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5 Newborn Hearing Screening
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.
5.2.4 Communicating with Stakeholders
Because many people have a stake in the results of a newborn
hearing screening program, it is essential for the success of the
program to make sure these people receive timely information.
Communicating with Parents
Communication with the baby’s parents is critical because they
have long-term responsibility for ensuring that the baby receives
appropriate care and also have the strongest feelings (but usually
limited experience) about what it means to have a child with
hearing loss. Therefore, it is essential that each parent be told
the results of their baby’s hearing screening test. Telling parents
about the results should involve more than saying that the baby
passed or failed. Instead, parents need to know what the result
means and what the next steps should be. Even when the baby
passes a screening test, the meeting to communicate this result
to parents is a great opportunity to help them understand the
importance of monitoring language development and of being
aware of the indicators of hearing loss that might occur later.
Most successful newborn hearing screening programs use a variety of materials to educate, inform, and follow up with parents.
A 6-minute video that explains how newborn hearing screening
is done, why it is important, what the results mean, and what
should happen next can be downloaded at no cost (in both
English and Spanish) from NCHAM.32 Other examples of parent
information include pamphlets about the screening program,
letters sent to parents about the results of the test, and cards
used to make return appointments for rescreens or diagnostic
evaluations. Examples of such materials currently being used in
other programs are available from NCHAM.
It is best if parents can be told about the results of the newborn
hearing screening before the baby is discharged. Then their questions can be answered and additional testing can be scheduled
before the parents leave the hospital. Some health care providers
want to be involved in communicating results of screening tests to
parents; others do not. Therefore, make sure you have discussed
your procedures for informing parents with health care providers
in your community.
Some writers have worried about creating unnecessary anxiety
in parents because most babies who fail the initial newborn hearing screening test will be false positives (in other words, they have
normal hearing even though they failed the test). This is expected,
and when screening is done correctly, it is not a problem.33 To avoid
creating unnecessary anxiety, make sure parents understand that
the screening test is not a diagnostic evaluation and that a referral
for further testing does not mean that the baby has a hearing loss.
A newborn hearing screening program provides an ideal opportunity to help parents understand the importance of language
development. Just because a child has passed a newborn hearing
screening test does not mean that there will not be future problems with hearing or language development. In fact, at least twice
as many young children acquire hearing loss by the time they
enter school as are born with hearing loss.34 Materials distributed
in conjunction with the newborn hearing screening should
emphasize the need to monitor the child’s language development
and what parents should do if the child does not achieve developmental milestones in a timely manner. It should also be clear that
28
the newborn hearing screening test provides information about
the status of the infant’s hearing at the time of discharge and does
not predict what might happen later. Common childhood illnesses
can cause temporary or permanent hearing loss that will interfere with language development. Educational materials should
emphasize the importance of parents’ requesting another hearing
evaluation if they have any concerns about the child’s language
development.
Pitfall
Some parents mistakenly assume that babies who pass the
newborn hearing screening test will always have normal hearing.
Babies can have normal hearing at birth and acquire permanent
hearing loss later in childhood.
Communicating with Health Care Providers
From the very beginning, the child’s primary health care
provider needs to understand how newborn hearing screening
contributes to better health care. Distributing written materials
to all primary health care providers in the community who see
children is a good beginning. When a baby with hearing loss
is identified, the results must be communicated to that baby’s
health care provider. Periodically, reports can be sent to the
hospital’s medical sta to inform them about the success of the
program. Personal experiences of families whose babies have
been helped by the program are particularly useful.
It is also important to have a system to notify each health
care provider about the screening results for his or her patients.
Although this is particularly important for babies who do not
pass the initial screening, it is best to provide information
about all babies along with a clear recommendation of what
should happen next. The success of a newborn hearing screening program will be seriously impaired if health care providers
tell parents during well-baby checks that it is really not that
important to follow up with the outpatient screen or diagnostic
evaluation procedures. Health care providers should encourage
parents to complete recommended testing as quickly as possible. Additionally, if parents have concerns about their baby’s
hearing or language development, they should be encouraged
to see an audiologist who has experience working with
infants and young children. It is also important that everyone
involved in the baby’s medical management understand how
detrimental it is when the diagnostic process requires several
months, instead of being completed within a few weeks. For
babies without other medical complications, the goal should be
to have a definitive diagnosis, to be fitted with hearing aids (if
parents choose to do so), and to begin early intervention within
a few weeks of birth. For that to happen, however, all members
of the team have to recognize the importance of early diagnosis
and intervention and then work together to make it happen as
quickly as possible.
61
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.
Communicating with Hospital Administrators
and Sta
Hospital administrators, risk managers, nursery supervisors,
and community education sta need to be kept informed about
the newborn hearing screening program. If key people in the
hospital are receiving the information they need on a timely
basis, the continuation of the newborn hearing screening pro-
gram is almost guaranteed, because the benefits will be well
documented and many dierent groups can work to support
and improve the program. It is also important to make sure that
hearing screening results are a part of the child’s permanent
medical record.
Having an eective data management system is important
for being able to produce regular reports to show information
such as the percentage of babies screened, the percentage who
passed prior to discharge, the percentage who failed the initial
screening and received diagnostic evaluations, and the number
of babies identified with permanent hearing loss. It is also useful
to produce a monthly report summarizing the successes of the
program, the challenges that still need to be addressed, and
the strategies for resolving those challenges. It is particularly
valuable to highlight success stories so that administrators see
that people’s lives are better o as a result of this program. Many
administrators will also want to know more about program costs.
A simple, but complete, cost analysis of the program at periodic
intervals is very useful.
Pearl
Accurate reporting about key variables related to the newborn
hearing screening program is valuable in identifying weaknesses
and in improving the program as well as in building support
among various stakeholders.
people (e.g., all of the nursing sta). Not only does this require
extra time for training and supervision, but it often results in a
less ecient program, because responsibility for screening babies
is diused and the quality of screening suers.
Although it is often said that practice makes perfect, it is more
accurate to say that practice makes permanent. Consequently, it
is important to provide timely feedback to people who are just
learning to screen so that errors can be corrected before they
become ingrained. Subsequently, there should be regular oneon-one observation and feedback. A regular report that shows
each screener’s performance with regard to variables such as
the number of babies screened, babies passed, invalid tests, and
screens completed per hour of work can be useful in identifying
screeners who are having diculty and need assistance. Such
supervision should be organized so that it is viewed as assistance
instead of punishment.
5.2.6 Operating an Ecient Program
Regardless of the type of technology or protocol used, the goal of
newborn hearing screening is to create the smallest reasonable
subset of the general population that needs more intensive diagnostic assessments without missing any babies with hearing loss.
The following strategies should be considered to ensure that most
of the babies with normal hearing will pass the screening test.
Do Screening When Babies Are Quiet
Even though it is possible to screen babies who are awake and
restless, screening is easier and quicker when the baby is quiet (or
screening should be done when babies are most likely to be in this
optimal state. When and where screening is done will depend on
other activities, routines, and available space at the hospital.
5.2.5 Training Newborn Hearing
Screeners
Regardless of which screening equipment or protocol is
used, screeners will become proficient much faster if there is
hands-on, competency-based training. Sales representatives can
demonstrate how to operate the screening equipment, but the
best training is done by people who are experienced screeners.
Ideally, such training should include ample time for the people
being trained to do supervised screening. Once a person acquires
skill with the screening equipment, it is easily remembered.
An interactive online training module (the Newborn Hearing
Screening Training Curriculum [NHSTC]) is available at no cost
from NCHAM.
The number of screeners needed for a universal newborn hearing screening programs depends on the number of births and how
the program is organized. Because some babies are discharged just
a few hours after being born, seven-day-a-week coverage will be
needed. However, the total amount of screening time is relatively
small. Many hospitals make the mistake of training too many
35
Test Multiple Times Before Discharge for
Babies Who Do Not Pass
Typically, the first attempt to screen the baby is made shortly
after birth. It is best not to spend too much time with the baby
during this initial attempt. If the baby passes (as the majority
will do), screening is finished. If not, wait several hours and try
again. Regardless of the equipment or protocol being used, these
second eorts before discharge can substantially reduce the
number of babies who need to come in for outpatient screens
or diagnostic procedures. Instead of spending 30 minutes with
the baby during an initial attempt, it is much more ecient to
make a quick first attempt, followed by a second or even third
attempt a few hours later. In most cases, it is not an ecient use
of time to screen a particular baby more than three or four times
in each ear before discharge. However, there is no evidence that
screening a baby too many times will lead to passing babies who
have a hearing loss.
36
Minimize Noise and Confusion in the Screening
Area
It is not necessary to take extraordinary measures to make the
screening area quiet. Newborn hearing screening is routinely
62
5 Newborn Hearing Screening
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.
done in crowded and noisy environments such as neonatal intensive care units. However, other things being equal, screening will
be faster and more eective if the screening area is relatively
quiet. Where possible, do the screening when physicians are not
making their rounds; do not screen directly under a ventilator
fan; and screen in an area that is not adjacent to a bathroom,
where running water creates unnecessary noise. Where sensible
and inexpensive modifications can be done to reduce noise (e.g.,
carpeting on the oor, curtains on windows), screening will be
easier to do.
Have Backup Equipment and Supplies Readily
Available
Because some babies are discharged after just a few hours in
the nursery, arrangements should be made to have a backup in
case there is an equipment breakdown. Most newborn hearing
screening equipment is extremely reliable. However, if the equipment unexpectedly stops operating and it takes 3 days to get a
replacement, 10% of the babies born at the hospital that month
will be missed. Although such babies can come back for screening, it is extra work for everyone and unlikely to be completely
successful. Thus, it is best to have made arrangements to obtain
replacement or loan equipment within a very short time from
the salesperson, a neighboring hospital, or a nearby university.
Pitfall
information management is not handled appropriately, it can be
much more time-consuming than the actual screening.
Arranging for a data and patient information management
system is the kind of task on which it is easy to procrastinate.
The amount of information that needs to be managed continues
to multiply as more and more babies are born. If a system is not
in place when the screening program starts, screening personnel
will soon find that they are overwhelmed, and the whole system
can collapse in piles of paper and yellow sticky notes.
Summarizing data from individuals into understandable
reports, generating letters to parents and health care providers
based on the most recent outcomes, and sending reminders about
upcoming and overdue screening and diagnostic activities are all
easily done with a computer-based program. Information about
several data and patient information packages that can be used for
newborn hearing screening programs is available from NCHAM.
37
5.2.8 Program Coordination
The person in charge of the newborn hearing screening program
needs a continual ow of information, including:
The number of births at the hospital and the percentage of
•
those babies screened
The percentage of babies who fail the screening test
•
The percentage of babies who completed diagnostic evaluations
•
The number of babies identified with hearing loss
•
Performance metrics for each screener
•
It is possible to become so xated on achieving very low “fail”
rates that the quality of the program suers. Remember, the
object of a newborn hearing screening program is to nd all
babies with permanent hearing loss, not to have every baby pass
the screening test.
5.2.7 Managing Data and Patient
Information
Ensuring that babies with hearing loss are enrolled as quickly as
possible in appropriate intervention programs requires coordination with the baby’s medical home, audiologist, and various state
and local agencies who are responsible for providing services
to infants and young children with hearing loss. The screening
that happens before hospital discharge is only the first step. Most
screening program managers report that keeping track of what
happens in the screening program and managing babies through
the referra l and diagnostic process are the most challenging parts
of an EHDI program. Data and patient information management
includes keeping track of which babies have been screened, what
screening or diagnostic procedures should happen next, and
which babies have missed appointments and need to be located.
It also involves generating reports for program management,
accountability, and program continuation and generating letters
to parents and physicians concerning the outcome of various
screening and evaluation procedures. If such data and patient
Regular and timely summaries of such information are critical
for a successful program. There should be regular coordination
meetings to review such information. This meeting should be
attended by the program coordinator, a representative of the
screening sta, the nursery coordinator, an audiologist who
is involved with the program, and a health care provider who
cares for newborns. The purpose of the meeting is to review the
functioning of the program to make sure that its goals are being
accomplished. Results from a computer-based tracking and data
management program will provide all of the necessary information, but the meeting must still be convened and follow-up done.
An
ecient newborn hearing screening program will identify
about 3 babies per 1,000 with permanent hearing loss.29 However,
because hearing loss is a low-incidence condition, it may take
10,000 or more babies to achieve that average. In other words, it
is not unusual for a hospital to screen 1,000 babies and not find
a single infant with permanent hearing loss. That same hospital,
however, may find 5 or 6 infants in the next 1,000 babies screened.
Pearl
Don’t be discouraged if it takes a while to identify the rst baby
with a hearing loss.
63
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.
Discussion Questions
1. What factors have contributed to the dramatic increase in
percentage of newborns screened for hearing loss during the
past 15 years?
2. What other components of an EHDI system are important to
have in place to make newborn hearing screening eective?
3. Why is it important for stakeholders to know that newborn hearing screening is considered to be a medical “standard of care”?
4. In what ways does an eective data management and tracking
system contribute to a successful newborn hearing screening
program?
5. What advice would you give to a hospital that wants to reduce
the unusually high percentage of newborns who fail their
newborn hearing screening test?
6. What information do parents need to know about their baby’s
newborn hearing screening test, and when do they need to
know it?
References
[1] White KR, Blaiser KM. Strategic planning to improve EHDI programs. Volta
Review 2011;111(2):83–108
[2] Babbidge H,Duning L, Edwards GF, et al. Education of the Deaf in the United
States: A Report to the Secretary of Health, Education, and Welfare by His
Advisory Committee on Education of the Deaf. Washington, DC: US Government
Printing Oce. https://eric.ed.gov/?id=ED014188. Published 1965. Accessed
December 6, 2017
[3] Downs MP, Sterritt GM. Identification audiometry for neonates: a preliminary
report. J Aud Res 1964;4:69–80
[4] American Academy of Pediatrics, Joint Committee on Infant Hearing. Year 2007
position statement: principles and guidelines for early hearing detection and
intervention programs. Pediatrics 2007;120(4):898–921
[5] Commission on Education of the Deaf. Toward Equality: Education of the Deaf.
A report to the Congress of the United States. Washington, DC: US Government
Printing Oce. http://archive.gao.gov/t2pbat17/135760.pdf. Published 1988.
Accessed December 6, 2017
[6] U.S. Department of Health and Human Services. Healthy People 2000: National
Health Promotion and Disease Prevention Objectives. Washington, DC: Public
Health Service. https://www.cdc.gov/nchs/healthy_people/hp2000.htm. Published September 1990. Accessed December 6, 2017
[7] National Institutes of Health. Early Identification of Hearing Impairment in In-
fants and Younger Children. Rockville, MD: National Institutes of Health. https://
consensus.nih.gov/1993/1993hearinginfantschildren092html.htm. Published
March 1993. Accessed December 6, 2017
[8] Bess FH, Paradise JL. Universal screening for infant hearing impairment: not sim-
ple, not risk-free, not necessarily beneficial, and not presently justified. Pediatrics
1994;93(2):330–334
[9] U.S. Preventive Services Task Force. Screening for hearing impairment. In: US
Preventive Services Task Force Guide to Clinical Preventive Services. 2nd ed.
Baltimore, MD: Williams & Wilkins; 1996:393–405. https://www.ncbi.nlm.nih
.gov/books/NBK15501/. Accessed December 6, 2017
[10] White KR, Behrens TR. The Rhode Island Hearing Assessment Project: implica-
tions for universal newborn hearing screening. Semin Hear 1993;14:1–22
[11] Barsky-Firkser L, Sun S. Universal newborn hearing screenings: a three-year
experience. Pediatrics 1997;99(6):E4
[12] Finitzo T, Albright K, O’Neal J. The newborn with hearing loss: detection in the
nursery. Pediatrics 1998;102(6):1452–1460
[13] Mehl AL, Thomson V. Newborn hearing screening: the great omission. Pediatrics
1998;101(1):E4
[14] White KR. Issues & Evidence: Prevalence of Congenital Hearing Loss. http://
www.infanthearing.org/summary/prevalence.html. Updated September 30,
2010. Accessed December 6, 2017
[15] Erenberg A, Lemons J, Sia C, Trunkel D, Ziring P. Newborn and infant hearing
loss: detection and intervention. American Academy of Pediatrics. Task Force on
Newborn and Infant Hearing, 1998–1999. Pediatrics 1999;103(2):527–530
[16] National Center for Hearing Assessment and Management. Position Statements.
http://www.infanthearing.org/resources_home/positionstatements. Updated
October 25, 2016. Accessed December 6, 2017
[17] US Preventive Services Task Force. Universal screening for hearing loss in new-
borns: US Preventive Services Task Force recommendation statement. P
2008;122(1):143–148. doi: 10.1542/peds.2007-2210
[18] Herrmann BS, Thornton AR, Joseph JM. Automated infant hearing screening
using the ABR: development and validation. Am J Audiol 1995;4(2):6–14
[19] Kemp DT. Stimulated acoustic emissions from within the human auditory
system. J Acoust Soc Am 1978;64(5):1386–1391
[20] Lonsbury-Martin BL, Martin GK. The clinical utility of distortion-product oto-
acoustic emissions. Ear Hear 1990;11(2):144–154
[21] National Center for Hearing Assessment and Management. EHDI Legislation:
Overview. http://www.infanthearing.org/legislation. Published 2014. Accessed
December 6, 2017
[22] Moeller MP. Early intervention and language development in children who are
deaf and hard of hearing. Pediatrics 2000;106(3):E43
[23] Yoshinaga-Itano C, Sedey AL, Coulter DK, Mehl AL. Language of early- and later-
fied children with hearing loss. Pediatrics 1998;102(5):1161–1171
identi
[24] Centers for Disease Control and Prevention. National EHDI goals. http://www.cdc
.gov/ncbddd/ehdi/nationalgoals.htm. Published 2004. Accessed January 23, 2017
[25] Council on Children with Disabilities and Medical Home Implementation
Project Advisory Committee. P
framework for integrating care for children and youth across multiple systems.
Pediatrics 2014;133(5):e1451–e1460. doi:10.1542/peds.2014-0318
[26] White KR, Forsman I, Eichwald J, Muñoz K. The evolution of early hearing
detection and intervention programs in the United States. Semin Perinatol
2010;34(2):170–179. doi:10.1053/j.semperi.2009.12.009
[27] White KR. The current status of EHDI programs in the United States. Ment Retard
Dev Disabil Res Rev 2003;9(2):79–88
[28] National Center for Hearing Assessment and Management. Home. http://
infanthearing.org/. Accessed December 6, 2017
[29] White KR. Newborn hearing screening. In: Katz J, Chasin M, English K, Hood LJ,
Tillery KL, eds. Handbook of Clinical Audiology. 7th ed. Philadelphia, PA: Wolters
Kluwer; 2015:437–458
[30] World Health Organization. Newborn and Infant Hearing Screening: Current Is-
sues and Guiding Principles for Action. Outcome of a WHO informal consultation
held at WHO Headquarters, Geneva, Switzerland, 09–10 November 2009. http://
www.who.int/blindness/publications/Newborn_and_Infant_Hearing_Screening_Report.pdf. Published 2010. Accessed December 6, 2017
[31] Winston RL, Roush J. Outsourcing hospital-based newborn hearing screening:
key questions and considerations. J Early Hear Detect Interv 2016;1(1):21–25.
doi: 10.15142/T32P4C
[32] National Center for Hearing Assessment and Management. Video: Giving
Your Baby a Sound Beginning. http://www.infanthearing.org/videos/featured/
sound-beginning.php. Accessed December 6, 2017
[33] Tueller SJ, White KR. Maternal anxiety associated with newborn hearing screen-
[34] Barrett TS, White KR. Prevalence and trends of childhood hearing loss based
[35] National Center for Hearing Assessment and Management. Interactive Web
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Based Newborn Hearing Screening Training Curriculum. http://www
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missed by repeated newborn hearing screening with otoacoustic emissions due
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atient- and family-centered care coordination: a
ediatrics
64
6 Hearing Test Protocols for 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.
Jane R. Madell, Carol Flexer, Erin C. Schafer, and Jace Wolfe
6 Hearing Test Protocols for Children
Summary
This chapter provides an overview of developmentally appropriate procedures for assessing hearing in infants and children.
When testing children, the cross-check principle ensures a valid
and comprehensive assessment of objective auditory system
funct ion as well as behavioral resp onses to auditory stimu li. Steps
to achieving a comprehensive evaluation include obtaining the
case history, selecting an appropriate test protocol, determining
functional auditory performance, and providing family-centered
counseling and education.
Keywords
cross check principle, pediatric test protocols, behavioral
observation audiometry (BOA), visual reinforcement audiometry
(VRA), conditioned play audiometry (CPA), immittance, transient
otoacoustic emissions (TOAE), distortion product otoacoustic
emissions (DPOAE), auditory brainstem response (abr), case
history, functional auditory assessments
Key Points
Pediatric audiologic assessments involve the selection of
•
developmentally appropriate protocols that include the
cross-check principle.
Before testing, the child’s cognitive age and physical status
•
must be determined.
A case history contributes valuable diagnostic information,
•
provides an opportunity to observe the child, and allows a
rapport to be established between the audiologist and the
family.
Functional auditory assessments, in the form of paper-and-
•
pencil surveys, can assist in monitoring the baby’s or child’s
auditory progress over time.
behavioral and electrophysiologic tests must be used to determine
the extent of a child’s auditory function.
furnishes detailed information, avoids drawing conclusions from
a single test, allows for the identification of multiple pathologies,
and provides a comprehensive foundation for observing a child’s
auditory behaviors. Table 6.1 summarizes each test in the pediat-
ric threshold test battery and discusses when each is appropriate.
The purpose of this chapter is to discuss the audiologic tests
in the various pediatric test protocols, to emphasize the need for
behavioral audiologic assessments for all infants and children,
to detail the steps in administering a test protocol (including
selecting the appropriate protocol), to describe obtaining pediat-
ric case histories, and, finally, to summarize functional auditory
assessments.
2,3
A test battery approach
6.2 Pediatric Audiologic Test
Protocols
The American Speech-Language-Hearing Association (ASHA)4
and the American Academy of Audiology (AAA)1 recommend the
following test protocols according to the chronological/developmental age of the child:
1. Birth through 6 months of age (age is adjusted for prematurity):
When infants are very young or experiencing severe developmental disabilities, ASHA and AAA recommend that the testing
of infants or children should rely primarily on physiologic measures of auditory function, such as auditory brainstem response
(ABR) and auditory steady-state responses (ASSR) using frequen-
cy-specific stimuli to estimate the audiogram. The tone burst
ABR is the current gold standard measure of choice for the esti-
mation of hearing thresholds in infants from birth to 6 months
of age. In addition, otoacoustic emissions (OAE) and acoustic
immittance measures should be used to supplement ABR and
ASSR results. Case history, parent/caregiver report, behavioral observation of the infant’s responses to a variety of sounds,
developmental screening, and functional auditory assessments
should also be performed.
6.1 The Cross-Check Principle for
Test Batteries
There are four main purposes for a pediatric audiologic assessment: (1) to obtain a measure of peripheral hearing sensitivity
that rules out or confirms hearing loss as a cause of the baby’s or
child’s problem; (2) to confirm the status of the baby’s or child’s
middle ear; (3) to assess auditory functioning using speech per-
ception measures when possible; and (4) to observe and interpret
the baby’s or child’s auditory behaviors.
To this end, a test battery approach employing the “cross-
check” principle is standard.1 The cross-check principle, originally
described by Jerger and Hayes, posits that several appropriate
Pearl
The authors propose that assessments of an infant’s behavioral
responsiveness to sound should be used routinely to serve as a
cross-check to objective measures (see Chapter 7).
2. Six months through 24 months of age: At these ages, ASH A4 and AA A1
suggest that behavioral assessments should be performed first,
with visual reinforcement audiometry (VRA) being the behavioral test of choice. OAEs may be used in routine assessments, but
ABRs should be conducted when behavioral audiometric tests are
unreliable, ear-specific thresholds cannot be obtained, behavioral
results are inconclusive, or auditory neuropathy is suspected.
65
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.
Table 6.1 A summary of tests used in pediatric assessments
Test Expected infant/
Behavioral
observation
audiometry
(BOA)
Visual
reinforcement
audiometry
(VRA)
Conditioned
play
audiometry
(CPA)
Immittance None All Provides information about middle ear functioning and about
Transient
otoacoustic
emissions
(TOAE)
Auditory
brainstem
response
(ABR)
child response
Change in sucking
in response to
auditory stimulus;
other behavioral
changes are
not accepted
because they
usually indicate
suprathreshold
response.
Conditioned
head turn to a
visual reinforcer,
usually a lighted
animated toy
Motor act by child
in response to
hearing a sound
(e.g., the listen
and drop task)
None All
None All
Cognitive
age range
Birth–6
months
5–36
months
30
months to
5 years
Benets Challenges
Enables the audiologist to obtain valuable behavioral
•
responses in infants; part of the cross-check principle
Can be conducted in sound elds, with earphones or with
•
bone oscillator, hearing aids, or cochlear implants
Enables accurate tting of technology because minimal
•
response levels (MRLs) can be obtained
Enables the audiologist to obtain valuable behavioral
•
responses in infants and young children; part of the crosscheck principle
More responses possible per test session because responses
•
are conditioned
Can be conducted in soundeld, with earphones or with
•
bone oscillator, hearing aids, or cochlear implants
Enables accurate tting of technology because MRLs can
•
be obtained
The state of the infant or child less problematic than in BOA
•
because the child can be more easily involved in the task
Accurate responses possible at threshold level
•
Can be conducted in soundeld or with earphones, with
•
bone oscillator, hearing aids, or cochlear implants
intactness of the auditory system reex arc
Measures outer hair cell function
•
Presence of emissions indicates no greater than a mild
•
hearing loss
Contributes to evaluation of the overall function of the
•
auditory system
Tonal ABR to provide frequency-specic threshold
•
information
Click ABR to provide information about the intactness of
•
the auditory pathways, including measures contributing to
the diagnosis of auditory neuropathy
Requires careful observation of
•
infant sucking by the audiologist
Cannot be used with infants
•
who do not suck (e.g., infants
who use feeding tubes)
Can be performed only when
•
the infant is in a calm awake or
light sleep state
BOA not generally accepted
•
in the audiology community
because audiologists typically
have not been trained to use a
sucking response paradigm
Obtaining individual ear data when
child will not accept earphones
Keeping the child entertained and
involved long enough to obtain all
the necessary information
Necessity for the child to sit still, not
speaking or moving, during the test
battery
Cannot rule out mild hearing loss
Necessity for the infant or child
•
to be asleep, sedated, or very
still for the duration of testing.
Not a direct measure of
•
hearing and not a substitute for
behavioral audiologic testing
Developmental screening and functional auditory assessments
also should be performed; please refer to Table 6.2
for a summary of functional auditory assessments. See Chapter 7
for detailed information about VRA.
3. Twenty-ve months through 60 months of age: ASHA4 and AAA1
suggest that behavioral tests (VRA or conditioned play audiom-
etry [CPA]) and acoustic immittance tests are usually sucient.
OAEs, speech perception tests, and developmental screening and
functional auditory assessments also can be used routinely to
assess this age group.
The expected outcomes of pediatric audiologic protocols are
extensive and include (1) identification of hearing loss; (2) identification of auditory neuropathy, if present, or of a potential central
auditory processing/language disorder; (3) quantification of
hearing status based on behavioral and electrophysiologic tests;
(4) development of a comprehensive report of historical, physical,
5,6,7,8,9,10,11,12,13,14,15
and audiologic findings, and recommendations for treatment
and management; (5) implementation of a plan for monitoring,
surveillance, and habilitation of hearing loss; and (6) provision of
family-centered counseling and education.
6.3 Why Behavioral Audiologic
Tests Need to Be Included in
the Evaluation of All Infants
and Children
The ASHA Portal on Permanent Childhood Hearing Loss4 and
the Audiologic Guidelines for the Assessment of Hearing in
Infants and Young Children1 both suggest that behavioral testing
66
Table 6.2 Functional auditory assessment tools for infants and young 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.
Measurement tool Authors Age range Purpose
Auditory Behavior in Everyday Life
(ABEL)
Children’s Home Inventory for
Listening Diculties (CHILD)
Children’s Outcome Worksheet
(COW)
Early Listening Function (ELF) Anderson 1989,
Functional Auditory Performance
Indicators (FÁPI)
Infant-Toddler Meaningful Auditory
Integration Scale (IT-MAIS)
Listening Inventory for Education—
Revised (LIFE-R)
LittlEARS Kuhn-Inacker et al
Meaningful Auditory Integration
Scale (MAIS)
Parents’ Evaluation of Aural/Oral
Performance of Children (PEACH)
Preschool Screening Instrument
for Targeting Educational Risk
(Preschool SIFTER)
Screening Inventory for Targeting
Educational Risk (Elementary
SIFTER, Secondary SIFTER)
Teacher’s Evaluation of Aural/Oral
Performance of Children (TEACH)
(2000)
Purdy et al 2002
Anderson and
Smaldino 2011
Williams 2003
8
2000
Stredler-Brown and
Johnson 2004
Robbins et al 1991
Anderson et al 1998,
11
2000
12
2003
Robbins et al 1991
Ching and Hill 2005
Anderson et al
14
2017
Anderson et al
14
2017
Ching and Hill 2005
5
Children 2–12 years Twenty-four-item questionnaire with three subscales (aural-oral,
Children 3–12 years Parent and self-report versions that assess listening skills in 15
6
7
9
Children 4–12 years Teacher, parent, and child rating scales of classroom and home
Infants and toddlers;
5 months–3 years
Infants through
school age
10
Infant-toddler and
older child versions
6 years and above Student and teacher rating scales designed to assess listening
Birth and up Questionnaire for the parent with 35 age-dependent questions
10
Children 3 to 4 years
and up
13
Preschool to 7 years Interview with parent with 15 questions targeting the child’s
3 to 6 years Questionnaire with 15 items completed by the teacher that
6 years through
secondary school
15
Preschool to 7 years Interview with teacher having 13 questions targeting the child’s
auditory awareness, social/conversation skills) that evaluates
auditory behavior in everyday life
natural situations
listening situations with amplication device; to specify ve
situations where improved hearing is desired
Parent observational rating scale of structured listening activities
conducted over time to record distance learning
Parent or interventionist assessment of functional auditory skills
over time
Structured parent interview scale designed to assess spontaneous
auditory behaviors in everyday listening situations
diculty in the classroom
Parental interview with 10 questions that evaluates meaningful use
of sound in everyday situations; attachment with hearing instrument,
ability to alert to sound, ability to attach meaning to sound
everyday environment. Includes scoring for ve subscales (use,
quiet, noise, telephone, environment)
identies children at risk for educational failure; has ve subscales
(academics, attention, communication, class participation,
behavior)
Teacher questionnaire designed to target academic risk behaviors
in children with hearing problems; has ve subscales (academics,
attention, communication, class participation, behavior)
everyday environment. Includes scoring for ve subscales (use,
quiet, noise, telephone, environment)
6 Hearing Test Protocols for Children
is not the preferred method for evaluating hearing in infants
from birth to 4 months of age for identifying hearing loss and
selecting hearing aids because of (1) the prolonged cooperation
required from the child, (2) excessive test time needed, (3)
poor frequency resolution, and (4) poor test-retest reliability.
There is no doubt that evaluating hearing in infants and young
children is time consuming and can require prolonged cooperation. However, the information obtained from behavioral
testing is also useful. The behavioral audiogram provides
valuable information not available from electrophysiologic
testing and should be attempted on infants and children of any
age or developmental status. Functional auditory assessments
(e.g., questionnaires) completed by the child’s caregivers also
provide valuable information regarding the child’s auditory
responsiveness.
Chapter 7 describes in detail the techniques for the behavioral
evaluation of infants and children. We hope the discussion will
assist the audiologist in learning the necessary skills to perform
and optimize behavioral test results. The DVD may also be helpful
to the experienced clinician who wishes to update skills.
6.4 Steps to Take Before Initiating
Behavioral Audiologic Testing
of Infants and Children
6.4.1 Selecting the Appropriate Test
Protocol
A pivotal factor in obtaining reliable test results is the selection
of the appropriate test protocol. To do so, it is essential to know
the child’s cognitive level and physical abilities. Knowledge of
what tasks the child is capable of performing before initiating
testing is critical.
Cognitive Age
There are three behavioral techniques, each of which is appro-
priate for children at dierent developmental levels, allowing
for some exibility at upper and lower age limits. Behavioral
67
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.
observation audiometry (BOA) is the appropriate behavioral
technique to evaluate auditory responsiveness of infants from
birth to 6 months cognitive age; VRA is appropriate to measure
auditory thresholds of infants from 6 months to 36 months
cognitive age; and CPA is the appropriate technique for the
assessment of auditory thresholds of children whose cognitive
age is 30 to 36 months and older.
Pitfall
It is critical to know the cognitive age of the child to select the
appropriate test protocol and obtain reliable results. Although
many children have compatible cognitive and chronologic ages,
some do not.
Unfortunately, it is not always possible to rely solely on chrono-
logic age to determine cognitive level. Although many children
unction at the same levels cognitively and chronologically, not all
f
do.
Much of the information obtained from the case history will
be helpful in determining cognitive level. If speech, language,
and motor skills are at or close to age level, one can assume that
chronologic and cognitive ages are the same or relatively close.
Unfortunately, many children undergo audiologic evaluations
because they are not developing speech and language skills
expected for their age level, so other information is needed to
ascertain cognitive age. Reports and scales from other clinicians,
including speech-language pathologists and pediatricians, can
provide very useful information about developmental level.
Experience spending time with young children will also assist the
audiology student in developing an “intuition” that will support
the selection of the appropriate test protocol. Expected developmental milestones for children are provided in Appendix 6.1.
Physical Status
Once a child’s cognitive level has been established, the child’s
physical condition needs to be evaluated to be certain that the
child is capable of performing the test tasks. For BOA, we are
primarily looking for changes in sucking, which is relatively easy
to discern. Does the child possess a sucking response (e.g., does
the child breastfeed or suck on a bottle or pacifier)? If yes, the
audiologist can implement the BOA procedure (see Chapter 7).
An infant may have an eating problem and receive food through
feeding tubes, but if the infant uses a pacifier, sucking still can be
observed. (See Chapters 7 and 8 for alternative test techniques.)
VRA uses a conditioned head turn in response to a sound stimulus, which requires the child to have vision good enough to see
the reinforcing toy and neck control sucient to turn and look
for the reinforcing toy. This task is most often performed with the
child sitting either in a high chair or on someone’s lap. A child
who cannot sit can be placed in an adaptive supported position,
such as an infant seat, that will still allow a conditioned head turn
to be made. If the child cannot make a head turn, it will not be
possible to use VRA. If the child is blind or, for some other reason,
cannot see the reinforcer, it will not be possible to use standard
VRA protocols. A creative audiologist may be able to generate
some adaptive protocols (Chapter 8).
Play audiometry requires that the child perform a motor task in
response to the presentation of a sound. The ability to accomplish
this task is limited only by the creativity of the audiologist. A
child who cannot hold a toy and drop it in a bucket, for example,
may be able to blink, move a finger, or push a button. Specific test
information about the various behavior protocols is discussed in
Chapter 7.
6.4.2 Setting Up the Test Room
Using a Two-Room Setup
There are several ways to set up a test room for evaluation of
hearing in infants and young children. The most common is a
two-room setup with an audiologist and audiometer in one room
and the child, parent, and audiology assistant in the other. When
using this setup, the audiologist and the audiology assistant must
have a full view of the child. The audiologist, who is presenting
the test stimuli, needs to be able to observe the child’s behavioral
state to know when to present stimuli and when not to (e.g., do
not present a stimulus if the child is fidgeting or trying to get
out of the chair), and both testers need to be able to judge the
presence or absence of a response.
It is also important that the two testers be able to communicate.
If possible, the audiology assistant should have an earphone to
hear directions or suggestions from the audiologist in the control
room. A wireless system also can work well for clinician-to-clinician communication. See Chapter 7 for more information about
behavioral testing and test room setups.
Pearl
A system needs to be set up so that the audiologist and the
audiology assistant can communicate about test protocols and
so that the audiology assistant knows when a sound is being
presented to the child.
Using a One-Room Setup
Some audiologists use a one-room test setup, either for all testing
or for selected testing. The advantage of a one-room test setup
is that testing can be accomplished with only one audiologist,
who now performs both the tester and test assistant roles, thus
having more control of the test situation. To accomplish this type
of testing, the audiologist places the audiometer in the test room
where the child will be.
Experimenting with a variety of test setups will assist the
audiologist in finding the one that is most comfortable for each
test situation. See “Necessary Steps Before Beginning the Pediatric
Assessment” for a summary of steps that need to be taken before
the actual pediatric assessment is initiated.
68
6 Hearing Test Protocols for 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.
Necessary Steps Before Beginning the Pediatric
Assessment
Determine the child’s cognitive age from:
•
Case history
◦
Reports from other evaluations
◦
Infant developmental screening scales
◦
Evaluate the child’s physical status in terms of:
•
Upper-torso control
◦
Head and neck control
◦
Vision
◦
Ability to manipulate toys
◦
Choose the test room setup:
•
One room with one audiologist
◦
Two rooms with two audiologists, or one audiologist and
◦
one test assistant
Two rooms with one audiologist and one parent who also
◦
functions as a test assistant
6.4.3 Obtaining a Case History
A good case history is a valuable tool and an often overlooked
part of an audiologic evaluation.16 All diagnosticians recognize the
need to obtain some information before beginning testing, and
the amount needed will vary according to the reason for the evaluation. If the evaluation is a presurgical or postsurgical evaluation
because a child is scheduled for insertion of pressure equalization
tubes, it may not be necessary to obtain an extensive history. If,
however, the child is being seen for evaluation because of concern
about hearing, speech and language development, developmental
delay, or problems in school, an extensive histor y is needed. Failure
to obtain sucient history information may reduce the quantity
and quality of data obtained from the evaluation and diminishes
the role of both the assessment and the audiologist to a technical
one rather than a professional and diagnostic one.
Taking a case history obviously provides information necessary
to learn about a child’s development and health. A case history
also provides an opportunity to observe the child and to become
acquainted with the family and caregivers to understand their con-
cerns and needs and to assess their objectivity. If dierent family
members have dissimilar viewpoints, this dierence of opinion
frequently emerges during the interview process. The time spent
obtaining a history also provides an opportunity to observe the
interactions between the child and family members and others, and
it may uncover dierences of opinion or interpretation between
the audiologist’s observations and those of the family members.
Finally, taking a case history provides an excellent opportunity
to develop rapport with and insights into the family, which may
increase their willingness to accept the audiologist’s assessment
results and subsequent recommendations for management.
By the end of the interview, the audiologist should have a good
picture of the child’s cognitive and developmental status as well
as an initial estimate of the child’s auditory skills.
Collecting Case History Information
Some clinics mail out questionnaires in advance of the appointment and have families complete them before coming in for
the evaluation. This method allows the family to think about
answers, to check with other family members or clinicians
if needed, and to find addresses of health care providers and
schools, for example. Advance information is especially helpful if
the child is brought to the evaluation by someone other than the
parents (e.g., older sibling, grandparents, or foster parents). If the
child is a foster child, mailing out the questionnaires in advance
enables the responsible social service agency to provide the
necessary information. However, not all families will complete
forms even if they are received in advance, and they will need to
complete the forms when they arrive at the center.
Pearl
Obtaining a case history enables the audiologist to learn about
the child and to understand the parents’ concerns and assessment expectations. History taking also facilitates the development of a rapport between the audiologist and the family that
will be invaluable when counseling about test results.
Even when the family has completed the history forms in
advance, the audiologist still needs to ask questions and spend
time reviewing the information before initiating testing. This
review will frequently reveal incomplete answers that will need
to be finished before testing can begin. Some audiologists prefer to
collect history information by asking all the questions themselves.
Although this method enables the audiologist to direct specific
questions as needed and expand or delete questions in certain
areas, it extends the time scheduled for an evaluation, because
all information must be obtained at the time of the audiologic
assessment.
Some basic areas should be reviewed in any history. Other
questions will present themselves as the interviewer learns more
about the child and the concerns of the parents or caregivers. A
printed history form is frequently useful because it provides basic
information; however, it is important not to let the form limit the
questions.
Caution
The case history form should be viewed simply as a guide to the
interview process.
Topics to Cover in a Case History
A complete history covers several content areas, and depend-
ing on the reason for the evaluation, emphasizes dierent
segments of information. For example, if this evaluation is an
initial one or if the child has not been seen recently, the obvi-
ous first question is, “Why have you brought your child here
today?” By determining the reason for the visit, the audiologist
can find out what the parent’s or caregiver’s concerns are and
69
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.
Table 6.3 Information to obtain in important case history content areas
Birth and prenatal history Communication history: Hearing
Previous pregnancies
•
Illnesses during the pregnancy, including the week of pregnancy an
•
illness occurred
RH incompatibility, ABO blood incompatibility
•
Medications, drugs (legal and illegal) taken during the pregnancy
•
Complications during the pregnancy
•
Length of the pregnancy
•
Delivery: caesarean section or vaginal
•
Birth weight
•
Complications at birth: anoxia, jaundice, Apgar scores, breech, other
•
Length of hospitalization
•
Health history Communication history: Speech and language
Colds, allergy, ear infections
•
High fevers
•
Immunizations
•
Meningitis
•
Other viruses (mumps, cytomegalovirus)
•
Immunization history; reaction to immunizations
•
Drugs taken regularly and drug reactions
•
Feeding or swallowing problems
•
Seizures
•
Head injury
•
Developmental history Social history
Motor milestones: sitting, crawling, walking
•
Age of visual response to parents
•
Is walking clumsy? Does the child fall a lot?
•
Feeding and eating history
•
Age of toilet training
•
Educational history Special services
Current school
•
Type of educational program
•
Previous school placements
•
Reasons for change in school placement
•
Special services received in school
•
Describe educational problems or concerns
•
Other evaluations
What other evaluations has the child had (evaluator, dates, and results)?
Audiologic
•
Speech-language
•
Hearing (auditory) therapy
•
Occupational therapy
•
Physical therapy
•
Parents’ thoughts of child’s hearing
•
Sounds to which child responds
•
Does the child distinguish between sounds (phone, doorbell)?
•
Does the child want TV/CD/DVD/computer loud?
•
Does hearing uctuate? Under what conditions?
•
Are sounds comfortable? What sound? Under what conditions?
•
Amplication history:
•
Does the child wear a hearing aid and/or a cochlear implant?
•
Name and model number of the instruments(s)? Which ears?
•
Does the child wear an FM system? Name and model number of the
•
instrument? Which ears?
Who recommended the devices?
•
When were they acquired?
•
When does the child wear them? (e.g., all day? only at school?)
•
Age of babbling, rst word, phrases, sentences
•
Does the child understand verbal requests with, without visual cues?
•
How does the child communicate his/her needs? Voice? Gesture? Sign?
•
Has there been a change in the child’s speech and language?
•
Did the child speak and then stop?
•
When did the child feed himself? Dress himself?
•
Does she play with other children?
•
What toys or objects does the child like to play with?
•
Does the child have any behavior problems?
•
How does the child get along with other children? Adults? Family?
•
Have there been any changes in the child’s behavior?
•
Does the child respond to others? Make eye contact?
•
What special services does the child receive in school? Outside of school?
•
Speech-language therapy
•
Hearing (auditory) therapy
•
Occupational therapy
•
Physical therapy
•
Psychological services
•
Educational tutoring
•
Other
•
Psychological
•
Educational
•
Pediatric
•
Otolaryngologic
•
Neurologic
•
Psychiatric
•
begin to get a picture of the goals of the evaluation. (Asking an
older child why he or she is here today helps the audiologist
understand what the child thinks is happening.) The next step
is obtaining specific information. See Table 6.3 for a list of case
history topics.
70
Conclusion
Obtaining a history takes time but provides valuable information. At the very least, by obtaining a history, the audiologist
should have a very good sense of:
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