Everyday evaluation of a child’s functional access to sound

If you work with children who are deaf or hard-of-hearing, then you’ve probably heard of the Ling Sounds – also known as the Ling Test, Ling 6, Ling 7, or 7 Sounds. Here’s a quick refresher on what they are, how to use them, the types of responses to look for, and why you should make the Ling Sounds a regular part of your pediatric appointments.

What are the Ling Sounds?

Developed by Dr Daniel Ling (1976), the Ling Sounds can be used as a quick check of a child’s everyday functional access to speech sounds across the spectrum from low to high frequency. Clear and consistent access to sound is critical for spoken language development.

The Ling Sounds were selected to represent low, medium, and high frequency speech sounds in spoken English. Initially there were 5 sounds, and then 6 sounds in the test, and most English-speaking countries continue to use 6 sounds. These sounds are ‘AH’ ‘OO’ ‘EE’ ‘MM’ ‘SH’ and ‘SS’. In Australia, you’ll find that 7 sounds are used rather than 6 and you can read more about the addition of the ‘OR’ sound in this article by Agung and colleagues (2005).

The aim when using the Ling Sounds is to establish a pattern of what the child can and cannot consistently hear.  This pattern helps the team around the child to troubleshoot and modify the child’s hearing devices to ensure consistent and clear access to these sounds as quickly as possible. Clear and consistent access to sound is critical for spoken language development, so a proactive approach to monitoring and managing changes in access to sound is key!

How do you use the Ling Sounds?

The basic premise of administering the Ling Sounds is that sounds are presented to the child and the child responds (or doesn’t respond) based on what they heard. The way that the sounds are presented, and the way that the child responds will change over time as the child grows and learns to listen.

The clinician or parent administering the Ling Sounds might change presentation variables around to gather additional information. The way that the presentation variables are selected and manipulated can give valuable diagnostic information. Clinicians should consider the clinical question they are asking and use the presentation variables that best help to answer that question.

For example, if the clinical question is ‘does this child hear better with hearing aids ON, than with hearing aids OFF’ then administering the test twice, once with hearing aids ON, and once with hearing aids OFF, would be a useful experiment.

Variables that can be manipulated include:

• How loudly the sounds are presented (e.g., soft conversational level, everyday conversational level, loud conversational level).
• How far away the person presenting the sounds is from the child – for example, right next to the child vs. 3m+ away from the child.
• Which side of the child the sounds are presented on.
• If the child is wearing one hearing device, or two, or none.
• If the child is using their personal listening device/s or not.
• Whether the environment is quiet, or if there’s background noise (and what type of noise is present).
• Whether additional acoustic cues are used (e.g., length, pitch, loudness) or not used.

How can children respond to the Ling Sounds?

The way that a child responds to the Ling Sounds will depend on their age and stage of listening development. Young children and early listeners will be working at detecting sounds, while older children and later listeners will be working at identifying and comprehending sounds. The response expected, and the task selected must be appropriate for the child’s age and stage of listening development, here are some examples.

Detection

A detection response is observed when a child changes their behavior in response to a sound. Changes in behaviour may be very clear (i.e., a head turn towards the sound, taking a turn at a game, or raising a hand), other changes in behavior may be subtle (i.e., a younger child may become still, raise their eyebrow, or widen their eyes). It’s important to remember that detection responses ONLY tell us that the child heard something (not nothing). Detection responses do not give us information on what the child heard, or how they heard it.

Detection responses are demonstrated by change in behavior in response to hearing a sound. Young children and early listeners are learning to demonstrate a detection response that shows ‘I heard something!’.

For example, you say ‘ahhHHhh’ and the younger child or early listener raises their eyebrows, become still, or changes their expression. An older child may turn to their head towards the sound, take a turn at a game, or raise their hand to show that they have heard.

Discrimination

Discrimination responses occur when a child can make ‘same’ or ‘different’ judgements about sounds. The tasks used help the child show us ‘I heard this, not that’. Importantly, discrimination tasks do NOT require the child to know what either sound is, just whether the sounds are the same or different.  

For example, when presented with two toys or two pictures, the child will look at or point to the picture that they’ve learned to associate with the sound they heard (e.g., the child points to the plane picture when they hear ‘ah’ – rather than the other picture offered as an option).

Identification

Identification responses occur when the child can show us what they have heard – ‘I heard this!’. Early identification responses occur when a child can correctly choose the toy associated with the sound they heard (e.g., they point to the snake for “ssssss”). Older children learn imitate the sound they heard (e.g., saying ‘sssss’ when they hear ‘sssss’). Once a child can imitate the sound they heard, we are able to troubleshoot with confidence knowing that what they said is what they heard.

For example, if a child is hearing ‘ss’ and repeating back ‘sh’, analysis of the difference between these two sounds suggests that they may not be hearing high frequencies above 4000Hz well.  

Problem solving may first start at checking the hearing aids are working and not blocked with wax, the microphone covers are clean and that the batteries are charged. The hearing devices may require reprogramming or the child’s unaided hearing levels may need to be checked for any change.

While working on imitation skills, it’s important to consider the child’s age and stage of speech development. Younger children may not be able to say later developing speech sounds clearly. If you’re not sure whether the child is saying the ‘correct’ sound, using an identification task that combines imitation and a picture or toy selection can help you decide if the error is due to listening, or reflect the child’s speech development.

Comprehension

Comprehension responses build on the child’s identification skills. At this stage, the child can now tell us ‘I heard this, and I know what it is!’. The difference between identification and comprehension is in the response that the child gives. Comprehension responses require an additional step of using the information heard to form a contingent response.

For example, the child hears ‘sssss’ and says, ‘I hear a snake!’

What’s in it for me?

Children who are DHH and using hearing technology to learn to listen and speak must have clear and consistent access to sound, across all frequencies, at soft conversational levels. In combination with proactive audiological management, the Ling Sounds can help to build a picture of what a child hears, and whether they are hearing clearly and consistently over time.

If used regularly, the Ling Sounds can help to identify changes or fluctuations in hearing. Ideally, parents should be guided and coached to use the Ling Sounds daily (particularly in the earlier years of listening development). Changes in the child’s responses to sounds can be a ‘red flag’ that audiological or medical review is required.

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References

Agung, K. B., Purdy, S. C., & Kitamura, C. (2005). The Ling Sound Test Revisited. Australianand New Zealand Journal of Audiology, 27(1), 33-41. https://doi.org/10.1375/audi.2005.27.1.33

Erber, N. (1996). Communication Therapy for Adults with Sensory Loss (2nd ed.). Clavis.

Ling, D. (1976). Speech and the hearing-impaired child: Theory and practice. Alexander Graham Bell Association For The Deaf.

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Co-Authors

Jenna Bongioletti, Research and Development Officer, Little Allied Health, South Australia

Jenna is an experienced Certified Practising Speech Pathologist (CPSP) and internationally certified Listening & Spoken Language Specialist (LSLS Cert. AVT) with almost 15 years experience working with children who are deaf or hard-of-hearing and their families. Jenna is passionate about every child having every opportunity to live their best life, and is an advocate for informed, empowered and evidence-based decision making. Jenna is currently researching the conversation and pragmatic skills of preschool children who are DHH through her PhD studies at The University of Sydney.

Nicole Eglinton, CEO and Principal Audiologist at Little Allied Health, South Australia

Nicole is the CEO and Principal Audiologist at All Ears and Speech and Little Allied Health. She has over twenty years experience working as a clinician and manager across government, profit-for-purpose and private enterprise. Nicole is passionate about choice, collaboration, innovation and excellence in clinical practice and service delivery, she has a keen interest in advancements in newborn hearing screening, implantable hearing technology, auditory processing disorders and aural rehabilitation for people of all ages.