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Welcome back to All About Audiology, the podcast that’s, well, all about audiology; with resources and information to empower you wherever you are on your hearing journey or the hearing journey of your child, family member or someone you love. I’m your host Dr. Lilach Saperstein and in today’s episode we are going to be talking about your child’s audiology appointment. What can you expect for their appointment and how can you help prepare them for an audiology appointment or hearing test.

In last week’s episode we spoke about adults hearing test and different tips for preparing for that as an adult but for children the testing is very different and preparing for the appointment will be different as well.

The first important thing to understand is that we have different kinds of tests in audiology in order to test hearing. Some tests are automatic and help us get an understanding of the health of the ear and the functioning of the ear without a person having to be involved. The second kind of tests are subjective and do require your child’s participation. When children are very, very young infants then we can only test them with the automatic tests, either an “OAE” or an “ABR”.

There are a lot of acronyms in audiology and I’ll just take a minute to explain what they mean. OAE stands for Otoacoustic Emissions Test and this is a very brief test where a little earphone is placed in the baby’s ear, sounds go in the ear and the healthy ear will take in those sounds and will actually produce a kind of an echo or a result that can be detected by the microphones in the OAE device. So we can have a very quick screening that can take just a few seconds in each ear that can tell us if that ear is functioning properly and if the outer hair cells respond to sound.

The second type of test we use on babies is the ABR, Auditory Brainstem Response and it’s sometimes called the BAER, Brainstem Auditory Evoked Response. This test includes putting electrodes on the babies forehead and behind their ears and then presenting sounds in through an earphone. This actually is measuring the electrical activity of their eighth nerve, of their auditory nerve and to see if there is activity at the level of the eighth nerve and the brain stem, meaning they can hear the sounds. The OAE and ABR are often used as screenings for newborns hearing screening in the first 24 to 48 hours of life and any babies that do not pass these screenings are passed on for further testing.

Now I’d like to talk to you more about how we do the behavioral testing for toddlers and young children. There are two basic ways of testing young children that are split into the younger category and a little bit of an older category. This is not a hard definition and it depends on the child’s age; not just their age of how old they are, but really on their developmental abilities. The first method called, Visual Reinforcement Audiometry, is used for children ranging from 6 months to two years of age. The second method called, Conditioned Play Audiometry is used for children from the age of 2 to about the age of 5, but really these two methods can be used whenever appropriate for the patient.

Now testing young children’s hearing can be an exciting challenge for an audiologist because each child requires a unique approach. The goal is for them to feel like it’s a game and not a test and to get the child motivated to focus, attend, listen and perform the task you are asking them to do. The task, for example, can be filling a peg board with pegs or throwing sand bags into a bucket or building a tower of blocks. Basically what we do is give the child the piece of the toy; the peg, sand bag, or the block and hold it up to their ear with them showing them that we are waiting for a sound.

With Conditioned Play Audiometry, we are trying to condition the child so that every time they hear the sound they should do the desired action; put the block in the bucket or put the peg in the peg board. What we are trying to condition them to do is to time-lock their response to the stimulus. That means every time the sound is heard, they should do the action, but only when the sound is heard. When we are first explaining the game and conditioning the child to the task, we are making sure that they understand that they should only put it down when they hear the sound and not just because they want to or because they think they want to build a tower. We are actually showing them that the game requires their attention to the sound.

The child’s developmental ability and their conceptual understanding all have to be taken into account. The child’s gross and fine motor skills should be taken into account as well; are they able to hold the toy, or manipulate and move their hands? Their excitability, their personality and their mood that very day will also affect the testing. So a lot of things come into play which is why you might need more than one appointment with many children. With Conditioned Play Audiometry there must be some level of impulse control. Developmentally this is something that comes later on so for some children so this might not be the right method for them yet.

The way the directions are given are also extremely variable. With some children the modeling has to be a very concrete approach so an assistant or another audiologist will hold the child’s hand over their hand in the training and conditioning phase showing them what to do a bunch of times to make sure they really understand the game before beginning to do the testing.

Visual Reinforcement Audiometry is used with younger children as a way to get an estimate of the child’s hearing ability by having the child sit in the booth, usually on the parent’s lap. The audiology booth has toys in the corners of the room hidden inside a black box. These toys can light up or make noise and the audiologist can activate them from the tester side. Also, some equipment is now configured to different screens with an Ipad. The audiologist uses this box of toys and the Ipad as a conditioning task where the child associates the introduction of the sound whenever it is activated. By looking over to see where the sound came from they will be rewarded with the toy moving or lights flashing in the box, or a video clip being played on the Ipad. So in the conditioning stage the child will hear for example, a chirping sound or a bird or a whistle and when they look to see where it came from, they get rewarded with this toy. That’s what Visual Reinforcement Audiometry is.

So I have a couple of tips for you if you’re preparing your child or your student for a hearing test. First of all, don’t refer to the appointment as a doctor’s appointment or that you are going to the doctor’s office because children generally associate their doctor’s office with shots, being sick, being undressed, or poked or prodded. The typical audiology appointment is much more laid back. If it’s a pediatric audiology office, they will often have toys in the waiting room. Audiologists who work with children, when introducing themselves, will right away say that they are going to play a game together, really framing this as a fun and pleasant experience for your child, not a scary doctor’s appointment.

Tip #2: Practice at home for several days before the appointment with children who are old enough to understand. Try playing a game where they have to hold up a block up to their ear and you tell them to only put it in the box when they hear you clap. You will teach them that every time you play a beep or play a drum, a certain action has to happen. By doing this you are connecting responding to a sound in their environment by placing a specific toy in a specific container and this will be the listening game or the music game.

Another tip can be to think of some things that you know work as an exciting motivator for this child that can maybe be a small token prize or a treat on the way home to know that this is something that they need to do well and that they will be rewarded after the appointment. Something that can be very helpful is to practice putting earphones in the ear and wearing headphones over the ear, just to get children used to the sensory experience of something large and heavy covering their ears if they are ready for it. If it’s a child that has sensory sensitivities then they can really benefit from this practice before they come into the appointment. We don’t do the testing with headphones for every child, but it is a goal to eventually have the child do the test with headphones on so we can get information on each ear individually.

So to recap, there are different ways that we test children. There are automatic tests like the OAE and ABR and there are tests that require the child’s participation. We may use two different kinds of methods depending on their age either Visual Reinforcement Audiometry (VRA) with the flashing toys or lights where they have to look towards the lights, or Conditioned Play Audiometry (CPA) where the children will take the toy and throw it into the bucket every time they hear the sound.

It’s very important when you are taking the child to an appointment with an audiologist or for their hearing test that you convey to them a sense of playfulness and interest and excitement about the appointment. Try to focus on making it feel like a game and that they are going somewhere fun where they probably will receive a reward of stickers or bubbles or something exciting. Children feed off of the energy of their parents and caregivers, so if the parent is relaxed, then the child can come in relaxed and ready and we can get an accurate test and accurate results of their hearing ability.

I would absolutely love to hear about your experience taking your child or your student for a hearing test and how it went. I really hope you will tune in to the the All About You episodes where I read your comments, feedback and reviews and answer some of your questions. Please write into allaboutaudilogy.com on the contact page or feel free to contact me on Instagram @allaboutaudiology podcast or on Facebook, look for the All About Audiology podcast. In the next episode we will talk more about the newborn hearing screening and a little bit more in depth about the OAE and the ABR, I’m Dr. Lilach Saperstein and you’ve been listening to All About Audiology.