. For CHL, the most critical thresholds to obtain by bone conduction are probably 250, 500, and 2,000 Hz. If hearing loss is sensorineural, 500, 2,000, and 4,000 Hz are

probably the most critical frequencies to test by bone conduction. It is not unusual with SNHL to have bone conduction thresholds at levels that are better than air conduction thresholds in the low frequencies, probably as a result of a tactile (not auditory) response. If a standard bone conduction headband of metal is used, a piece of foam should be used to make it more comfortable

and to improve ﬁt. A Velcro headband can also be used; this is

often more comfortable for little heads.

7 Behavioral Evaluation of Hearing in Infants and Children

7.7.4 Presentation of Test Stimuli

Many normal-hearing infants respond better to high-frequency stimuli, so it is reasonable to begin at a high frequency, usually

2,000 Hz. After obtaining thresholds at 500 and 2,000 Hz, make

a determination about how to proceed. For example, if thresholds

at both 500 and 2,000 Hz are normal, it would be more important to obtain a threshold at 4,000 Hz than at 1,000 Hz, since hearing is likely also to be normal at 1,000 Hz. However, if hearing at 500 Hz is at 30 dB HL and hearing at 2,000 Hz is at 70 dB HL, it would be very

important to know what hearing is at 1,000 Hz. Fig. 7.10 shows an

audiogram with information obtained from dierent transducers. Some thresholds were obtained in soundﬁeld, some with insert

earphones and some with bone conduction. Taken together, it provides a fairly complete picture of how the child hears.

Presentation of stimuli should begin at a soft level, slightly above where you expect the infant to respond, and then should be increased in 10-dB steps until a response is observed. The initial stimulus should not be so loud as to startle the infant. If the

initial stimulus is much louder than threshold, it may be dicult

to regain the infant’s attention to threshold-level stimuli. When the infant responds, decrease and increase intensity in 10-dB

steps, and when close to estimated threshold, move to 5-dB steps.

Especially with infants, no response should be recorded until it is observed at the same level three times.

Timing is critical. If stimuli are presented too quickly, the infant will ignore them. A sound that comes out of silence is more likely to elicit a response. To obtain reliable responses, it is important to observe the infant carefully. If an infant startles to a sound, it is

probably signiﬁcantly above threshold. The way the baby responds

when the stimulus is loud will provide clues about the type of response and latency that can be expected. This information can be used to interpret responses when the stimulus intensity decreases.

7.7.5 Test Room Setup

For many infants and children, testing is most easily accomplished using two testers in a two-room test setup. One audiologist will present test stimuli from the control room, and the second audiologist or audiology assistant will work with the child in the test room.

When earphone testing is being performed, it is possible to have

one tester sit next to the child in the sound room and act as both

tester and test assistant. In a one-tester situation, it is dicult to test hearing in soundﬁeld or to perform speech perception testing.

7.7.6 Testing Children with Hearing Loss

Children with mild or moderate hearing loss or with CHL do not require any special test adaptation, except that the audiologist may need to be creative in keeping the child entertained and cooperative through repeat testing. However, children with

severe and profound hearing loss, especially if not identiﬁed

in infancy, may need some test adaptations. The probe from the insert earphones can be attached directly to their personal earmolds for comfort. If the child does not respond at the audiometric limits, it may be possible to obtain a response using a bone vibrator held either in the child’s hand, on the knee, or on the mastoid. No matter how severe a child’s hearing loss, she will

feel the vibrator at 250 Hz, since this is a tactile stimulus, not an

auditory one. Once the child responds consistently to the tactile

stimulus, begin testing with earphones at 250 or 500 Hz. Insert

earphones are preferable. (For more information, see Chapter 8, Evaluation of Hearing in Children with Special Needs.)

Fig. 7.10 Audiogram with dierent information from dierent

transducers.

7.7.7 The Role of the Audiology Assistant

The audiology assistant plays a critical role in all behavioral testing (see Chapter 12). Testing of infants and young children is best accomplished by two testers. The audiology assistant is responsible for managing the infant or child (positioning, playing, and keeping the child cooperating), keeping the test room neat and organized, and being a second pair of eyes in observing the child. An experienced audiology assistant will make testing

most ecient.

In BOA, the second observer (audiologist or audiology assistant) typically sits next to the infant. Both testers need to be able to see the infant’s mouth easily. The audiology assistant will monitor the infant to be certain that the baby’s head and torso are comfortably balanced to minimize or preclude fussing and straining.

older infants, or infants using a bottle or a paciﬁer, the audiology

assistant keeps the infant focused at the midline, so that the infant is comfortable and not distracted. The audiology assistant will be one of the observers who judges whether or not the infant responded to the sound presentation by changing sucking behavior.

Accurate VRA depends on the ability of the examiner or audiology assistant to keep the child attentive. An audiologist, audiology assistant, or parent needs to be responsible for keeping the infant

15,19

For

II Diagnosing Hearing Disorders in Infants and Children

facing forward so that a conditioned head turn can be clearly iden-

tiﬁed as such, for assisting in training the head-turning response,

and keeping the child interested to facilitate as many responses to sound as possible.

When an audiology assistant is not available, parents or caregivers can often be very good at this task. The older the child is, the more likely it is that a parent can act as the audiology assistant. With limited instruction, parents can frequently do this job very well, especially with typically developing children. They know their children well and know how to entertain them. If a parent is going to have the responsibility of distracting the child, she needs to be told to be relatively quiet so as not to interfere with presentation of test stimuli. Even more critical, she must understand that she must not react to the sound in any way that might cue the child. Instructions for the parent or the test assistant should include the following: Don’t respond to the sound, don’t look at the

reinforcement toy until after the child does, don’t change your body language when the sound is presented, and don’t alter the way you are playing with the toys when the sound is presented.

7.7.8 What to Do If the Child Will Not

Cooperate

A child is a child. Especially with a very young child, the audiologist, not the child, should be in control. If testing cannot be accomplished, the audiologist needs to accept responsibility and

say “I was not able to test this child” rather than “This child is not testable.” Owning responsibility for a test failure encourages

the audiologist to try many procedures before giving up. There are some children from whom it is not possible to obtain good cooperation. However, there should be very few children for whom little or no information is available at the end of a test session. The answer to the question of what to do if the child will not cooperate really starts with what not to do. First, do not

oer choices that are not bona ﬁde choices. For example, do not

ask the child whether he wants to have a hearing test or whether he wants to put on earphones when there actually is no choice

about the matter. Genuine choices can be oered about which of

two games the child wants to play or whether he wants to start testing with words or beeps. Those are realistic choices that can permit the child to feel he has some control over the situation.

Next, do not give up. If cooperation is dicult to obtain, try

taking a short rest. Have the child go for a walk or take a drink from the water fountain and then try again. Try some new toys. Try a new audiology assistant. Perhaps a parent would be a

better test assistant for a particular child. Try using dierent test

stimuli to make the game more interesting; children need to be

entertained. Try a dierent test room or a dierent chair, or allow

the child to sit on a parent’s lap.

Do not try to use a dierent test technique if that dierent technique is not appropriate. For example, if a child is cognitively

at 3 to 4 years of age, do not try to use VRA. Although the older

child may make a few responses using VRA, the child will quickly become bored and results will be unreliable. It will not be possi-

ble to obtain more than a few responses, and it will be dicult

to determine whether the responses were really at threshold. However, VRA reinforcers may be used to support the play task. Tell the uncooperative child that if he cooperates, the toy will be turned on.

Pitfall

When a child is not cooperating, it is tempting to try a dierent

test protocol, such as moving from play audiometry to VRA. This is almost always a bad choice. If the child is cognitively old enough to do CPA, testing with VRA will give inaccurate test results and may suggest hearing loss that is not present.

Other “bribes” may also be useful. Promises such as “after

we are ﬁnished you can have . . .” work very well. Possible

rewards include stickers, stamps, food, and candy. Sometimes

it is useful to oer the treat during testing. Providing occasional

tangible reinforcement during the test session (in addition to the audiologist cheering the child on) if the child seems to be fading (such as a piece of a cookie, fruit, raisins, cereal, or candy) may prolong the child’s cooperation. As with all other promises, when a child is told that something will or will not occur, the

promise should be fulﬁlled. For example, if a sticker is promised after putting ﬁve blocks in the box, be sure to provide the sticker after exactly ﬁve blocks. If the child is told he cannot leave until the game is ﬁnished, that promise too, needs to be kept. (You

may not complete the test, but you may get one or two more thresholds so that the child understands that you are in charge.) In other words, think about what is promised to children before the words are spoken, and be prepared to carry out any promises that are made.

ving some indication about how long the task will take is very

Gi useful. The audiologist can say something like “When all of these marbles are put in the jar, we will be ﬁnished.” Children have no

idea how long an audiometric test will take unless a concrete referent is provided for them.

7.7.9 Parents in the Test Room

Under most circumstances, parents should be involved in testing. Their role will be limited, but they are a source of comfort for the child. In addition, seeing how the child performs and hearing what the child can and cannot hear is very helpful when counseling about test results. When two parents accompany a child, one can sit with the child and the other can observe from the control room. Having a parent on the control room side permits the audiologist to point out events and behaviors that are happening during testing that will assist in later counseling. For

example, pointing out that a child is having increased diculty

hearing the soft speech signal may help the parent understand

the eect of hearing loss.

On the other hand, for some children, having a parent in the test room reduces cooperation. Some parents have a parenting style that does not require the child to carry out tasks he does not want to complete. For some parents, if the child becomes distressed or frustrated, the parent will remove the child from the situation rather than have the child be distressed. If that is the case, it may be best to have the parent leave the room and watch from the control room. As a last resort, and one that should be used only very, very rarely, it is sometimes necessary to tell children that if they do not cooperate, the parent will have to wait outside. Sending the parent out for a short time may increase

7 Behavioral Evaluation of Hearing in Infants and Children

the child’s cooperation. Removing parents is not a procedure

that should be tried on a ﬁrst visit, but it may be considered at

a reevaluation if testing cannot be accomplished because of the child’s uncooperative behavior.

7.8 Conclusion

With a little creativity, behavioral testing is easy to accomplish with children. Be optimistic about what is possible to accomplish. Expect to be able to obtain test results on infants and children of any age and any developmental status. Work to improve testing skills to enable you to obtain accurate test results. Include parents in the testing process to assist them in understanding audiologic results. Communicate with all clinicians working with families to ensure that children are receiving optimal services.

Discussion Questions

1. How do you determine the appropriate test protocol for

infants of dierent ages?

2. Discuss ways to maximize BOA testing.

3. Describe the conditioning paradigm for VRA testing

4. Discuss ways of improving attention to the task for infants and

children of dierent ages.

5. What are some techniques for persuading a child to cooperate when he is not interested in doing so?

6. What are the steps in deciding what frequencies to test and in what order for a child with suspected SNHL? For a child with suspected CHL?

References

[1] Joint Committee on Infant Hearing of the American Academy of Pediatrics. Year

2007 position statement: principles and guidelines for early hearing detection

and intervention programs. Pediatrics 2007;120(4):898–921

[2] Joint Committee on Infant Hearing of the American Academy of Pediatrics; Muse

C, Harrison J, et al. Supplement to the JCIH 2007 position statement: principles and guidelines for early intervention after conﬁrmation that a child is deaf or

hard of hearing. Pediatrics 2013;131(4):e1324–e1349

[3] Appuzzo ML, Yoshinaga-Itana C. Early identiﬁcation of infants with signiﬁcant

hearing loss and the Minnesota Child Development Inventory. Semin Hear

1995;16(2):124–139

[4] Yoshinaga-Itano C, Coulter D, Thomson V. Developmental outcomes of children

with hearing loss born in Colorado hospitals with and without universal newborn hearing screening programs. Semin Neonatol 2001;6(6):521–529

[5] Dillon H, Cowan R, Ching TY. Longitudinal outcomes of children with hearing

impairment (LOCHI). Int J Audiol 2013; 52(2, Suppl 2):S2–S3

[6] Sininger YS. Evaluation of hearing in the neonate using the auditory brainstem

response. In: Consensus Development Conference on Early Identiﬁcation of Hearing Impairment in Infants and Young Children. Bethesda, MD: National Institutes of Health; 1993:95–97

[7] Nicholas JG, Geers AE. Spoken language beneﬁts of extending cochlear implant

candidacy below 12 months of age. Otol Neurotol 2013;34(3):532–538

[8] Tomblin JB, Harrison M, Ambrose SE, Walker EA, Oleson JJ, Moeller MP. Lan-

guage outcomes in young children with mild to severe hearing loss. Ear Hear 2015;36(Suppl 1):76S–91S

[9] Sharma A, Dorman MF, Spahr AJ. A sensitive period for the development of the

central auditory system in children with cochlear implants: implications for age of implantation. Ear Hear 2002;23(6):532–539

[10] Sharma A, Campbell J, Cardon G. Developmental and cross-modal plasticity

in deafness: evidence from the P1 and N1 event related potentials in cochlear implanted children. Int J Psychophysiol 2015;95(2):135–144 Amer

[11]

ican Academy of Audiology. Audiologic guidelines for the assessment of

hearing in infants and young children. https://audiology-web.s3.amazonaws.com/

migrated/201208_AudGuideAssessHear_youth.pdf_5399751b249593.36017703.

. 2012. Accessed December 11, 2017

pdf

[12] Delaroche M, Thiebaut R, Dauman R. Behavioral audiometry: protocols for mea-

suring hearing thresholds in babies aged 4-18 months. Int J Pediatr Otorhinolaryngol 2004;68(10):1233–1243

[13] Gravel J. Audiologic assessment for the ﬁtting of hearing instruments: big

challenges from tiny ears. In: Seewald RC, ed. A Sound Foundation through

Early Ampliﬁcation: Proceedings of an International Conference. Nashville, TN: Vanderbilt-Bill Wilkerson Press; Phonak, AG; 2000:33–54

[14] Hicks CB, Tharpe AM, Ashmead DH. Behavioral auditory assessment of young

infants: methodological limitations or natural lack of auditory responsiveness?

Am J Audiol 2000;9(2):124–130

[15] Madell JR. Using behavioral observation audiometry to evaluate hearing in

infants from birth to 6 months. In: Madell JR, Flexer C, eds. Pediatric Audiolo-

gy: Diagnosis, Technology, and Management. 2nd ed. New York, NY: Thieme;

2014:68–78

[16] Gravel JS, McCaughey CC. Family-centered audiologic assessment for infants and

young children with hearing loss. Semin Hear 2004;25(4):309–317

[17] Bess FH, Humes LE. Audiology: the fundamentals. 3rd ed. Philadelphia, PA:

Lippincott Williams & Wilkins; 2003

[18] Jerger JF, Hayes D. The cross-check principle in pediatric audiometry. Arch Oto-

laryngol 1976

[19] Madell JR. Behavioral Evaluation of Hearing in Infants and Young Children. New

York, NY: Thieme; 1998

[20] Martin FN, Clark JG. Behavioral hearing tests with children. In: Martin FN, Clark JG.

Hearing Care for Children. Needham Heights, MA: Allyn & Bacon; 1996:115–134

[21] Thompson M, Thompson G, Vethivelu S. A comparison of audiometric test meth-

ods for 2-year-old children. J Speec

[22] Lidén G, Harford ER. The pediatric audiologist: from magician to clinician. Ear

Hear 1985;6(1):6–9

[23] Flexer C, Gans DP. Distribution of auditory response behaviors in normal infants

and profoundly multihandicapped children. J Speech Hear Res 1986;29(3):425–429

[24] Widen JE. Adding objectivity to infant behavioral audiometry. Ear Hear

1993;14(1):49–57

[25] Olsho LW, Koch EG, Carter EA, Halpin CF, Spetner NB. Pure-tone sensitivity of

human infants. J Acoust Soc Am 1988;84(4):1316–1324

[26] Ewing JR, Ewing AWG. The ascertainment of deafness in infancy and early child-

hood. J Laryngol Otol 1944;59(9):309–333

[27] Downs MP, Sterritt GM. Identiﬁcation audiometry for neonates: a preliminary

report. J Aud Res 1964;4(2):69–80

[28] Berg KM, Smith MC. Behavioral thresholds for tones during infancy. J Exp Child

Psychol 1983;35(3):409–425

[29] Eisele WA, Berry RC, Shriner TH. Infant sucking response patterns as a conjugate

function of changes in the sound pressure level of auditory stimuli. J Speech Lang

Hear Res 1975;18:296–307 [30] Olsho LW. Infant frequency discrimination. Infant Behav Dev 1984;7(1):27–35 [31] Werner LA, Gillenwater JM. Pure tone sensitivity of 2- to 5-week old infants.

Infant Behav Dev 1990;13(3):355–375 [32] Suzuki T, Ogiba Y. Conditioned orientation reex (COR) audiometry. Arch Otolar-

yngol 1961;74(2):192–198 [33] Lidén G, Kankkunen A. Visual reinforcement audiometry. Acta Otolaryngol

1969;67(2):281–292 [34] Wilson WR, Moore JM. Pure-tone earphone thresholds of infants utilizing visual

reinforcement audiometry (VRA). Paper presented at American Speech and

Hearing Association Convention, San Francisco, CA: 1978

[35] Wilson WR, Moore JM, Thompson G. Sound-ﬁeld auditory thresholds of infants

utilizing visual reinforcement audiometry (VRA). Paper presented at American

Speech and Hearing Association Convention, Houston, TX: 1976 [36] Wilson WR, Thompson G. Behavioral audiometry. In: Jerger J, ed. Pediatric Audi-

ology. San Diego, CA: College Hill Press; 1984:1–44 [37] Primus MA, Thompson G. Response strength of young children in operant audi-

ometry. J Speech Hear Res 1985;28(4):539–547 [38] Primus MA. Repeated infant thresholds in operant and nonoperant audiometric

procedures. Ear Hear 1991;12(2):119–122 [39] Moore JM, Thompson G, Thompson M. Auditory localization of infants as a func-

tion of reinforcement conditions. J Speech Hear Disord 1975;40(1):29–34

;102(10):614–620

h Hear Disord 1989;54(2):174–179

II Diagnosing Hearing Disorders in Infants and Children

[40] Schmida, M, Peterson, H, Tharpe, AM. Visual reinforcement audiometry using

digital video disc and conventional reinforcers. AJA 2003:12, 35–40

[41] Diefendorf AO, Gravel JS. Behavioral Observation and Visual Reinforcement

Audiometry. Washington DC: Gallaudet University Press; 1996

[42] Widen J. Behavioral audiometry with infants. In: Seewald R, Tharpe AM.

Comprehensive Handbook of Pediatric Audiology. San Diego, CA: Plural;

2011:483–493

[43] Thompson G, Folsom RC. A comparison of two conditioning procedures

in the use of visual reinforcement audiometry (VRA). J Speech Hear Disord

1984;49(3):241–245

[44] Hoversten G, Lowell EL, Rushford G, Stoner M. Evaluation of pure tone audiome-

try with preschool age children. J Speech Hear Disord 1956;21(3):292–302 [45] Neumann S, Smith J, Wolfe J. Conditioned play audiometry: It should be all fun

and games. HearJ 2016;69(4):34,36,37 [46] Ling D. Speech and the Hearing Impaired Child. 2nd ed. Washington DC: Alexan-

der Graham Bell Association for the Deaf and Hard of Hearing; 2002 [47]

Madell JR. Speech audiometry for children. In: Gerber SE, ed. Handbook of Pedi-

atric Audiology. Washington, DC: Gallaudet University Press; 1996:84–103 [48] Scollie S, Glista D, Tenhaaf J, et al. Stimuli and normative data for detection of

Ling-6 sounds in hearing level. Am J Audiol 2012;21(2):232–241

<<< < Предыдущая 1 2 3 4 5 6 7 8 9 1011 / 4311 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
31.08.202641 Мб0Книга_4479_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202641 Мб0Книга_4480_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202640 Мб0Книга_4482_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202640 Мб0Книга_4484_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202639 Мб0Книга_4487_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202638 Мб0Книга_4488_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202638 Мб0Книга_4489_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202636 Мб0Книга_4492_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202636 Мб0Книга_4493_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202636 Мб0Книга_4495_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202636 Мб0Книга_4496_Библиотеки_им_академика_М_И_Перельмана.pdf