Hearing loss, being an invisible disability, can remain unnoticed, particularly since typically developing children might not start speaking until around the age of two. Consequently, if hearing loss isn't identified through newborn hearing screening initiatives, it frequently remains undetected beyond 18 months of age, especially among children without any medical conditions or additional disabilities.

1. Overview of Behavioural
and Objective Techniques
in Screening Hearing Loss
Mr. Ambuj Kushawaha
Research Scholar
AIISH- MYSORE

2. Introduction
 The critical period for development of the auditory system
and speech commences in the first 6 months of life and
continues through 2 years of age.
 Hearing loss is not a visible disability, and even normal
hearing children may begin talking up to 2 years of age.

3. Continue
• if hearing loss is not detected through newborn hearing screening
programs, Specific linguistic experience in the first 6 months of
life, before meaningful speech begins, affects infants’ perception
of speech sounds and their capacity to learn.

4. • In Concert with recommendations of the Joint Committee
of Infants Hearing (JCIH, 2000) and The National
Institute of Deafness and other Communication Disorders
(NIDCD-1997), early hearing detection and intervention
programs must use screening measures that demonstrate
certain response and measurement characteristics.

5.  The response should be capable of being
measured reliably under a wide variety of
conditions.
 The response should have predictive value i.e. it
should be present in nearly all norma- hearing
infants and abnormal in nearly with hearing
loss..
These are as
follows-

6.  A screening procedure should use objective
criteria to define both the method for technically
correct screening tests and the guideline for pass
versus refer outcome.
 The procedure should achieve a low referral rate
for follow-up, prevent unnecessary cost and
parental anxienty.
These are as
follows-

7. Screening
 A Variety of procedures are presently used in
hearing screening programs for children form
infancy through high school. Not a single
procedure is effective in identifying all hearing
loss.

8. Type of
hearing
Screening
procedures.
 Developmental
Checklist
 High Risk Resister.
 Auditory Brainstem
Response (ABR).
 Otoacoustic Test
 Visual reinforcement
audiometry

9. Developmental Checklist
 It has been to obtain information from parents or other caregivers
regarding the auditory behaviours of children.
 It is useful to obtain functional information regarding auditory and
oral development, especially for very young children or children
who are difficult to assess.

10. According to Northern and Down (1974)
Developmental
Checklist
 At 0 to 4 Months- When he was sleeping quiet, did sudden noise awaken him
Momentarily ? Did he cry at very loud noise ?
 At 4 to 7 Months- Did he turn to find towards sound that was out of his sight?
Did he keep on making babbling noises of a large variety at 5 and 6 months ?
 At 7 to 9 Months- Did he turn to find the source of sound out of his vision ? Did
he gargle or coo to voices or sounds that he could not see ? Did he make sound
with rising and falling infections?

11. Developmental
Checklist
 At 9 to 13 months- Did he turn and find a sound anywhere
behind him? Did he begin to imitate some sounds what
Specific sounds did he say ?
 At 13 to 24 Months- Did he hear you when you called from
another room? Did his voice sound normal?
Checklist develop by All India Institute
of Speech and Hearing (AIISH)- Mysore
Click Here

12.  Family history of permanent childhood sensorineural hearing loss.
In utero infection such as cytomegalovirus, rubella toxoplasmosis,
or herpes. Craniofacial anomalies, including those with
morphological abnormalities of the pinna and ear canal.
High-Risk
Resister
Professional leadership in infant hearing and early detection
has largely provided by Joint Committee Infant Hearing
(JCIH)- 1972

13. They provided by the historical risk factor of hearing loss-
• Family History
• Hyper Bilirubinemia requires an
exchange.
• Congenital Infection (TORCH-
toxoplasmosis. Other Include syphilis,
Rubella, Cytomegalovirus, herpes
simplex)
• Craniofacial anomalies (Defects)
• Birth weight less then 1500 gram
• Bacterial meningitis
• Apgar score of <3 at 5 minutes
• Ototoxic medications including, but not
limited to, the aminoglycosides used for
more than 5 days.
• Associated with syndrome.
Click Here

14. Auditory
Brainstem
Response
• An auditory brainstem response (ABR) test is a safe and painless
test to see how the hearing nerves and brain respond to sounds.
• It checks your child’s brain’s response to sound.
• The test is mostly done on infants and children who may not be
able to respond to behavioral hearing tests because of their age.
The child will not feel anything during this test.

15. ABR and Automated auditory brain stem response are
electrophysiological procedures used for hearing screening
based on brainstem response to sound.
When used as a screening procedure ABR primarily detect
greater hearing losses then 30dB in the frequency range 1000 to
4000Hz.

16. How is
the test
done?
 The test can only be done when your child is sleeping.
Small electrodes (sensors that measure brain activity) will be placed
on your child’s forehead and earlobes or mastoid bone, and earphones
will be placed over his or her ears.
 An electrode gel will be used on your child’s head and ears so that
there is good contact between the skin and the electrodes.
 Once your child is sleeping, sound will be played through the
earphones. His or her brain’s response to this sound will be recorded
through the electrodes and recorded on the computer.
Click Here

17. Otoacoustic Test
The OAE (Otoacoustic Emissions) test
checks part of the inner ear’s response to
sound.
The test is mostly done on infants and
children who may not be able to respond to
behavioral hearing tests because of their age.

18.  The OAE test determines how well your inner ear, or cochlea,
works.
Your ear is made up
of three parts—
• The outer
• The middle
• The inner ear.

19.  Otoacoustic emissions are sounds given off by one small part
of the cochlea when soft clicking sounds stimulate it.
 The sound stimulates the cochlea, the outer hair cells vibrate.
 The vibration produces a nearly inaudible sound that echoes
back into the middle ear. This sound is
the OAE that
is measured.
Click Here

20. • If you have normal hearing, you will produce OAEs.
• If your hearing loss is greater than 25–30 decibels (dB), you will not
produce these very soft sounds.
• This test can also show if there is a blockage in your outer or middle ear.
• If there is a blockage, no sounds will be able to get through to the inner ear.
This means that there will be no vibration or sounds that come back

21. Visual reinforcement
audiometry (VRA)
Visual reinforcement audiometry (VRA) is a
behavioral test of hearing best suited for infants from
six months to around two and a half years of age.

22.  The aim of VRA is to identify minimum response levels at
different frequencies to get information on the child's
hearing.
 the child sits on the parent’s lap in a sound booth (booth
with a window that is insulated from outside noise), where
speech sounds, and tones are presented through two
speakers in the corners of the booth.
Click here

23. • The typical response is a head turn in the direction of the
speaker, reinforced by lighting an animated toy above the
speaker.
• Once the child is conditioned to respond to the sound,
intensity of the signal is decreased to determine his or her
child’s hearing sensitivity.

24. Behavioural Observation
Audiometry
The audiologist will be measuring your child’s hearing levels for several
different frequencies (pitches)of sound.

25.  BOA is a test used to observe hearing behaviour
to sound when VRA is not possible.
 This is often used for infants less than 6 months
of age or who are developmentally not able to
turn their head towards a sound. Additional
testing is often necessary to supplement BOA

26.  In BOA the testing of infants and young children is
accomplished without reinforcement of responses and
rests on the subjective observation of response under
structured conditions
 In BOA, Infant’s response is observed to a variety of
moderate to high-intensity stimuli, such as calibrated
noise makers, to observe startle, use widening,
localization or cessation of activity.

27. Stimulus
Used
 When planning the
test session, it is
important to keep
in mind:
The infant will provide only a limited number of
response
1. Speech Signals (e.g. bha-bha-bha, pa-pa-pa)
2. Warbal Tone
3. Narrowband Noise/Speech Noise
4. Various handheld noise makers (Rattles, Drums)
Click here

28. Expected responses (stimulus & Level of
Response)
• Newborn Period (0-4 months)
• Normal infant is aroused from sleep by sound signals of 90dB in noisy
environments- 50-60dB in quiet.
• (3-4 Months)
• Normal Infants begins to make a rudimentary head turn toward a sound.-
Signal 50-60dB
• (4-7 months)
• Baby turns head directly toward the side of signals 40-50 dB but cannot find it
above or blow.

29. • (7- 9 Months)
• Baby directly locates a sound source of 30-40 dB (Spl) to the side and indirectly
below.
• ( 9-13 Month)
• Baby directly located a sound source of 25-35 dB (SPL) to the side and below.
• (13-16 Months)
• Toddler localizes directly sound signal of 25-30 dB (SPL) to the side and blew;
indirectly above
• (16-21 Months)
• Toddler localizes directly sound signals of 25-30 dB (SPL) on the side, blow and
above
• (21- 24 Months)
• Child locates directly a sound signals of 25dB (SPL) at all angle..

30. Conditioned Play
Audiometry (CPA)
This is a hearing test in the form of a game and is typically
used for children 2 to 4 years developmental age.

31.  The child will be taught how to do a specific action, such as
dropping a block in a bucket or feeding Cookie Monster,
every time he or she hears a tone.
 Tones are presented at different pitches through headphones
or speakers. This test relies on the cooperation of your child
to sit still and listen

32. • These activities are assumed to be interesting to children, are
within their motor capability and represent a specific behaviour
that is used to donate an response to a stimulus.
• The Challenges in play audiometry teach the child to wait, listen
and only respond with the play activity when the auditory signal is
presented

33. Acoustic Immittance Audiometry
• Acoustic Immittance measurement
• Objective Measurement
• Impedance= Opposition to flow of Sound through auditory
system
• Admittance= ease with which sound flows through the
auditory system

34. Acoustic Immittance measurements have consisted of
three procedure
Tympanometry Peak Pressure: This is the air pressure of the air
contained within the middle ear. It is shown by where the “peak” of the
tympanometric trace falls along the pressure axis.
Static Admittance: the most acoustic energy absorbed by the middle ear
system (the vertical peak of the tympanogram tracing).

35. Acoustic Reflex: The acoustic reflex is a
feedback loop of the auditory system. It occurs
when stapes bone, in the middle ear, gets pulled
due to the contraction of the stapedius muscle in
response to sounds of sufficient intensity

36. Procedure
A probe is
placed in the
ear canal
consisting of
three-part:
• Loudspeaker
• Monometer pressure
pump
• Microphone

37. • A 226 Hz ton introduced by the loudspeaker while the manometer
pressure pump automatically and slowly varies pressure in the ear
canal form +200 to -400 dapa (Deca pascals)
• In the meantime, the microphone measures the change in intensity in
the ear canal as pressure varies.
daPa = decapascals is the unit of measure of pressure in the
external ear canal.

39. Brain-evoked
reinforcement Audiometry
is an objective test used to determine how electrical waves are sent
from the eighth cranial nerve to the brainstem in response to click
noises delivered through the ear.

40. • The BERA hearing test is an electrophysiological test procedure that helps identify
and study the electrical potential generated at various levels of the auditory
system, starting from the cochlea to the cortex.
• BERA provides a rapid and efficient way to screen for deafness in infants.
• Hearing test is the most specific and sensitive test for brain stem dysfunction as it
is one of the most important objective methods for evaluating the peripheral
auditory system in neonates, infants, sedated and comatose patients, and other
people who don’t understand the language.

41. Why is Brain Evoked Response Auditory (BERA) Test done?
This test is performed for various different reasons such as:
•Determining the abnormalities
•Diagnosis of hearing threshold
•Diagnosis of hearing loss

42. • The Brainstem Evoked Response Audiometry (BERA)
is an ideal test to interpret the communication of
electrical waves from the VIIIth cranial nerve to the
brainstem, in reply to capture the sounds given through
the ear.
• The process is also called Auditory Brainstem
Response (ABR), Brainstem Auditory Evoked
Potential (BAEP), Brainstem Auditory Evoked
Response (BAER) and Evoked Response Audiometry
(ERA).

43. References
https://www.aiishmysore.in/workshops-and-seminars/public-education-pamphlets
https://aiishmysore.in/pdf/1_1_HRR_For_Non_Medical_Persons_English.pdf
https://aiishmysore.in/pdf/1_1_Remember_and_Care_Check_List_English.pdf
https://www.nationwidechildrens.org/specialties/audiology/abr-testing
https://emedicine.medscape.com/article/836277-overview
https://www.youtube.com/watch?v=ZzMUD0RzNnM

44. http://www.phsa.ca/Documents/HearingTestinginToddlersandOlder.pdf
https://www.pediatrics.wisc.edu/education/acute-otitis-media/tympanometry/
https://www.ganeshdiagnostic.com/blog/bera-test-know-everything-in-detail
https://www.ashaspeechhearingclinic.com/what-is-bera-hearing-test-and-why-it-is-
always-recommended-for-infants/