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Audiology Review: Preparing for the Praxis and Comprehensive Examinations
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252
Testing Considerations
As with adults, the purpose of pediatric audiological testing is to obtain a comprehensive picture of
hearing abilities. However, pediatric testing often requires modifications to allow for the child’s ability
to respond according to their developmental age level. Testing may require more than one appointment
to obtain the comprehensive results.
Otoscopic Considerations
Otoscopy, theoretically, should be completed prior to insertion of probes and insert earphones; however,
this is not always a practical approach. Despite the benefits of performing otoscopy first, audiologists
routinely elect to perform it later in the test session. Common reasons for this decision include sensitivities to touch or individuals being in their personal space that result in aversion to otoscopy.
n
Examination includes the preauricular area, postauricular area, and auricle to examine for
dermatologic issues such as sores, rashes, pits, and tags.
n
Look for auricular malformations, size (micro or macro), and location (offset, low-, or
high-set ears).
These malformations may be an indication of a syndrome or genetic contribution that may
be associated with specific hearing loss.
n
Next, examine the external ear canal and tympanic membrane (TM) for landmarks and
anomalies, especially looking for signs of otitis media and presence of PE tubes.
n
Otoscopic inspection
Choose appropriate specula size for canal.
Bridge/brace against the side of the head to allow contact to absorb force if bumped or
patient moves suddenly.
Infants and toddlers should be braced by the caregiver (e.g., in a “side hug” position), which
reduces child movement.
Visual distractions (e.g., showing a spinning toy in front of the child) can be beneficial.
Pull auricle to the back (sometimes will be back and downward as opposed to upward in
adults).
Insert speculum tip and adjust tip to view the TM.
n
Note that abnormalities in the outer ear and ear canal may be one factor associated with
otoscopic findings include:
Blockage by cerumen or foreign body
Otitis externa as a fungal growth in the ear canal
Necrotizing otitis externa can occur in immunocompromised individuals and necrotization
can progress to the point of affecting cranial nerves.
Abnormal middle ear pressure (positive = bulging TM; negative = retracted TM)
Tympanosclerosis appears as white patches on the TM, caused by plaque buildup.
CHAPTER 6 Pediatric Assessment and Differential Diagnosis
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Scarring looks like white scratches on the TM; can be the result of infections, perforations,
or PE tube placement.
Perforations can be in any area of the TM and range in sizes; the size and location impact
hearing loss differently.
Monomeric membranes may appear as a perforation, where the outer layers of the TM have
healed but not the fibrous layer(s), so there is a clear view into middle ear space.
Tympanoplasty may show atypical landmarks due to repair of the TM.
Otitis media signs include the TM may not be translucent (possibly red and retracted) and
may appear discolored with infection with possibly bubbles or a meniscus.
PE tubes may be visualized for children with chronic or acute otitis media and may include
short-acting grommets or longer-term T tubes.
Behavioral Techniques and Procedures
Behavioral Observation (BO) [previously known as
Behavioral Observation Audiometry]
253
The audiologist presents stimuli and is then looking for responses (e.g., eyes widening, increase or
decrease in sucking) from a patient who is not actively involved in the task. BO is used in infants up to
6 months of age but may be used in older children with developmental delays or other disorders such
as cerebral palsy. No reinforcement is used, as studies show infants’ responses are not impacted by such
reinforcement (e.g., Hicks et al., 2000; Moore et al., 1977). There can be problems with habituation,
with variability of responses, with repeatability of responses, and with bias of examiner.
Also note that BO responses are considered minimal response levels (MRLs: softest intensity that
the clinician sees a response), not true thresholds. The MRLs are used as a measure of responsivity and
should not be used for diagnosis of hearing loss or for treatment purposes (e.g., when fitting amplification). Instead, physiologic testing and functional testing should be utilized for diagnosis and treatment
purposes. The responses obtained during BO can be used as confirmation of caregiver reports and
can be used to show behavioral responses in conjunction with the physiologic testing (Diefendorf &
Tharpe, 2017).
n
Testing considerations:
Most often conducted in the soundfield (responses not ear specific); can be conducted
via headphones or insert earphones if tolerated by the child, providing ear-specific
information.
Stimuli should be varied (narrowband noise [NBN], FRESH noise, warble tones, filtered
songs) to prevent habituation.
Ascending (i.e., increasing in stimulus intensity as opposed to decreasing intensity)
presentations could help prevent habituation.
The Pediatric Observation, Testing, and Tallying System (POTTS) form can be beneficial
to document responses.
The overall goal is to obtain responses within the speech-frequency range for at least a
low-frequency (500 Hz) and a high-frequency sound (2000 Hz).
Audiology Review: Preparing for the Praxis and Comprehensive Examinations
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Speech awareness testing (note that this is not threshold, but an MRL) is beneficial with
BO, as this test can be beneficial in counseling parents when used along with other
counseling tools.
AUDIOLOGY NUGGET
MRLs must be compared to age-appropriate behaviors rather than defining
responses as a specific degree of hearing loss. For example, expected MRLs for
warble tones are 70 to 75 dB HL for infants up to 4 months of age and 45 to
50 dB HL from infants 4 to 9 months of age (Northern & Downs, 2002). If
an infant who is 5 months of age exhibits MRLs of 50 dB HL to warble tones,
these results would be consistent with expected responses for a 5-month-old.
However, if MRLs are obtained at 70 dB HL, these responses would be poorer
than expected for a 5-month-old. Again, MRLs are not used to define hearing
loss, although responses can be used as part of the cross-check principle (crosschecking electrophysiologic results) or as part of counseling with the family.
Visual Reinforcement Audiometry (VRA)
Visual reinforcement audiometry (VRA) is used with slightly older infants/toddlers (i.e., those who
have controllable head movements and core strength to sit with minimal support, such as in a highchair). The typical age range for VRA is 4 to 6 months of age up to 24 months of age based on
developmental age (or until they can perform a conditioned play task). The audiologist is looking for
active responses to sound (e.g., head turning) either in the soundfield (younger infants/toddlers, testing
the better ear only) or with earphones (ear specific) or bone oscillator (can use if the infant/toddler
tolerates them), with the responses being reinforced with visual stimuli (e.g., video, mechanical toy).
Note that localization is not required for VRA, though the child will turn their head. Reinforcement
occurs when an infant looks for the sound, regardless of whether the response is in the correct direction of the sound. Localization is required, however, for conditioned orientation reflex (COR), which
includes conditioning to the task. If the child is well conditioned to the task, responses are considered
thresholds as opposed to MRLs.
n
Testing considerations:
Conditioning can occur but is not required for VRA testing.
Stimuli can be frequency specific (e.g., warble tones, NBN) or nonfrequency specific
(speech, e.g., calling the child’s name, repeated syllables).
The overall goal is to obtain frequency-specific information within the speech frequency
range.
●
Typical to test octave frequencies between 500 and 4000 Hz
●
Frequency order can be modified to ensure that at least one high-frequency response and
one low-frequency response are obtained if the child habituates to the task.
●
If the child is still attending, consider testing under earphones (if initially testing in
soundfield) or via bone conduction.
CHAPTER 6 Pediatric Assessment and Differential Diagnosis
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Considerations for testing include use of larger step sizes (e.g., 20 down/10 up until close to
threshold) or using of an ascending technique to prevent habituation.
Make sure to use control trials to ensure that the child is not responding to a presentation
pattern rather than hearing the sound.
For a more in-depth discussion of testing considerations, see Diefendorf and Tharpe (2017).
KNOWLEDGE CHECKPOINT
VRA is often conducted in soundfield. When testing in soundfield, warble/
frequency-modulated (FM) tones should be used instead of pure tones. This
will prevent standing waves and will allow for a consistent signal even with
movement of the child (ASHA, n.d.). Narrowband noise (NBN) may also be
used. The child’s head must be in the calibrated position within the booth,
which is often marked.
When testing in soundfield, use of an assistant can be beneficial. The assistant can help center the child to look forward, allowing for easier visualization
of head turns toward sounds. When using an assistant, it is important to ensure
they do not provide any cues to the child. For example, the assistant may wear
headphones and listen to noise through an external device (e.g., CD player).
If this is not possible, the audiologist should provide direct instructions to the
assistant to not provide any cues (e.g., calling attention to the sounds, stopping
movement of distractor toys) when sounds are presented. If parents are in the
booth with the child during testing, they should also be instructed to not provide
cues to the child.
255
Conditioned Play Audiometry (CPA)
With CPA, the audiologist uses a play task to obtain hearing test results. The child is taught/conditioned to respond using play task (e.g., building blocks, throwing toys into a basket) in response to
sounds. This test can be used as a testing technique starting at approximately 24 months of age up to
3 years of age or as developmentally appropriate (Diefendorf & Tharpe, 2017).
n
Testing considerations:
Condition the child to the task.
Stimuli typically include frequency-specific pure tones (steady or pulsed), but other
frequency-specific stimuli can be used.
The overall goal is to obtain ear-specific and frequency-specific information within the
speech frequency range (500–4000 Hz).
●
Frequency order can be modified to ensure that at least one high-frequency response and
one low-frequency response are obtained if the child stops responding to the task.
●
Testing can also include responses in both ears at each frequency (e.g., testing 1000 Hz in
the right ear and then the left ear before moving to 4000 Hz) to ensure that some results
from both ears are obtained if the child tires of the task.
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Can use larger step sizes (e.g., 20 down/10 up until close to threshold) to prevent
habituation or to allow for additional threshold estimations (e.g., both air and bone
conduction).
Typically, ear-specific (headphones/insert earphones) or bone conduction; can use
soundfield if child will not tolerate headphones.
Make sure to use control trials to ensure that the child is not responding to a pattern rather
than hearing the sound.
For a more in-depth discussion of testing considerations, see Diefendorf and Tharpe (2017).
AUDIOLOGY NUGGET
When thresholds are obtained for pediatric patients, the normative data for
degree of hearing loss vary as compared to adult normative data. The primary
difference is the inclusion of a “slight” or “minimal” hearing loss category. This
is due to research showing the impact of slight to mild hearing losses in children
(e.g., Winiger et al., 2016). The pediatric normative data are:
≤15 dB HL
Hearing within normal limits
16–25 dB HL Slight/minimal hearing loss
26–40 dB HL Mild hearing loss
41–55 dB HL Moderate hearing loss
56–70 dB HL Moderately severe hearing loss
71–90 dB HL Severe hearing loss
≥91 dB HL Profound hearing loss
Tangible Reinforcement Operant Conditioning Audiometry (TROCA)
For TROCA, the audiologist conditions the child to a task in which the child responds (such as
pressing a button or giving a high five) when sounds are heard. The child is reinforced with a tangible
object (stickers, edible reinforcements such as candy pieces) for correctly responding to sounds. This
testing is typically used in children from approximately 2 years of age who cannot condition to CPA.
n
See CPA section for testing considerations.
Traditional Audiometry Considerations With Children
Traditional techniques (e.g., raising a hand) can be used as early as 3 years of age. By the time the child
is school-aged, traditional techniques are commonly utilized.
n
Testing considerations:
With false positives, the first step is to reinstruct; ascending technique could be beneficial.
Stimuli typically include pure tones; the frequency and ear order are often similar to the
considerations noted above for CPA.
CHAPTER 6 Pediatric Assessment and Differential Diagnosis
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CASE EXAMPLE
Juan is a 3-year-old child scheduled for an audiological evaluation. The audiologist has planned to test him using CPA. When seen for the appointment, Juan’s
parents report that he just started walking last month and that he is just beginning to say his first words. He is scheduled for a comprehensive development
evaluation by a developmental pediatrician next week. Would this information
change the plan of testing?
The testing plan should be reviewed to consider that motor and speech
development are delayed. The reported milestones are consistent with a child
who is 12 months of age, as opposed to the chronological age of 3 years. Case
history questions could address cognitive development in addition to motor and
speech development. Behavioral testing should be chosen based on the estimated
developmental age. The audiologist’s plan of testing would be modified to be
VRA, which is appropriate for a child who is developmentally 12 months of age.
257
Goal is to obtain ear-specific information.
●
The child can be tested in soundfield if they will not tolerate use of headphones/insert
earphones.
With younger children, larger step sizes (20/10 dB) can be beneficial to more quickly
estimate threshold, with traditional step sizes (10/5 dB) used when closer to possible
threshold.
With children who do not appear to be giving consistent and accurate responses, the
audiologist can try the “yes/no” technique. With this technique, the audiologist instructs
the child to say “yes” when a sound is heard and “no” when they do not hear the sound.
Chapter 5 includes applications related to patients who do not appear to be giving true
threshold information. For more in-depth information on this topic, see Peck (2017).
Screening of Pure Tones in Children
Screening of pure tones may be conducted in large-scale screening settings (e.g., in preschools). The
pure-tone screenings typically use play or conventional techniques for children ≥ 3 years of age.
n
ASHA guidelines (1997) for hearing screening include screening at an intensity of 20 dBHL
at 1000, 2000, and 4000 Hz. It is recommended to get two repeatable responses at the
screening level in both ears at all frequencies tested in order to pass the screening.
n
Newer recommendations add 6000 Hz into the screening battery in order to detect high-
frequency hearing losses due to noise exposure.
Threshold Speech Testing
Testing of pediatric patients may include speech stimuli instead of tonal stimuli. The audiological evaluation of pediatric patients may also include speech as a stimulus. Threshold speech
testing is used to allow for an estimation of reliability of the threshold tonal responses (e.g., is the
Audiology Review: Preparing for the Praxis and Comprehensive Examinations
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258
SAT/SRT in good agreement, or within 7 dB, of the PTA or of the best thresholds in the speech
frequency range).
n
Speech awareness threshold (SAT)
Softest level the child responds to sound, typically lowest intensity that the child responds
50% of the time
Obtain MRL to speech up to 24 months of age.
SAT may be used up until the child can identify simple objects, which could be as early as
18 months (Northern & Downs, 2002).
Often running speech (repetitive syllables, “where am I?” “uh oh”) or child’s name delivered
via live voice
n
Speech reception threshold (SRT)
Softest level the child correctly identifies objects or repeats words
Spondee words are used (i.e., two-syllable words with equal emphasis on both syllables).
●
Examples of child-specific SRT words: baseball, cowboy, hotdog, airplane
To complete the SRT task, familiarize the child with the words, then perform the test
procedure.
SRT is often a word repetition task but can be obtained via picture pointing.
●
Number of pictures can vary by language ability.
●
Can use spondee words with picture representations
●
Familiarize child to the pictures/words, then perform procedure with the child pointing
to the picture.
●
Can use body part identification when necessary.
Ask parent/caregiver if child knows body parts (and which ones).
Familiarize at higher intensity to confirm child will respond to the body parts, then use
items the child is familiar with during the identification task.
Word and Sentence Recognition Testing
Word recognition testing (WRS) and sentence recognition testing (SRS) vary by developmental/
language age, articulation abilities, and auditory development. ASHA guidelines have recommendations for WRS in the 25- to 60-month age range, dependent upon the abilities of the particular child
(ASHA, 2004). Word and sentence lists vary in structure (for example, phonetically or phonemically
balanced) as well as language level. Developmentally appropriate lists should be used when testing a
child, with considerations for receptive language ability, expressive language ability, primary language
of the child, and the abilities of the audiologist to accurately and reliably judge responses. Testing may
be performed in quiet, as well as in noise. Table 6–1 lists age-appropriate word lists and Table 6–2 lists
age-appropriate sentence lists. The reader is also referred to Uhler et al. (2017) for information on the
Pediatric Minimum Speech Test Battery.
n
For closed-set word lists, one must consider chance level. For example, the NU-CHIPS has
a chance level of 25% (child chooses from a set of four pictures), and the WIPI has a chance
level of 16% (child chooses from a set of six pictures).
PRESENTATION
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FORMAT RESPONSE USAGE
WRS for children who
have speech difficulties
one of
six color
Recorded or live Point to
lists of 25
monosyllabic
WRS for children who
pictures
Recorded or live Point to
words each
have speech difficulties
one of four
grayscale
WRS or SRS or
APD; can be tested as
performance-intensity
pictures
one of five
pictures
Recorded Point to
words
words and two
sentence formants
(PI) function or
message-to-competition
ratio (MCR)
HA or AR
one of three
Recorded Point to
in two lists of 10
sentences each
sounds, words,
WRS
pictures
Repeat the
words
Recorded or live
stereotypic
messages arranged
in 10 subtests
words
WRS
words
Tape or CD
Recorded or live Repeat the
words
WRS
WRS
words
Recorded or live Repeat the
Recorded or live Repeat the
words
words
words
RECOMMENDED
AGE STIMULI
TABLE 6–1. Word Lists for Testing Children of Various Ages
CODE TEST AUTHOR
4–6 years Four equivalent
Ross and
Leman (1970;
rev. 2004)
Picture Identification
WIPI Word Intelligibility by
3–5 years 50 monosyllabic
Elliott and
Katz (1980)
University Children’s
Perception of Speech
NU-CHIPS Northwestern
3–6 years 20 monosyllabic
Jerger and
PSI Pediatric Speech
Jerger (1982)
Intelligibility Test
259
4–17 years Environmental
Trammel
(1981)
Comprehension
TAC Test of Auditory
6–12 years 50 monosyllabic
Haskins
(1949)
Eagan (1948) 12 years and up Monosyllabic
kindergarten word lists
PBK Phonetically balanced
ratory phonetically
balanced 50-word lists
PAL PB 50 Psychoacoustics Labo-
12 years and up Monosyllabic
Hirsh et al.
12 years and up Monosyllabic
(1952)
Tillman and
the Deaf W-22
CID W-22 Central Institute for
NU-6 Northwestern
Carhart (1966)
University 6
Source: Adapted from Thibodeau, L. M. (2007). Speech audiometry. In Audiology Diagnosis, 2nd ed. Eds. Ross Roeser, Michael Valente, & Holly Hosford-Dunn. New York: Thieme.
Pages 300–301.
HA or APD
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HA or APD
HA or APD
HA or APD
HA or APD
HA or APD
PRESENTATION
FORMAT RESPONSE USAGE
RECOMMENDED
AGE STIMULI
sentence
5–14 years Sentences Recorded Repeat the
sentence
6–12 years Sentences Recorded Repeat the
13 years and up Sentences Recorded Repeat the
sentence
12 years and up Sentences Recorded Repeat the
sentence
the final
word of the
Recorded Repeat
predictability
sentences
12 years and up High and low
sentence
Recorded Identify the
12 years and up Sentences that
sentence
from a list
of ten
do not convey
meaning
TABLE 6–2. Sentence Lists for Testing Children of Various Ages
CODE TEST AUTHOR
Etymotic
Research
(2005)
Bench Speech in
Noise
BKB SIN Bamford-Kowal-
Nilsson et al.
(1996)
for Children
HINT-C Hearing in Noise Test
HINT Hearing in Noise Test Nilsson et al.
(1994)
Etymotic
Quick SIN Quick Speech in
260
Research
Noise
(2001)
Bilger et al.
SPIN Revised Speech
(1984)
Perception in Noise
Speaks and
Jerger (1965)
Identification
SSI Synthetic Sentence
Pages 300–301.
Source: Adapted from Thibodeau, L. M. (2007). Speech audiometry. In Audiology Diagnosis, 2nd ed. Eds. Ross Roeser, Michael Valente, & Holly Hosford-Dunn. New York: Thieme.
CHAPTER 6 Pediatric Assessment and Differential Diagnosis
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n
Word lists that are repetition tasks (e.g., PBK) can be impacted by articulation abilities of the
child’s speech. If the audiologist has difficulties understanding the child and does not believe
they can accurately record the responses, a closed-set task should be chosen.
n
Adult lists: Sanderson-Leepa and Rintelmann (1976) showed the Northwestern Auditory Test
No. 6 (NU-6) was more difficult than the PBK in children who were 7.5, 9.5, and 11.5 years
of age. The authors indicated use of these tests may depend on the purpose of the assessment.
n
Sentence materials are often used to examine performance in situations closer to
conversational speech and are frequently used in educational environments (e.g., functional
listening evaluations). More information is in the later Educational Audiology section of
this chapter.
KNOWLEDGE CHECKPOINT
According to Sanderson-Leepa and Rintelmann (1976), use of pediatric versus
adult word lists can vary depending on the purpose of the testing. For diagnostic
purposes, utilizing a pediatric list is appropriate to ensure that results relate to
audibility of words rather than the child’s language and vocabulary. However,
if the purpose is more functional testing, such as comparing aided to unaided
abilities in a child with a mild hearing loss, then an adult word list may be preferable. For example, a 7-year-old child with a mild hearing loss may have a very
high (e.g., 96% correct) word understanding score in quiet utilizing the PBK
words. This would not allow for any improvement of scores in an aided condition and may not represent actual listening conditions for the child. As such,
testing in soundfield without and with hearing aids could use a more difficult
adult word list, such as the NU-6 lists. The child may have more difficulty in
the unaided condition, allowing the audiologist to see if there is improvement
with use of amplification. This testing would be used in conjunction with additional functional assessments (including speech in noise tasks and parent/teacher
rating scales).
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Testing in Background Noise
Testing speech in the presence of background noise gives more ecologically valid (“real life”) considerations of functional abilities, especially for school-aged children (Deconde Johnson & Seaton, 2021).
n
Can use tests such as the Selective Auditory Attention Test (SAAT), the BKB-SIN, or the
auditory figure-ground tests from the SCAN-3.
If there is a hearing loss present, the testing would be for the purpose of functional abilities
only rather than diagnosis of processing difficulties. The audiologist would have to consider
the intensity level chosen for the testing, as many of these tests were normed at a normal
conversational level (e.g., 50–55 dB HL). For a child with hearing loss, this may be a lower
sensation level (SL); as such, the testing intensity may need to be raised to take the degree
of hearing loss into account.
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