Application of visual reinforcement audiometry (VRA) to low-functioning children

Identifying reduced hearing in children who have developmental disabilities: Insights for inclusive research practices with electronic health records

Introduction

Recent advancements in big data analytics and the formation of large-scale clinical data repositories provide a unique opportunity to determine the current state of pediatric hearing health care for children who have developmental disabilities. Before answering unresolved questions about diagnostic practice, it is paramount to determine a standard and reliable method for identifying children who have reduced hearing because clinical management is affected by hearing status. The purpose of this study was to compare 5 different methods for identifying cases of reduced hearing from pure-tone thresholds based on developmental disability status.

Methods

Using retrospective clinical data from 100,960 children (0–18 years), hearing status was determined for a total of 226,580 encounters from three clinical sites. 9% of the children had a diagnosis of intellectual disability, autism spectrum disorder, Down syndrome, or cerebral palsy.

Results

Results revealed that encounters from children who have developmental disabilities were more likely to have insufficient data to allow hearing status to be determined. Moreover, methods with higher data demands (i.e., number of thresholds and ear-specific thresholds) resulted in fewer classifiable encounters. The average child age when hearing status was classified for the first time was older for children who have developmental disabilities than for children in the comparison group. Allowing thresholds to build up over multiple test sessions did result in more children who have developmental disabilities being classified than for single-encounter methods, but a meaningful decrease in child age at the time of classification was not seen for this strategy. Compared to the comparison group, children who have developmental disabilities were more likely to have reduced hearing that was stable over time, yet their hearing status was determined at older ages.

Discussion

Results provide key guidance to researchers for how to determine hearing status in children for big data applications using electronic health records. Furthermore, several assessment disparities are spotlighted for children who have developmental disabilities that warrant further investigation.

Behavioral Audiology Procedures in Children With Down Syndrome

Purpose Normative data regarding behavioral audiologic testing procedures are based upon the general population and often do not apply to children with Down syndrome (DS). Testing children with DS can be challenging, and outcomes may be unreliable due to their different cognitive demands and delays. The aim of this study was to assess optimal audiologic testing procedures for specific age groups of children with DS. Method This study used a retrospective investigation of 273 children with DS (145 boys, 128 girls; average age at evaluation = 5.92 ± 4.74 years) who received an audiologic evaluation during 2013 as part of their medical care at a large pediatric hospital (satellite facilities included). Results Age ranges for the completion of audiometry procedures in children with DS are provided. Average age to reliably complete behavioral testing in children with DS was delayed by up to 30 months compared to typically developing children. The majority of children with DS achieved at least good-to-fair reliability for audiologic results starting at 16 months (85.7%) and two ear results at 6-10 years (76.1%). Though not statistically significant, the use of a two-tester assistant compared to a single tester appeared to be helpful in obtaining reliable results. Conclusion The results provide a guide to optimal audiologic test procedures for children with DS, as the standard audiologic guidelines for typically developing infants and children do not apply.

Animated Toys Versus Video Reinforcement in 16–24-Month-Old Children in a Clinical Setting

Purpose

To compare the clinical efficacy of visual reinforcement audiometry (VRA) with animated toy animal reinforcement (AVRA) to the efficacy of VRA with video reinforcement (VVRA) in children age 16 to 24 months in a fast-paced medical practice.

Method

The 145 participants (age 16 to 24 months) were referred by either their primary care physician or an otolaryngology practitioner (physician or nurse practitioner) for audiologic assessment. Children were assigned in a counterbalanced manner to either the AVRA or VVRA group.

Results

Significantly more threshold estimates were obtained with AVRA ( M = 5.52) than with VVRA ( M = 3.47). There were no significant differences in performance based on age, hearing status, or gender.

Conclusions

Number and relative strength of the visual reinforcers used are posited as the main reasons for the disparate outcomes. Clinical practices that test large numbers of children with VRA would be well-served to have both AVRA and VVRA available to meet the needs of individual patients.

Verification of speech spectrum audibility for pediatric Baha Softband users with craniofacial anomalies

OBJECTIVE

The purpose of this study was (1) to determine benefit of the Baha Softband coupled to the Softband for infants and children with bilateral conductive hearing loss; and (2) to verify audibility of the speech spectrum for octave frequencies 500 through 4000 Hz.

DESIGN

The research design for this retrospective chart study is pretest-posttest repeated measures.

SETTING

The study was conducted in the Department of Audiology and Speech Pathology, Arkansas Children's Hospital.

PARTICIPANTS

Twenty-five children aged 6 months to 18 years with craniofacial disorders and bilateral conductive hearing loss participated in the study. Participants were consistent, full-time unilateral Baha users with the Baha Compact bone-conduction amplifier coupled to the head via the Softband.

INTERVENTIONS

The intervention was the Baha device coupled to the head via the Softband as a prerequisite to surgical implantation.

MAIN OUTCOME MEASURE(S)

The primary study outcome measures used aided and unaided soundfield audiometric thresholds to calculate functional gain. Audibility of the speech spectrum was verified by comparison with target aided thresholds.

RESULTS

Results revealed an improvement in soundfield thresholds with Baha amplification for the four octave frequencies. Means, standard deviations, and confidence intervals for aided and unaided thresholds are reported. Percentages of thresholds meeting target levels were significant at all frequencies, exceeding the 80% criterion.

CONCLUSIONS

Benefit of the Baha in providing audibility of the speech spectrum for infants and children with bilateral congenital conductive hearing loss has been demonstrated, offering important and timely data supporting third-party reimbursement.

Behavioral audiometry: protocols for measuring hearing thresholds in babies aged 4-18 months

OBJECTIVE

This paper provides the first report in English of original behavioral audiometry protocols for measuring hearing thresholds in very young children, including the multiply handicapped.

METHODS

Based on reactions to one or two well-calibrated acoustic stimulations delivered in the sound field, the protocol first involves the use of a vibrator to measure hearing levels by bone conduction. This measurement technique, which is not affected by middle ear infections, is the key diagnostic step. Moreover, in profoundly hearing loss children, it triggers reactions through vibratory stimulation and sets the scene for the conditioning of responses. Next, hearing levels are assessed by air conduction with the aid of headphones, in order to measure hearing levels in each ear as early as possible. A unique set-up is used to facilitate the emergence of reliable "surprise reactions", which may be interpreted by a sole examiner. Classical visual reinforcement is replaced by a highly interactive, dynamic and playful exchange between child and examiner, which gives meaning to the perception of stimuli and heralds the learning of hearing.

RESULTS

The results concern 105 babies suffering from bilateral sensorineural hearing loss and aged 4-18 months at the first behavioral test. Group 1 comprised 91 babies with no other handicap, in whom full bilateral air conduction was obtained in 82.4% before 12 months and in 98.9% before 18 months. In this group, air conduction in each ear was obtained in 47.0% before 12 months and in 70.3% before 18 months. In Group 2, which included 14 multiply handicapped babies, full bilateral air conduction was obtained in 37.5% before 12 months and in 78.6% before 18 months. Air conduction in both ears was obtained in 28.6% before 18 months.

CONCLUSION

The protocols described make it possible, in a minimum number of sessions, to measure hearing thresholds early over the whole range of hearing frequencies, even in multiply handicapped babies and those suffering from developmental retardation.

Audiologic assessment of children with suspected hearing loss

In assessing children with suspected hearing loss, audiologists are faced with the challenge of attempting to describe auditory function in a population that presents with a wide range developmental levels and abilities. Fortunately, there are a number of behavioral and physiologic tools available for the evaluation of auditory sensitivity and system integrity in children of all ages and developmental abilities. As powerful as many of these tools may be, however, it is important that the diagnosis of hearing loss be based on the outcome of independent measures of auditory function, which serve to cross-check and complement one another. Failure to do so is likely to result in inaccurate or incomplete delineation of auditory function.

Physiologic and behavioral approaches to pediatric hearing assessment

A behavioral approach is the first choice for hearing assessment in infants and children. It is the only true test of hearing. Physiologic measures are not tests of hearing, only indicators of auditory function. The use of physiologic measures in estimating hearing levels makes some presumptions regarding the concept of hearing. As such, these measures are used when a definitive statement about hearing cannot be made on the basis of behavioral audiometric results, or when other factors (e.g., age or developmental delay) preclude obtaining reliable behavioral information.

Auditory thresholds in children for narrow-band noise and warble tones in sound field

Auditory thresholds for frequency-modulated (warble) tones and narrow bands of noise in a sound field were obtained for children between the ages of eight and 48 months. Differences between the two types of stimuli centered at either 500 Hz or 4,000 Hz and among three age groups were not statistically significant (P greater than 0.01). Auditory thresholds for these frequency-selective stimuli did coincide closely with the speech awareness and spondee threshold measurements obtained in the present study, and with thresholds for complex noise obtained in previous reports. Sound field warble tone thresholds differed, however, from published data in adults and unpublished data in children. Explanations for discrepancies between data in present study and previous studies are suggested, and a cautious recommendation for the use of frequency-selective stimuli in the assessment of auditory thresholds in children is emphasized.