Behavioral Tests

Question 1

Pediatric Test Battery

Answer 1

No simple test battery–need to figure out what the goal of the appointment is–ME? SNHL? Prioritize and work fast

Question 2

Pediatric Test Battery

Answer 2

If possible, obtain status of ME & peripheral auditory system, speech perception testing and interpret auditory behaviors

if audiogram is normal there could be underlying problems: autism, AN

Question 3

Steps to take before beginning a test

Answer 3

1. Cognitive Age
2. Physical status
3. Test room set up

Question 4

Cognitive Age

Answer 4

Cognitive Age: think development issues, NOT chronological age–concerns about development, ask parent about development, ask if parent has talked to pediatrician –making best guestimate to see if they are capable to do a certain test

What kind of motor task can they do? Can they pick up cheerios?

Question 5

Physical Status

Answer 5

Physical status: can they sit up? do a VRA, do they have head control, vision: any concerns with eyesight? if they have reduced visual capabilities then VRA may not be for them not going to differentiate that toy from the wall—kid’s ability to manipulate toys, cerebral palys cannot do CPA–give them big blocks instead

Question 6

Test Room Set Up

Answer 6

Do you need a test assistant? What type of testing will you do

Choose test booth: Can this be done one-on-one? All in the same room, ideally you have a test assistant to help with this—is the kid easily distracted? Need to take toys outside so it is a blank canvus for the child

Question 7

Behavioral Observation Audiometry

Answer 7

watching for change in child in response to sound
-either stop/start sucking when sound plays

can be used up to 6-7 months of age

Looking for an overt change in an infant’s behavior to the presence of sound—we think about 0-6 month old babies, baby is lying there and maybe eating bottle–suck away present sound, when they stop sucking that is your response – some kids might need behavioral observation and their face changes—extremely subjective and takes a lot of practice to get good at it

Question 8

Case History Concerns

Answer 8

Complications while pregnant, during birth, gestational diabetes, born with umbilical cord wrapped around neck, did baby go home with parent, how many ear infections, ask development history, tell me how you think your kid hears–how does he respond to your voice, social history, does he make eye contact, smile appropriately—are their concerns about hearing, communication or how they will perform in the sound booth

Question 9

Behavioral Audiology Goals

Answer 9

Obtain ear specific, frequency specific information about the child’s hearing -not always possible

Question 10

Factors that Influence Testing

Answer 10

• Age
• presence of other impairments
• child’s state (hungry, tired)
• language development
• attention span

Question 11

ASHA Guidelines Testing from Birth-6 months

Answer 11

ABR or BOA

Question 12

ASHA guidelines 5-36 months

Answer 12

-VRA primarily, ABR if necessary, OAEs, functional assessment tools (speech inventories for parents, questionnaires)

Question 13

ASHA 30 months-5 years

Answer 13

CPA or VRA with speech perception testing

Question 14

Factors that can Influence BOA

Answer 14

Developmental age: if they are too old, they are not going to give you this reaction

Infant state: if they are sleepy and they are cuddled up with mom and hanging there, if they’re sleepy they will just leave, if they are too hungry it won’t happen either

Judge: can bring in your own biases–if you know they are delayed and there are risk factors, you as the AuD are gonna be biased even if the kid has very subtle signs—not consciously it’s what we do. Also if asked to help test a kid with CI, the kid wasn’t really responding and AuD was saying everything was a response

Stimuli: can impact outcomes, if using pure tones (standing waves in the sound booth also), use warble tones or narrow band noise (best speech for infant is speech—can almost always get a speech awareness threshold) soon as you switch to something more frequenncy specific, more salient because of extra energy (narrowband) are good stimuli also. warble tones or pure tones infants don’t have as much interest in it

Environment: too warm, too cold, too dark, mom comes in need comfortable chair with arms

Question 15

BOA: Habituation & Response Repertoire

Answer 15

Response repertoire: what is this kid gonna do, what do they bring to the table? Might only have a suck response so baby will suck on the bottle whenever the sound comes off and when sound goes on will stop— on responder: his response to sound is to stop sucking–generally don’t shift mid stream

Habituation: Not exciting for a long time and kid will eventually get bored—may only get one response from a kid before they habituate to it, objective test measures can get more information from

Question 16

BOA Responses

Answer 16

• cessation of movement
• movement
• eye movement
• crying
• startle

As get closer to threshold, responses will become more subtle

Question 17

BOA: Observation Bias

Answer 17

Observer may become biased watching the child in sleep state, best to have test assistant/audiologist to help determine if it is a response to sound or not

-in a study, judge responded “Yes” 39% of the time when there was no stimulus present

Question 18

Behavioral Audiometry Stimuli

Answer 18

• Narrowband Noise or Warble Tones for soundfield testing ( at least 500, 1000, 2000, 4000Hz)
• Pure tone testing if under headphones
• Speech (SAT/SRT)=very salient and children usually respond best to this –good way to start testing because can get valuable information

Question 19

Transducer Types for Behavioral Audiometry

Answer 19

• inserts

- sound field

Question 20

Test Stimuli: Pure Tones, Narrow Band, Speech

Answer 20

at 75 dB, worst stimulus is 4000 Hz at 3 months BUT if you use your voice or white noise these 3 month olds will respond every single time

Go down in volume, 4000Hz is still the hardest frequency to get information. Speech gets you the most information regardless of volume

Point is: Speech is most salient stimulus, narrowband noise would result in good responses also (fricative) noise factor

Speech vs Pure Tone: speech is a complex stimulus pure tone is very simple stimulus — babies respond more to complex stimuli

Question 21

BOA Test Technique

Answer 21

Low-Moderate intensity: can get them to respond at 40dB you have ruled out a moderate/severe/profound hearing loss right off the bat
Change stimuli if baby starts to get habituated

Start at 40dB speech get a response drop down to 15dB to get as much bang for your buck—ask if i get a response at 40, where would you want me to go next. No response at 15dB, go up to 30dB get a response. Then he habituates so respond with a different sitmuli

test-restest is 5dB so can stop at children’s at 20dB can rule out significant HL

Question 22

Visual Reinforcement Audiometry

Answer 22

6 months-2.5 years of age

kid is seated in room with speakers at 90 degrees away and when sound source comes on, waiting for them to search for a sound source—turning head to look and see where the sound came from. Light up toys when they turn their head—reduce habituation because it’s a fun thing to do. when i turn to see the sound, i get to see a toy light up

Question 23

Considerations for VRA setup

Answer 23

Kid shouldn’t be leaning against their parents, get too comfy and don’t want to turn their head as much—high chair works well also — need to be forgiving because kid is looking for toy

In left ear kid has ear infection, they might look right when present sound left that is a good sign and reinforce it anyway–No ear specific information Results you get are for at least the better ear when doing sound field presentation–only under headphones can you give ear specific recommendations

Typically use sound field but as they get older can use headphones to get ear specific info

Question 24

VRA Stimuli & Reinforcement

Answer 24

More complex stimuli, more of a response

More reinforcer, more of a response

social reinforcement: good job, you heard that–not very effective. Not a good tool to use instead of visual reinforcement

simple visual reinforcement (light pops on)

Complex reinforcer: puppet is the best

Question 25

VRA vs BOA

Answer 25

Always do VRA if possible because while the averages are around the same, there is a larger range of acceptable responses (error bars) for BOA

Question 26

VRA: Stimulus and Conditioning

Answer 26

Getting child to turn their head is easy, it’s getting them to refocus that is hard

want to make sure signal is salient–start out with their name and see how they respond because speech is most salietn

Question 27

How to not make a response: problem with false negatives

Answer 27

False Positive: unreliable threshold estimates

False Negative: not catching that you are on a pattern and kid is looking but the kid has caught pattern—need to mix it up OR so caught up in what audiologist assistant is doing that they don’t pay attention to sound

Question 28

Reliability during session

Answer 28

Child is much more reliable the first half of the session (90% hit vs only 70% hit second half)

Question 29

Test Assistant

Answer 29

make sure not to cue kid with toy, don’t stop playing with the toy when the sound comes on, make sure not to lead the kid to the sound

Question 30

Minimum Response Levels

Answer 30

normal tymps, OAEs, ABR normal, but doesn’t give good responses at softer levels for VRA—criteria set in head stimulus has to be this level before it responds—do not report it as definitive test of hearing

Question 31

Conditioned Play Audiometry

Answer 31

2.5-5 years of age

CPA: kid is sitting in chair and hopefully have test assistant, give kid a toy and they are listening for the sound, once they hear the sound they do something with the toy —conditioning session then threshold determination—put toy to cheek, not ear (don’t want to block sound

Question 32

Conventional Audiometry

Answer 32

5 years - adult

can do modified conventional audiometry–shout your favorite food or your best friends name

Question 33

SAT/SDT

Answer 33

doesn’t matter what i’m saying, at what level can you barely detect speech stimuli—good indicators of best frequency —if best frequency is 0 dB at 500Hz, will expect SAT to be 0. If have 30dB SAT, expect best frequency threshold is 30dB (within 5dB)

Cross Check Principle!!—minimum response levels (if SAT is at 10dB but go to pure tones, cannot give response lower than 30dB….gut reaction is probably getting minimal responses to the narrow band noises….there is a disconnect there—not quite intuned to these frequency specific stimuli—-recondition, ABR or bring them back a different day)

Matches Best threshold to conductive threshold

Whatever task is, just getting threshold —bbbb, uh oh uh oh

Question 34

SRT

Answer 34

using 2 syllable spondee words (equal stress on both syllables–hot dog, baseball, ice cream)

-Should be same as pure tone threshold at 500, 1000, 2000 (PTA)

• Flat HL at 40 dB, SRT should be 40dB also or within 5dB
• —have never seen kid responding better to tones than to speech—maybe better thresholds to speech than tones

Whatever task is, need to find out what kids receptive vocabulary —need at least 4 words/pictures they can identify

-Familiarize the kid with the list

Question 35

Word Rec score tests

Answer 35

NU-CHIPs: closed set test—only have certain number of choices, have test booklet you need to do it—Carrier phrase “Show me the….Where is the….Point to the….”Need to be consistent and have same carrier phrase

WIPI: closed set test—only have certain number of choices to choose from, have test booklet you need to do it

PBK: phonetically balanced kindergarten list (age 5)–open set, could say anything and kid needs to figure out what is being said, true test of what is being heard

NU-6: open set, higher level of linguistic challenge, older kids—word list of 50, may give them 2

Question 36

OAEs

Answer 36

don’t always need to do OAEs–always wanna do tymps

if you see a PE tube and get no OAEs it tells you nothing because somethings they are present and other times they are absent