Practical Flashcards
goal of behavioral testing
determine if the child has sufficient hearing to develop S/L
protocol that provides a direct measure of hearing
behavioral audiologic testing
Purposes of audiological assessments in infants and children:
To determine the type, degree, and configuration of hearing loss in each ear.
To assess the impact of hearing loss on speech, language, communication, and education.
To identify risk factors for progressive or delayed-onset hearing loss for ongoing monitoring.
To evaluate candidacy for sensory devices (hearing aids, assistive devices, cochlear implants).
To refer for medical evaluation and early intervention services when appropriate
Indications for Comprehensive Audiological Evaluation
Referral from newborn hearing screens or risk factors for hearing loss.
Behaviors indicating hearing loss vary by age:
Infants: No response to loud sounds or not turning to sudden sounds.
Toddlers: Not responding to verbal instructions, talking too softly or loudly, or speech misarticulations.
School-aged children: Frequently asking for repetition, turning up TV volume, difficulty following directions, inattention, or social isolation.
Parental concerns about hearing or speech/language delays.
what is the cross check principle
achieved through a test battery approach, where multiple tests cross-check each other to ensure accuracy, especially in infants and young children.
adv of test battery approach
Provides detailed information
Avoids drawing conclusions from a single test
Allows for the identification of multiple pathologies
Provides a comprehensive foundation for observing a child’s auditory behaviors
behavioral test protocon needs to include
ross-check principle (ensures valid & comprehensive eval) & developmentally appropriate for assessing hearing in infants and children
how do you choose the appropriate testing
Determine child’s cognitive age - determined from case hx, reports from other evals & infant developmental screening scales
Evaluate their physical status - used to determine his/her ability to perform the test task, evaluating their ability to control head, neck & upper torso, see objects (vision) and ability to manipulate toys
Choose the test room setup
for behaviorally testing if there is significant physical limitations but cognitively they are there what should you do
can verbally say they heard it
can use eye movement
physiological measures
what factors affect behavioral assessment
state of the child during the assessment
audiologists skills
clinican assistance
testing environment & setup
past experience
describe the stimuli used for behavioral audiometry
Frequency specific
Warble tones (pure tones?)
Narrow band noise
Non-frequency specific
Music
Noise
Speech - used to capture their attention & determine SAT
Speech can be used to confirm
warble/NBN threshold levels
Used to condition during audiometry to gain their attention more?
Ba - close to 500 (low)
Sh - close to 2000 (mid high)
S - close to 3-4000 (high)
ba
close to 500 (low)
sh
close to 2000 (mid high)
s
close to 3-4 (high)
presentation procedure for behavioral audiometry
Start at 30dB(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
Begin at HFs because many infants respond better to these (usually 2000 Hz) (obtain one HF & one LF)
If SNHL suspected start at 500 Hz
If middle ear pathology/CHL , start at 2000 Hz because CHL affects LFs more
After 500 and 2000 Hz, these answers determine the next most important piece of info
Significant difference between 5 and 2: test 1 next & if flat loss test 4 next
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
Attention concerns, test 2-3 frequencies
CHL - test 250, 500, & 2,000
SNHL - test 500, 2,000 & 4,000
If HL present, BC testing is next
Alternate bw ears
how is stimuli presented for behavioral audios
Inserts, supras, SF, BC, HA’s CIs
adv/dis of headphones & SF
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
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.
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
probe 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
control trials
what to do with no responses
Stimulus might not be audible or engaging enough (increase PL or change stim type or frequency)
Use VT stimulus w/ bone oscillator (~ 40 dB HL at 250 Hz)
what are some reasons a child might have to return for a follow up
Inconsistent responses
Inadequate cooperation: might be fussy, sleepy, uncooperative
If infant is unwell (cold, flu, ear infections)
Ototoxicity monitoring
Ear canal/tympanic membrane abnormalities
what can you do to test behavioral audio in severe to profound
May need 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
what are ped audiology tools
case hx
speech audiometry (SAT, SRT, WRS)
behavioral audiometry (BOA, VRA, CPA, Conventional
physiologic tests (TYMPS, OAEs, reflexes)
electrophysiologic tests (ABR, ASSR)
dev measures (ASQ, IDA, CDL etc.)
fxnal measures (ITMAIS, LITTLEARS, CHAPS, ETC.)
what is the importance of case hx
Accurate diagnosis of hearing loss relies on interpretation of a test battery within the context of the child‘s medical and/or developmental history.
Understanding the Child: Provides essential information about the child’s development and health, offering insights into their cognitive and developmental status and helping estimate their auditory skills.
Understanding the Family: Enables the audiologist to understand the parents’ concerns, needs, and assessment expectations, and helps build rapport with family and caregivers, which is crucial for effective counseling.
Observational Opportunities: Allows the audiologist to observe the child’s behavior and note interactions with family members and others.
Accurate diagnosis of hearing loss relies on interpretation of a test battery within the context of the child‘s medical and/or developmental history.
true
describe behavioral audiometry
measures the whole system
requires cooperation
direct measure of hearing
parents can observe and understand the results
when is boa performed
Birth to 6 mos
what are we looking at with BOA
Observation - sucking response
Looking for changes in sucking response to sounds (with bottle, nursing, pacifier (nonnutritive sucking); this change in sucking pattern is most likely to provide threshold responses
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
how do you detect a response in BOA
TIMING - responses need to be within 2 s of sond presentation
Some respond to the ON and some respond to the OFF
Infants are consistent in their pattern of response
Response time is slightly shorter for louder stimulus
testers needed for BOA
Minimum of 2
Audiologist - control room
Audiologist or assistant next to infant - monitoring child making sure the head and torso are comfortably balanced
Both need good visualization
when should you get ear specific information with headphones
Ear specific info might not be required at initial visit unless medical condition warants it or HL detected
Hearing is normal in general - can wait to get it
Evidence of HL - this info is needed and need to test under earphones
when do you see startle responses
when the sound is suprathreshold
can you change the response criteria durig testing
no
can you get minimum response levels (MRLs) in BOA
yes
what is the dis of using Auro Palpebral & 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
how do you maximize sucking responses 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
describe the protocol for BOA
infant comes in hungry state
seat them so torso is supported and they are not fidgety and so the tester can easily see the infant’s mouth
monitor their state during testing to test stimuli or responses from the child
instruct parents to not respond to stimuli or their child
assistant keeps infant visible, centered and monitors the parents behavior
begin testing in SF & w/ stimulus slightly above estimated threshold
test one low and one high then do the procedure next for which one
reduce thresholds in 10 dB and increae in 5-10 to bracket threshold. record response after 3
take breaks as need3d & calm infnant to increase test time
if SF indicates hL, test bc
if infant is still responding or at next session test with inserts
test with tech as needed
when should you use VRA
developmental ages 6-36 mos
what is VRA and what does it entail
Involves training an infant to make a conditioned head turn response to a test stimulus
Infant make a head turn in response to sounds and receives reinforcement.
Correct response is rewarded by activation of a light or lighted toy
The best reinforcers are novel and interesting
reinforcers for VRA
Speakers/reinforcers at 45 or 90 degrees
Best placed at the child’s ear level & 90 degrees to the side of the child
One or two?
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
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 distractors in VRA should be used
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!!
positioning for vra
High chair is preferred
Parent - do not react to any stimulus
what is the role of the in room examiner
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
Parents
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!
describe the training/conditioning phase
Start 100% reinforcement then slowly decrease to less frequent reinforcement
pairing phase is either simultaneous stimulus reinforcer pairing approach or 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
testing phase (threshold procedure)
Larger step sizes can be used (20 down 10 up instead) to get to the thresholds faster so we do not lose the attention of the child
Starting level: 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
what are minimum response levels (MRL)
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 that we should anticipate further improvement in response behavior as the child grows.
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.
protocol for VRA
seat child in high chair, child chair or parents lap
test assistant or parent keeps their attention centered using quiet toys
stim presented at a comfy level loud above expected threshold & conditioning/reinforcement toy turned on and if child doesnt turn, test assistant calls their attention to it. stim and toy are kept together for 3-4s
when child is conditioned to respond, stim is presented without the reinforcement and if they turn to the sound, the reinforcing toy is turned on and conditioning is done
testing begins with one lf and one hf with stim decreased until they stop responding
add other frequencies determined by the responses
testing then needs to be done with headphones bc and technology
reinforcing toy is now only turned on when they make a conditioned head turn in response to the sound
when in doubt do not reinforce
describe the conditioning phase
2 kHz is presented supra (60-70 HL) unless HL then use judgement or another frequency (like if there is HF loss use LF instead)
if they turn head witin 2-3s of stim presenteion then visual reinforcement is provided in combo with the sound for another 2-3s. if they repeat then conditioning is established and begin testing
if child doesn’t respond spontaneously with head turn then a more formal conditioning phase occurs - initally stim and reward is presented together and a number of this might be required. when head turn is reliably elicited with this combined method check with just presentation of tone alone and the visual as a reinforcer and once they respond to sound alone testing can begin
if they respond to combined stim/reward but not the stim alone, stim may not be interesting enough or not audible. Increase PL by 10dB & if no response at a higher level assess stim type
if they are not responding to stim/reward combo, reward may not be interesting or visible. Lower room lighting, change the reward, use 2 or more rewards in combo or move the visual reward closer to the child.
child may also not be developmentally ready for procedure or sufficiently motivated by the reward so other test procedures are required
when should CPA be used
Developmental age 30 months to 5 years (2.5-3 yrs to 5 yrs?)
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
The response must be deliberate, consistent with the child’s motor skill, and time efficient.
in CPA you want to start with the most difficult task first
false
when do you test bone
when there is concern of CHL or HL
AC & BC thresholds from 250-8 in each ear
procedure
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
what level should you condition in CPA
Condition around 40-50 dB if hearing is assumed to be normal
Pre play comforts the child in their new environment and can see which toys draw their attention
Process: Auditory stimulus to behavioral response to reinforcement
what is the first step in conditioning 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)
Hold toy next to ear do give 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
what is the second step in conditioning CPA
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
waht is the third conditioning step in CPA
child attempts alone (if they are hesitant, guide them by saying “you heard it, you can put it in”)
if the child is successfully conditioned for CPA what do you do? if they are not conditioned what do you do?
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
what is considered a response in CPA
Performance of the desired motor behavior within 3s after the stimulus onset of the signal
what are reinforcements that can be used in CPA
Positive reinforcement
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 toys that can be used in 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
CPA Protocol
set child in high chair or at a children’s table so they are comfy
select a toy that is enjoyable and within their skills
begin using test stimuli child will be able to hear
begin demonstrating the task. assistant holds toy to ear & when she hears the sound she says “I hear that” and drops it into the bucktet
after a few presentations the child is given the toy and assistant holds the toy to the child’s ear. when sound is heard the assistant helps the child drop it into the bucket
repeated until child can perform the task without assistance & performing reliably test can begin
if child gets bored change toys
testing can be accomplished by ac bc has cis baha & fm systems
procedure for birth to 6
BOA
procedure for 5-36 mos
VRA
procedure for 30 mos to 5 yrs
CPA
challenges of BOA
requires careful observation of infant sucking by the audiologist
can’t be used in infants who do not suck
only performed when they are calm and in a light sleep state
not generally accepted in audiology community due to lack of training
benefits of BOA
audiologists can get valuable behavorial responses in infants; part of the cross check principle
can be done in SF, earphones, BC, HAs, or CIs
ensures accurate fitting of tech becuase we can obtain MRLs
challenges to VRA
getting ear specific data when child won’t wear earphones
benefits of VRA
audiologists can get valuable behavorial responses in infants; part of the cross check principle
can be done in SF, earphones, BC, HAs, or CIs
ensures accurate fitting of tech becuase we can obtain MRLs
challenges to CPA
keeping child entertained and involved long enough to obtain all the necessary info
benefits to CPA
accurate responses possible at threshold level
can be done in SF, earphones, BC, HAs, or CIs
change in sucking in response to auditory stimulus
other behavioral changes are not accepted because they are suprathreshold responses
boa
conditioned head turn to a visual reinforcer usually a lighted animated toy
vra
motor act by a child in response to hearing a sound
listen & drop task
cpa
when can conventional audiometry be used
children >/=5yrs
only part of the audiology test battery that assess functional auditory performance
speech perception testing
what is the point in speech perception testing
provides information about how a child can be expected to function in daily listening situations.
Speech audiometry principles
Needs to match their capabilities (cognitive, motor, & attention)
Has to be interesting and motivating
Needs to match speech perception abilities in realistic scenarios
*if a child isn’t repeating or identifying, is it because they cannot hear or because they do not understand the words or langauge
use words familiar to the child & that are within their vocabulary; incorporate pictures or objects to represent words or sounds being tested
true
articulatioin problems in kids
make it difficult to score speech tests
instead do picture pointing, perform speech awareness
what is the procedure for presenting WRS
NH - present 30 dB SL
HL - present 40 dB SL
sloping - make sure it is audible at 2 kHz & in HFs
when should you do SRT vs SDT
SDT - dev age of 5 mos to 24 mos
SRT - receptive language skills >/= 2 yrs
when should you consider normal spondee words for SRT
around 5 yrs
when should you rely on picture boards, body parts, etc
below 5 yrs
what are tests that can be used with SRT
pointing to body parts or familiar objects
point to spondee pictures
CRISP
what are ways to test SDT
stimuli can be child’s name, nonsense words (bababa) , short phrases (hi, hey can you hear me, hi johnny)
usually MLV in SF or headphones
ling 6 sounds
Use when they are too young, delayed, have limited vocab or significant HL
sat/sdt
what is considered a response in SAT/SDT
Can be eye widening, head turn, facial change, etc.
what are the ling 6 sounds
Provides frequency specific information telling us how a person can be expected to perceive speech stimuli across the frequency range needed for speech
Can be compared directly to pure tone thresholds
indicates useable hearing through 1000 Hz (low frequency)
Audibility of /a/, /u/, /i/
hearing through 2000 Hz (mid-high frequency)
Audibility of /∫/
hearing through 4000 Hz (high frequency)
Audibility of /s/
assessing low-frequency information
ba
assessing mid- to high-frequency information
sh
assessing high-frequency information.
s
how to perform SRT
start around 30dB
if no response, go to 50 etc (like adults)
present with carrier phrase (show me, point to the, say the word)
carrier phrase is presented 10-15dB above the spondee level presentation
if your threshold for srt for snowman is 20 dB what do you present the carrier phrase at and the next srt presentation
present show me at 35 dB and immediately decrease to 20 and say “snowman”
carrier has to be audible for them to be attentive
when is a closed WRS appropriate
< 5 yrs or S/L delay
when is an open list appropriate
> /= 5 yrs
when should you use NU CHIPS
language age 3-5 yrs
Scored as %
Closed set of picture pointing word recognition test
how do you set up for NU CHIPS
just like adult WRS
ext A channel 1 track 3 for cd
or mic channel 1 for MLV
when should you use WIPI
Most common
Language age bw 5-8 yrs
Can be administered as an open-set measure by not using the picture book.
The test can be performed in an “auditory only” or “auditory and visual” (lip reading allowed) modality.
how to set up for WIPI
just like adult WRS
cd: ext a channel 1 track #3
mlv: mic channel 1
when should you use PBK-50
language ages 5-8 yrs
Cannot be used younger than kindergarten due to vocab too hard
only an open set
requires a verbal response
when do you use bkbsin
language age 5-8
Pre recorded signal to noise ratios, noise increasing with each sentence, used to est snr in kids 5+ or adults which quicksin is too hard
how to set up for bkbsin
channel 1
ext b
#19&20 are calibration
#13 is the list
when can you use NU-6
older children
12??
what can be used to test sev to profound HL for WRS
AND
used when they cannot perform standard tests
Determines whether child w/ HL can perceive spectral aspects of speech or only gross temporal acoustic patterns
how is ANT performed
Examiner calls out numbers w/ mouth covered, child points to the correct card or says the number
Scoring: 1 point for each one identified correctly & can range from 0-5
High Score = 3 to 5: Child capable of perceiving some spectral qualities of words
Low score = 1 to 2: Child tentatively considered having a profound hearing loss, requiring appropriate intervention
when should we use ABR ASSR
under 6 mos
