Improving Hearing Tests for Little Ones

Many years ago, I had the good fortune to have David Luterman as my mentor. He had been my undergraduate professor at Emerson College and taught me how exciting pediatric audiology could be. I went off to the University of Wisconsin to earn a master’s degree in Communication Sciences and Disorders, and then returned to work as the audiologist in the nursery for deaf children that David was starting at Emerson College.

One day I came into David’s office and reported to him about a child I was testing. I said, “This child is untestable.” David looked at me and said “What you mean is, you do not know how to test this child. You will need to write in the report, I was unable to test this child.”

To this day, I believe that his comment was the most important thing anyone said to me during my many years of education. I did not want to write “I was unable to test this child,” so I worked very hard to develop pediatric testing skills that would make it unnecessary for me to write it often. I do still have to write it on occasion, but I am happy to say, not often. I have told this to every audiologist in whose education I participated, and I hear from many of them, that they continue to pass on the message. (David would be proud.)

Hearing testing with little kids is both a skill and an art. We need to be able to figure out what is needed to get cooperation from a child, understand what information we need to obtain at each evaluation, and know how to make hearing tests interesting, or at least not deadly dull. We also need to know how to share test results with both parents and kids. Here are some suggestions.


Try not to keep kids waiting

Having a kid sitting around in the waiting room for a long time will result in a child coming into the test booth already cranky and annoyed. Believe me, I understand that things can get backed up, but it is important to do all we can to reduce the wait. This is also true once the child comes into the test room. Yes, we need to talk to the parents before we test, but we should not expect a little kid to just sit there politely. Ideally, there will be a test assistant who can entertain the child while the audiologist talks with the parents. If not, the audiologist will need to have our hands and do it all, find a way to play with the child and talk to parents at the same time.


Find toys that are fun

Hearing testing is boring for a child, but with the right toys we can keep kids engaged. Every clinic that sees kids needs a big toy collection. I was asked to consult in a large clinic once and the test booths each had one toy in the room. The toys were old and not particularly interesting. I could not imagine any little person wanting to play with that toy long enough to obtain separate ear information, much less to also get information about hearing with technology.

You need toys that are easy to manipulate, but still interesting. Ring stands, peg boards, and small pieces that can go into a can (such as Lego parts or Sesame Street figures) will be exciting, but you need several ring stands and peg boards, not just one. Building toys, like blocks to make a tower are great because they will fall down, causing hilarious laughter and a reason to rebuild. As kids get older they need toys that are more challenging to keep them interested.

Some audiologists like to use puzzles. I use them sparingly because of the time it can take to find the correct place to put an individual piece. On the other hand, I love toys that have parts that attach. They can be very interesting. I have had parents bring in new toys that they thought might be effective in keeping their child’s attention and I am always happy to receive these gifts or loans.

It is important to keep an eye on the child’s interest level. If you see it flagging, suggest doing one more piece and then changing the toy. That sends the message that you, not the child, are deciding when it is time to change toys, but that you are also paying attention to what is interesting to the child.

Toys should be kept in a closed cabinet that faces the audiologist, and not the child. If toys are out in the open they will be distracting and the child will be looking at what is next rather than attending to what is on the table right now.


Toys for visual reinforcement testing

How many times would you want to look at a bear playing a drum? With very young babies (6-8 months), you may be able to hold their attention for a while with one toy, but having a variety of toys available definitely helps.

I like a set up that has two VRA reinforcing toys on each side of the child, usually sitting on top of one another, and either next to or on top of the loudspeaker. The additional variety that this provides will help maintain attention.

As kids come closer to the time when they will be ready to move to conditioned play, even having multiple reinforcing toys will not be that interesting. At this time, a video monitor with cartoons (without sound) will be more interesting and will help maintain interest longer. Video VRA is not the best reinforcement for young babies; they respond better to the bear with the drums, so it is best for a clinic that sees lots of kids to have both kinds of reinforcers.


Order of tests

When testing kids I understand that I am not likely to get enough cooperation to collect all the information I want in one test session, so I try and order testing that gives me enough information to help determine what services are needed next. When working with older kids or adults we usually want to do a tympanogram and otoacoustic emissions before we start with earphone testing, but this may not work best with little kids.

When I am working with little ones, I play with the child for a bit and make a judgment about how the child will respond if I come toward him with an Immittance probe. Maybe it is useful to become friends first. I often start testing in soundfield. Once the child is more comfortable, I will make a decision about what information I need next. Should I try earphones first or will Immittance provide more important information? Obviously, I hope I will get everything I need, but I know that is not likely, so I am selective about order.


Order of test frequencies

Yes, I hope I am going to have thresholds from 250 through 8000 Hz in the right and left ear when I am trying to obtain an audiogram, but I may not get that much cooperation, so I need to decide what matters most. My test protocol involves a starting testing goal of obtaining at least one low frequency and one high frequency in each ear. (If I test several frequencies in one ear and the child stops cooperating, then I have no information about the other ear, so I go back and forth between ears. – 500 Hz right and left, 2000 Hz right and left, etc.)

If the child is still cooperating, I will fill in the other frequencies as the first few frequencies suggest. For example, if the concern seems to be middle ear disease, I will usually start by getting one high-frequency threshold first since the high frequencies are likely to be better. So I will get thresholds at 2000 or 3000 Hz in the right and left ears, and then move to 500 Hz, right and left ears. If the audiogram shows an upwardly sloping audiogram, I will then test a mid frequency to be sure that I understand the slope. If the history suggests a sensorineural hearing loss, I will start with a low frequency since that is likely to be where hearing is better, and then move to a high frequency. Again, depending on the slope I will decide if I need to next go to a mid frequency or a higher frequency.


How many frequencies do I need to consider hearing aids?

Even with thresholds for three frequencies in each ear, I usually feel as if I have enough information to get started with hearing aids. Would I like more information? Absolutely! Will I get more information as I proceed? Again, absolutely! But if I identify a baby with a hearing loss there is no time to waste. I want to begin to support auditory brain development as quickly as possible. If my three-frequency audiogram is fairly flat, then I have a good start for setting the hearing aids. So I feel comfortable taking earmold impressions. When the family returns I can try and get a couple of more frequencies.

I will set hearing aids conservatively – but not too conservatively – and arrange another appoint to complete the audiogram in 1-2 weeks. As I continue to see the family, I will fill in the frequencies, and repeat the ones I obtained early. Monitor, monitor, monitor.


How do I know if the hearing aids are doing what they need to do?

Never assume! Real ear tells you how much sound is reaching the eardrum. We need to know what is reaching the auditory brain. We can only know what is reaching the brain by using behavioral testing. So, let’s try and get aided thresholds for noise bands and for speech information with the right and left hearing aids. We want to be sure that the child is hearing what she needs to hear. My goal is thresholds at the top of the speech banana – in the speech string bean. I also want to see thresholds to the Ling sounds so that I know that the baby is hearing enough soft speech to develop auditory brain, language, and literacy.


Using parents as test assistants

It is great to have two professionals when testing kids. The second person can be an audiologist, a student, or a person who is a full time test assistant. In many busy clinics a person who is a full-time test assistant can be justified. When there is not a test assistant available, parents can often be good assistants. This is especially true after the child has had a few evaluations and the parent is familiar with the test situation. Parents also know their children better than we do and will be able to provide good insight. It is important to help parents understand that they need to be careful not to provide any cues about when to respond. I have found that most parents are easily educated about how to be good test assistants.


Be optimistic

We need to be optimistic about what is possible in testing infants and children. Like anything else, we need to build our skills so we can be great pediatric audiologists. We can do it, and the families we work with need us to be successful. Have fun.




About Jane Madell

Jane Madell has a consulting practice in pediatric audiology. She is an audiologist, speech-language pathologist, and LSLS auditory verbal therapist, with a BA from Emerson College and an MA and PhD from the University of Wisconsin. Her 45+ years experience ranges from Deaf Nursery programs to positions at the League for the Hard of Hearing (Director), Long Island College Hospital, Downstate Medical Center, Beth Israel Medical Center/New York Eye and Ear Infirmary as director of the Hearing and Learning Center and Cochlear Implant Center. Jane has taught at the University of Tennessee, Columbia University, Downstate Medical School, and Albert Einstein Medical School, published 7 books, and written numerous books chapters and journal articles, and is a well known international lecturer.