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Pediatric Audiology Requires a Degree of Competence

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I have had three upsetting experiences in the last few weeks about pediatric audiology. All involved incompetence. I will confess right from the start that I am not tolerant of incompetence. If you ask people who have worked with me they will confirm this.

When it comes to a child’s future, incompetence seems unacceptable.


Pediatric Audiology Requires Competence


The first situation was a family who had a one year old who failed newborn hearing screening and had been seen by three audiologists who had different diagnoses in the year since failing screening. I asked mom to send me all the test results. At 8 months of age this little guy had an ABR and a behavioral test in one center. The audiologist read the ABR as normal and the behavioral test indicated a moderately severe hearing loss.

The audiologist told them to come back in 3 months. I was very glad the mother wasn’t sitting in front of me because I went berserk.

First of all, the audiologist read the ABR wrong. It clearly indicated hearing loss. I sent it to another audiologist to look at and she confirmed that it clearly indicated hearing loss. Second, behavioral testing is the gold standard, so if behavioral testing indicates hearing loss you move very quickly. Third, if you have inconsistent test results on a child you bring them back tomorrow to determine what is wrong and, if you cannot solve the problem, you refer to someone else.


In this case the child had a moderately severe hearing loss and a year has been wasted.

The second situation happened with two different children. One was a three year old who failed newborn screening, was referred for diagnostic evaluation, was fit with hearing aids and there everything stopped. Neither the audiologist or this child’s pediatrician referred this child for any other testing. No one referred this child to early intervention, for a speech-language evaluation, for auditory-verbal therapy, for a psycho-educational evaluation etc.

This mom had done everything she was told to do for her child. She was horrified when she discovered that there were other things that she should have, and could have done to help her child. She felt very guilty but it wasn’t her fault. She is not an expert in pediatric hearing loss but the audiologist who has been following this child and the pediatrician are supposed to be experts.

At least this child had hearing aid but he did not have the therapy he should have had and, as a result, his language is more delayed than it would have been if he had had appropriate referrals and services.

The third situation is similar to the second one. I was asked to help with a child who was in kindergarten, with an identified hearing loss, who was not doing well. I went to school and the first thing I did was listen to his hearing aids. Neither one was working.

So this little guy had a hearing loss (moderate it turns out) and he has earmolds stuffing up his ears in addition to the hearing loss. I spoke with the mom. Her son was seen by a pediatric audiologist who identified the hearing loss after he failed newborn hearing screening, fit the hearing aids and that was that. Mom was told to return once a year.

She was not told to check the hearing aids every morning to be sure they were working, she was not referred for early intervention, speech-language, auditory-verbal, or psycho-educational evaluations. When he got to school age no one told her that her son was entitled to a school evaluation, that he should have an FM system in school, etc.

A fourth situation happened two years ago. I was asked to consult about a little girl who was finishing 1st grade and was not doing well. Lots of people had messed up in this case. She had failed newborn hearing screening but there were other problems including problems swallowing and no one followed up with the hearing loss.

She was seen by a speech-language pathologist for swallowing. Neither the SLP or the pediatrician referred this family for audiological evaluation even though she had a significant speech-language delay. When she went for her 5 year old annual checkup the dad suggested that mom discuss hearing with the pediatrician because he did not think she heard well. The pediatrician agreed to a referral to an ENT. A moderately severe hearing loss was identified and she was fit with hearing aids.

The audiologist in the ENT office told the mom that the little girls hearing loss was “not bad enough for her to need an FM system”, no one referred her to an auditory-verbal therapist or a speech-language pathologist who specialized in children with hearing loss. The school did not arrange for a tri-annual evaluation, nor did they offer teacher of the deaf services to help with academics.


So, what do kids with hearing loss actually need?


The services that a child with hearing loss receive will make a difference in the child’s life so we need to be very very clear about what children need. Here is my bare bones list. It is only a start but, in my view, everything on this list is critical.


  1. Early diagnosis – Hearing loss in children is a neurologic emergency. If there is any question about the hearing loss a child should be referred to another audiologist for a 2nd Testing should be accomplished very quickly. “Come back in 3 months” is never acceptable when you do not know if hearing loss is present or the degree of hearing loss.
  2. Fit technology quickly – If families choose listening and spoken language, it is essential that the child be fit with appropriate technology quickly and that the technology provides the child with access to audition sufficient to provide good auditory brain development.
  3. Routine audiological follow-up – My recommendations are that kids with hearing loss be seen every 3 months until age 4, every six months until age middle school, then annually.
  4. Families need to understand the importance of using technology EVERY WAKING HOUR. If children wear technology 4 hours/day it will take them 6 years to hear what a typical hearing child hears in one year. They need to understand the importance of hearing for development of language and literacy
  5. Families need direction to assist in developing language in their children with hearing loss. They need referral to an auditory verbal therapist or a speech-language pathologist with experience in teaching listening and spoken language to children with hearing loss. Families are their child’s primary teachers but they need direction.
  6. Psycho-educational evaluations will assist in determining if a child has any other learning concerns which should be addressed
  7. Medical evaluations including genetics, ophthalmology, and others as needed.
  8. Once children reach school age remote microphone systems should be provided for all academic classes, teacher of the deaf services should be provided for preview and review of all academic subjects, speech-language services, and other services are needed.



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.

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