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‘Oh, Behave!’ How to Enhance Behavioral Audiometric Assessment

Smith, Joanna MS; Wolfe, Jace PhD

doi: 10.1097/01.HJ.0000461187.28616.73
Tot 10

Ms. Smith, left, is cofounder and executive director of Hearts for Hearing in Oklahoma City. Dr. Wolfe, right, is director of audiology at Hearts for Hearing and an adjunct assistant professor at the University of Oklahoma Health Sciences Center and Salus University.



It is almost impossible for a single professional to test a child's hearing or program a cochlear implant while managing the child's behavior, maintaining his attention, operating the computer, and observing the child's discreet behaviors and responses.



Many clinics have an audiologist administer the test or program the cochlear implants, while a second audiologist or a speech–language pathologist who is a Listening and Spoken Language Specialist (LSLS) serves as the test assistant. In our experience, using a Listening and Spoken Language Specialist as the test assistant is most effective, as children are more comfortable with their therapist, and the therapist is familiar with the behaviors of each child.



In this month's column, we offer best practices for teams who utilize an assistant when conducting hearing assessment and cochlear implant programming for children. The tips that follow are built on the premise that the examiner has determined the cognitive age of the child prior to the evaluation or mapping appointment.

We dedicate this column to the late Marion Downs, MA, DHS, DSc (Hon.), who led the way in changing the outcomes of children with hearing loss worldwide.

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When working with children, it is very important to avoid lengthy waits in a waiting room, booth, or other room that may look scary. The buildup can heighten fear.

Therefore, while the audiologist speaks with the family, the assistant should begin playing with a favorite toy and engage the child in the activity.

Because it is hard to get a child back to a conditioning game once the “extra cool” toys are brought out, every attempt to engage the child using silly antics is made before these toys, which are hidden in a box out of sight, are utilized. For a child who is not impressed with traditional games, some of the “extra coolest” toys are light spinners, bubbles, windup toys, and an iPhone or iPad if developmentally appropriate.

If the assistant feels the child is losing interest, it may be necessary to move quickly to the testing before completing the case history.

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The distraction of a silly activity (e.g., big splashes in the bucket of water that will be used for conditioned play audiometry [CPA] or tall towers to knock over) can make it less traumatic when the audiologist reaches for the otoscope.

If a baby is diagnosed with hearing loss in the first few months of life, he often does not exhibit any fear, but, for a child who is older and may have a history of middle ear infections, one sight of the otoscope elicits a wail heard throughout the clinic.

For a child wary of the otoscope, it is useful to have the audiologist demonstrate how the light works by shining it on his hand or the assistant's hand and even in a parent's ear. For an older child, it can also be helpful to allow the child to hold the otoscope and look into the ear of a stuffed animal.



Often, an audiologist will look for favorite characters in the child's ears, such as Olaf from Disney's animated film Frozen, or animals, with comments like, “I wonder if there is a puppy in your ear?”

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Perhaps one of the most important aspects of the assistant's role is to ensure that the child's attention is at midline for visual reinforcement audiometry (VRA). The assistant can bring the child's focus back to the center by holding a mundane toy (e.g., peg or block). The toy should be interesting enough to establish midline attention but not so distracting that it causes the child to ignore the programming stimulus.

The child's positioning is also critical because a complete 90-degree head turn is required for a response. It is important to remind any family members in the room to be relatively quiet and avoid reacting to the sound presented.

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When a child is cognitively aware and developmentally ready to transition from visual reinforcement audiometry to conditioned play audiometry, there are some important tips for conditioning in the booth and programming sessions.

  • Near the ear: From the earliest visits, teach the child that the listening posture is important, and the ready position is holding the toy near the ear rather than over the jar of water used for dropping plastic fish or the tube through which cars are dropped.
  • Everybody plays: When teaching a conditioned response to a reluctant child, involve everyone in the booth or mapping room in the activity, including parents, siblings, and favorite stuffed animals. When a small child sees this is a fun game for everyone, he is likely to be more eager to participate.

For children who are slow to engage, the element of competition can be motivating. In our experience, racing a child to drop the plastic fish first into the bucket of water is an effective way to encourage participation. Once the behavior is established, it is critical that the assistant delay responding so as not to cue the child to the presentation of a stimulus.

  • I wanna hold your hand: When teaching a conditioned response, often the best way to practice is by using hand over hand. The audiologist presents a stimulus that is audible, and together the assistant and child hold the object next to the child's ear. When the stimulus is presented, together with hand over hand, the assistant and child drop the object into the water.

After several trials, typically the child will spontaneously begin to move his hand to drop the block, and his efforts should be reinforced.

  • Be in charge: One of the biggest mistakes that new professionals make in the booth is allowing a child to select the fish to drop, the peg to place, or the car to go down the tube. We have seen two-year-olds spend several minutes deciding which toy should go next. It is far more efficient and effective if the assistant holds the box of toys, handing a toy with excitement to the child after every response.
  • Keep it simple: The key to getting the most responses in the shortest amount of time is making sure that the task is simple. Although beads are great to drop in a container for stringing later, it is not a good idea to allow the child to string while conditioning. Games that require fitting pieces into a puzzle can be fun for practice at home, but, in a busy pediatric practice, the key is quick, consistent responses.
  • Thirty-one flavors: Because most little ones have short attention spans, variety is critical. We have found that when dropping items in a bucket of water, changing only the item dropped (e.g., from plastic fish to plastic bears) can make it possible to obtain five to 10 more responses.

Hiding activities in separate boxes under the table (often up to 15 different activities) offers a moment of surprise when a new box is pulled from under the table. When water is used, providing objects that will sink and float can lengthen a child's attention to the task.

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Knowing his place in space is critically important to a growing child, so we must make sure the child is seated in a chair that allows his feet to be firmly on the floor.

If an adult-size chair is all that is available, a box or stool can be placed under the child's feet to offer stability. When using a high chair or Stokke chair, it is important that there is a ledge under the child's feet.

A small table and chair should be in every booth where children are evaluated. Lastly, we can use weighted lap pads for a wiggly child.

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The Listening and Spoken Language Specialist should consider modeling and practicing conditioned play responses in therapy sessions.

Parents should also be encouraged to practice at home within their daily routines, such as laundry (e.g., throwing rolled socks into the laundry basket), dinnertime (e.g., putting fruit snacks into a bowl), and play (e.g., stacking blocks). It is helpful for parents to practice with a variety of activities so as to avoid the situation of a child participating only if his favorite puzzle is used or a certain yogurt treat is available for dropping.

As far as yogurt treats, we have found it better to avoid using food for conditioning if at all possible. Even if Cheerios are dropped for later consumption, a child will slip a quick one in his mouth, delaying the timing of the next stimuli. That being said, we have often saved food as a last resort, and we've visited the candy machine down the hall for the most stubborn children.

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Because we have babies who received hearing aids and cochlear implants before nine months of age, it can be a challenge to remove the technology for unaided testing or cochlear implant programming.

As the child ages, typically he is able to cognitively process that the implants are off only for a short period of time. It is important to explain to the child, with his hearing aids or cochlear implants on, what is going to happen, how long it will take, and, if he is able to understand, the reason for removal of the technology.

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Another very effective tool for conditioned play audiometry is a PowerPoint slide show with child-friendly pictures (e.g., images of Disney or Pixar figures, princesses, animals, etc.). When the child pushes a button, the show advances to a new slide.

In order to reduce the distraction created by a favorite slide, we have found it most effective if the audiologist or assistant advances the slide to a blank screen between every character slide. The anticipation for the next slide maintains the children's attention longer than a slide of a Teenage Mutant Ninja Turtle who happens to be the child's favorite character.

Additionally, tablet apps for the Angry Birds games may be used during a programming session, allowing the child to launch an angry bird each time he hears the test signal. A creative Listening and Spoken Language Specialist will likely have other suggestions for new apps to use.

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If a child's behavior begins to deteriorate, and the bubbles, tops, and whirly toys are no longer working, it is better to end on a high note, before the child pulls out the insert earphones and things go completely south.



Should a child remove the earphones, it is important that they are reinserted and later removed by the assistant after a certain number of responses from the child. Counting out five more fish and telling the child that after these have been dropped in the water, he will be finished, teaches the child that the task is over when the audiologist and the assistant determine so, not when he thinks he is done.

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It is critical that the audiologist and assistant work out a way to communicate with each other without cueing the child or his family members. Although that can be done through nods and finger taps, we have found the use of a wireless remote microphone system to be invaluable.

During testing in the booth, the audiologist utilizes the microphone, and the assistant wears the ear-level receiver, thus making it possible for the assistant to be alerted when a stimulus is presented.

The assistant can communicate with the audiologist that perhaps the signal appears to be audible but the child is not responding. Because providing credit for responses other than a full head turn or a conditioned play audiometry response is playing with fire, this communication is most important for obtaining reliable results.

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We recognize that not everyone has the benefit of two professionals working with pediatric patients, but these tips can also be used when parents participate as assistants. Parents have contributed great ideas to the growing list of activities that are quick, effective, and fun for use when partnering.

A dream team will make it possible for little ones to enjoy themselves while we obtain information critical for the development of listening and talking.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.