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Audiology Review: Preparing for the Praxis and Comprehensive Examinations
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504 services address lack of access to information in an educational setting. Reasonable
accommodation would be provided to have appropriate access to general education.
This may include seating assignment, HATS, and so on. However, it would not include
modifications to instruction such as a special education teacher who modifies assignments
or instruction or speech-language therapy.
KNOWLEDGE CHECKPOINT
Section 504 of the Rehabilitative Act of 1973 protects a child against discrimination for a disability that impacts a major life activity, which includes
hearing-related disabilities. In these cases, the child would have a 504 plan but
would be provided accommodations through general education. Children with
slight losses or unilateral losses may not qualify for services under IDEA. In
states that have not expanded the definition of DHH for IDEA to include slight
or unilateral hearing loss, a 504 plan may be used to provide accommodations.
n
Services for birth to 5 and preschool/school age children
Legislation has described how provisions should be outlined and documented.
●
IFSP — Individualized Family Service Plan for the child and family of children that are
less than 3 years old
●
Provides services to train parents/caregivers and family members how to facilitate
communication and development for a child with hearing loss as well as:
Teaches the family how to be an advocate for their child
Provides connections to other DHH families, mentors, and role models
Includes transition planning to move to preschool services
Different states implement these services through different programs, either through
early childhood intervention (ECI) or through the area educational services.
n
Services for school-aged children
Eligibility is covered through IDEA utilizing the criteria for hearing loss.
●
IEP — Individualized Educational Program for school-aged children up to the age of 21
Provides for educational placement
Includes FAPE (free and public education) and LRE (least restrictive environment),
including opportunity to communicate with peers and staff in the child’s preferred
language/communication system
Directs accommodations and services the child will receive to promote educational
A child served through IDEA (i.e., with an IEP or an IFSP) is provided
access
accommodations and modifications through special education services. As such,
they must qualify for these services through formal and informal testing indicating a
significant educational impact of the hearing loss.
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Eligibility criteria are set by each state. However, the hearing loss may still negatively
impact auditory performance (e.g., difficulty understanding in background noise),
even if other eligibility criteria are not met.
Includes audiologic services to be provided through the schools, such as programming/
verification of amplification, hearing assistive technology systems, assessment of
performance with equipment, and training for families and educators. These services
may be provided by an audiologist working directly for the school, contracted with the
school, or the child’s personal audiologist.
Eligibility is based on interdisciplinary coordination of assessment by different
professionals
Assessment
IDEA clauses related to evaluation (300.101, 304, and 303.324) “use a variety of assessment tools and
strategies to gather relevant functional, developmental, and academic information about the child,
including information provided by the parent, that may assist in determining whether the child is
a child with a disability” (300.304(b)(1)). Functional skills are not solely related to academic performance and cannot be measured using one assessment or criterion. Testing should include both
formal as well as informal methods. The goal is to measure performance and determine functional
performance. Testing should include assessment performed both in an audiometric booth and in the
classroom. Multiple measures should be administered to determine how to provide free and appropriate education (FAPE) by determining services and supports that will be needed to meet the identified
academic and functional needs.
n
Assessment should be performed regularly to assist in development of the Individualized
Education Program (IEP).
Reevaluations every 3 years are required by the IEP; however, testing may be recommended
more frequently. Best practice for audiologic monitoring is annually or as recommended
according to the audiologist.
Testing should also be considered if the child is experiencing difficulties, changing schools,
changing classrooms, changing teachers, changing academic level (e.g., elementary to
middle school), or if the child has a change in listening skills or amplification.
Testing should also be performed if the team and parents express concerns.
Addendums or modifications can be made at any time by the IEP or 504 team based on
assessment data.
n
An audiologist is responsible for several areas in educational assessment.
The initial purpose is an assessment to determine eligibility.
Further assessment provides information about the impact of the child’s hearing loss and
the functional difficulties associated with the loss.
Other areas of assessment beyond diagnostic testing for eligibility include speech perception
and auditory skills development, assessing the learning environment, determining
equipment benefit, and determining functional performance.
n
Basic assessment procedures start with an age-appropriate typical pediatric audiologic
evaluation as discussed earlier in the chapter, with a few additions of measurement of speech
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using more conversational speech measures (such as sentences) to examine more functional
components. Speech perception in noise should also be performed to evaluate functional
components.
Additional measures should include:
●
Speech recognition for sentences and phrases, with and without visual support to assess
auditory-only versus auditory-visual condition
●
Listening in noise at various signal-to-noise ratios with a baseline of testing in quiet for a
comparison of performance
n
Measuring auditory skill development can include parent measures (especially for very young
children) and measures requiring response from the child. This can be performed by the
speech-language pathologist or obtained via data from other members of the team.
Examples of parent/teacher measures that can be used to describe what the caregiver sees
as the child’s perception of sound include the IT-MAIS and PEACH/TEACH described
earlier in this chapter.
Examples of child perceptual measures
●
Ling 6: gross determination of if a child can perceive speech sounds across the frequency
spectrum, as well as being used to check equipment function
●
Early Speech Perception Test (ESP; Geers & Moog, 2012): identify skills for children as
young as 3 years old
●
Cottage Acquisition of Speech and Language Learning (CASLLs; Wilkes,
2001): checklists that can be used to report if a child has age-appropriate auditory
perceptual skills
●
Developmental Approach to Successful Listening II (DASL II; Stout & Windle,
1986): checklist that corresponds to a stimuli booklet to help examine perceptual skills
n
An audiologist is also needed to examine the child’s learning environment to determine the
impact of reverberation and noise in a classroom. The audiologist will perform assessment to
determine the signal-to-noise ratio (SNR) by examining the qualities of the class environment that
may impact hearing and provide recommendations to improve the acoustic environment. Performance in the classroom for listening comprehension (recognition) in the classroom (e.g., speech
recognition, functional listening evaluation [FLE]) should also be assessed. Assessment includes:
Classroom acoustic measures including noise levels, reverberation, critical distance, SNR,
and the distribution of speaker’s voice in the classroom. These should be examined in light
of the ASHA/ANSI recommendations of:
●
Unoccupied classroom level should be ≤35 dBA
●
SNR of at least +15 dB at the child’s ears
●
Reverberation time for a smaller classroom (<10,000 cubic feet) should be 0.6 seconds or
less and for a larger classroom <0.7 seconds.
Classroom observations should be performed to examine acoustics, teacher presentation
(rate, language, volume), teaching methods, and organization of material. This can be
informal or use forms such as the Classroom Observation Checklist and Classroom-at-a-
Glance Checklist (Deconde Johnson & Seaton, 2021).
CHAPTER 6 Pediatric Assessment and Differential Diagnosis
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Teacher, parent, and child questionnaires can be used to determine functional performance
in the classroom. Some that are used include:
●
Children’s Auditory Performance Scale: C.H.A.P.S. (http://www.edaud.org) has
36 questions on a 6-point scale, with six listening conditions (Noise, Quiet, Ideal,
Multiple Inputs, Auditory Memory Sequencing, Auditory Attention Span). The child’s
performance is rated by parents or teachers in these areas as compared to their sameaged peers.
●
Screening Instrument for Targeting Educational Risk: SIFTER (http://
successforkidswithhearingloss.com) has 15 questions on a 5-point scale, in five areas
(academics, attention, communication, classroom participation, behavior). The child’s
performance is rated by parents or teachers in these areas as compared to same-aged
peers. Preschool, Elementary, and Secondary versions are available.
●
Listening Inventory for Education: LIFE (http://successforkidswithhearingloss.com) has
two versions, one for the child (10 questions) and one for the teacher (15 questions).
Questions relate to commonly encountered educational listening environments and has
the child/teacher rate on a scale from always easy to always difficult for the child or no
challenge to almost always challenged for the teacher’s choices.
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n
The audiologist will also be responsible for assessing the performance of the child’s
amplification equipment. This includes verification and validation measures to confirm
equipment is functioning properly. The educational audiologist also needs to assess how
the child is performing functionally in the classroom and determine if a HATS is beneficial;
an FLE can be used for this assessment (Deconde Johnson & VonAlmen, 1993, updated
2013).
An FLE compares a child’s listening ability in a variety of situations to identify effects of
noise, distance, and visual cues. Testing can also be performed with HATS.
An FLE can be used to estimate a child’s listening performance in different listening
situations, provide evidence for benefits of HATS, and make decisions about what
components of HATS meet a child’s needs.
Performing an FLE
●
For an evaluation of functional performance, sentences should be used to be more
representative of conversational speech encountered in the classroom. Some sentence lists
include Blair, Pediatric Az Bio, CID Everyday Sentences, BKB Sin, WIPI Sentences, and
HINT Sentences.
●
Signal can be provided via live voice (monitored through a sound level meter) or recorded
(with video for visual cue condition).
●
Presentation level should be an average 65 dB A at the student’s ear when the examiner/
recording is 3 ft away.
●
Recorded noise that is representative of the child’s listening environment (e.g.,
multitalker babble, cafeteria noise, Child’s Noise CD from Auditec) presented at an
average 60 dB A at the student’s ear, when the noise is 3 ft from the child’s ear. Noise
should come from the direction that is typical of the child’s environment. Figure 6–5
shows the setup of the noise and signal used in FLE testing.
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FIGURE 6–5. Functional listening evaluation setup diagram.
Q & A
Figure 6–6 is adapted from Deconde Johnson and VonAlmen (1993, updated
in 2013) and shows scoring for a child’s FLE evaluation.
On this form are a few sample readings. For this case, examine the child’s
scores in quiet in the functional listening scorebox. The score for the auditoryonly condition is 88% (Box 2). Next, examine the scores in noise for this
condition (Box 4), which shows 72% correct.
Question:
in noise?
Answer: Noise has a negative effect on the child’s speech recognition
performance.
Any area with a diagonal line can be performed both with and without a HATS
system. Scores above the line show performance without the HATS system.
Scores below the line represent findings using the HATS system. In this case,
there is an example shown in the auditory, distant condition, in noise (shown
in Box 6).
What does that tell you about the child’s speech understanding
Question: What does the change from 46% to 92% correct suggest?
Answer: The child’s performance improves significantly with the use of HATS.
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FIGURE 6–6. Sample FLE form. Adapted from Deconde Johnson, C., & VonAlmen, P. (1993 updated in 2013) with permission.
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●
Presentation of the signals is presented with the child wearing their daily amplification
configuration.
●
Sentences (or other signals) presented in different conditions: auditory only (A) versus
auditory with visual cues (A/V), close versus distant (12–15 feet), and in quiet versus
noise, creating eight conditions that are then repeated with HATS in place
n
Interpretation and recommendations of the FLE
Describe the effects of different listening conditions to describe what situations enhance or
decrease auditory function
Identify best listening environment as far as visual cues and distance
Recommend HATS and components that improve hearing in noise
Recommend other accommodations that would reduce noise (e.g., reduce reverberation) or
increase visual cues (e.g., have the teacher face the child)
n
Another issue related to a student’s equipment is equipment transparency. With the addition
of another device (receiver) to a child’s hearing aid, there is the possibility that the frequency
response (output) is affected. Transparency addresses whether addition of the receiver impacts
the frequency response of a hearing aid.
Measures are used to determine if a change in the frequency response occurs. If the hearing
aid is transparent, there is not a significant change to electroacoustic output in the speech
frequencies when testing through the hearing aid microphone versus the output when
presented through the HATS transmitter.
Testing performed with the hearing aid inside the test box at 65 dB SPL and the output for
750, 1000, and 2000 Hz is noted.
The hearing aid is then placed outside the test box but still connected to the 2- cc coupler.
Because it is outside the test box and the hearing aid microphone is still active, testing must
be conducted in a quiet setting.
The HATS microphone is placed inside the test box. Then testing is performed again,
noting the output for the three primary frequencies.
The results with hearing aid alone are subtracted from the results through the HAT
transmitter and then averaged.
Transparent systems will show no more than ± 2 dB as the average.
If the system is transparent, then you know that the system is not significantly changing the
frequency response.
If there is a significant difference, then the HATS should be adjusted.
Testing setup varies based on the hearing aid companies and requires some specific setting
or verification mode. Instructions for specific companies need to be downloaded and used.
●
Phonak Offset Protocol (POP) (Phonak, 2021)
●
EduMic Verification Guide (Oticon, n.d.)
n
Assessment of social skills, self-advocacy, and auditory fatigue are other areas that an
audiologist will provide input on during assessment. Using various scales and observations, the
CHAPTER 6 Pediatric Assessment and Differential Diagnosis
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audiologist can determine the impact of the hearing loss on these areas. This information will
be helpful to the psychologist or counselor in examining the impact of hearing loss.
Hearing loss impacts how a child learns to interact with others by impacting ToM,
pragmatic language, and social skills. Checklists such as The Pragmatic Checklist or
Summary of Social Interaction can give an idea of areas of difficulty.
Self-advocacy is often an area of concern for children with hearing loss. Use of
equipment and communication strategies is important to help the child show they
have taken ownership of their hearing loss. The Student Expectations for Advocacy and
Monitoring Hearing Technology questionnaire monitors a child’s understanding of and
advocacy for hearing aid use. Self-advocacy in different listening situations is also covered
in the LIFE, which has Before-LIFE and After-LIFE sections where students discuss how
they would handle different situations and is designed to be a pre- and postmeasure of
training.
Fatigue due to the additional load of processing the auditory signal may be experienced
by the child with a hearing loss. This can be examined informally or with tests such as the
Vanderbilt Fatigue Scale–Child (VFS-C; Hornsby et al., 2022).
n
Scales and questionnaires mentioned in this chapter section are samples of available test
materials. For more options, check resources.
299
Educational Audiology Handbook (Deconde Johnson & Seaton, 2021)
Building Skills for Success in the Fast-Paced Classroom: Optimizing Achievement for
Students with Hearing Loss (Anderson & Arnoldi, 2011). This resource also comes with
supplemental files, including assessments.
Management by Educational Audiologists
Recommendations related to management of hearing loss include monitoring the hearing status and
providing the school information about the child’s ongoing performance and progress. The student
who is DHH should have regular hearing evaluations to monitor any progression of hearing loss,
examine changes that would affect the aided audibility, and make referrals/recommendations if there
are changes in hearing status. Providing information to the school should extend beyond presenting
the standard audiogram. Audibility information using the Count-the-Dot Audiogram or a measure
of the audibility index (AI) to provide insight into aided audibility is important to the management
process. Aural habilitation for speech perception and auditory skills is addressed as a multidisciplinary
team along with the speech-language pathologist and teacher of the deaf. More information about aural
habilitation can be found in Chapter 4.
n
Managing the educational environment by the audiologist includes addressing the classroom
SNR issues, providing HATS, and implementing recommendations based on FLE results.
Classroom participation and observation data will provide information to assist with
facilitating access to communication in the classroom, leading to management strategies
such as controlling other students and classroom noise; modifying teacher presentation
level, rate, and vocabulary; and facilitating reception of signals from other media (e.g.,
HATS for computer, closed captioning).
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Theory of Mind
Theory of Mind (ToM) is the ability to understand and consider the mental state (beliefs, intents,
desires, emotions) of others and understand these states may be different from our own. It includes
using what is known about other people to understand a situation, as well as predicting what others are
thinking by what we know of them. Children with hearing loss experience difficulties with ToM and
are often delayed and need assessment in the educational setting.
n
Impact of hearing loss on ToM
Research has shown that children with hearing loss act much like children with autism on
ToM tasks and struggle with pragmatic issues (Westby, 2017).
Research indicates that children with hearing loss are around 3 years behind peers with
normal hearing (Lundy, 2002).
Children who sign and are from a home environment rich in sign (e.g., Deaf parents who
sign) have ToM development similar to typical development.
Difficulties developing ToM are associated with limited incidental conversational access.
Language skills were found to be related to the child’s vocabulary and ability to comprehend
syntactic complements.
n
Table 6–8 provides a description of the subdivisions and expected development of ToM.
TABLE 6–8. Development of Cognitive and Affective Theory of Mind
COGNITIVE THEORY OF MIND AFFECTIVE THEORY OF MIND
AGE SKILL SKILL
Birth–
6 months
6–8 months •
8–12
months
13–17
months
18 months–
2 years
Has joint attention • Displays joy, sadness, disgust, and anger
• Follows line of regard
• Regulates behavior to initiate request
• Initiates joint attention of objects
• Understands line of sight and its
impact on behavior
• Develops sense of self
• Engages in pretend
• Understands different people like
different things
• Responds to emotional reactions of others
• Imitates expressions
• Uses expressions of others as social reference
for approach/avoidance
• Displays happy, mad, sad, surprised,
disgusted, afraid
• Tries to change how others feel by direct
contact
• Coordinates interactions
• Recognizes distress of others
• Develops altruistic behaviors to comfort
others
• Uses words “happy,” “mad,” “sad,” and
“scared”
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TABLE 6–8. continued
COGNITIVE THEORY OF MIND AFFECTIVE THEORY OF MIND
AGE SKILL SKILL
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3 years • Knows imaginary objects are different
than real
•
Knows actions dictates desires,
intentions, and thoughts
Knows perceptual activity is connected
•
to knowing
•
Uses words such as “remember,”
“know,” and “think”
•
Realizes different people see things
differently
4–5 years •
Can pass false content and false beliefs
tasks
Predicts person’s action based on false
•
beliefs
Understands how something someone
•
sees appears to them
•
Knows people access information by
casually hearing/seeing
Understands beliefs cause people to
•
act in a particular way
• Identifies happy, sad, mad, and afraid in
photos
Matches primary emotions to situations in
•
pictures
•
Develops schematic facial recognition
• Discusses causes and outcomes of emotions
• Works with object and a friend to change
affect
Evidences self-conscious emotions such as
•
pride and guilt
• Identifies what another may be feeling based
on whether wishes are fulfilled
Predicts what people should be feeling
•
• Describes a situation where they were sad,
mad, happy, surprised, or scared
•
Understands emotions can be caused by what
someone thinks, even if what they think
conflicts with reality
• Has sense of self in the moment and in the
future
6–8 years •
8–10 years •
Develops an opinion on what one
person may be thinking about what
another person thinks
• Judges situations based on what a
person knows, remembers, forgets, or
guesses
Uses strategies to hide/detect deceit
and recognizes lies
• Understands figurative language
• Facilitates comprehension by using
metacognitive strategies
•
Describes what they believe another feels
• Identifies situations that cause complex
emotion
Recognizes a person can have first one and
•
then another emotion to situations
• Uses words like proud, jealous, worried
•
Uses strategies to regulate emotions
• Understands someone can have two opposite
emotions at the same time to a situation
• Recognizes, understands, and uses sarcasm
• Identifies social faux pas
• Hides emotions
• Understands and can perform polite lies
• Begins to use words such as relieve and
disappointed
Source: Adapted from Westby, C., & Robinson. L. (2014). A developmental perspective for promoting theory of mind. Topics
in Language Disorders, 34(4), 362–382.
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