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AlexanderGrahamBellAssociationsRecommendedProtocol

forAudiologicalAssessment,HearingAidandCochlearImplant
Evaluation,andFollowup

TableofContents
ContributorsandReviewers
I.Introduction
II.OverviewofAudiologicalManagement
III.RecommendedElementsoftheInitialAudiologicalDiagnosticAssessment
IV.RecommendedProcedurestoAssessAmplification
V.RecommendedAudiologicalManagementforChildrenwithCochlearImplants
VI.RecommendedAudiologicManagementRegardingFMSystems
VII.DisclaimerandCopyright

ContributorsandReviewers
Contributors:CarolFlexer,Ph.D.,LSLSCert.AVT;JaneMadell,Ph.D.,LSLSCert.AVT;JoanHewitt,Au.D.,
CCCA

Reviewers:ElizabethFitzpatrick,Ph.D.(withcollaborationCarmenBarrieruNielsen,Au.D.);StaceyLim,
Ph.D.,Au.D.,CCCA;JohnnieSexton,Au.D.,CCCA;DonGoldberg,Ph.D.,CCCSLP/A,FAAA,LSLSCert.
AVT

AdoptedJune2014

I.Introduction
Thisaudiologicalprotocolisintendedtosupportprogramsforearlydetectionandmanagementof
hearinglossininfantsandchildren.Thisprotocolalsoisaguidetoappropriateandongoingaudiology
servicesrecommendedforchildrenparticipatinginlisteningandspokenlanguage(LSL)programs.

TheAlexanderGrahamBellAssociationfortheDeafandHardofHearing(AGBell)recognizesand
recommendsanaudiologicalprotocolthatincludesthetestbatteryapproachasanoptimummeansto
accessspokenlanguage.Nosingletestshouldbeusedinisolationtodefineanddescribethenatureand
extentofahearingloss.Ideally,everylisteningandspokenlanguageprogramwillhaveonsite
audiologicalservices.Butregardlessofsetting,closecollaborationofparents,audiologists,therapists,
andeducatorsisessential.Parentsshouldbepresentandparticipateinallassessments.Whenever

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possible,theListeningandSpokenLanguageSpecialist(LSLS)certifiedprofessionalalsoshouldbe
presentataudiologicalassessmentsorcommunicatehis/herquestionsorconcernsregardingthechild's
hearingortechnology.

Therecommendedproceduresandelementsinthisdocumentareconsistentwiththefollowing
guidelinesandpositionstatements:

JointCommitteeonInfantHearing(JCIH)(2007).Year2007positionstatement:Principlesand
guidelinesforearlyhearingdetectionandinterventionprograms.Pediatrics,120(4),898921.
AmericanSpeechLanguageHearingAssociation(2004a).Guidelinesfortheaudiologic
assessmentofchildrenfrombirthto5yearsofage.Availableat
http://www.asha.org/policy/GL200400002.htm
AmericanSpeechLanguageHearingAssociation(2006).Roles,knowledge,andskills:
Audiologistsprovidingclinicalservicestoinfantsandyoungchildrenbirthto5yearsofage.
Availableathttp://www.asha.org/policy/KS200600259/
AmericanAcademyofAudiology(2013).Clinicalpracticeguidelines:Pediatricamplification.
Availableathttp://audiology
web.s3.amazonaws.com/migrated/PediatricAmplificationGuidelines.pdf_539975b3e7e9f1.7447
1798.pdf

II.OverviewofAudiologicalManagement
Initialscreening,diagnosis,andconfirmationshouldbecompletedwithinthefirstthreemonths
oflifeassoonaspossibleafterbirthinordertoensurethatappropriateamplificationand
habilitationisunderwaypriortoage6months.JCIH(2007)recommendsthatscreeningbe
accomplishedbyage1month,diagnostictestingbeaccomplishedbyage3months,and
interventionbeginbyage6months.
Whenhearinglossisdiagnosed,routineevaluationshouldoccurideallyatfourtosixweek
intervalsuntilfullaudiogramsareobtained,andatthreemonthintervalsthroughage3years.
Assessmentatsixmonthintervalsfromage4yearsisappropriateifprogressissatisfactoryand
iftherearenoconcernsaboutchangesinhearing.
Immediateevaluationshouldbeundertakenifparentorcaretakerconcernisexpressedorif
behavioralobservationbyparent,therapistorteachersuggestsachangeinhearingordevice
function.

Morefrequentevaluationisappropriatewhenmiddleeardiseaseischronicorrecurrent,orwhenrisk
factorsforprogressivehearinglossarepresent.

III.RecommendedElementsoftheInitialAudiologicalDiagnosticAssessment

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ThefollowingsectionisbasedontheJointCommitteeonInfantHearing2007positionstatement.

AudiologicalEvaluation

Comprehensiveaudiologicalevaluationofnewbornsandyounginfantswhodonotpassnewborn
hearingscreeningshouldbeperformedbyexperiencedpediatricaudiologists.Theinitialaudiological
testbatterytoconfirmahearinglossininfantsmustincludeelectrophysiologicalmeasuresandwhen
developmentallyappropriatebehavioralmethods.Confirmationofaninfant'shearingstatusrequiresa
testbatteryofaudiologicaltestprocedurestoassesstheintegrityoftheauditorysystemineachear,to
estimatehearingsensitivityacrossthespeechfrequencyrange,todeterminethetypeofhearingloss,to
establishabaselineforfurthermonitoring,andtoprovideinformationneededtoinitiatethefittingof
amplificationdevices.Acomprehensiveassessmentshouldbeperformedforeachearevenifonlyone
eardidnotpassthescreeningtest.

Evaluation:BirthtoAge6Months

Forinfantsfrombirthtoadevelopmentalageofapproximately6months,thetestbatteryshould
includeachildandfamilyhistory,anevaluationofriskfactorsforcongenitalhearingloss,andaparental
reportoftheinfant'sresponsestosound.Theaudiologicalassessmentshouldinclude:

Otoscopicinspection
Childandfamilyhistory
AuditoryBrainstemResponse(ABR)testingusingairconductedclickandtoneburststimuliand
boneconductedstimuliwhenindicated.Whenahearinglossisdetected,frequencyspecific
ABRtestingisneededtodeterminethedegreeandconfigurationofhearinglossineachearfor
fittingofamplificationdevices.
ClickevokedABRtestingusingbothcondensationandrarefactionsinglepolaritystimulus,if
thereareriskindicators(e.g.,hyperbilirubinemiaoranoxia)forneuralhearingloss(auditory
neuropathyspectrumdisorderorANSD)todetermineifacochlearmicrophonicispresent.
AuditorySteadyStateResponse(ASSR)testingmaybeusedasanothermeansofassessingear
andfrequencyspecificthresholds.ASSRtestingcanalsobeusedtoassessauditorynerve
functionwhennoABRispresent.
Distortionproductortransientevokedotoacousticemissions(OAE)testing
Tympanometryusinga1000Hzprobetone,andacousticreflextesting
Parentandclinicianobservationoftheinfant'sauditorybehaviorasacrosscheckinconjunction
withelectrophysiologicmeasures.Behavioralobservationaloneisnotadequatefordetermining
whetherhearinglossispresentinthisagegroup,anditisnotadequatealoneforthefittingof
amplificationdevices.

Evaluation:Age6to36Months

Forsubsequenttestingofinfantsandtoddlersatdevelopmentalagesof6to36months,the
confirmatoryaudiologicaltestbatteryincludes:

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Otoscopicinspection
Childandfamilyhistory
Parentalreportofauditoryandvisualbehaviorsandcommunicationmilestones
Behavioralaudiometry(eithervisualreinforcementorconditionedplayaudiometry,depending
onthechild'sdevelopmentallevel),includingpuretoneaudiometryacrossthefrequencyrange
foreachearandspeechdetection,speechaudibility(e.g.,usingtheLing6soundtest)orspeech
recognitionmeasures
OAEtesting
Acousticimmittancemeasures(tympanometryandacousticreflexthresholds)
Electrophysiologicaltestingasdescribedabove,ifresponsestobehavioralaudiometryarenot
reliable.

Forchildrenofallages,AGBellrecommendsthatallresults,questions,andrecommendationsare
discussedwiththeparentsinaculturallysensitivemannerandinthefamilysnativelanguage.

Parentsshouldleavetheaudiologyappointmentunderstandingthemanagementplan.Theyshould
knowwhentoreturnforfollowupappointmentsandwhattheirresponsibilityisintheprocess
(includingmonitoringfulltimeuseofamplificationtechnologyandmonitoringwhatthechildhearswith
theamplificationtechnology).ParentquestionnairessuchastheITMAIS(InfantToddlerMeaningful
AuditoryIntegrationScale)andELF(EarlyListeningFunction)maybeusefulinthemonitoringprocess.

Writtenreportsshouldbeprovidedandinclude:

1. Descriptionsoftestprocedures,conditionsoftesting,andreliabilityestimate
2. Acompleteaudiogram(ifavailableattheinitialdiagnosis)withsymbolkey,calibration,and
stimuliidentified,aswellasanexplanationofresultsusingtoolssuchasa"FamiliarSounds"
audiogramtosupportparent/teachercounseling
3. Copiestoparents,aswellastoprimarycareprovider,ListeningandSpokenLanguageSpecialist,
andotherhealth/educationprovidersasrequestedinwritingbyparents
4. Referraltomedical,otolaryngological,orotherresources(e.g.,geneticcounseling,social
services,psychologicalcounseling,occupationaltherapy)asappropriate.

IV.RecommendedProcedurestoAssessAmplification
Identifythehearinginstrument,includingmanufacturer,model,outputandresponse,compressionor
specialfeaturesettings,earmoldspecifications,andqualityoffit.Inaddition,earmoldsneedtobewell
madeandacousticallytuned(e.g.,tubing,venting,boresizetomatchthechildshearinglossinorderto
maximizethechildsaccesstosound).Theaudiologistshouldlistentothehearingaidsatthestartof
everytestsession,andshouldconfirmthatparentsknowhowtoperformalisteningcheckofhearing
aids.

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Electroacousticanalysisofhearingaidstodocumenthearingaidperformanceatthefollowing
times:
o Atinitialfitting
o Atregularintervals(e.g.,atfollowupappointments)
o Uponreturnfromrepairs
o Ifparentalconcernsarisefrombehavioralobservationorlisteningcheck.

RealEartoCouplerDifference(RECD)measures
o UsedwithprescriptionmethodsuchasDSL(DesiredSensationLevel)orNAL(National
AcousticLaboratories)toestablishtargetgainandoutput
o Toconverthearingaidperformancein2cccouplertorealearhearingaidperformance
o ToconverthearinglevelsindBHLtoearcanalSPL(SoundPressureLevel)
o Toassesschangeinearmoldstyleandfit.

Corticalevokedresponsetestingtovalidatehearingaidfittings,whereavailable.
SoundFieldAidedResponseTodemonstratethechildsresponsetospeechforparent
educationpurposes
o Tomonitorthechildsauditoryprogress
o Toassessspeechperceptionatsoft(e.g.,35dBHL)andataverageconversationallevels
(e.g.,50dBHL)inquietandinthepresenceofnoisetoevaluatetheeffectivenessof
amplificationtechnology.Eachhearingaidshouldbeevaluatedseparatelyandthen
bothtestedtogether.
o AssessmentofspeechaudibilityusingtheLing6SoundTestatvaryingdistances(e.g.,
through6metersorapproximately20feet)
o ComparisonofLingresultswithNALspeechogramifavailabletoevaluatehearingaid
fitting
o Functionalauditoryassessments(e.g.,PEACH[Parents'EvaluationofAural/oral
performanceofChildren],LittlEARSAuditoryQuestionnaire)tovalidatehearingaid
fitting.

NOTE:Functionalgainmeasureisanappropriateverificationprocedureforboneconductionhearing
aidsandcochlearimplants.VerificationofamplificationrequiresaRECDmeasureforchildrenwearing
hearingaids.

V.RecommendedAudiologicalManagementforChildrenwithCochlearImplants
Ifadequateaccesstothefullspectrumofacousticinformationofspokenlanguagecannotbe
achievedforaninfantorchildthroughconventionalamplification,informationshouldbe
providedtothefamilyregardingcochlearimplant(CI)technology,includingbenefitsandrisksas
documentedinpublished,peerreviewedliteraturealongwithreferraltoapediatriccochlear
implantcenter.

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Uponparentalconsent,thecochlearimplantteamwillreviewtheaudiologicinformation
obtainedtodateandperformfurtherassessmentstoevaluatethechildssuitabilityforcochlear
implantation.SpeechperceptiontestingshouldbeincludedinthepreCIevaluationandused
bothindeterminingcandidacyandtocomparetopostCIevaluations.
TheLSLSshouldparticipateinthecochlearimplantcandidacyprocess.
Followinginitialmappingofthecochlearimplantspeechprocessor(s),remappingshouldbe
conductedontheschedulerecommendedbythecochlearimplantteamgiventhechild'sage,
device(s)implanted,numberofelectrodesactivated,andadditionalindividualconsiderations
suchasabilateralorbimodalfitting.
Oncethespeechprocessorisprogrammedtoprovideoptimalaccesstothespeechspectrum,
ongoingevaluationatregularintervalsisrecommended(e.g.,atthreemonthintervalsforthe
firstyear).Afterthisperiod,routineassessmentofperformancewiththecochlearimplant
continuestoberecommendedatsixto12monthintervalsifprogressissatisfactory.
SoundFieldwarbletoneornarrowbandnoisethresholdsandspeechperceptiontestingshould
beperformedwheneverthespeechprocessorisprogrammedandmaybehelpfulalongwith
othertroubleshootingtechniqueswheneverproblemsaresuspected.Additionalpurposesof
soundfieldtestingare:
o Todemonstratethechildsresponsetospeechforparenteducationpurposes
o Tomonitorthechildsauditoryprogress
o Toassessspeechperceptionataverage(e.g.,50dBHL)andatsoft(e.g.,35dBHL)
conversationallevelsinquietandinthepresenceofnoise,toevaluatetheeffectiveness
ofthecochlearimplant,orofeachcochlearimplantinthecaseofbilateralfitting
o SubjectiveassessmentofdistancehearingusingtheLing6SoundTesttodemonstrate
therangeofaudibilityprovidedbythetechnology.Inaquietenvironment,thechild
shouldbeabletodetectalloftheLingsoundsatclosedistances(e.g.,onemeteror
approximately3feet)andatsubstantialdistances(e.g.,approximately12metersor
approximately40feet).
Immediateevaluationisrecommendedifparent,caregiver,oreducator/therapistobserve
behaviorssuggestinganegativechangeinperformanceorexpressconcernregardingdevice
function.
Functionalauditoryassessments(e.g.,PEACH,LittlEARS)tovalidatehearingaidfitting.

VI.RecommendedAudiologicManagementRegardingFMSystems
EverychildwithhearinglosswillbenefitfromtheuseofanFMsystemtoreducethenegative
effectsofdistanceandcompetingnoise.
AlltechnologyselectedforchildrenshouldbeFMcompatible.
ValidationandverificationshouldbeincludedinevaluationsforchildrenusingFMsystems.See
ClinicalPracticeGuidelinesforRemoteMicrophoneHearingAssistanceTechnologiesforChildren
andYouthBirth21Years(AmericanAcademyofAudiology,2008;availableat

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http://www.audiology.org/publicationsresources/documentlibrary/hearingassistance
technologies).

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RECOMMENDEDUNAIDEDANDAIDEDAUDIOLOGICPEDIATRICASSESSMENT
PROTOCOLSBYAGE*OFCHILD

06 612 1224months 2436months Over36months


months months

UNAIDED

TESTING

ABR X X Xifnotperformed
previously

Immittancetesting X X X X X

1000Hz
probe
tone

OAEtesting X X X X X

Behavioraltesting X X X XVRAuntil X
childcan
2508000Hz BOA VRA VRAwith performCPA CPA
transitiontoCPA

SATLingSounds X X X

SRTtesting X X X

Bodyparts, Bodyparts, Standardizedtests


familiarobjects familiarobjects
SpeechPerception
Begin
testingat40dB standardized
abovethresholdif tests
possible.Thistest
maybeusefulfor
helpingfamilies
understandwhatthe

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childishearing.

TESTINGWITH
TECHNOLOGY

RECD X X X X X

CorticalResponses X X X X X

SATLingSounds X X X

SRTtesting X X X

Aidedthresholds X X X X X
2508000Hz

AidedSpeech X X X
Perception
Right,Left, Right,Left, Right,Left,Binaural
50dBHLQuiet Binaural Binaural

AidedSpeech X X
Perceptionat35dB
HLQuiet Right,Left, Right,Left,Binaural
Binaural

AidedSpeech X X
Perception
Binaural Binaural
50dBHL/+5SNL

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Note1:Thepurposeofallauditorytechnologiesistodeliverthemostcompletesoundpossibletothe
childsbrain,whereactualhearingoccurs.Thetaskoftechnologiesistoaccess,stimulate,and
developneuralpathwaysthatarethebasisforlistening,talking,readingandlearning.

*Note2:Theagelevelspresentedrepresentachildsdevelopmentallevelsaswellaschronologicalage.
Achild(oradult)withdevelopmentaldelaysshouldbeassessedwithtestsappropriatetohis/her
developmentallevel,notchronologicalage.

Note3:Aidedtestingreferstowhatevertechnologythechildisusing.Thismaybehearingaids,cochlear
implants,osseointegrateddevices,FMsystems,andother.Eachearshouldbetestedseparatelywith
technology,aswellasbinaurally.

Abbreviationsusedinthechart:

Xmeansthetestshouldbeperformed

BOABehavioralObservationAudiometry

VRAVisualReinforcementAudiometry

CPAConditionedPlayAudiometry

ABRAuditoryBrainstemResponseTesting

SATSpeechAwarenessThreshold

SRTSpeechRecognitionThreshold

RECDRealEartoCouplerDifference

OAEOtoacousticEmissionsTesting

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RECOMMENDEDAUDIOLOGICSPEECHTESTPROTOCOLSBYAGE*OFTHECHILD

Birth6 612 1218 1824 2436 35yrs 68yrs 8+years


months months months months months

SAT x x x x

SRT x x x x x x

ESP x x x

NU x x x
CHIPS

WIPI x x

PBK x x

NU6 x x

CNC

HINTC x x
orA

Baby x x
Bios

AzBio x

Note1:Thepurposeofallauditorytechnologiesistodeliverthemostcompletesoundpossibletothe
childsbrain,whereactualhearingoccurs.Thetaskoftechnologiesistoaccess,stimulate,and
developneuralpathwaysthatarethebasisforlistening,talking,reading,andlearning.

*Note2:Theagelevelspresentedrepresentachildsdevelopmentallevelsaswellaschronologicalage.
Achild(oradult)withdevelopmentaldelaysshouldbeassessedwithtestsappropriatetohis/her
developmentallevel,notchronologicalage.

Note3:Speechtestsaretobepresentedinunaidedandaidedconditions.Aidedtestingrefersto
whatevertechnologythechildisusing.Thismaybehearingaids,cochlearimplants,osseointegrated

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devices,FMsystemsandother.Eachearshouldbetestedseparatelywithtechnology,aswellas
binaurally.

Abbreviationsusedinthechart:

Xmeansthetestshouldbeperformed

SATSpeechAwarenessThreshold

SRTSpeechRecognitionThreshold

ESPEarlySpeechPerceptionTest.Availableat
http://www.cid.edu/ProfOutreachIntro/EducationalMaterials.aspx

NUCHIPSNorthwesternUniversityChildrensPerceptionofSpeech.Availableat
http://www.advancedbionics.com/content/dam/ab/Global/en_ce/documents/libraries/AssessmentTool
s/Test%20Reference%20for%20Cochlear%20Implants.pdf

WIPIWordIntelligibilitybyPictureIdentification.Availableat
http://www.auditec.com/cgi/Auditec2013Catalog.pdf

PBKPhoneticallyBalancedKindergartenWordTest.Availableat
http://www.asha.org/eweb/OLSDynamicPage.aspx?title=Childrens+Spondees+PBK
50A&webcode=olsdetails

CNCConsonantNucleusConsonantTest.SeeMackersie,C.L.,Boothroyd,A.,&Minnear,D.(2001).
EvaluationoftheComputerAssistedSpeechPerceptionAssessmentTest(CASPA).Journalofthe
AmericanAcademyofAudiology,27,134144.

AzBioSeeSpahr,A.J.,Dorman,M.F.,Litvak,L.M.,VanWie,S.,Gifford,R.H.,Loizou,P.C.,Cook,S.
(2012).DevelopmentandvalidationoftheAzBiosentencelists.EarandHearing,33(1),112117.doi:
10.1097/AUD.0b013e31822c2549

BabyBioSeeSpahr,A.J.,Dorman,M.F.,Loiselle,L.,&Oakes,T.(2011).Anewsentencetestfor
children.10thEuropeanSymposiumonPediatricCochlearImplantation.Athens,Greece,May1215.

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Disclaimer:Theprotocoloutlinedinthisdocumentisnotprescriptiveforprofessionalswhoholdthe
ListeningandSpokenLanguageSpecialist(LSLS)certificationtoutilizeintheirscopeofpracticeandis
notrequiredbyAlexanderGrahamBellAssociationoftheDeafandHardofHearingortheAlexander
GrahamBellAcademyforListeningandSpokenLanguage.Thisreferencecontainsguidelinesand
recommendationsforuseattheprofessionalsdiscretion.AGBelldisclaimsanyliabilitytoanypartyfor
theaccuracy,completeness,oravailabilityofthisdocument,orforanydamagesarisingoutofuseofthis
documentandanyinformationitcontains.

ListeningandSpokenLanguageSpecialist(LSLS),AuditoryVerbalTherapist(LSLSCert.AVT)and
AuditoryVerbalEducator(LSLSCert.AVEd)aretrademarksoftheAGBellAcademyforListeningand
SpokenLanguage.

Copyright2014AlexanderGrahamBellAssociationfortheDeafandHardofHearing.Allrights
reserved.AlexanderGrahamBellAssociationfortheDeafandHardofHearing(2014).

Recommendedprotocolforaudiologicalassessment,hearingaidandcochlearimplantevaluation,and
followup.Washington,DC:author.

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