Session 2: Behavioural testing Flashcards
1
Q
what is the difference between behavioral and objective testing and are they used in isolation?
A
behavioural testing= expecting the child to respond to a sound.
Objective testing: child does not need to respond for a response to be recorded.
- the best test battery approach is to use them together
2
Q
what is the purpose of behavioural assessment?
A
*sound detection:
- awareness, presence or absence of sound
- stimuli include warble tone, BNB, pure tones, speech sounds.
*Sound discrimination:
- ability to distinguish between sounds.
- often involve speech sounds
- sound identification: requires memory, not necessarily understanding
- require matching sounds to animals
- speech audiometry
*sound comprehension: Understand the meaning of sound
- involve speech tests
3
Q
why is knowing the purpose of the behavioural assessment important?
A
depending on what the appointment s for, you will have different approaches: are you screening for a HL?
are you diagnosing a HL?
are you assessing the impact of HL?
are you testing a child with confirming PCHI?- for this child you wont just be screening thresholds, you’re going to need to get an accurate threshold, making sure you have all the freqs BC, AC etc
4
Q
what is the purpose of screening for HL in behavioural assessment?
A
- To identify hearing loss early.
- Commonly uses school screening with pure tone audiometry.
5
Q
What is the purpose of diagnosing hearing loss in behavioural assessment?
A
- To identify sensorineural hearing loss (SNHL) cases not detected by the newborn hearing screen.
- To detect children with severe otitis media with effusion (OME).
6
Q
What is the purpose of assessing the impact of hearing loss in behavioural assessment?
A
- To determine the need for intervention.
- To evaluate and assess the benefit of intervention.
7
Q
What is the purpose of behavioural assessment for infants/children with confirmed PCHI (Permanent Childhood Hearing Impairment)?
A
- To accurately fit hearing aids.
- To monitor hearing levels over time.
- To assess suitability for cochlear implants.
8
Q
should we be practicing BOA?
A
no, Behavioral observational audiometry is under review so it is not in practice but just be aware of it
9
Q
name some behavioural audiological assessments techniques with reinforcements and without reinforcements
A
*techniques without reinforcement:
- Behavioural observational audiometry (BOA)
- Distraction testing (DT)
*techniques with reinforcement:
- Visual reinforcement audiometry (VRA)
- Play audiometry
10
Q
what are the different developmental ages or each of the behavioural tests and why?
A
BOA= 0-6 months
DT= 6/7- 12 months because they develop object permanence so it wont work beyond this
VRA= 6-24 months because they get head control so it works
Play Audiometry= 2-5 years because they can follow simple instructions
Pure Tone Audiometry= >5 years
*it might be that you still need to adapt
11
Q
what is sound field audiometry?
A
sound field audiometry is a procedure to assess the hearing sensitivity of a person in which acoustic signals are presented through one or more sound sources in a room (i.e. not earphones)
12
Q
what are some limitations with sound field testing?
A
- ensuring that the level of signals at the 2 ears is what is intended
- remember the threshold in sound field testing only refer to the better hearing ear = so don’t discharge based on this as you could be missing a unilateral HL
KNOW YOUR DISCHARE CRITERIA
SO THE LIMITATIONS ARE:
- As the sounds are coming from a speaker it only tests the better hearing ear, the loss could be unilateral or
bilateral (2 marks).
- Doesn’t give information if the hearing loss is conductive or SNHL (2 marks)
13
Q
Why is ear-specific information preferable in audiometry?
A
Ear-specific information is preferable as it allows for precise assessment of each ear’s hearing sensitivity. However, it is not always possible to obtain such information in sound field audiometry.
14
Q
What are the two main uses of sound field audiometry? explain fully use, who its performed on?
A
- Unaided testing: Evaluates a person’s natural hearing sensitivity without the use of hearing aids or other amplification devices.
- This provides a baseline.
- Its mainly performed on young children who are unable to comply with individual ear testing using earphones or inserts.
- Aided testing: Assesses effectiveness of hearing aids, CIs, or other assistive devices in use.
- It measures the minimal response levels to determine the functional performance of the device.
- Performed on children of all ages who are using HA or CI
15
Q
what are the 2 systems used for testing children in the sound field?
A
1- Hand- held Audiometry:
- A portable device used for informal or quick assessments, such as in schools or home settings.
2- Static Speaker System:
- A fixed system with calibrated speakers placed strategically in a room, commonly used in clinical settings for consistent and accurate sound presentation.
16
Q
What is the purpose of aided testing in sound field audiometry?
A
- Functional Aided Gain: Provides a basic demonstration of how much a hearing aid or device improves hearing.
- Hearing Aid Adjustment: Checks how well the device is working and helps audiologists make necessary adjustments to improve its performance.
17
Q
what are the types of sound field?
A
- Free sound field
- Diffuse sound field
- Quasi-free sound field
18
Q
What is a Free Sound Field?
A
- What it is: A room where sound waves are not affected by the walls, ceiling, or floor.
- Example: Happens in a special room called an anechoic room that absorbs all sound reflections.
- Reality: Rarely used in clinics because these rooms are expensive and difficult to build.
19
Q
What is a Diffuse Sound Field?
A
- What it is: A room where sound waves bounce off the walls, ceiling, and floor a lot, creating many echoes.
- Example: A very echoey room, like a large empty hall.
- Reality: Not used in clinics because it doesn’t give accurate results for hearing tests.
20
Q
What is a Quasi-Free Sound Field?
A
- What it is: A room where sound waves are slightly affected by the walls, ceiling, and floor.
- Example: A normal clinic room where there are some echoes, but not too many.
- Reality: This is the most common type of sound field used in hearing tests because it is practical and reflects real-world listening conditions.
21
Q
What are the requirements for the loudspeaker?
A
- The loudspeaker must be placed at head height of the seated listener.
- It should be directed towards the reference point.
- The distance from the loudspeaker to the reference point must be a minimum of 1 metre.
22
Q
Where should the loudspeaker be placed?
A
- At head height of the seated listener.
- Directed towards the reference point (where the listener’s head would be).
23
Q
What is the required distance between the loudspeaker and the reference point?
A
A minimum of 1 metre.
24
Q
What are the SPL (Sound Pressure Level) requirements around the reference point without the test subject and chair?
A
- 15 cm above, below, left, and right of the reference point: SPL should not deviate by more than 2 dB.
- 10 cm in front and behind the reference point: SPL should not vary by more than 1 dB.
25
What types of test signals are specified for sound field testing?
- Frequency modulated tones (warble tones): Used because they reduce issues caused by echoes.
- Narrow band noise (NBN): Provides frequency-specific stimuli for testing.
26
Why should pure tones only be used in anechoic rooms with sound field testing?
- Pure tones can cause standing waves (areas where sound cancels out or amplifies), which distort results in regular rooms.
- Anechoic rooms are free of echoes, making pure tones suitable for testing.
27
What are RETSPLs?
- RETSPLs (Reference Equivalent Threshold Sound Pressure Levels) are standardized reference values used to calibrate audiometric equipment.
- They represent the minimum sound pressure level (in decibels, dB) that an average person with normal hearing can detect under specific conditions.
28
Why are RETSPLs important for calibration?
RETSPLs provide a universal standard so that results are comparable, whether testing is done in the UK, USA, or any other country.
29
What are the reference thresholds in ISO 389-7 used for?
- They are used to measure how soft a sound can be for someone with normal hearing to detect it.
*This includes:
- Pure tones heard with both ears in an open space (free-field) while facing the sound source.
- Noise bands heard with both ears in a room where sound reflects off walls evenly (diffuse sound field).
30
What are correction factors, and why are they important?
- Correction factors are adjustments provided by ISO 8253-2.
- They account for the increase in sound pressure at the ear closest to the loudspeaker when sound comes from 45° or 90° angles.
- This ensures test results remain accurate despite differences in sound intensity between ears.
31
which is more reliable: hand held generators or static speaker set up?
static speaker set up
32
Whats the role of hand held generators?
1- used for conditioning young children to respond to tonal or NBN prior to ear specific testing
2- used in distraction testing in community clinics where VRA facilities are not available
33
What is dB SPL (Sound Pressure Level)?
*What it is:
- dB SPL is referenced to a very low baseline of sound pressure: 20 micropascals.
- It measures the physical intensity of sound but doesn’t link to how humans perceive it.
*Usefulness:
- It’s useful for things like hearing aid prescription formulas but less helpful for everyday sound field measurements.
- Instead, REM (Real Ear Measurements) is preferred for fitting hearing aids.
*Takeaway:
- While dB SPL is scientifically precise, it doesn’t offer much advantage for clinical work compared to other methods.
34
What is dB HL (Hearing Level)?
*What it is:
- dB HL adjusts sound measurements to reflect normal human hearing thresholds, making it easier to understand hearing test results.
*Why it’s important:
- It’s the ideal standard for hearing tests with headphones or inserts.
- Tests in a quasi-free sound field (like a clinic room) are accurate if sound variation is small (less than 2 dB at all frequencies up to 4 kHz).
- Listening with both ears (binaural) is 2–3 dB more sensitive than listening with one ear (monaural).
*Correction Factors:
- These adjustments account for how the angle of sound (e.g., 45° or 90°) affects the louder ear.
35
What is dB(A)?
*What it is:
- A sound measurement based on the A-weighting scale, which mimics how the human ear hears different frequencies.
*Why it’s useful:
- It’s based on the 40-phon equal loudness curve, which reflects normal human hearing sensitivity at low sound levels.
- You can convert dB(A) to dB HL for clinical work when using natural or hand-held sound generators.
- The sound level meter (SLM) must be set to A-weighting for accurate results, and conversions are applied afterward.
36
How is sound measured in sound field testing for children?
- In sound field testing, sound is measured at certain distances using a sound level meter (SLM) set to dB(A).
- It is important to note that the sound level at the child’s ear may not be exactly the same due to variations in distance, positioning, and room acoustics.
- These slight variations are acceptable within the context of sound field testing.
37
what is the advantage of hand held generators?
- sound source closer to an ear can improve more significant
left/right differences (5-10dB) helping distinguish between which ear is responding, so is therefore and advantage of distraction testing
38
what are the 3 stages of calibration for sound field testing?
Stage A: routine examination and listening test.
- check connections, cables etc
- check audiometer output at 'just audible' levels for all appropriate signals.
- listen at higher output levels (60-70 dBHL) to check for distortion, function of interrupter switches etc.
- check of subject responses and monitor circuits
Stage B: periodic electroacoustic test (12 monthly)
- Does equipment meet standards of;
*frequencies and characteristics of FM tones
*Attenuator steps- linearity
* Harmonic distortion
- Every 3 months the SPL at the reference point should be checked and compared to relevant standards and adjustments made as appropriate.
- normally performed by the manufacturer
- this is one so output levels are adjusted so dial settings are achieved in a quansi- free sound field at the recommended distance.
Stage C: every 5 years.
- at the initial set up of a sound field system, the ambient noise level should be checked.
- the uniformity o the field around the reference point should be checked.
- the room reverberation time should also be checked
39
What is BOA?
(Behavioral Observation Audiometry) which is observing changes in a child's behavioural in response to an auditory stimuli
40
What type of response is observed in BOA?
BOA observes an unconditioned response, which is a natural reaction to sound without prior training.
41
is BOA an objective or subjective procedure?
- BOA is a subjective procedure, as the results depend on the observer's interpretation of the child’s behavior.
- The observer reports whether the child has responded to the sound stimulus based on observed behavioral changes.
42
Does BOA test hearing thresholds?
No, BOA identifies supra-threshold responses, meaning it detects reactions to sounds louder than the hearing threshold, but it does not determine the exact threshold.
43
Who benefits most from BOA testing?
BOA is particularly useful for children with complex needs, who may not be able to participate in other types of hearing tests.
44
what is the testing prep for BOA?
- appropriate history
- explain the test and subjective observation
- observe the child and record the child's responses before testing
- use child's mode of of communication
- quiet room- large soundproof booth
- accommodate wheelchair users
- ventilated
- minimal sensory stimulation
45
what equipment do you need for BOA testing?
- audiometer
- sound- field speakers
- transducers
- Instruments: drum, rattle, chime bar, xylophone
- CD/MP3 players
- Sounds/ songs
46
what is the BOA test procedure?
1- mother and baby seated comfortable
2- second tester- good view of the child to monitor changes
3- present sound at an audible level
4- present sound 2-5 seconds- look for a change in behaviour
5- if it is repeatable, decrease intensity
6- decrease in 20 dB and increase in 10dB steps
7- responses can habituate quickly
8- use no sound trials
47
what are some indications of responses for BOA testing?
- eye-widening
- blinking
- changes in body movement
- searching
- vocalisations
- quieting
- head or limb reflex
- body startle
48
Q: What factors should be addressed to ensure the child is comfortable?
- Make sure the child is not hungry.
- Be prepared for several appointments, as the child may not complete the test in one session.
49
Why is it important to alternate between different stimuli for BOA testing?
Alternating between stimuli helps maintain the child’s interest and ensures accurate responses to auditory testing.
50
What should the tester ensure the child is not responding to during BOA testing?
- Vibrations
- Tactile sensations
- Perfumes or strong smells that might distract or influence the child’s response.
51
How are results interpreted in behavioral hearing tests?
Results are interpreted using video recordings, peer review, and analysis of responses observed during the test.
52
Are hearing thresholds or minimal response levels estimated during BOA tests?
No, these tests do not estimate hearing thresholds or minimal response levels.
53
what are the limitations of BOA ?
* Limited effectiveness
* Large range of acceptable responses
* Observer bias
* Parental cues
* Habituation to responses
* Baby not sleepy when testing
54
What is DT (Distraction Testing)?
DT is a hearing test where an infant turns to locate a sound stimulus
55
Is DT still used?
Yes, DT has been superseded by the Newborn Hearing Screening Programme but is still used as a cross-check or when a child cannot condition to other tests.
56
Where is DT performed?
DT is conducted in a soundproof booth to minimize external noise interference.
57
What staff are required for DT?
a tester and a distractor
58
what are the roles of the staff in DT?
* Distractor:
- captures the child's attention
- phasing of the attention; child is ready for another stimuli
- observe the child but not make eye contact
- judges response validity
* Tester:
- present the stimuli at appropriate place, time and level
- present stimuli at 135 degrees to the child's ear with the horizontal plane of the ear
- decide which sound to present
* the tester and distractor should both be looking for any intentional or unintentional cues
59
What equipment is used in DT?
- sound level meter and test signals
60
What sound stimuli are used in DT?
- Repeated unforced "ss" sounds for testing at 4 kHz.
- Humming with minimal voice for testing at 500 Hz.
61
what is the set room set up for DT?
- Signal sources: Positioned at +135° and -135° relative to the child.
- Distance: The signal source is placed 1 metre away from the child.
- Child's position: The child sits at a low table with a distractor and parent nearby.
- Staff roles:
*Distractor: Keeps the child engaged. not in eye line of child
*Tester/Assistant: Operates the signal source and observes the child's responses. sits in front of child
62
what are the steps involved in the DT procedure?
1- check the baby is able to follow an object through 90 degrees.
2- Distractor:
- Gains the attention of the baby with a simple toy
3- phases out play activity
4- tester: presents the sound stimulus from behind the child for up to 10 seconds.
5- baby is rewarded (well done, smile, tickle) if they respond
6- distractor takes child's attention back to the front and tester moves behind the child again
7- use 'no sound trials'
63
What is the Minimal Response Level (MRL) for DT (Distraction Testing)?
The Minimal Response Level (MRL) is determined when the child responds to the sound stimulus in two out of three presentations.
64
What is the BSA recommended procedure for DT?
1- Start by presenting the sound at a quiet level and gradually increase the level until the child responds.
2- Once a supra-threshold response is observed, reduce the sound level to find the minimal response level.
65
Why should you use no sound trials in DT?
To ensure the child is not responding to visual or non-auditory cues, confirming that responses are due to the sound stimulus only.
66
What should you do if suspected hearing loss is present?
Use a high presentation level early in the test to identify if the child can respond to louder sounds, ensuring quicker identification of potential hearing loss.
67
Is the 10 down, 5 up method appropriate for DT?
No, the 10 down, 5 up method is not suitable for Distraction Testing.
68
Why is it not possible to measure thresholds traditionally in Distraction Testing (DT)?
DT does not provide exact thresholds because it relies on observing behavioral responses rather than precise measurements of hearing sensitivity.
69
What does a response at 30 dB(A) indicate in DT?
A response at 30 dB(A) suggests satisfactory hearing or at least the absence of a significant degree of hearing loss.
70
What adjustments are needed when using warble tone generators in DT?
When warble tone generators are used, correction factors must be applied before recording the results as dBHL
71
What is VRA?
Visual Reinforcement Audiometry
- it uses:
* Classical conditioning: establish relationship between stimulus and reward
*Operant conditioning: reward provided when the child turns appropriately
72
What is the purpose of reinforcement in Visual Reinforcement Audiometry (VRA)?
To reinforce an observable response, such as a head turn, to frequency-specific sounds by providing a visual reward (e.g., a flashing light or moving toy).
73
Why is VRA considered a flexible approach?
It allows adjustments to the testing setup and removes the need for the child to locate the sound source, making it easier to assess their hearing responses.
74
Where did VRA originate, and how was it developed?
- VRA evolved from earlier methods where the loudspeaker was removed from the position of the reinforcer to prevent confusion between the sound source and the reward.
- The loudspeaker was repositioned 15 cm from the child’s ear at 90°, while the reinforcers (visual rewards) were placed at 30–45° from the child’s line of sight.
75
What are the drawbacks of VRA?
- Use of pure tones, which may not maintain the child’s interest.
- Equipment can be complex or expensive.
- Misalignment or offset of visual rewards can affect the child's response.
76
Why does a child’s interest in the sound decrease during VRA and how can we make it more interesting 4 child?
Habituation occurs as the child becomes less interested in repetitive or unchanging sounds.
- Using interesting sounds, such as the child’s name or a favorite toy.
+Increasing the bandwidth of the sound (making it richer or more complex)
77
what is VRA prep?
* Morning calibration
* Introductions
* History taking
* Otoscopy
* Instructions for the testing procedure
* Involuntary cueing
* Child’s ability to head turn
* Family seated behind the child being tested
* Play- keeping the child interested, but not distracted
77
explain how visual rewards work in VRA testing?
* In a smoked plexi-glass cabinets
* Rewards on both sides
* Variety of rewards:
– Blinking lights
– Mechanical toys that are able to be illuminated and move
– Cartoons or videos
* The more complex the reward the more responses that can be obtained
78
What is the room setup for Visual Reinforcement Audiometry (VRA)?
- Double-Walled Test Room:
*Soundproof to eliminate external noise.
- Loudspeakers:
*Positioned at 90° to the child’s left (L) and right (R).
*Deliver frequency-specific sound stimuli.
- Reinforcer Cabinets:
*Located near the loudspeakers.
*Contain visual rewards (e.g., lights or toys) to reinforce responses.
- Subject (Child):
*Sits at a low table between the loudspeakers.
*Positioned centrally for consistent sound delivery.
- Parent:
*Seated behind the child to provide comfort without influencing responses.
- Tester 1 (Audiologist):
*Located in the observation room.
*Operates the audiometer and monitors the child’s responses via a microphone.
- Tester 2:
*Observes the child inside the test room.
*Verifies behavioral responses to the stimuli.
- Observation Window:
*Allows Tester 1 to observe the child’s behavior through a soundproof partition.
79
what is the full VRA procedure (conditioning, testing and localisation)?
CONDITIONING:
1- supra- threshold stimuli: 60-70dBHL at 2kHz
2- sound and reward presented at the same time
3- tester can draw child's attention to the reinforce
5- if the child does not respond, raise stimulus level or change frequency
6- change stimulus type to NBN which may hold attention better
7- use vibrotactile stimulation (if needed): for ppl who font respond to auditory stimuli, tactile can be used for conditioning
TESTING:
1- start with bigger increments (20dB Down): this is to quickly determine the child's response range
2- Apply 10dB down and 5dB up process can be applied closer to threshold
3- Remember efficient testing as limited attention time
4- Frequency testing order: 2kHz, 0.5 kHz, 4KHz, 1KHz= good representation of the child hearing range
LOCALISATION:
1- Begin testing by presenting narrow band noise at a level 30 dB above the child’s minimal response level.
2- Check for Asymmetric Hearing Loss.
3- Remember Sound Field Testing is Not Ear-Specific
4- Whenever possible, try to gather ear-specific information using OAEs (Otoacoustic Emissions), headphones, or inserts.
5- Ear-Specific Data is Essential for Fitting Hearing Aids.
6-
80
how do we know whether conditioning is successful for VRA?
– Child turns clearly to sound alone repeatedly and reliably
– Clear head turns
81
what is normal hearing screening at for VRA?
* Normal hearing screened:
82
When should Bone Conduction VRA be used?
- Bone Conduction VRA should be performed if air conduction thresholds are raised or if sound field testing results are not within normal limits, indicating possible hearing loss.
- It helps determine if there are issues with the inner ear or if the sound is bypassing the outer and middle ear.
83
Why are inserts preferred for ear-specific VRA?
Inserts are lighter, making it easier for the child to turn their head in response to sound stimuli.
84
What is a benefit of using inserts in VRA regarding masking?
Inserts reduce the need for masking, which simplifies the testing process.
85
What might be required when using inserts for VRA?
Reconditioning the child with the inserts may be necessary to ensure they respond appropriately.
86
Is the VRA test procedure different when using inserts?
No, the test procedure remains the same when using inserts.
87
How should inserts be used with the child during testing?
Couple the inserts to the child’s ear moulds to ensure a proper fit and accurate results.
88
What equipment can be used for Bone Conduction VRA?
A soft headband can be used to secure the bone vibrator, or it can be held in place if necessary.
89
what are limitations of bone conduction VRA?
- Masking may not be possible
* Always the better ear responding
90
what is play audiometry?
* Child following an instruction on how to play a game
* Waiting for a sound before responding
* Fun game so the child is engaged
* Game demonstrated before child is conditioned
* Useful when English is not their first language
* Performed in sound field or using transducers
* Initial conditioning may be easier in the sound field
* Multiple appointments may be necessary
91
what are the steps for play audiometry procedure?
- Conditioning at Supra-Threshold Levels:
- Demonstrate the task and guide the child.
- Ensure the child provides two reliable conditioned responses before moving to testing.
- Stimulus Presentation:
*Use warble tones or narrow band noise in the sound field.
*Use warble tones for headphones or inserts.
*Present the stimulus for 1–3 seconds.
Frequency Testing: 2kHz, 0.5kHZ, 4kHz, 1kHz
Complete one frequency before moving to the next.
Acceptable Response:
Record 2 out of 3 responses at the minimal level.
No Sound Trials:
Include trials with no sound to confirm valid responses.
Unconditioned Responses:
If the child cannot condition, switch to a different behavioral test.
Additional Support:
Condition through vibrotactile stimulation if needed.
Advise parents/guardians to practice at home to help the child.
Documentation:
Record results if hearing is screened.
91
what are games for play audiometry?
* Nearly anything can be used!
* Be imaginative
* Need reliable responses to the task you condition the child to perform
* Men in the boat/money in the jar/rings on a stick
* Swap games during the appointment
- use toys or maybe even your hands (not distract them a lot) to distract them from the sound or stimulus. child attention I shift towards the sound. second tester distracts the child to ensure a sound, not visual cues.
91
Why is conditioning performed at supra-threshold levels in play audiometry?
To ensure the child clearly hears the sound and learns to associate it with the task.
92
How should a tester reinforce the child’s behavior during play audiometry?
Praise the child for correct responses and gently correct any incorrect ones.
- you might need to involve the parents for the first one
93
Why should other toys not be visible during play audiometry?
To avoid distractions and keep the child focused on the task.
94
What should you do if the child is unable to condition?
Try a different behavioral test or use vibrotactile stimulation to assist with conditioning.
95
What stimuli are used for sound field and ear-specific testing?
- Sound field: Warble tones or narrow band noise.
- Headphones/Inserts: Warble tones only.
96
what is PTA?
- gold standard for children that are over 5+ years and adults. you measure a threshold across a range of frequencies (250hZ-8khz)
- child reponds to the tone by pressing a button.
- * Ensure they don’t pick up on visual cues
* Similar to adults; vary presentation time and length
* Use no sound trials
* Should be able to perform threshold if you can hold the child’s attention
* Perform masking
