Exam 1 (Weeks 3&4) Flashcards
hearing loss is more prevalent in babies receiving care in the NICU
true
20x greater
_____ babies every 1000 are born with congenital permanent bilateral HL
2-3
what are risk factors of hearing loss
Family history of hearing loss
Genetic disorders or syndromes
Problematic pregnancy
Drugs or alcohol use during pregnancy
Maternal infections during pregnancy such as rubella, sexually transmitted diseases, cytomegalovirus, and numerous others
Trauma during pregnancy
Trauma during birth
Anoxia/hypoxia at birth
Apgar scores below 5 at 1 min or less than 6 at 5 min
Postnatal infections
Hyperbilirubenemia
Ototoxic medications including aminoglycosides alone or in combination with loop diuretics
Patients undergoing chemotherapy or radiation for cancer treatment
Craniofacial anomalies
Recurrent otitis media with or without ventilation tubes
Mumps, measles
Noise exposure, particularly excessive use of personal listening devices
what overall impact does mild HL have
impacts communication, language learning, and educational achievement
kid misses 10% of speech with distance
what impact on perception of speech sounds does mild HL have
vowels are heard clearly, voiceless consonants might be missed, louder voiced sounds heard, short unstressed words and less intense speech sounds inaudible (voiceless stops & fricatives)
what impact on education and behavior does mild HL have
auditory learning dysfunction may result in inattention, classroom behavior problems & could have mild language delay and speech problems
what impact does moderate HL on
speech perception have
miss most conversational speech sounds, vowels heard better than consonants, short unstressed words & word endings (-s, -ed) are difficult to hear
what impact on communicaton does moderate HL have
reduced auditory cues can lead to confusion in distinguishing speech sounds and understanding word meanings
waht impact on speech articulation does moderate HL have
Speech often features omissions and distortions of consonants, making it difficult for strangers to understand them
what impact on behavior and leanring does moderate HL have
can result in behavioral problems, inattention, language delays, speech issues, and learning difficulties.
what impact on S/L development does severe hl have
Language and speech do not develop spontaneously without intervention. With early intervention, properly fitted hearing aids, and specialized education, children can achieve significant functional improvement.
what impact on auditory perception without amp does severe hl have
Cannot hear typical sounds or normal conversation; can hear distorted self-vocalization, very loud environmental sounds, and only the most intense speech at close range.
what are other challenges that are impacted by severe hl
Significant language problems speech problems and associated educational problems.
if a child is uncooperative, should you switch test techniques?
NO
try taking a short rest
go for a walk, take a drink
try some new toys
try different stimuli
try a different assistant or using a parent
bribing “after we are finished you can have _____”
rewards like stickers, stamps, food, & candy
or by saying “when all of these marbles are put in the jar, we will be finished”
protocol that provides a direct measure of hearing
Behavioral audiologic testing
Importance of Pediatric Audiologic Assessments
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
To confirm the status of the baby’s or child’s middle ear
To assess auditory functioning using speech perception measures when possible
To observe and interpret the baby’s or child’s auditory behaviors
choosing the appropriate test protocol
Cognitive age - 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.
Physical status - evaluates whether the child is capable of performing the test tasks or not
does the child possess a sucking response? This can be used
Some may have earting problems, feeding tubes etc that cannot be used
BOA
child needs good vision to see the reinforcing toy and neck control to turn and look at it
If child is blind or cannot turn their head this wont work
VRA
child has to be able to perform a motor task in response to sound
This can be adjusted to the child’s ability
CPA
infants from birth to 6 mos
boa
5 mos to 36 mos
VRA
30-36 mos and older
cpa
what are the necessary steps before begining a ped assessment
Determine the child’s cognitive age from:
Case history
Reports from other evaluations
Infant developmental screening scales
evaluate their physical status (vision, head and neck control, ability to manifpulate 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 assistan
gold standard for evaluation of hearing in infants and children.
behaviroal assessment
Behavioral tests can be used with
earphones, bone conduction, HA’s, CIs, or remote mic systems
Goal of audiologic eval of infants/young kids
Determine if they have sufficient hearing (auditory brain access) to develop S/L
presence/absence of HL
Degree & configuration of HL
Integrity of AS
why is the Audiogram cut off for normal at 15 db
because children are still developing language and need to have access to the input to develop these skills
</= 15
normal
16-25
slight/minimal2
26-40
mild
41-55
moderate
56-70
mod sev
71-90
sev
> /= 91
profound
diagnostic eval and most common protocol for chidlren
Includes frequency and ear specific threshold information
Most common protocol -
ABR
Auditory steady-state evoked potential
OAE
Behavioral testing - different procedures that can be done to do this (VRA etc)
fxnal assessment
why do we like physiological measurements?
the child doesn’t have to participate to give any results
when they refer
Referral from newborn hearing screen
Presence of risk factors
Not startling to loud sounds
Parental concern about hearing or speech delays
Etc
waht is the cross check principle
In very young children, employing multiple testing procedures is critical to accurately assess their hearing status.
important role of including behavioral assessment in hearing evaluations.
Allows for cross-checking physiologic results with behavioral data by using a battery of tests to determine hearing sensitivity.
behavioral assessments show how the individual actually perceives and processes sound
Behavioral assessments are used alongside objective tests (like Otoacoustic Emissions or Auditory Brainstem Response testing) to provide a more complete picture of an individual’s hearing
are essential for early detection and intervention
waht is the first step in behavioral testing
finding a child’s cognitive age
through case history s/l or psychoeducatinoal evals
what are advatanges/disadvantage to early testing using noise makers as he sound source
Cannot fully assess hearing but can provide some information about an infant’s ability to alert to sound & localize to the source
Advantages of noisemakers: readily available, inexpensive & simple, can be used in any setting
Disadvantages: very broad frequency responses & intensity is not easy to control
what are adv/dis of physiological testing in infants
ABR, ASSR, & DPOAEs - objective, reliable, provide info about the status of the auditory status
Limitations - not direct tests of hearing & not always able to provide complete & accurate assessments of hearing in early infancy
what influences boa
Spend time w/ infant to make sure they can perform the task = more reliable results
Gastrointestinal feeding tube
Infants neurologic status
Visually alert
what are the essentials for testing little ears
Procedure Selection: Choosing the right method based on the child’s cognitive and physical development is crucial for accurate test results.
Influencing Factors: A child’s response to sound during tests can be affected by their development stage, condition during the test (like being hungry or tired), and the experience of the audiologist.
Soundfield testing: will not provide ear-specific information but will provide an indication as to whether or not hearing is sufficient to develop speech and language.
Response fatigue: Younger or developmentally delayed children tire quickly. Individual ear testing may follow sound field tests or be scheduled for another day.
Importance of Setup: A proper testing setup is vital to ensure the assessments are reliable and precise.
why are responses obtained from speech higher than with warble
they like speech and pay attentin more to it and ignore what they dont want to listen to
what is the difference between conditioned and unconditioned responses
unconditioned: An unconditioned response is an automatic, natural reaction to a stimulus that occurs without any prior learning or conditioning
an unconditioned response might be a newborn startling or blinking when they hear a loud sound.
conditioned: learned reaction to a previously neutral stimulus
In a hearing test, a child might be conditioned to drop a block into a bucket (a conditioned response) every time they hear a tone (the stimulus). Initially, the child wouldn’t naturally associate the tone with the action, but through repeated pairing of the sound with the action, they learn to respond in this specific way.
what is boa
unconditioned procedure used to test hearing in infants from birth to 6 mos of age & is the only behavioral test for this age group
Can also use in older children with developmental delays or other disorders like cerebral palsy
Present sounds to a baby who is not actively involved in a task & observing the response
what is the goal of testing
determine if the child has sufficient hearing to develop S/L
BOA measures an infant’s awareness of sound & doesn’t provide threshold information
true
They do not respond to sounds at threshold but only to sounds more clearly audible
minimum response levels
what is BOA useful and not usefl for
Useful for corroboration of parent/caregiver report but shouldn’t be used to determine thresholds for purposes of HAFs
Cannot differentiate between mild & moderate HL
Dependent on state, alertness, attention etc.
Infant habituation after only a few responses
what response is required in BOA
initiation or cessation of sucking in response to the stimulus within 2s of presentation
BOA protocol
looking at sucking response 2 ms after stimulus
baby comes hungry
observing the mouth
infant needs to be comfortable with full support of head and torso or in the carseat (adv because not receiving signals from caregiver)
minimum of 2 testers
warble tones/NBN
presentation: start in HF if CH, if SNHL start in LF, test 5 & 2 then assess
if SF indicates HL, test bone & test inserts
when is ear specificity required in infants
Hearing is normal in general - can wait to get it
Evidence of HL - this info is needed and need to test under earphones
benefits & limitations to BOA
benefits: Audiologist can obtain valuable behavoral responses in infants - part of cross-check principle
Conducted in soundfield, earphones, bone oscillator, HAs or CIs
Enables accurate fitting of technology because minimal response levels (MRLs) can be obtained
limitations; Requires careful observation of infant sucking
Can’t be used on infants who do not suck (feeding tubes for ex)
Performed only when the infant is calm, awake or in a light sleep state
Not generally accepted in audiology because they have not been trained to use a sucking response paradigm
Speech can be used to confirm warble/NBN threshold levels
true
close to 500 (low)
ba
close to 2000 (mid high)
sh
close to 3-4000 (high)
s
how many people are needed for BOA
Minimum of 2 reaching a consensus
Audiologist - control room
Audiologist or assistant next to infant - monitoring child making sure the head and torso are comfortably balanced
Both need good visualization
Consistency is considered in the response
what is the role of the parent in BOA
Not an observer
Remain silent and not react to any sound (even muscle stiffening can be transferred to the infant) - they can wear earphones
Make baby comfortable
Share previous baby experiences to sound stimulation
At least one parent in the room to assist and understand test procedure
test stimuli for BOA
Warble tones
Narrow band noise
\
What doesn’t give frequency specific info? What will
Speech or music
Pure tones
\
presetenation of stimuli in BOA
Begin at HFs because many infants respond better to these (usually 2000 Hz)
If SNHL suspected start at 500 Hz
If middle ear pathology, start at 2000 Hz because CHL affects LFs more
After 500 and 2000 Hz, these answers determine the next most important piece of info
Ex: if thresholds are 500 and 2000 Hz are normal more useful to test 4000 Hz than 1000 Hz but if hearing at 500 Hz is 30 dB and 2000 is at 70 then testing 1000 Hz is more crucial
what do startle responses indicte
sound is above threshold
response reliability in BOA
Predetermine what constitutes a response
Stick to chose response (e.g. sucking) and do not accept others (e.g. eye widening or head turns)
Do not change response criteria during testing
Response is time locked with stimulus & repeatable
Multiple observers increase reliability
what is VRA
Successfully used in developmental ages 5-36 mos
Can be used in older developmentally delayed children
Involves training an infant to make a conditioned head turn response to a test stimulus
Correct response is rewarded by activation of a light or lighted toy
The best reinforcers are
novel and interestig
Instead of verbal instructions they are show what is expected of them through
operant conditioning
Feedback about correct responses is provided by
visual reward that also acts to reinforce continued response.
VRA capitalizes on child’s natural instinct to turn towards an auditory stimulus and when they do it is reinforced
true
what is operant conditioning
operant conditioning response = desired behavior is rewarded therefore increasing the likelihood that the behavior will continue (reinforcement)
what is + reinforcement
combination of rewards to encourage certain behaviors
Used in ped to strengthen child’s responses to auditory presentations
test environment in VRA
Performed in a room to accommodate parents, child & test assistant
Minimal distraction
Speakers/reinforcers at 45 or 90 degrees (Best placed at the child’s ear level & 90 degrees to the side of the child)
can a child be tested with one reinforcer in VRA
They can perform with one side
Even if sound is presented to one side and they look to the other it still counts as a + response because they only have to detect the sound; NOT dependent on localization
what are appropriate reinforcers for VRA
Plexiglass boxes
Lighted toys htat can be lighted or animated
Monitors
Animated images
Cartoon video reinforcer
Older children or those not interested in the VRA toys
No sound
what are good distractors for VRA
Quiet and simple but less interesting than the reinforcer toy
Colorful toys, puppets, finger toys, pieces that connect, magnets on a magnet board
Examiner can also make funny face
Let the child play with distractor only as a last resort!!
what is the role of the in room examiner in VRA
Keep child in a listening posture and environment
Keep child busy with visual stimuli at midline
Do not talk or smile at infant unless a + response has been provided
Keep a quiet environment
Keep a rapport with parent
Insert or reinsert earphones
*you can train the parent to perform this role if needed
what instructions are given to the examiner/parent in VRA
Don’t respond to sounds
Don’t look at the reinforcement toy until the child does
Don’t change your body language when the sound is presented
Don’t alter the way you play with the toys when the sound is presented
Act deaf to the sound!
best stimuli to use in VRA
Frequency specific
Warble tones
NBN
Non-frequency specific
Speech - usually used to capture their attention and determine speech awareness thresholds
Noise
Music
SAT uses
MLV with “ba, ba, ba” or “Shhh”
Frequency specific uses low, mid, high stimuli corresponding to pure tone thresholds (ba, sh, s)
how can stimulus be delivered to VRA
Inserts
Supras
Speakers
Bone conduction
HAs, CIs
how should you deliver stimulus first in VRA
Start with soundfield
Global idea with hearing
Info reflects better hearing ear
Switch to earphones if ear specific information is needed
if a child is hesitant to eaeerphones what should youdo
demonstrate use with adult first, use distraction toys, try different ones (inserts, supras, etc.), reschedule, encourage parents to practice earphones at home
Inserts are good option
Adv to condition in the soundfield and then moving to earphones to get ear specific information
Soundfield testing yields more responses than for insert earphone
Using earphones first upsets the child and little info is obtained
Infant responses are better for localization in the soundfield than lateralization under earphones
what are the two parts to VRA
Training/conditioning phase & testing phase (thresholds)
do we reinforce 100% in VRA
Start 100% reinforcement then slowly decrease to less frequent reinforcement
*rule: if in doubt, don’t
when should you reinforce in VRA
Intermittent reinforcement is more reliable than constant reinforcement
Reinforcing ever response leads to reinforcement when they haven’t heard the stimulus, confuses the child and reduces response reliability, and causes more rapid habituation of the response
what are the pairing phase in training/conditioning pbase of VRA
includes Simultaneous stimulus-reinforcer pairing approach & Response observation and shaping approach
what is the Simultaneous stimulus-reinforcer pairing approach
tone and visual are presented together
method that pairs an auditory stimulus with a visual reinforcer (toy) to teach them to turn towards the sound, they then learn to associate the sound with the toy & if they notice the sound but do not turn, audiologist/helper helps by pointing to the toy
what is the Response observation and shaping approach
Tone is presented and the reinforced with visual when turn
preferred, method that the audiologist observes and reinforces a child’s natural response to sound, if they hear but do not turn, response is shaped by directing attention to the reinforcement during sound presentation, training continues until the child consistently responds to the sound without additional cues
Initial presentation needs to be audible
severe/profound HL present vibrotactile stimulus (LF through BC) for pairing
true
presentation for conditioning phase of VRA
present 2kHz stimulus at supra threshold (60-70 HL) but consider hl on case by case
if child turns head within 2-3s then reinforce in combo of the stimulus for another 2-3s. if this continues conditioning has happened and can test
if not, stim & reward are presented simulataneously. once child responds to auditory alone, can begin testing
if child fails to respond to stim alone, might not be audible and needs to be increased PL or vibrotactile
if they do not respond to stim/reward combo reward might not be interesting or visible
3 primary variants in protocols across clinics & labs i VRA
use of conditioning or training the baby’s response at the start of the test session
The starting level (starting at too high or too low level?)
The step size used in bracketing
how to present stimulus for testing
start close to the subjects threshold and not too loud (leads to greater false response rate)
Start at 30 dB (improves probability of starting close to threshold) & increase in 20 dB if no response happens
Completed from 500-4000 Hz: most critical for S/L development
Start at HF: Obtain one low (500) and one high (2000)
CHL - test at 2
SNHL - test at 5
Significant difference between 5 and 2: test 1 next & if flat loss test 4 next
If HL present, BC testing is next
Alternate bw earsa
if there is suspected CHL
test 2
if suspected SNHL
test 500
sign difference bw 500 and 2
test 1
if flat lost test 4 after that
if HL is present
conduct BC testing next
what is stim control
strength of discriminative stimulus in producing the desired responsew
what happens with stim control
Compromised when a test signal that previously resulted in head turn no longer results in the response (false negative) or when the head turn occurs when the signal is not present (false positive
Infants with normal hearing (7-12 mos) rsepond to sound levels just above adults, typically bw 15-20 dB HL
By age 1, children should respond at adult levels
true
what is minimum response level
Describes the lowest intensity of auditory stimulus that produces the desired response
Not adut like thresholds but they are repeatable and reliable and close to true threshold
Referring to these responses as MRLs rather than thresholds emphasizes
we should anticipate further improvement in response behavior as the child grows.
what are practical considersations in testing infants
Infant decides how long it will take
Time and attention span is limited
Work in bigger ascending and descending steps
Look for normal levels & not thresholds (15-20)
Delay habituation
Avg length of testing = 15 min
Avg number or reinforced stimuli trial: 45
2-3 stimuli were required to condition before threshold searching
Reconditioning throughout testing had to be repeated
Took more time to test an infant with HL because clinicians are less confident in finding MRL at levels lower than 20 dB
protocol for VRA
seat in high chair, child chair or on parent’s lap
test assistant/parent keeps child’s attention focused to front using quiet toys
stim is presented at a comfy level above threshold; conditioning toy is turned on and if they dont turn assistant points to it; toy & stimulus are presented together for 3-4 s
repeat until they consistently turn
then stim is presented without toy if they turn toy is turned on
obtain thresholds for 1 LF (5) and 1 HF (2) 3 responses are needed
determine other frequencies that should be tested
test with inserts, supras, bone, HA etc.
reinforcement is only turned on when child makes conditioned head turn in response to sound
what cna be used with 2-3 yrs instead of VRA
VROCA - Visual Reinforced Operant Conditioning Audiometry
Child presses a button to activate reinforcement toy
TROCA - Tangible Reinforced Operant Conditioning Audiometry
Child is offered food or tokens
what is CPA
Method of testing toddlers and preschoolers hearing through conditioned motor responses to sound with game activities
Train the child to react to a sound in a specific way
cognitive age older than 2.5-3 yrs to 5 yrs
<2.5 yrs is usually challenging
Goal of initial audiologic eval is to be certain the child has sufficient hearing (auditory brain access) to develop s/l
true
what techniques used to be used in BOA as responses
techniques included observation for eye widening, quieting, eye shifting, head orienting, arousal, limb movement, respiration changes
Early methods haven’t proven to be sufficiently repeatable & not good indicators of threshold because they are typically revealed at suprathreshold level
Cessation or initiation of sucking rate is a reliable response for observing auditory behavior in younger than 6 mos within 2s of the stimulus presentation
BOA
Infant make a head turn in response to sounds and receives reinforcement.
Judgment can be influenced by the placement of the reinforcers relative to the child.
90° angle to the child’s midline
45° angle to the child’s midline
vra
Limitations of using the Auro-palpebral and Moro reflexes in BOA.
Using auro-palpebral, moro reflexes, changes in limb movement or respiration are not elicited responses to threshold stimuli but suprathreshold stimuli instead
Discuss some ways to maximize the sucking response in BOA.
Infant is in a quiet, alert state
Hungry enough to have a strong sucking reflex but not hungry enough to be upset to participate
Ensure they are in a comfortable position
Given that most babies in pediatric audiology typically have normal or near-normal hearing, starting tests at 30 dB improves the probability of starting close to threshold.
Increase in 20 dB steps, if no response occurs.
true
Advantages and disadvantages of using headphones and soundfield testing.
Soundfield testing yields more responses than for insert earphone
Using earphones first may upset the child; very little information is obtained.
Infant responses are better for localization in soundfield than lateralization under earphones.
Soundfield:
Global idea about hearing
Information reflects better hearing ear
Natural head turn seems more intuitive in this localization task than in lateralization task.
Headphones
Needed for ear specific information
Inserts are good options for infants
what are probe trials
Suprathreshold stimuli presented at a level at which the infant previously responded
Used to demonstrate understanding of the task before descending in level to determine threshold and through the test to determine if the infant is still on task
what are control trials
Observation trials in which the examiner judges whether a head turn occurs in teh absence of sound stimulation
Primarily used to determine if the responses “head turn” being judged are truly responses to the test stimuli and not just random head turns
what reasons would a no response be obtained in VRA procedure
stimulus might not be audible or engaging enough
reward might not be visible or interesting
the child might not be developmentally ready for the test or unmotivated by the reward
If the child responds to the combined stimulus/reward but fails to demonstrate a response to the stimulus alone:
Assess the stimulus: The stimulus might not be audible or engaging enough. Consider increasing the presentation level or changing the type of stimulus (e.g., NBN) or its frequency.
Use a vibrotactile stimulus generated from the bone vibrator (such as ~ 40 dB HL at 250 Hz) with reconditioning using the paired presentation should show a response even in a deaf child.
If the child is not responding to the stimulus/reward combination
Enhance the reward: The reward may not be sufficiently visible or interesting. Try dimming the room lighting or offering more attractive rewards.
Alternatively, possible the child is not developmentally ready for the test or is not motivated by the reward; consider other procedures.
High rates suggests infant is not under stimulus control
true
List specific patient-related factors that would require the patient to return to the clinic for a follow-up/repeat session.
Inconsistent responses
Inadequate cooperation: might be fussy, sleepy, uncooperative
If infant is unwell (cold, flu, ear infections)
Ototoxicity monitoring
Ear canal/tympanic membrane abnormalities
Discuss some ways in which the clinician can determine the cognitive age of the child.
Case history
Normal motor and language development milestones
Absence of significant developmental delays (e.g. autism)
S/L or psychoeducational evaluations
If they are grossly in normal limits determined by evaluation reports then cognitive level can be assumed to be close to normal
Developmental milestones: parental reports & observation in clinic
Observing how the child communicates with their parents
Case history
what are some pitfalls of vra
Inadequate test set-up and communication between testers
Not establishing clear responses at supra-threshold levels before descending to threshold
Incorrect scoring as true responses i.e. scoring of movement other than a clear head-turn, or false positive (checking) responses
Distinct and/or rhythmical phasing of attention by Tester 2 such that response cues are given to the patient
Use of toys or behavior by Tester 2 (or parent) that provides too little or too much engagement for the child and therefore inhibit responses
Overemphasis on quantity of results (number of MRLs obtained) rather than quality (reliability) of those MRLs obtained
Not using time efficiently, often spending too long at high intensities
Inaccurate interpretation and reporting of results due to inadequate consideration of differences in infant MRLs compared to adult normative (threshold) values
Obtaining MRLs with speakers on right and left and interpreting these as providing ear-specific information (which they do not)!!!
Cues from parents (e.g., parents moving when sound is presented)
Tester response bias (e.g., tester believing or wishing that child’s hearing is normal) leading to lack of objective interpretation of turns vs. checks.
adv/limitations of VRA
adv: 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 soundfield, with earphones or with bone oscillator, hearing aids, or cochlear implants
Enables accurate fitting 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
limitaiton: Obtaining individual ear data when child will not accept earphones
transducers in CPA
Supras - easier to put on & remove but heavy for small head & positioning has to be at the opening of EAC
Inserts - no monitoring position, provides best results, but needs more effort and convincing to insert
BC
HAs & CIs
FM systems
stimulus in CPA
Goal is to obtain frequency specific results
Warble tones
NBN
No BB stimulus
Speech - condition to listen and drop task & once done switch to tones
Developmental delays - tones, NBN, music
Pre play comforts the child in their new environment and can see which toys draw their attention
true
process of CPA
Auditory stimulus to behavioral response to reinforcement
how do you condition in CPA
First: start by showing the task (make eye contact, hold toy next to ear, say I hear that when sound is present & put toy into bucket)
Second: assistant performs it with the child (hold child hand with toy next to their ear, say we hear that when sound is presented moving the child’s hand & dropping it in), after a few trials, feel for the child to move their hand first
Third: child attempts alone (if they are hesitant, guide them by saying “you heard it, you can put it in”)
explain what to do if you condition or do not condition during CPA
*if successful move to threshold exploration, if not increase intensity and present additional conditioning trials, still if not consider using another method (VRA) or switch to bone vibrotactile (place on their head or in their hand or on their knee) & after conditioning go back to air conduction
Start with least amount of cooperation then move to more difficult tasks
give an exampl
Resistant to earphones - start in SF, get 2-3 thresholds then try again
Condition around_____f dB if hearing is assumed to be normal
40-50
Start at 2 in one ear, move to 2 in the other ear then repeat at 500
If thresholds at both 5 and 2 are normal get 4
If thresholds are worse at 2 then get 1
true
Testing children with severe to profound hL
Inserts can attach directly to their personal earmolds
No response to limits of machine, gain response using bone on their hand, knee or mastoid & once they respond start testing air at 250 or 500
when should you test bone conduction
When there is concern of a conductive component
HL
If attention is an issue, test 2-3 thresholds
CHL - test 250, 5 & 2
SNHL - test 500, 2, & 4
* with bone use foam to support the transducer or a velcro headband
what is a response in CPA
Child holds a toy to their ear and drops it in a bucket when they ear the sound
*choose activities appropriate for their dexterity level
Performance of the desired motor behavior within 3s after the stimulus onset of the signa
what do to with fake responders
the audiologist can place an open hand just in front of or resting against the child’s hand holding the response peg or block. The child then has to go around or through the audiologist’s hand to complete the task once the sound is heard
wait until they are visually prompted to do the task
reluctant respnders
what to do with reluctant responders
want to identify if there is a definite facial response or reaction when the tone is presented and can then assist the child in completing the play task and watch for the child’s reaction to the next stimulus.
what to do with off responders
Using a continuous tone can often assist them in feeling more confident in responding because there is a definite “off” to the signal.
wait until the stimulus stops before doing the task
off responders
what are positive reinforcements for CPA
Verbal praise (that’s good, good listening)
Social (pat on the back, smile & nod, applause)
Tokens - traded in for stickers or small toys
Food
Changing computer display screen
what are acceptable toys to use for CPA
Toss a ball in a basket
Place puzzle piece together
Put ring on the cone
Place peg in pegboard
Give mom/dad a high five
Place block on a castle
protocol for CPA
seated in high chair, children’s tablel
enjoyable toy is chosen within their skill level
test stimulus at level they can hear (40-50 w/ normal)
demonstrate the task, after a few give to child and do together, then have them do it themselves
begin testing when they can reliably do it themselves if they are bored change toys
accomplish testing with air and bone and with HA, CIs, BAHA, fm
what is computer assisted testing in CPA
Child uses a mouse to add features to a screen (ex: hat added to a clown)
The child clicks the mouse
Audiologist controls the mouse from control room
Explain how you would instruct a child during these tests, providing examples of instructions.
BOA
Priority is making sure the child is calm and comfortable & observing sucking response
No instruction required for the child
Parental Role: Instruct the parent holding to not react to any sound and stay neutral, where ear plugs if needed
VRA
No instructions required for the child
Parental Role:
Explain to the parent that they should remain quiet and avoid giving any cues to the child during the test. Their role is to keep the child comfortably seated and calm.
Emphasize that the parent should not point to the reinforcers or direct the child’s attention, as this could interfere with the test results.
CPA
Explain the game: “We are going to play a game together where you get to put a block in the bucket every time you hear a beep.”
Demonstrating the task: “When you hear the beep you get to put a block in the bucket. I hear that & drop the toy in the bucket”
Practice together & condition: “Now lets do it together. Hold this block up to your ear and when we hear the beep, we will say we hear that and place it in the bucket.” “Now you do it by yourself.”
Discuss the training process for children with severe to profound hearing loss.
Children with severe and profound hearing loss, especially if not identified in infancy, may need some test adaptations.
The probe from the insert earphones can be attached directly to their personal earmolds.
If the child does not respond at the audiometric limits, it may be possible to obtain a response using a bone vibrator held either in the child’s hand, on the knee, or on the mastoid.
Once the child responds consistently to the tactile stimulus, begin testing with earphones at 250 or 500 Hz.
Describe techniques for engaging a child who is uncooperative during a conditioned play audiometry test.
What we offer has to be realistic
Do not ask if they want to put on the headphones
But which game do they want to play is good
Dont switch test techniques
Instead try
Short breaks
New toys
Try a new assistant
Like a parent
New stimulus
Bribe
If you finish you can have ____
Allow them to sit on a parent’s lap
Or indication of how long the test will last
Explain the rationale for instructing a child to hold the toy next to their ear during testing.
It gives you a clear indication of yes they heard it for certain
A clear indication of the motor act of dropping the toy i the bucket in response to the test stimuli
Lets you know that the child is ready to listen
Identify different types of responders and strategies for managing them.
Fake responders - the audiologist can place an open hand just in front of or resting against the child’s hand holding the response peg or block. The child then has to go around or through the audiologist’s hand to complete the task once the sound is heard
Reluctant responders - want to identify if there is a definite facial response or reaction when the tone is presented and can then assist the child in completing the play task and watch for the child’s reaction to the next stimulus.
These wait until they are visually prompted to do the task
Off responders - Using a continuous tone can often assist them in feeling more confident in responding because there is a definite “off” to the signal.
These ones wait until the stimulus stops before doing the task
Describe what constitutes an acceptable behavioral response during testing.
The response must be deliberate, consistent with the child’s motor skill, and time efficient.
With conventional and play audiometry, a response is defined as performance of the desired motor behavior within 3 s after stimulus onset of the auditory signal, and no later than 4 s.
Discuss the limitations and advantages of conditioned play audiometry.
Advantages
Accurate responses possible at threshold level
Can be conducted in soundfield or with earphones, with bone oscillator, hearing aids, or cochlear implants
Limitations
Keeping the child entertained and involved long enough to obtain all the necessary information
benefit/challenge in BOA
benefit: audiologist can obtain valuable behavioral responses in infants as part of cross check, enables accurate fitting because MRLs can be obtained, can be conducted in SF, earphones, bone, HA, CI
challenge: requires careful observation of sucking, can’t be used with those that canot suck, not generally accepted because most are not trained in the sucking response paradigm
benefit/challenge with VRA
benefit: audiologist can obtain valuable behavioral responses in infants as part of cross check, enables accurate fitting because MRLs can be obtained, child can be more easily involved & more responses possible due to conditioning, can be conducted in SF, earphones, bone, HA, CI
challenge: getting individual ear data when child will not accept earphones
benefit/challenge with CPA
benefit: accurate responses possible at threshold level, can be conducted in SF, earphones, bone, HA, CI
challenge, keeping child entertained and involve din order to obtain necesary info needed
Can be used in children older than 5 yrs
Child raises their hand or presses the button in response to a stimuli rather than completing a play task
conventional audiometry
