Hearing Test Protocols for Children

Key Points

Pediatric audiologic assessments involve the detection 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 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

There are four main purposes for a pediatric audiologic assessment
1. 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 perception measures when possible
4. to observe and interpret the baby's or child's auditory behaviors
"Cross-check" principle is standard
- several appropriate behavioral and electrophysiologic tests must be used to determine the extent of a child's auditory function
- a test battery approach
  - furnishes detailed information
  - avoids drawing conclusions from a single test
  - sllows for the identification of multiple pathologies
  - provides a comprehensive foundation for observing a child's auditory behaviors

Birth through 6 months of age
- testing of infants or children should rely primarily on physiologic measures of auditory function
  - ABR
  - ASSR
  - OAE
  - 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
Five months through 24 months
- behavioral assessments with VRA (visual reinforcement audiometry) being the behavioral test of choice
- OAEs, ABRs assessment when tests are unreliable
- or auditory neuropathy suspected
25 months - 60 months
- behavioral tests (VRA or CPA (conditioned play audiometry)) and acoustic immittance tests are usually sufficient
- speech perception tests
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, and audiologic findings and recommendations for treatment and mangement
5. implementation of a plan for monitoring, surveillance, and habilitation of hearing loss
6. provision of family =-centered counseling and education

Behavioral testing 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
4. poor test-retest reliability
The behavioral audiogram provides valuable information not available from electrophysiological testing and within certain limits, it should be possible to obtain good-quality behavioral evaluations on infants and children of any age or developmental status

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 crucial
behavioral observation audiometry (BOA) is the appropriate behavioral technique for infants from birth to 6 months cognitive age;
Visual Reinforcement Audiometry (VRA) is appropriate for infants from 5 months to 36 months
Conditioned Play Audiometry (CPA) is the appropriate technique for children whose cognitive age is 30 to 36 months and older
Case history will be helpful in determining cognitive level
Motor development can be a useful marker
Using an inappropriate test may give the false appearance of hearing loss or yield inaccurate thresholds
Physical condition needs to be evaluated
If the child sucks, BOA can e implemented; Behavioral Observation Audiometry
- if the infant does not suck, it is probably not possible to obtain reliable observation audiometry responses
VRA uses a conditioned head turn in response to presentation of a sound stimulus
- good vision
- neck control

Using a Two-Room Setup

Two-room setup with an audiologist and audiometer in one room and the child, parent and test assistant in the other
- full view of the child
- both testers need to be able to judge the presence or absence of a response
Two testers are able to communicate
- hear directions or suggestions from the audiologist in the control room
- test assistant knows when the stimulus is being presented
- example: if a child looks toward the VRA toy when a sound has been presented, the test assistant must be enthusiastic, clapping and laughing
- the tester and test assistant must develop visual cues to ensure that they are communicating

Using a One-Room Setup

Some audiologists use a one-room test setup
testing can be accomplished with only one audiologist allowing more control of the test situation
arranged so that the child cannot see the audiometer controls and does not know when the interrupter switch is being pressed
there are times when it is convenient to have the tester and child in the same room

a good case history is a valuable tool and an often overlooked part of an audiologic evaluation
failure to obtain sufficient 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
learn about a child's development and health
If different family members have dissimilar viewpoints this difference of opinion frequently emerges during the interview process
provides an opportunity to observe the child and his interactions with family members and others
develop rapport with and insights into the family
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

Advance information is especially helpful
However, not all families will complete forms even if they are received in advance
the audiologist still needs to ask questions and spend time reviewing the information before initiating testing
it extends the time scheduled for an evaluation
The case history form should be viewed simply as a guide to the interview process