Hearing testing plays an important role in the overall health of today’s young children. Pediatric hearing loss can be frustratingly easy-to-miss, resulting in delays in diagnosis and associated treatment. Early identification of hearing loss in children is crucial to their cognitive, social, and emotional development. Testing this age group can present with various challenges. Children younger than approximately 5 years of age, or those with developmental issues, are usually not able to sit through a traditional hearing test on their own.
Pediatric audiologists are experts on Play Audiometry, or Conditioned Play Audiometry (CPA), a testing technique often used in children ages 2-5 years old, or those with developmental delays. The clinicians often work in teams of two, with one operating the audiometer and the other sitting with the child in the booth to help direct the child, and keep them on task.
Mobile audiometry with ambient noise monitoring helped pave the way for reliable and valid out-of-the-booth testing that many professionals have incorporated into their clinical practices. With mobile audiometry the clinician is positioned next to the patient, as opposed to being outside of the booth. This in turn allows for excellent access to the patient, and SHOEBOX Audiometry users have discovered that this audiometer form factor is an effective tool which easily enables solo play audiometry with young children.
Our in-house audiologist, Renée Lefrançois, recently found herself in a primary care medical setting testing four-to-five year-olds using tablet-based SHOEBOX Audiometry. “These children presented with active otitis media and were not feeling up to the manual testing task. I turned to conditioning them with Play Audiometry and was able to complete the testing needed on all four children in under an hour – solo. I was initially skeptical as I was in full view of the child and was using one hand to assist with conditioning and the other to operate the tablet simultaneously. I was pleasantly surprised to see that my close proximity did not distract the child from the task at hand. I employed false taps to replicate pressing the stimulus button and did not observe false-positive responses to those movements.”
Play Audiometry is a well-established method of pediatric audiological testing that utilizes behavioral conditioning to train the child to reliably react to the presence of sound, with the help of objects or toys. As young children can be intimidated when interacting with healthcare professionals, the introduction of toys can help bridge that issue. Being able to perform Play Audiometry outside of a booth is advantageous for two reasons: firstly booth space is a sparse resource in most clinics. Secondly, audiometric booths can seem scary to some children and may increase their level of anxiety which in turn negatively impacts the testing process.
When conducting Play Audiometry, the tester begins with a conditioning task to help train the child to demonstrate the desired response. In the image above, this 3-year old child is being trained to put the magnetic square into a bucket if she hears a sound. If she does this appropriately, she is rewarded by being given the next object. At the beginning, the audiologist will often use a hand-over-hand technique to demonstrate to the child what they would like them to do. Once the audiologist feels that the child is making the conditioned motion on their own, they remove their hand and the child is on their way for the new upcoming sounds. Once the child is conditioned to easily detect tones, the audiologist will then start to lower the presentation level. Should the child react when no sound is presented, the object is brought back in their hand and they are re-instructed to wait for a sound.The child must demonstrate that they are reliably conditioned before beginning the actual threshold-seeking technique.
Visual reinforcement is a powerful motivator for children of this age. Big smiles, thumbs-up gestures, no-sound clapping, and pointing to the ear when waiting for a sound are all effective techniques to help keep the child engaged. Shy children, or those on the Autism Spectrum Disorders may react better with less direct eye contact from the tester. If the child provides an undesirable reaction, pointing to the ear and waiting, or shaking your head can help communicate that we are looking for another behavior. Vocal encouragement and comments should be avoided as the noise environment should remain as quiet as possible throughout the test. This applies to both the tester and the child.
If the child starts to lose focus during the test, a good strategy is to switch out the toy to help re-engage them. Often it doesn’t matter what the specific toy is, it is the newness of the toy that buys the clinician more time to test. Sometimes, a clinician can go through 3-4 sets of toys to get a full audiogram. Quiet toys are best, but small cars on plastic tracks are a big hit, and kids love throwing things into buckets so adapting to the child is key to obtaining the required results. Another consideration is that the child be appropriately positioned for this concentration task, keeping in mind that very soft sounds will be presented and a calm, engaged child will yield more accurate results. Ensuring that the child is seated upright, with their feet flat on the floor or on a box, helps them keep their focus on the task at hand. It is also helpful for the tester to be as close to head level with the child as possible – hovering over them can be unnecessarily intimidating.
There are precautions to take to ensure good reliability when performing solo play audiometry. It is important that the child not react to the clinician’s hand movements, instead of sounds themselves. To address this, false taps on the tablet are essential to ensure the child is abiding by the listening task and not visual cues. Should the child react to non-sound producing (false) taps, re-conditioning may be warranted.
Incorporating mobile audiometry, including solo play audiometry, into your clinical toolbox can open new doors to successfully testing more patients, including young children. SHOEBOX Audiometry allows for testing in clinical settings without access to a booth, as well as in remote locations and schools, giving parents and clinicians better ability to detect hearing impairments early in a child’s development. All children deserve to achieve their linguistic, cognitive, and developmental potentials. Ensuring that their hearing is optimized helps them do just that.
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Renée is a licensed audiologist and CAOHC-certified Professional Supervisor (PS/A) whose professional background includes clinical experience in cochlear implants, pediatric audiology, global hearing health, adult rehabilitation, auditory neuropathy, FM system optimization, ototoxicity, and the genetics of hearing loss. As the Director of Audiology, she is responsible for clinical applicability, audiological testing program review, education, and support guidance for SHOEBOX Audiometry.