Why do we put technology on kids with hearing loss? One reason and only one reason: to be sure they are hearing well enough to learn speech and language. There is an enormous amount of data demonstrating that the amount of auditory exposure a child receives will determine how much language they develop. Parents can talk talk talk, but if the child is not hearing absolutely every phoneme it will effect brain development. So how do we know that a child is receiving sufficient brain development?



Validation AND Verification

The standard of care to be sure that children are hearing well includes BOTH verification using real ear measures, and validation using behavioral measures. If we don’t do both we do not know what a child is hearing. If the audiologist does not do both, your child can be missing out.


Will real-ear testing tell us what a child hears with technology?

Real ear testing is a critical first step when fitting hearing aids. It is the beginning of determining how to set equipment. But it is important to remember that real ear tells us how much sound is reaching the tympanic membrane – not what is reaching the brain. We need to verify what a child is hearing with technology and real ear will not tell us. Real ear is a starting place, but without validation we will not know what the child is hearing. Unless we can ensure that a child is hearing with her technology we cannot expect children to learn using audition. So how do we find out what the child is hearing?


Behavioral testing

Behavioral testing is the gold standard. It is the only way we can measure the entire auditory system and know what the child is responding to. Many audiologists will validate a child’s performance using speech perception testing, and I believe that speech perception testing is a critical part of validation, but speech perception testing does not provide all the information we need.


Aided thresholds – yes we can !!

Aided thresholds are really critical. We do them routinely for children with cochlear implants. Why are audiologists so resistant to using them for children with hearing aids? As we develop more technology, like real ear and ABR, we seem to think that they substitute for behavioral testing. They do not, they should be in addition to what we already do. Aided testing can help us fine tune a child’s hearing aid settings. I routinely test aided thresholds after the hearing aids are set using real ear verification. I often find that the child is not hearing enough high frequencies. I know, that if the child is not receiving enough high frequency information, she will not hear /s/, /sh/, /f/, and all the other high frequency sounds. That means she will miss hearing plurals, possives, and some non-salient morphemes. Does this matter? Will it effect language? Literacy? Absolutely. So I am not comfortable sending a child out unless I know for sure she is hearing what she needs to hear. The goal? Aided thresholds at 20 dB from 500 – 4000 Hz.


Testing speech perception

Speech perception testing is an essential part of validating hearing aid performance. For very young children, we may only be able to obtain thresholds to the Ling Sounds but that will provide critical information. If presented in the way speech falls in general conversation, we will get good information about what a child is hearing and what they are missing. Don’t try and make the /s/ as loud as the /u/. Vowels carry most of the energy of speech, but consonants, the meaning. But /s/ is much softer when presenting we should keep that in mind. For example, if a child does not hear the /s/ I know, he is not hearing enough at 4000 Hz and I need to boost 4000 Hz in the settings.

Once a child can point to pictures or repeat words, we can do extensive speech perception testing with each ear separately and both ears together. Why do we need to do it this way? If testing is only performed with both ears we will not know if one ear is not performing well or what we need to do: improve settings, do therapy with the poor performing ear alone, or change technology. If you don’t test you don’t know.

Testing at normal conversational levels in quiet (50 dB HL) monaurally and binaurally, at a soft conversational levels (35 dB HL) at least binaurally, and at 50 dB HL with competing noise will provide a lot of information. But the best information will be provided if speech perception testing is accomplished using phoneme scoring. Whole word scoring provides good information but it does not tell you what, specifically, a child is not hearing. Phoneme scoring gives the audiologist, speech-language pathologist, listening and spoken language specialist and parents the opportunity to determine what a child is not hearing. That tells us all what we have to do to first, fix technology settings, and, once we know technology is providing information at normal levels throughout the speech frequencies, to plan remediation.


So what needs to be tested with technology to know if a child is hearing well enough?



Right Ear

Left Ear


Aided thresholds

500-4000 Hz


Speech perception

50 dB HL

35 dB HL



50 dB HL + 5 SNR



This week on Thursday April 6, I am going to be awarded the Marion Downs award for Excellence in Pediatric Audiology. It is always an honor to be recognized by your peers. This is an extraordinary honor, and for me a very special one because it recognizes Marion Downs and her work and focuses on Pediatric Audiology. In some ways it feels a little like cheating because I am being honored for work I have always loved to do. I considered Marion a mentor to me so receiving an honor in her name is wonderful.


Marion and me

More than 20 years ago I was running down the hall at an AAA convention and Marion stopped me and said, “You are getting old, and you are not doing enough to share what you know. You better get going!” It struck me as funny at the time because, here was Marion, about 30 years older than me telling me that I was getting old. But she did move me along. I went to work immediately on my first pediatric audiology textbook – a book on Behavioral Evaluation of Hearing in Infants and Young Children published by Thieme. It came out with a video (do you remember video’s) which demonstrated BOA, VRA, CPA, and speech testing of infants and children.


Then sometime, (we cannot remember when but likely early 80’s) Marion, Steffi Resnick, Laura Wilber, and I decided we needed to do a talk on the Role of Woman in Audiology at AAA. We were concerned that there were not enough woman being active and we thought the history of woman’s role in the field might excite some people.


Then when Carol Flexer and I decided to write our textbook, Pediatric Audiology: Diagnosis, Technology and Management, Marion very generously agreed to write the Preface. It was a great honor, especially considering that she and Jerry Northern had a competing textbook. But that was Marion. She was very generous.


Other influences that have contributed to my being me

David Luterman was my first mentor. (I babysat for the Luterman kids while I was an undergrad) I was the audiologist in the Emerson College Deaf Nursery the year it began. I tested lots of little kids. One day I walked into David’s office and said “This kid is not testable.” He looked at me and said “What you mean is that you can’t test this child. You will need to write in the report that you could not test this child.” It was, maybe, the most important lesson I learned. I made the decision right that minute, that I was going to learn to test well enough so that I did not have to write I could not test this child too often. David also taught me a lot about providing support for families and how critical family support is. Thank you David.


Robert Goldstein was my doctoral advisor. I was his first student and we learned together. Bob taught me a lot about research, about organizing a clinic, about working with people. He continues to influence me.


When I was a high school student I was trying to decide what I was going to be when I grew up, and I volunteered at the New York League for the Hard of Hearing. Dorothy Noto Lewis was the director and she taught me how to work with kids with hearing loss, to believe that kids who were deaf could learn to listen and talk, and that I could help. Dorothy showed me that speech and hearing was where I wanted to be. Then in 1970 we moved back to NY and I went back to the League to see if there was a job for me. Dorothy and Ruth Green were reorganizing the League and moving from Adult and Children’s programs to Audiology and Speech-Language programs. Since I was both an audiologist and speech-language pathologist they gave me the choice of which program to direct. It wasn’t easy but I chose Audiology and never looked back.


Of course, the most significant influence on me has been the families I worked with. I learned from every family who honored me by allowing me to work with them. I always kept David’s words in mind. I believe that every child is testable. As I worked with students, clinical fellows and 4th years I tried to pass on that point of view. Passing this on to students may be what I value most.


And most important

I started working in this field when most women stayed home. I was lucky. I have a husband who supported having a working wife and was happy for all I accomplished and helped me accomplish lots. I had two great kids, Jody and Josh, who had no trouble with a mom who was not there as much as other moms. (They learned to cook and to be independent.) My daughter sent a postcard from camp one year to tell me that one of the kids in her bunk had hearing loss and ask me what I was going to do to help. My son, the musician, wears musician plugs and sees that his friends do also.


I have been fortunate

I have been fortunate. I had lots of opportunities, I had mentors who encouraged and supported me, I had a family who helped and supported me, and I worked with wonderful families who helped me learn. Thank you all.