1. A Trip to the Audiologist: What to Expect When Your Child Needs a Hearing Test
Katherine Duncan, Au.D., and Stacia Thomas, Au.D.
Maine Educational Center for the Deaf and Hard of Hearing/Governor Baxter School for the Deaf

2. Purpose of this webinar
To provide an explanation about the various test procedures used by pediatric audiologists
To provide parents with expectations surrounding their child’s visit to the audiologist
To provide tips on how to make the visit to the audiologist as smooth as possible

3. Why is my child being referred for a hearing test?
Refer on newborn hearing screening
Concern from daycare, preschool, or pediatrician
Parental concern
Ear infections
Family history of hearing loss
Other risk factors

4. Case History
The audiologist will need to collect a detailed case history from the parents
Some examples of questions include:
Birth history (ex: hypoxia at birth)
History of ear infections
Family history of childhood hearing loss
Presence of risk factors (in-utero infections, ear tags)
Other health issues or diagnoses (syndromes, etc.)
Other audiologic evaluations (including whether the child referred on UNHS)

5. Otoscopy
The audiologist will use an otoscope to look at the external ear, ear canal, and eardrum/middle ear
This is important to allow the audiologist to rule out occlusion of earwax, or concerns with middle ear health that can contribute to reports of diminished hearing and impact test findings
Depending on a child’s comfort level, the audiologist may choose to wait until the end of the appointment in order to complete this
Parents: if you anticipate your child will not cooperate with this portion, please let the audiologist know so they can wait until the end. Starting with a traumatic otoscopy experience can set a negative tone for the full evaluation session.

6. Tympanometry and Acoustic Reflexes
A soft plastic tip will be held firmly against the opening of the child’s ear canal
A tone and puff of air are emitted simultaneously to measure how the middle ear is moving

7. Tympanometry
Tympanometry results do not tell the audiologist if the child can hear
Tympanometry will tell the audiologist:
If the ear drum is moving back and forth normally
if the ear drum is stiff and not moving back and forth normally (this can mean fluid)
if there is negative pressure in the space behind the ear drum, which is typically seen with allergies, sinus congestion, or at the beginning or end of a cold or ear infection

8. Acoustic Reflexes Can be completed in conjunction with tympanometry
Loud tones are emitted, and the equipment looks for a response in the form of a contraction of a muscle in the middle ear called the stapedius (i.e., the stapedius reflex)
This information can be used to determine the origin of a hearing loss
Is not always completed for young children due to time, need for the patient to stay still, and loudness of the presented tone

9. Otoacoustic Emissions
A soft tip is placed in the ear canal, sending a tone to the inner ear
A response from the hair cells of the cochlea (organ of hearing) is measured
This response is known as an otoacoustic emission
OAEs are sensitive to noise, movement, and health of the middle ear system
Presence of OAEs suggests that there is no greater than a mild hearing loss
The audiologist may recommend the child sits in the parents lap and parent gently hold the child’s hands. Then the audiologist may gently place the tip in the ear and show child a book, light up toy, phone/tablet with favorite show (muted) and then start the test when child is quietly engaged. Important for parents to remember when the testing is running to refrain from talking to child.
In order for OAEs to be measured the ear drum needs to be moving back and forth in a normal manner. If the audiologist completed tympanometry and the middle ear system isn’t moving normally OAEs will likely not be completed during the visit.

10. Behavioral Audiometry
Dependent on the developmental age and abilities of the child
Requires a response from the child in some way (head turn, block in bucket, button press, etc.)
Visual Reinforcement Audiometry
6 months-2.5 years of age
Play Audiometry
2.5 years to 4 years of age
Standard Audiometry
4 years of age and above

11. Visual Reinforcement Audiometry
The child will sit on a parent’s lap in the booth
The parent will be asked to “become part of the chair”: sit still and remain quiet at all times
The audiologist will present sounds and talk quietly through speakers in the booth
The audiologist will initially try to “condition” the child to the task, by presenting tones at a level they think the child will hear clearly, and reinforcing any response they receive
After conditioning, tones and speech will be presented at varying intensities to determine the softest sounds to which the child will respond

12. Visual Reinforcement Audiometry
The audiologist looks for the child to turn their head in response to a presented sound
When the child turns their head successfully in a response to a sound, the audiologist will provide visual reinforcement
There will be darkened boxes/screens in the corners of the booth where a brief video will play or puppet will be illuminated/move
The visual reinforcement is meant to encourage the child to continue participating in the listening task
Don’t be alarmed if your child stops responding with a clear head turn towards the speakers (the audiologist is watching your child closely, sometimes a child won’t provide a distinct head turn but will shift their eyes or tilt their head slightly). As nerve wracking as it is to sit quietly please do your best, the window for testing in the booth can be short and the audiologist is trying to work as quickly as possible to obtain reliable responses before your child fatigues. Excessing talking from a parent will reduce the opportunities an audiologist has to present sounds and observe your child.
If siblings are accommodating you for the visit please bring another adult to tend to siblings if possible.
The information obtained through VRA is often not ear-specific, meaning it will only provide information about the better hearing ear, if there is a difference between the two ears
Depending on child state, may introduce headphones/inserts or bone conduction, which may help to provide ear-specific information, or determine the type of hearing loss

14. Play Audiometry
The child is trained to listen for a sound and complete a task whenever they hear the sound
Drop a block in a bucket, place a ring on a stacking ring toy
Tones can be presented through the speakers or through headphones/inserts, depending on the child’s comfort level with headphones
Children at this age may also be asked to repeat words or point to body parts to determine their ability to access speech stimuli

16. Standard Audiometry
The child will be expected to raise their hand or press a button each time they hear a tone
This typically happens through headphones or inserts
The child will repeat words for the audiologist
This is similar to the hearing test performed with adults

18. Auditory Brainstem Response Evaluation
The ABR measures the hearing nerve’s response to sound
An ABR is typically performed whenever a child refers on the newborn hearing screening in order to confirm or rule out a hearing loss
An ABR might also be performed on an older child if behavioral testing is inconclusive or the child cannot participate in behavioral testing
The results of an ABR provide an objective measure of a child’s hearing and auditory function

19. ABR Evaluation The ABR test is safe and does not hurt
The ABR test can be completed only if the child is sleeping or lying perfectly still, relaxed and with his or her eyes closed
If the child is younger than 6 months of age, the ABR test typically can be done while he or she naps
If the child is older than 7 years, the ABR test typically can be done while the child is awake if he or she can relax and lie still
For children between the ages of 6 months and 7 years, the ABR test is done under anesthesia, which means that the child will need medication to help him or her sleep throughout the test. ABR tests with anesthesia are done at a same day surgery center or hospital

20. ABR Evaluation
3-4 small stickers or electrodes are placed at various points on the child’s head and in front of their ears
The electrodes are connected via wires to a special computer
Sound is sent to the child’s ears using insert earphones
The electrodes measure how the auditory nerve and brainstem respond to the sounds sent through the inserts
The audiologist interprets the responses provided by the ABR equipment by looking for certain neurological “markers” that correspond with expected areas of stimulation along the auditory system
The audiologist will look for the softest loudness level at which these markers are present across multiple frequencies, which will help determine the child’s hearing levels
The Auditory Brainstem Response (ABR) test is a helpful tool in determining a child’s ability to hear. The test uses a special computer to measure the way the child’s hearing nerve responds to different sounds.  Three to four small stickers called "electrodes" will be placed on your child’s head and in front of his or her ears and connected to a computer. As sounds are made through the insert earphones the electrodes measure how your child’s hearing nerves respond to them.
The audiologist looks for certain neurological "markers" as your child’s hearing nerves respond to sounds. The softest intensity (or loudness level) at which these markers appear roughly corresponds to the child’s hearing level in that frequency range or pitch. By analyzing the waveforms of your child’s responses and interpreting these markers, the audiologist can tell you how your child’s auditory nerve is functioning and in turn how they are hearing

21. Parents and guardians can contribute to the success of the ABR!
Babies under 6 months
Testing will occur with the child asleep
Ideally, should arrive with the child tired and hungry
The child should be fed just before the test, with the goal to get them to nap during the test
Testing can occur with the child in the car seat, or in a parent’s arms
Babies under 6 months
The most important way to prepare your baby for the test is to show up with a tired, hungry baby. Most young babies will sleep through the entire test if they are brought to the appointment ready for a feeding and a nap. Try to keep your baby awake, bring another adult with you if possible to keep baby awake during the car ride, and hold off feeding him or her until you get to the appointment. Once you are in the testing room and your child has been prepped for the test, you can nurse or feed your baby a bottle so he or she falls asleep naturally. The test will take place while your child sleeps in your arms or in their car seat, whatever is most comfortable for you and your baby.

22. Preparation for the ABR
Children between 6 months and 7 years of age
Typically, requires sedation to sleep throughout ABR
Hospital/surgical center should prep parents regarding rules for eating/drinking prior to anesthesia
If rules for eating/drinking are not followed, the ABR may be rescheduled
Children older than 6 months but younger than 7 years
Children in this age range usually need anesthesia medication in order to sleep throughout the ABR evaluation. When anesthesia medication is needed, there are important rules for eating and drinking that must be followed in the hours before the test. If those rules are not followed, your child’s ABR test usually will be rescheduled for another day. Please follow the special rules provided to you by the medical staff at the surgical center or hospital.

23. Preparation for the ABR
Children older than 7 years
Typically, the child can be tested while awake if they are relaxed and still
If non-sedated testing is not successful, the child may be referred for a sedated ABR
Children older than 7 years
Most children who are 7 years and older can be tested while they are awake if they relax and lie still during the test. If your child is not able to cooperate, the test might need to be rescheduled so it can be done under anesthesia.

24. Tips for having a successful trip
Each trip to the audiologist may be different!
Traveling far for your audiology appointment?
Try to relax
Siblings
Cell phone
Morning vs. afternoon appointment
Be present during the counseling session at the end of the appointment
Depending on your child’s age/mood or what information the clinician is trying to obtain during the evaluation, your visit can look a little different each time. The audiologist may tailor the order of tests during the visit to obtain as much reliable information about your child’s hearing as possible.
-may be asked to assist in the booth, testing environment is best quiet without additional visual/auditory distractions
-a cell phone ringing/dinging during testing interrupts the flow of the evaluation, interfere with ABR…but may be helpful during OAEs
-arrive early so your child can move around & play prior to being expected to sit & attend for a hearing evaluation
-If your child is completing a behavioral evaluation schedule appointment during a good time of day if your child will be completing a behavioral
-Audiologist may discuss with you the outcome of each test after it is completed but realistically the audiologist is pulling together the information from each test (like the piece of a puzzle) to formulate a conclusion which will be discussed at the end of the appointment. It may be nerve-wracking to wait until the end of the appointment for a synopsis or conclusion about what the audiologist sees/feels about hearing but completing this at the end of the appointment allows the audiologist to take advantage of the short period of time a child is willing and engaged for testing.
Also then the child can play while you discuss outcomes with audiologist, ask your questions, and talk about next steps and possible additional recommendations/testing/etc. We certainly don’t expect you to remember everything and the audiologist can be reached after the appointment for additional questions.