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AUDE 6140 - Pediatric Audiology > Visual Reinforcement Audiometry (VRA) > Flashcards

Visual Reinforcement Audiometry (VRA) Flashcards

1
Q

What was the first operant conditioning procedure for audiometry?

A

Conditioned orientation reflex (1961)

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2
Q

When did VRA come along?

A

1969
Requires a change in behavior

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3
Q

How was VRA done in the early years?

A

Single SF speaker
When the child made any motion of awareness of the presentation of the stimulus, a blinking light reinforce drew the child attention to localize to the speaker

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4
Q

What age range has VRA proven to be successful?

A

As young as 5-12 months

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5
Q

Are VRA responses significantly better than BOA responses?

A

Yes

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6
Q

What is VRA?

A

An audiometric technique used in pediatric assessment
It involves training the infant to make a conditioned head turn in response to a test stimulus
Correct response is rewarded by the activation of a light or lighted toy

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7
Q

What is the target population for VRA?

A

5 to 36 months of age
It is also a viable technique for older developmentally delayed children

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8
Q

Is the procedure of VRA similar to adult hearing tests?

A

Yes
Instead of verbal instruction, infants are shown what is expected of them through a process of operant conditioning
Instead of hand raise, the expected response is a head turn
Feedback about correct responses is provided by a visual reward that also acts to reinforce continued responses

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9
Q

Does VRA capitalize on a child’s natural instinct to respond to auditory stimuli by turning towards it?

A

Yes
When a child responds by turning, reinforcement is provided for that response with the momentary lighting and activation of a motorized toy

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10
Q

What is operant conditioning?

A

A process in which the frequency of occurrence of a particular behavior is modified by the consequences of that behavior
The desired behavior is rewarded, thus increasing the likelihood that the behavior will continue (Reinforcement)

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11
Q

What is reinforcement?

A

Applying a combination of rewards to encourage certain wanted behaviors or withholding reinforcement to extinguish unwanted behaviors
Positive or negative

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12
Q

Is the number of responses obtained dependent on the type of reinforcement used?

A

Yes
No reinforcement
Social reinforcement
Blinking lights
Complex visual reinforcement

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13
Q

What are the best reinforcers?

A

Ones that are novel and interesting

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14
Q

What is the ideal test environment for VRA testing?

A

The test should be performed in a room that is of adequate size to accommodate parent(s), child and test assistant comfortably.
Minimum floor dimensions of 6m x 4m are advised.
Minimal distraction to keep the child focused.
Speakers/reinforcers at 45 or 90 degree

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15
Q

What are the two types of reinforcers or toys used?

A

Plexiglass boxes
Monitors

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16
Q

What are the plexiglass boxes used?

A

Three dimensional lighted toys that can be lighted or animated typically housed in plexiglass boxes.
Controlled by an on-off switch
Some clinics are equipped with several toys to keep the child engaged

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17
Q

What are the monitors used?

A

Can also serve as excellent reinforcers
The animated images were shown to be equally effective or superior to conventional toy reinforcers

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18
Q

Where is the best place to place the toys or reinforcers?

A

Child’s ear level and 90 degrees to the side of the child

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19
Q

When is the cartoon video reinforcer used?

A

For older children, or children who are no longer interested in the VRA toys
Sound should be off so as not to interfere with test stimuli
Ongoing interest

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20
Q

Is one or two reinforcements better?

A

Infants can perform VRA with reinforcement on just one side or both sides. However, there are clinical advantages for placing one on each side in terms of conditioning
Even if the sound is presented on one side and the child turns to the other, it is counted as a positive response
The child only needs to detect the sound

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21
Q

Is VRA dependent on localization?

A

No

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22
Q

How should the child be positioned for VRA testing?

A

High chair (preferred)
Parent’s lap

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23
Q

What is an ideal number of examiners for VRA?

A

Two
One in the control room (control test stimuli and reinforcement)
One in the test room (with parent and child)

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24
Q

What are the parent instructions?

A

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

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25
Q

What are the two types of stimuli that can be used?

A

Frequency specific
Non-frequency specific

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26
Q

What is frequency specific stimuli?

A

Warble pure tones
NBN

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27
Q

What is non-frequency specific stimuli?

A

Speech
Noise
Music

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28
Q

What is the role of the in-room examiner?

A

Keeps the child in a listening posture and environment
Keeps the child busy with some visual stimuli at the level of the midline (center)
Refrain from talking or smiling to the infant unless a positive response has been provided
Maintain quite environment
Maintain rapport with parent
Available for quick insertion or reinsertion of earphones

29
Q

Is it possible to train the parent to serve as the in-room examiner?

A

Yes

30
Q

Are speech stimuli commonly used as the initial test stimulus in behavioral testing to capture their attention and determine speech awareness thresholds?

A

Yes

31
Q

How is SAT measured?

A

Using live voice presentation of sounds such as “ba, ba, ba” or “shh”

32
Q

What should you do if you want frequency specific information for SAT?

A

Use low-, mid-high-, and high-frequency stimuli (e.g., “ba,” “sh,” “s”), which correlate with pure tone thresholds across these frequencies

33
Q

How long is the test stimulus?

A

A short signal duration of 1-2 seconds
Some may respond to onset or offset
If the stimulus is long, your patient may just wait longer to respond
Waiting for too long between stimuli: the child may turn to the reinforcer just out of curiosity

34
Q

How is the stimuli delivered?

A

Insert earphones
Supra-aural earphones
Loudspeakers
Bone conduction
Hearing aids, CI

35
Q

Should you use headphones or SF?

A

There are advantages to start conditioning in the soundfield and then move to the earphone to obtain ear-specific information
Using earphones first may upset the child (and very little information would be obtained)
Infant responses are better for localization in the SF than lateralization under earphones (more natural)

36
Q

Are inserts a good option for infants and young children?

A

Yes

37
Q

What should you do if you have to use headphones for a child?

A

Demonstrate earphone use with adults first
Use distraction toys
Try different types of transducers
Consider rescheduling
Encourage parents to practice earphone use at home (for testing next time)

38
Q

Should we reinforce every response?

A

Intermittent reinforcement may be more reliable than constant reinforcement and provides more responses

39
Q

What could reinforcing every response lead to?

A

Will lead the audiologist to reinforce when, in fact, the infant has not really provided a head turn and may not have heard the stimulus.
Will confuse the child and reduce response reliability
Will cause more rapid habituation of the response

40
Q

How often should you reinforce throughout the testing?

A

Start with reinforcing 100% of the time
Slowly decrease to less frequent reinforcement

41
Q

What are distracters?

A

Quiet, 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
Something to draw their attention back to midline

42
Q

Can the child play with the distracter?

A

Only as a last resort

43
Q

What are the two phases to VRA?

A

Training/conditioning phase
Testing phase (thresholds)

44
Q

What is the pairing phase?

A

Associating the sound with the VRA toy

45
Q

What are the two approaches to the pairing phase?

A

Simultaneous stimulus-reinforcer pairing - present both sound and toy at the same time, learn to associate them together
Response observation and shaping - audiologist observes and reinforces natural responses to sound, response shaped by directing attention to reinforcer after hearing the sound

46
Q

What pairing phase approach is preferred by audiologists?

A

The response observation and shaping approach

47
Q

Does the initial presentation need to be audible to the child?

A

Yes
If the child has a severe to profound loss, then present a vibrotactile stimulus (low frequency through bone oscillator)

48
Q

Is there a standard accepted protocol for VRA?

A

No
There are three primary variants in protocols

49
Q

What is the threshold procedure for VRA?

A

Make sure to note every response along the way
Modified Hughson Westlake procedure can be used
Larger steps may be used (20 dB down, 10 dB up)

50
Q

What is the starting level for VRA?

A

Evidence shows that starting close to a subject’s threshold leads to more accurate threshold estimates
The starting level can influence false responses
Also saves time
Start around 30 dB (increase in 20 dB steps if no response occurs)

51
Q

What frequencies should be tested with VRA?

A

500 to 4000 Hz frequency range (most critical for speech and language development)
Testing proceeds by obtaining thresholds for one low- (500 Hz) and one high- (2000 Hz) frequency stimulus; typically start at 2000 Hz, easier to detect for infant

52
Q

Can the sequence of frequencies be modified due to the referral question or the case history?

A

Yes, it is decided on a case-by-case basis
If the concern is for CHL, begin testing at 2000 Hz; if the concern is for SNHL, begin at 500 Hz
If a significant difference between 500 and 2000 Hz thresholds is present, test 1000 Hz next. If flat, test 4000 Hz next
If hearing loss is present, bone conduction testing should be tested next

53
Q

When obtaining ear-specific information, should you alternate testing between the two ears?

A

Yes

54
Q

How many responses should you collect at each intensity level?

A

Obtaining many may significantly reduce the total number of thresholds obtained (only respond for a limited time)
Collect less than or equal to three

55
Q

How long should you present the stimulus?

A

Taking time with the presentation after a longer period of silence will increase the likelihood that the child will look up
Presenting the stimulus too quickly will make the reinforcer less interesting to the child
Avoid extended off periods

56
Q

What are probe trials?

A

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 throughout the test to determine if the infant is still on task

57
Q

What are control trials?

A

Observation trials in which the examiner judges whether a head turn occurs in the 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

58
Q

What happens when there is a high false alarm rate?

A

Require audiologists to further consider that test may be inaccurate
Suggests that the infant is not under stimulus control

59
Q

What can you do to rectify high false alarm rates?

A

Reinstitute phase 1 shaping and conditioning
Increase the entertainment level of the distraction activity to engage the infant

60
Q

What is normal hearing for VRA?

A

Infants do not always respond at their detection thresholds
Information available on the relationship between adult thresholds and MRLs for sound-field VRA, indicates that:
Infants with normal hearing (ages 7–12 months) respond to sounds at levels just above adults, typically between 15 to 20 dB HL.
By the age of one, children should be responding at adult levels

61
Q

How long do you usually test a young child?

A

15 minutes is the max
They decide how long the test will take
After this, they are no longer reliable

62
Q

What are some practical considerations to perform during peds testing?

A

Work in bigger ascending descending steps in order to minimize the number of required responses from the infant
Look for normal levels (15 or 20 dB HL) instead of thresholds
Delay habituation

63
Q

What is visual reinforced operant conditioning audiometry?

A

The child presses on a button to activate the reinforcement toy
Done at 2 to 3 years

64
Q

What is tangible reinforced operant conditioning audiometry?

A

Child is offered food or tokens

65
Q

How should you decide what test to use?

A

Base it on the developmental corrected age
VRA successful with the corrected age of 6-8 months up to 3 years

66
Q

What is happening if the child responds to the combined stimulus/reward but fails to demonstrate a response to the stimulus alone?

A

The stimulus might not be audible or engaging enough
Use a vibrotactile stimulus with reconditioning using the paired presentation should show a response even in a deaf child

67
Q

What should you do if the child is not responding to the stimulus/reward combination?

A

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

68
Q

What are some advantages to VRA?

A

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

69
Q

What are the limitations of VRA?

A

Obtaining individual ear data when child will not accept earphones

AUDE 6140 - Pediatric Audiology (15 decks)

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