10 tips for challenging hearing assessments

Audiologist Jane Woodward shares tried and tested tips to consider the next time your patient is hiding under the table.

A colleague recently asked what my biggest learnings were during my clinical years as a pediatric audiologist.

I told her my first learning was that hearing assessments with children are often not straightforward. And my second learning was that there are always ways to get results when hearing assessments are challenging. 

To give you a bit of background, when I worked at the Children’s Hospital in Zürich, two thirds of the children I saw had additional needs such as significant developmental delays, language disorders, serious illnesses or multiple disabilities.  Every child was unique and didn’t always want to participate at first. Patient hiding under the table? Had that more than once. Child throwing building blocks? Been there. Patient too shy to respond, or won’t wear headphones? Check.

Does this mean we gave up and didn’t get results? Absolutely not. To provide the highest standard of care for children with hearing loss and their families, we needed to start with reliable hearing assessments. As well as listening to the family’s concerns and questions, hearing assessments are a crucial basis for optimally selecting and fitting technologies.

So, here are my tried and tested clinical tips for getting results from challenging assessments, such as when the little girl hid under the table in my testing booth.

  1. Engage

Work out a way to engage with the child before testing so they feel comfortable with you. Get down to their level, talk clearly, show them the games using your hands and facial expressions, talk about something relatable, a toy or a cartoon on their t-shirt. Know your Disney characters!

2. Toys

Have a good selection of brightly colored toys, with varying amounts of pieces. Change the toy at the first sign of boredom. When I just needed a few more hearing thresholds I would change to a toy with four pieces and say, “Listen for four more sounds and then we’re finished and ready for a sticker!”

3. Interact and observe

Obtain an idea of the child’s hearing levels and personality before testing. Ask them questions when you look in their ears. Watch how they interact with their parents when you collect them from the waiting room. Do they need to lip read to help compensate for a hearing loss? Do they intently stare at your face when you’re talking to them?

4. Calibrate

Everyone knows the importance of calibration at the beginning of the day. And don’t just check the headphones. Also check the Soundfield speakers, tympanometry, otoacoustic emissions (OAEs), speech tests, and anything else you are going to use so you can 100% rely on the results.

5. Cross-check principle

Back up behavioral testing of difficult-to-test children with objective tests such as OAEs. Whilst distracting the child, these are simple to use.

6. Key questions

When assessing children’s hearing, it sometimes looks like we’re playing all day, but we’re applying scientific principles throughout all our testing. Our key questions can be applied to children of all ages from day 1 to age 18 years.

Choose the appropriate test depending on the developmental age of the child and answer these key questions: Is the hearing within normal limits? If no, is there a permanent or conductive hearing loss? Is it in one or both ears? Is there a sign of an auditory processing disorder? Are the results reliable?

7. Flexibility

Is the toddler taking a nap on arrival? Start with OAEs. Let them wake in their own time before moving on to behavioral testing. Does the child love throwing blocks and you managed to dodge the one aimed at your head? Have them throw a ball into a bucket every time they hear a sound.

For really shy children, or those who have had many invasive medical tests, it helps to not ask direct questions, rather “You’ve been so good, you get to use headphones, you’re so lucky!” Or demonstrate first on mum, dad or teddy.

8. Reliability of results (give nothing away)

Be aware of other cues in the room. Is the parent’s tummy rumbling (yes, really), does the parent jump to the sound each time? Does your arm or finger move when you play a sound? Never ask, “Did you hear that?”

9. Rewards

Offering a sweet, a sticker at the end of testing or a video whilst carrying out OAEs works miracles. Parents always agree, if it gets results without an anesthetic or sedation it is worthwhile.

10. Non-verbal communication

Working at the Children’s hospital in Zurich taught me how little spoken language we need to assess children’s hearing. I am English, and worked in German, although less than half of my patients spoke German at home. Zürich is a beautiful multicultural city full of an array of languages and cultures. Portuguese, Spanish, Turkish, Serbo-Croat, Albanian speaking children, and many more – I used facial expressions, thumbs up, hand claps.

Working with children has shown me the very best of human nature. It is humbling seeing the resilience and positivity of children ill with cancer or after a serious accident. Our hearing assessment games were a ray of light for some families and provided fun amongst the many appointments of their day, whilst enabling comprehensive, scientific results to help each and every child reach their potential.

Further Reading

I found the following international audiology gold standard protocols invaluable, particularly whilst working in a clinic, culture and language different from my home country.

British Society of Audiology Recommended Procedures and Publications   

American Academy of Audiology Clinical Practice Guidelines